Chronic Kidney Disease Secondary To Chronic Glomerulonephritis

Chronic Kidney Disease secondary to Chronic Glomerulonephritis

Physical Assessment

ASSESSMENT

TECHNIQUE USED

NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

A. Skin Skin color

Inspection

Varies to light – deep brown

Pallor

Poor oxygenation of the skin tissues

Assess edema

Inspection

No edema

With bipedal Edema (grade II)

Due to water retention and increase permeability of membrane that results from shifting of fluids

Observe and palpate skin moisture

Inspection

Moisture in skin folds and the axilla

Generalized dryness of the skin

Decreased activity of oil glands and deposits of nitrogenous waste.

Skin turgor

Inspection

When pinched, skin springs back to Previous state

Good skin turgor noted

Normal

Observe for scratching

Inspection, observation and palpation

No pruritus

Pruritus noted

Decreased activity of oil glands and deposits of nitrogenous waste.

B. Nails Nail bed color

Inspection

Highly vascular, pink

Pallor

Circulatory impairment due to decreased hemoglobin

Tissues Surrounding nails

Inspection And palpation

Intact epidermis

Intact epidermis

Normal

Allen’s test

Inspection

Prompt return

Weak return (5 sec)

Circulatory impairment due to decreased hemoglobin

C. Head Size, shape and symmetry

Inspection and Palpation

Rounded,smooth skull contour

Rounded, smooth skull contour

Normal

Presence of nodules, masses

Inspection and Palpation

Absence of nodules and masses Even distribution

Absence of nodules And Masses Even distribution

Normal

Hair

Inspection

Silky and resilient hair; No infection or infestation

No infestation Dry

Abnormal due to poor hygiene

D. Face

Palpation Inspection

Symmetric; no involuntary muscle movements

Symmetric; no involuntary muscle movements

Normal

E. Eyes eyebrows

Inspection

Hair evenly distributed; intact skin

Hair evenly distributed; intact skin

Normal

Sclera

Inspection

White in color

White in color

Normal

Conjunctiva

Inspection

Pinkish or red in color

pale

Circulation impairment

Pupils

Inspection

equal size, normally 3 -7mm in diameter, both pupil equally reactive to light and accomodation

equal size, about 2-3 mm; both pupil equally reactive to light and accomodation

Normal

F. Ears Auricles

Inspection

Client’s response to normal voice tones

Inspection

Color same as facial skin; Color same as facial skin; symmetrical; aligned with symmetrical; aligned with outer canthus of eye outer canthus of eye Normal voice tone audible

Normal voice tone audible

Normal

Normal

G. Nose Deviations in shape, size, color and presence of flaring/discharge from nares

Inspection

Symmetric, Straight, no discharge/flaring

Symmetric, straight, no discharge/flaring;

Normal

Presence of tenderness, masses and Displacements of bone and cartilage

Palpation

Uniform color Absence of lesion/tenderness

Uniform color Absence of lesion/tenderness

Normal

Patency of both nasal cavities

Inspection

Air moves freely as the client breathes

Air moves freely as the client breathes

Normal

H. Mouth Lips

Inspection

Uniform pink in color; moist, smooth texture

Pallor, dry

Due to excessive Dryness, poor hydration and Impaired circulation

Teeth

Inspection

Teeth is smooth, white in color

Teeth is smooth, white in color

Normal

Tongue

Inspection

Central position; no lesion

Central position; no lesion

Normal

Gums

Inspection

Pinkish in color, no bleeding

Pale and Bleeding

Due to poor Circulation and impaired platelet function

I. Neck

Palpation

Muscle equal in size; head centered; Lymph node not palpable

Muscle equal in size; head centered; Lymph node not Palpable; with intrajugular catheter At right intrajugular vein, dry and intact

The catheter is a temporary access for hemodialysis

J. Thorax and Lungs Breathing patterns

Auscultation

Full and symmetric chest expansion, quiet, rhythmic and effortless breathing

Full and symmetric chest expansion, quiet, rhythmic and effortless breathing

Normal

Adventitious Breath Sounds

Auscultation

Absence of adventitious sounds

Absence of adventitious sounds

Normal

K. Heart

Inspection

No pulsation, lift and heaves; symmetric pulse volumes

No pulsation, lift and heaves; symmetric pulse volumes

Normal

No abnormal heart sounds is heard

Normal

Auscultation No abnormal heart sounds is heard Auscultation

Cardiac rate ranges from 60 – 100 bpm.

94 bpm

Normal

Palpation

Jugular vein is not visible

Jugular vein is not visible

Normal

L. Abdomen

Inspection and Palpation

Unblemished skin, uniform in color, no evidence of enlargement of liver or spleen, flat rounded or scaphoid

Unblemished skin, uniform in color, no evidence of enlargement of liver or spleen, the abdomen is destended

Increased serum uremic toxins

Palpation

Bladder not palpable

Bladder is not palpable at time of assessment

Normal

M. Extremitie s Upper

Inspection and Palpation

Equal in size, no deformities, no tenderness, swelling and edema

No tenderness, swelling, edema formation; no lesions; equal in size. Dry skin;

Dry skin is due to deposits of Nitrogenous waste and poor Hydration

Lower

Inspection and Palpation

Equal in size, no deformities, no tenderness, swelling and edema

With bipedal edema (Grade II) Pruritic

Due to water retention and increase permeability of membrane that Results from shifting of fluids

Review of System

• Integumentary system a. Pallor b. Pruritus c. Dry skin • Gastrointestinal a. Anorexia b. Uremic fector c. Bleeding gums d. Nausea e. Abdominal distention f. ascites • Hematopoetic a. Anemia b. Defects in platelet function c. Thrombocytopenia • Reproductive a. decreased libido

Neurologic a. Confusion b. Sleep disturbances c. Muscle irritability Genitourinary a. Decreased urine output b. Protenuria c. Damaged nephrons d. Decreases urine sodium e. cast and cells in urine Musculoskeletal a. Decreased calcium absorption b. Decreased phosphate excretion c. Loss of muscle strenght d. muscle cramps • Cardiovascular a. hypertension b. hypervolemia

Anatomy and Physiology

The Kidney The kidneys are a pair of bean-shaped organs located below the ribs near the middle of the back. They are protected by three layers of connective tissue: the renal fascia (fibrous membrane) surrounds the kidney and binds the organ to the abdominal wall; the adipose capsule (layer of fat) cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection.

Parts of the Kidney • • • • • •

Renal Vein carries blood away from the kidney and back to the right hand side of the heart. Renal Artery supplies blood to the kidney from the left hand side of the heart Pelvis is the region of the kidney where urine collects Ureter carries the urine down to the bladder Medulla is the inside part of the kidney Cortex is the outer part of the kidney

Functions of the Kidney • • • • • • • • • •

Urine formation Regulation of electrolytes Regulation of acid-base balance Control of water balance Renal clearance Secretions of prostaglandins Regulation of calcium and phosphorous balance Activates growth hormone Detoxify harmful substances (e.g., free radicals, drugs) Increase the absorption of calcium by producing calcitriol (form of vitamin D) • Produce erythropoietin (hormone that stimulates red blood cell production in the bone marrow) • Secrete renin (hormone that regulates blood pressure and electrolyte balance)

The Nephrons • Functional and structural unit of the kidney • Each kidney has over one million nephrons Two types of Nephron 1. Cortical Nephron (80-85%) located at outermost part of cortex 2. Juxtamedullary Nephron distinguished by long loops of henle

Parts of the Nephron • The afferent arteriole receives blood rich in oxygen from the renal artery. • The glomerulus is a knotted up capillary that contains small pores. • The efferent arteriole is smaller in diameter than the afferent arteriole and increases the pressure in the glomerulus aiding pressure filtration • Bowman's capsule collects the filtrate • Proximal Convoluted Tubule has a brush border with many villi to increase the surface area for selective reabsorption. • Loop of Henle dips down into the hypertonic environment of the kidney medulla and is responsible for the reabsorption of water from the filtrate • Distal Convoluted Tubule is the site of tubular secretion • Peritubular Capillary Network acts as the blood supply to the nephron. • Collecting duct receives filtrate from several nephrons.

Functions of the Nephron • Filtration • Reabsorption • Secretion

Pathophysiology

BODY SYTEMS MANIFESTATION IN CHRONIC KIDNEY DISEASE (CHRONIC RENAL FAILURE)

BODY SYSTEM

CAUSES

SIGNS AND SYMPTOMS

ASSESSMENT PARAMETERS

HEMATOPOETIC

•SUPPRESSION OF RBC PRODUCTION •DECREASED SURVIVAL TIME OF RBC. •BLOOD LOSS THROUGH BLEEDING AND DIALYSIS •MILD THROMBOCYTOPENIA •DECREASED ACTIVITY OF PLATELET

•ANEMIA •LEUKOCYTOSIS •DEFECTS IN PLATELET FUNCTION •TROMBOCYTOPENIA

•HEMATOCRIT •HEMOGLOBIN •PLATELET COUNT •OBSERVE BRUISING, AND OTHER SIGNS AND SYMPTOMS OF BLEEDING

CARDIOVASCULAR

•FLUID OVERLOAD •RENIN-ANGIOTENSIN MECHANISM •ANEMIA •CHRONIC HYPERTENSION •CALCIFICATION OF SOFT TISSUES •UREMIC TOXINS IN PERICARDIAL FLUID •FIBRIN FORMATION ON EPICARDIUM

•HYPERVOLEMIA •HYPERTENSION •TACHYCARDIA •ARRYTHMIAS •CONGESTIVE HEART FAILURE •PERICARDITIS

•VITAL SIGNS •BODY WEIGHT •ECG •HEART SOUNDS •MONITOR ELECTROLYTES •ASSESS FOR PAIN

GASTROINTESTINAL

• • • •

NEUROLOGIC

• • •

CHANGES IN PLATELET ACTIVITY SERUM UREMIC ACID ELECTROLYTE IMBALANCE UREA COVERTED TO AMMONIA BY SALIVA

• •

UREMIC TOXINS ELECTROLYTE IMBALANCES CEREBRAL SWELLING RESULTING FROM FLUID SHIFTING

• • • • • •

• • • • •

• • •

ANOREXIA NAUSEA AND VOMITING GASTROINTESTIN AL BLEEDING ABDOMINAL DISTENSION DIARRHEA CONSTIPATION UREMIC FECTOR

•

LETHARGY CONFUSION CONVULSION STUPOR COMA SLEEP DISTURBANCE UNUSUAL BEHAVIOR ASTERIXIS MUSCLE IRRITABILITY

•

• • • • •

• • • •

MONITOR INTAKE AND OUTPUT HEMATOCRIT HEMOGLOBIN GUALAC TEST FOR STOOLS ASSESS THE QUALITY OF STOOLS ASSESS FOR ABDOMINAL PAIN LEVEL OF ORIENTATION LEVEL OF CONSCIOUSNESS REFLEXES EEG ELECTROLYTE LEVEL

MUSCULOSKELETAL

• • •

SKIN

• • • • •

UREMIC TOXINS DECREASED CALCIUM ABSORPTION DECREASED PHOSPHATE EXCRETION

• •

•

• • •

MUSCLE CRAMPS LOSS OF MUSCLE STRENGTH RENAL OSTEODYSTROPHY RENAL RICKETS BONE PAIN BONE FRACTURES

ANEMIA PIGMENT RETAINED DECREASED ACTIVITY OF OIL GLAND DECREASED SIZE OF SWEAT GLAND PHOSPHATE DEPOSIT

• • • • • • •

PALLOR PIGMENTATION PRURITUS ECCYMOSIS EXCORIATION UREMIC FROST DRY SKIN

•

•

• •

• • •

ELECTROLYTE LEVEL REFLEXES PAIN ASSESSMENT

OBSERVE FOR BRUISING ASSESS SKIN COLOR ASSESS SKIN INTEGRITY OBSERVE FOR SCRATCHING

GENITOURINARY

•DAMAGED NEPHRONS

REPRODUCTIVE •HORMONAL ABNORMALITIES •ANEMIA •HYPERTENSION •MALNUTRTITION •MEDICATIONS

•DECREASED URINE OUTPUT •DECREASED URINE SPECIFIC GRAVITY •PROTEINURIA •CAST AND CELLS IN URINE •DECREASED URINE SODIUM

•MONITOR INTAKE AND OUTPUT •SERUM CREATININE •BUN •SERUM ELECTROLYTES •URINE SPECIFIC GRAVITY •URINE ELECTROLYTES

•INFERTILITY •DECREASED LIBIDO •IMPOTENCE •AMENORRHEA •DELAYED PUBERTY

•MONITOR INTAKE AND OUTPUT •MONITOR VITAL SIGNS •HEMATOCRIT •HEMOGLOBIN

Laboratory Results

Hematology Actual Value

Normal Values

Analysis

Hematocrit

0.16

0.42-0.52 %

Result is below normal.

Hemoglobin

55

140-170

Result is below normal.

RBC

1.88

4.0-6.0 x 10

Result is below normal.

WBC

8.9

5.0-10.0 x 10

Normal

Platelet count

142,000

150,000-350,000 Result is below normal.

Diferrential count Neutrophils

0.85

0.55-0.65%

Result is above normal.

Lympocytes

0.15

0.25-0.35%

Result is below normal.

Eosinophils

0.00

0.02-0.04%

Result is below normal.

Interpretation The kidney produce erythropoietin the stimulates bone marrow to produce red blood cells that increase hemoglobin and hematocrit.

In chronic kidney disease, the production of erythropoietin is impaired thus decreasing the ability of the bone marrow to produce red blood cells and decreasing the number of hemoglobin and the hematocrit level resulting to anemia. There was bone marrow suppression thereby increasing the neutrophils while lympocytes and eosinophils decrease because of anemia

Blood Chemistry TEST

RESULT

NORMAL RANGE

Analysis

Creatinine

2,482.40

62.00-133.00

The result is above normal.

Sodium

155.4

135-148

The result is above normal.

Potassium

5.93

3.5-5.5

The result is above normal.

Phosphorous

10.8

2.5-4.5

The result is above normal.

Calcium

1.08

1.12-1.32

The result is above normal.

Interpretation Creatinine is a break-down product of creatine phosphate and a nitrogenous waste.Creatinine is excreted mainly in the urine. In CKD, excretion of the nitrogenous wastes is impaired thus resulting in an increase in level of nitrogenous wastes like creatinine.

Increased serum level of the sodium, phosphorous and potassium is caused by loss of excretory renal function. The impaired conversion of the vitamin d to its active form causes the decreased serum level of calcium which then causes the increased serum level of phosphorous. Hyperparathyroidism also causes the decreased level of the calcium.

Urinalysis Result

Analysis

Physical Color

Light Yellow

Normal

ph

5.0 ph

Normal

Transparency

Turbid

The result is abnormal

Specific Gravity

1.020

Normal

Albumin

+++

The result is abnormal.

Sugar

Trace

The result is abnormal.

4-6/hpf

The result is abnormal.

Pus cells RBC

0-2/hpf

Epithelial cells

Many

Bacteria

Few

Interpretation The increased permeability of the capillary causes the excessive passage of protein in the urine. The impaired tubular reabsorption of glucose causes the traces of sugar in the urine. The transparency of the urine is turbid. There are many substances that causes the turbidity of it.