CASE REPORT MR.

Z WITH MEDICAL DIAGNOSIS

“CHRONIC KIDNEY DISEASE (CKD) DURING HEMODIALYSIS”
AT HEMODIALYSIS UNIT IN IIUM MEDICAL CENTER

NEPHROLOGY GROUP :

MINANTON
SRIYATI
TINA MUZAENAH

MASTER OF NURSING
UNIVERSITY MUHAMMADIYAH OF YOGYAKARTA
2018
 I. Patient Bibliography
1. Name : Mr. Z
2. Age : 64
3. Sex : Male
4. Religion : Islam
5. Marital Status : Maried
6. Occupation :
7. Source of Health care : Hospital
8. Date Of Admission : 9 October 2018
9. Provisional Diagnosis : CKD end stage
10. Date Of Surgery (if any) : 24 September 2018 for IJC

II. Presenting complaints

On Monday morning at 8 october 2018, patient complaints of
shortness of breath (dyspnea) and progressively. Then he comes to the hospital
IIUMMC, patient was admitted to ICU due to shortness of breath and also AV
Fistula swollen. He was stabilized in ICU then transfer to ward, plan to start on
hemodialysis (HD) right IJC was inserted. 9 october 2018 hemodialysis was
started and patient has nausea, fell bitter and sour taste.

III. History Of illness (Medical & surgical)

Before the patient got CKD, the patient has lived with hypertension
for 30 years. He has antihypertensive drugs and he checks blood pressure one
or two times a month. Since 4 years back, he was diagnosed with CKD and
advised to start on hemodialysis. He is on regular HD, three times a week. He
has AV fistula at left upper arm but can’t be use for the time being, because he
has problem so right IJC (intra jugular vein catheter) inserted for HD

IV. Diagnosis (Provisional & Confirmed)

1. Definition of CKD
Chronic kidney disease (CKD) involves progressive, irreversible loss of
kidney function. The Kidney Disease Outcomes Quality Initiative
(KDOQI) of the National Kidney Foundation defines CKD as either the
presence of kidney damage or a decreased GFR less than 60 mL/min/1.73
m2 for longer than 3 months. The last stage of kidney failure, end-stage
kidney (renal) disease (ESKD), occurs when the GFR is less than 15
mL/min. At this point, dialysis or transplantation is required to maintain
life.

2. Pathophysiology
As renal function declines, the end products of protein metabolism
(normally excreted in urine) accumulate in the blood. Uremia develops and
 adversely affects every system in the body. The greater the buildup of
waste products, the more pronounced the symptoms are.
The rate of decline in renal function and progression of ESRD is
related to the underlying disorder, the urinary excretion of protein, and the
presence of hypertension. The disease tends to progress more rapidly in
patients who excrete significant amounts of protein or have elevated blood
pressure than in those without these conditions.

3. Etiology and risk factors

CKD has many different causes, the leading causes are diabetes (about
50%) and hypertension (about 25%). Less common etiologies include
glomerulonephritis, cystic diseases, and urologic diseases. The increasing
prevalence of CKD has been partially attributed to the increase in risk
factors, including an aging population, rise in rates of obesity, and
increased incidence of diabetes and hypertension. Mortality rates are as
high as 19% to 24% for individuals with stage 5 CKD on dialysis. About
20% of patients with ESKD receiving dialysis die each year.

4. Stages Of Chronic Kidney Disease

Description GFR Clinical Action Plan
(mL/min/1.73
m2)
Stage 1 ≥90 Diagnosis and treatment
Kidney damage with CVD risk reduction
normal or ↑ GFR Slow progression
Stage 2 60-89 Estimation of progression
Kidney damage
with mild ↓ GFR

Stage 3 30-59 Evaluation and treatment of

Moderate ↓ GFR complications
Stage 4 15-29 Preparation for renal
Severe ↓ GFR replacement therapy
(dialysis, kidney transplant)
Stage 5 <15 (or Renal replacement therapy
Kidney failure dialysis) (if uremia present and patient
desires treatment)
Source: National Kidney Foundation.
www.kidney.org/kidneydisease/aboutckd.cfm.
5. Renal Replacement Therapies
The use of renal replacement therapies becomes necessary when the
kidneys can no longer remove wastes, maintain electrolytes, and regulate
fluid balance. This can occur rapidly or over a long period of time and the
need for replacement therapy can be acute (short term) or chronic (long
term). The main renal replacement therapies include the various types of
dialysis and kidney transplantation
a. Dialysis
Types of dialysis include hemodialysis, CRRT, and PD. Acute dialysis
is indicated when there is a high and increasing level of serum
potassium, fluid overload, or impending pulmonary edema, increasing
acidosis, pericarditis, and severe confusion. It may also be used to
remove medications or toxins (poisoning or medication overdose)
from the blood or for edema that does not respond to other treatment,
hepatic coma, hyperkalemia, hypercalcemia, hypertension, and
uremia.

b. Hemodialysis
Hemodialysis is used for patients who are acutely ill and require short-
term dialysis (days to weeks) and for patients with advanced CKD and
ESRD who require long-term or permanent renal replacement therapy.
Hemodialysis prevents death but does not cure renal disease and does
not compensate for the loss of endocrine or metabolic activities of the
kidneys. More than 90% of patients requiring long term renal
replacement therapy are on chronic hemodialysis (USRDS, 2007).
Most patients receive intermittent hemodialysis that involves
treatments three times a week with the average treatment duration of 3
to 4 hours in an outpatient setting. There are types of HD based on
vascular access, mainly:
1) Arteriovenous Fistulas and Grafts.
A subcutaneous arteriovenous fistula (AVF) is usually created in
the forearm or upper arm with an anastomosis between an artery
and a vein (usually cephalic or 4asilica). The fistula allows
arterial blood to flow through the vein. The vein becomes
“arterialized” with a larger caliber and thicker walls. The arterial
blood flow is essential to provide the rapid blood flow required
for HD. As the arterialized vein matures, it is more amenable to
repeated venipunctures. Maturation may take 6 weeks to months.
AVF should be placed at least 3 months before the need to initiate
HD. Normally, a thrill can be felt by palpating the area of
anastomosis, and a bruit (rushing sound) can be heard with a
stethoscope. The bruit and thrill are created by arterial blood
 moving at a high velocity through the vein. AVFs are more
difficult to create in patients with a history of severe peripheral
vascular disease, those with prolonged IV drug use, and obese
women. For these individuals, a synthetic graft may be required.
2) Arteriovenous grafts (AVGs)
Arteriovenous grafts are made of synthetic materials
(polytetrafluoroethylene [PTFE, Teflon]) and form a “bridge”
between the arterial and venous blood supplies. Grafts are placed
under the skin and are surgically anastomosed between an artery
(usually brachial) and a vein (usually antecubital). An interval of
2 to 4 weeks is usually necessary to allow the graft to heal, but
some centers may use it earlier.
3) Temporary Vascular Access.
In some situations, when immediate vascular access is required,
catheterization of the internal jugular or femoral vein is
performed. A flexible Teflon, silicone rubber, or polyurethane
catheter is inserted at the bedside into one of these large veins and
provides access to the circulation without surgery. The catheters
usually have a double external lumen with an internal septum
separating the two internal segments. One lumen is used for blood
removal and the other for blood return. It is now recommended
that patients not be discharged from the hospital with a temporary
catheter. These catheters have high rates of infection,
dislodgment, and malfunction.
Long-term cuffed HD catheters are often used for temporary
vascular access. These catheters provide temporary access while
the patient is waiting for fistula placement or as long-term access
when other forms of access have failed. This type of catheter exits
on the upper chest wall and is tunneled subcutaneously to the
internal or external jugular vein

6. Complications of Hemodialysis
a. Hypotension.
Hypotension that occurs during HD primarily results from rapid
removal of vascular volume (hypovolemia), decreased cardiac output,
and decreased systemic vascular resistance. The drop in BP during
dialysis may precipitate light-headedness, nausea, vomiting, seizures,
vision changes, and chest pain from cardiac ischemia. The usual
treatment for hypotension includes decreasing the volume of fluid
being removed and infusion of 0.9% saline solution.
b. Muscle Cramps.
 The pathogenesis of muscle cramps in HD is poorly understood.
Factors associated with the development of muscle cramps include
hypotension, hypovolemia, high ultrafiltration rate (large inter dialytic
weight gain), and low sodium dialysis solution. Cramps are more
frequently seen in the first month after initiation of dialysis than in the
subsequent period. Treatment includes reducing the ultrafiltration rate
and administering fluids (saline, glucose, mannitol). Hypertonic saline
is not recommended, since the sodium load can be problematic.
Hypertonic glucose administration is preferred.
c. Loss of Blood.
Blood loss may result from blood not being completely rinsed from
the dialyzer, accidental separation of blood tubing, dialysis membrane
rupture, or bleeding after the removal of needles at the end of dialysis.
If a patient has received too much heparin or has clotting problems,
post dialysis bleeding can be significant. It is essential to rinse back all
blood, to closely monitor heparinization to avoid excess
anticoagulation, and to hold firm but non occlusive pressure on access
sites until the risk of bleeding has passed.

V. Physical Examination of patient (Date & Time)

Physical Examination of patient during HD (intra) on 9 October 2018 at 10.23
am, the patient looks good & conscious, internal jugular vein catheter (IJC)
insitu.
1. Symptoms (None, Chest pain, Dyspnea, Vomiting, Pain, Others)
a. Pre HD : None

b. Intra HD : Nausea

c. Post HD : None

2. Vital sign (BP ; RR ; T; Pulse; Weight)

a. Pre HD : BP : 139/71 mmHg; pulse : 54/min; Weight : 65,3 kg

b. Intra HD : BP : 165/75 mmHg; pulse : 54/min;

c. Post HD : BP : 165/75 mmHg; pulse : 54/min; Weight : 64,3 kg

3. Neuro Status (Oriented , Alert, Sleepy, Uninterested , Others)

 a. Pre HD : Oriented

b. Intra HD : Oriented

c. Post HD : Oriented

4. Psychologis (anxiety,distress, others)

a. Pre HD : none

b. Intra HD : none

c. Post HD : none

5. Physical Status (Ambulatory, Wheelchair, Walk with Assistance, Others)

a. Pre HD : Ambulatory

b. Intra HD : -

c. Post HD : Ambulatory

6. Edema
a. Pre HD : none

b. Intra HD : none

c. Post HD : none

VI. Management (medical /surgical)

 Diagnostic examination: laboratories
8 October 2018
 Urea : 12.4
Creatinine : 8.69
HB : 9.2
 Therapy
CaCO3 1.5 gr (3x1)
Thelmisartan 80 mg (1x, night at 12.00 pm)
Simvastatin 20 mg (1 x1 at 10.00 pm)
Haematinics (1x1)
 Treatment of HD
1. Time Started : 08.50
2. Time Ended : 12.50
3. TD : 240 min or 4 hours
4. Qb : 200 ml/min
5. Qd : 500ml/min
6. U.f : 1 liter
7. Heparin : free

VII. Nursing Care Plan

The nurse in the dialysis unit has an important role in monitoring,
supporting, assessing, and educating the patient. During dialysis, the patient,
the dialyzer, and the dialysate bath require constant monitoring because
numerous complications are possible, including clotting of the circuit, air
embolism, inadequate or excessive ultrafiltration hypotension, cramping,
vomiting, blood leaks, contamination, and access complications. Nursing care
of the patient and maintenance of the vascular access device are especially
important.
 N NURSING
NOC NIC RATIONAL
O DIAGNOSIS
1 Nausea Nause control Nause management  To identify etiologies and plan
 Perfom complete assessment of appropriate interventions
nausea, including
frequency,duration, severity, and
precipitating factors
 Reduce or eliminate personal  To avoid precipitating factors of nausea
factor that precipitate or increase
the nausea(anxiety, fear, fatigue)
 Use frequent oral hygiene,  To promote comfort
unless it stimulates nausea
 Ensure that effective antiemetic  To prevent nausea
drugs are given when possible
 Monitor effect of nausea  To evaluate effectiveness of
management throughtout intervention
2 Risk For Maintain fluid Fluid Monitoring :
Fluid Volume balance  Monitor BP, pulse, and
deficient hemodynamic pressures  Hypotension, tachycardia, falling
if available during dialysis. hemodynamic pressures suggest volume
depletion.
 Weigh daily before/after dialysis  Weight loss over precisely measured time
run. is a measure of ultrafiltration and fluid
removal.
 Assess for symptoms of orthostatic  Dialysis potentiates hypotensive effects if
hypotension. these drugs have been administered.
 Use of heparin to prevent clotting in blood
lines and hemofilter alters coagulation and
 Observe for bleeding. potentiates active bleeding.

 Assess the patient’s level of  To prevent hypotension occurs.

consciousness.

 Assess for headache, nausea, and

vomiting.
VIII. Discharge Planning
Discharge Instructions for Chronic Kidney Disease (CKD)
Chronic kidney disease (CKD) can happen because of many things. These
include infections, diabetes, high blood pressure, kidney stones, circulation
problems, and reactions to medicine. Having kidney disease means making
many changes in the life. Treatments may vary based on the progression of
CKD. The patients always follow their healthcare provider's instructions on
how to manage their condition. There are some things patient can does to help
his condition.
1. Diet changes
a. Salt (sodium) in the patient’s diet
 Based on patient’s condition, he may be told to eat 1,500 mg or less
of sodium daily
 Limit processed foods such as:
 Frozen dinners and packaged meals
 Canned fish and meats
 Pickled foods
 Salted snacks
 Lunch meats
 Sauces
 Most cheeses
 Fast foods
 Don't add salt to patient’s food while cooking or before eating at
the table.
 Eat unprocessed foods to lower the sodium, such as:
 Fresh turkey and chicken
 Lean beef
 Unsalted tuna
 Fresh fish
 Fresh vegetables and fruits
 Season foods with fresh herbs, garlic, onions, citrus, flavored
vinegar, and sodium-free spice blends instead of salt when cooking.
 Don't use salt substitutes that are high in potassium. Ask your
healthcare provider or a registered dietitian which salt substitutes to
use.
 Don't drink softened water, because of the sodium content. Make
sure to read the label on bottled water for sodium content.
 Don't take over-the-counter medicines that contain sodium
bicarbonate or sodium carbonate. Read labels carefully.
b. Potassium in your diet
 Based on patient’s condition, he may be told to eat less than 1,500
mg to 2,700 mg of potassium daily.
  Always drain canned foods such as vegetables, fruits, and meats
before serving.
 Don't eat whole-grain breads, wheat bran, and granolas.
 Don't eat milk, buttermilk, and yogurt.
 Don't eat nuts, seeds, peanut butter, dried beans, and peas.
 Don't eat fig cookies, chocolate, and molasses.
 Don't use salt substitutes that are high in potassium. The patient
must asks his healthcare provider or a registered dietitian which salt
substitutes to use.
c. Protein in your diet
 Based on patient’s condition, his healthcare provider will talk with
him about why patient should limit protein in his diet.
 Cut back on protein. Eat less meat, milk products, yogurt, eggs, and
cheese.
d. Phosphorus in your diet
 Don't drink beer, cocoa, dark colas, ale, chocolate drinks, and
canned ice teas.
 Don't eat cheese, milk, ice cream, pudding, and yogurt.
 Don't eat liver (beef, chicken), organ meats, oysters, crayfish, and
sardines.
 Don't eat beans (soy, kidney, black, garbanzo, and northern), peas
(chick and split), bran cereals, nuts, and caramels.
Eat small meals often that are high in fiber and calories. Patient may be
told to limit how much fluid he drink.
2. Other home care
 Try not to wear himself out or get overly fatigued.
 Get plenty of rest and get more sleep at night.
 Move around and bend patient’s legs to avoid getting blood clots
when he rests for a long period of time.
 Weigh himself every day. Do this at the same time of day and in the
same kind of clothes. Keep a record of his daily weights.
 Take your medicines exactly as directed.
 Keep all medical appointments.
 Take steps to control high blood pressure or diabetes. Talk with the
healthcare provider for advice.
 Talk with the healthcare provider about dialysis. This procedure may
help if his chronic kidney disease is progressing to end stage renal
disease.
3. Follow-up care
Follow up with the healthcare provider, or as advised.
Call the healthcare provider right away if patient has any of the following:
  Chest pain
 Trouble eating or drinking
 Weight loss of more than 2 pounds in 24 hours or more than 5 pounds
in 7 days
 Little or no urine output
 Trouble breathing
 Muscle aches
 Fever of 100.4°F (38°C) or higher, or as advised by your healthcare
provider
 Blood in your urine or stool
 Bloody discharge from your nose, mouth, or ears
 Severe headache or a seizure
 Vomiting
 Swelling of legs or ankles

IX. Summary of the case

Mr. Z, is a 64-year-old man with chronic kidney disease receiving routine
hemodialysis. On Monday morning at 8 october 2018, he complaints of
shortness of breath (dyspnea) and progressively. Then he comes to the hospital
IIUMMC, patient was admitted to ICU due to shortness of breath and also AV
Fistula swollen. He was stabilized in ICU then transfer to ward, plan to start on
hemodialysis (HD) right IJC was inserted.
In additional, Mr.Z’s medical history includes hipertention & he has it for
30 years. He has antihypertensive drugs and he checks blood pressure one or
two times a month. He receive dialysis treatment 3 days a week. He has
laboratory test, results include urea : 12.4, creatinine : 8.69, HB: 9.2. His
current medications are CaCO3 1.5 gr (3x1), Thelmisartan 80 mg (1x, night at
12.00 pm), Simvastatin 20 mg (1 x1 at 10.00 pm), Haematinics (1x1).
At 9 october 2018, the patient is undergoing hemodialysis on 08.50
(Time Started) with TD : 240 min or 4 hours, Qb: 200 ml/min, Qd : 500ml/min,
U.f : 1 liter, Heparin free and on hemodialysis, patient report that patient has
nausea, fell bitter and sour taste. His vital signs are Pre HD (BP : 139/71
 mmHg; pulse : 54/min; Weight : 65,3 kg), Intra HD (BP : 165/75 mmHg; pulse
: 54/min), Post HD (BP : 165/75 mmHg; pulse : 54/min; Weight : 64,3 kg).

X. References

NANDA. (2018). Nursing Diagnoses: Definitions & Classification 2018-2020.

Philadelphia: NANDA International
Patient Education: Discharge Instructions for Chronic Kidney Disease (CKD).
https://www.fairview.org/patient-education/86310. Accssed: 10 october
2018 at 9.15 pm
Lewis, S., et al., (2014) Medical-surgical nursing : assessment and
management of clinical problems, ed 9. Missouri : Elsevier Mosby
Smeltzer, et,al, (2010) Brunner & Suddarth’s textbook of medical-surgical
nursing. — 12th ed. Lippincott Williams & Wilkins
Ignatavicius, D.D. & Workman, M. L. (2013) Medical-Surgical Nursing
Patient-Centered Collaborative Care. Ed 7. Missouri. Elsevier