Case Presentation

GROUP : 412 A&B

 Introduction
Nephrotic syndrome disorder characterized by proteinuria, edema,
hypoalbuminemia, and hyperlipidemia. Nephrotic syndrome is a primary
glomerular disease characterized by Marked increase in protein in the urine
(proteinuria) ,Decrease in albumin in the blood (hypoalbuminemia) Edema, High
serum cholesterol and low-density lipoproteins (hyperlipidemia) The syndrome
is apparent in any condition that seriously damages the glomerular capillary
membrane and results in increased glomerular permeability. The major
manifestation of nephrotic syndrome is edema. It is usually soft and pitting and
most commonly occurs around the eyes (periorbital), in dependent areas
(sacrum, ankles, and hands), and in the abdomen (ascites). Other symptoms,
including malaise, headache, irritability, and fatigue, are common (Fogo, 2000).
 Biographical Data
Patients Name : M, Dela Pena
Age : 57 years old
Height : 5 feet 4 inches
Date of birth : July 28, 1962
Gender : Male
Address : Quirino, Province Isabela
Civil Status : Married
Nationality : Filipino
Educational Attainment : High School Graduate
 Occupation : Retired Soldier
Insurance Coverage : Phil Health
Reason for seeking health care/Chief complaint : Dyspnea (Difficulty/Labored Breathing)

Medical Diagnosis : Nephrotic Syndrome secondary to Diabetic Nephropathy

History of Present Illness : Patient is having a hard time breathing and impaired physical
immobility due to Ascites, Pedal Edema (L) foot.
Previous Illness : Managed PTB (2015)
DM and Hypertension
Family Medical History

Disease Mother Father

Hypertension + +
Diabetes Mellitus + -
 Environmental Factor
A resides in Quirino, Isabela Province and occupies the ancestry house of her family. The
location of their house is easily accessible and there is a nearby hospital in her area. The area in
which He lives is not crowded and you can reach it by riding a jeep or tricycle. He said their
house has a first floor with a proper ventilation. In their house, they have two televisions, 3
electric fans, living room set, and kitchen appliances. They cook using a gas operated- stove. He
also said that they were using a pour flush toilet. He stated that their source of water is
Maynilad while Meralco supplies their electricity. They have one dog and cat in their house. They
do not practice garbage segregation and their garbage is collected by the city sanitation 2-3
times per week.
 Gordons Pattern of Functioning
FUNTION / HEALTH PATTERN Before Hospitalization
Health Perception/ Health Management
The patient perceives that he is healthy
because he can perform his daily activities.
Only seeks medical attention when the need
arises. Whenever he has headaches he rests
for a while and take
paracetamol 250 mg for headache
During Hospitalization Analysis
Patient said that he feels weak and is He only seeks medical help
accepting his condition and current situation whenever he needs. The patient
because he said that’s what God gave him as accepted his condition and is
his trials. He follows the doctor’s order to hoping to get better.
improve his health.
Oxygen 2LPM
Intra Jugular catheter at right subclavian
access for hemodialysis
 FUNTION / HEALTH PATTERN BEFORE HOSPITALIZATION
Nutrition Metabolic The patient has a very good appetite he
eats 2-3 cups of rice per meal.
Pattern Eats 3x/day and sometimes even eats
biscuits for snacks.
Very fond of eating sweets, salty foods,
and fatty foods.
Patient wt 73 kg
When patient develops a wound it slowly
heals.
In the morning he usually eats
2 cups of fried rice,
4 pcs of hot dog,
1 pc of egg,
1 cup of coffee,
In the afternoon he usually eats
karekare, sinigang, kilawin, fish, Nilaga
and papaitan, 2 cups of rice
His side sauces are fish sauce and soy
sauce. Patients eats the same thing for
his dinner.
DURING HOSPITALIZATION
Decrease in appetite.
Change sense of taste
Patient is on Low salt, low fat, low
cholesterol, high fiber renal diet 1800
kcal/day.
Water is limited (1000 ml of water)
Patient wt is 96 kg
When pt develops a wound it slowly
heals, dry skin
ANALYSIS
The average adult drinks about
1500 ml per day with moderate
activity and temperature, but
needs 2500 ml. per day, and
additional 1000 ml
(Fundamentals of Nursing,
Kozier, pp. 1067-1068)
An insufficient fluid intake
reduces the amount of fluid in
the chime, which enters the
large intestine which in turn
results in drier, harder feces
(Fundamentals of Nursing,
Kozier. Pg 1185)

Drinks approximately 4-5 cups of glasses

of water, and 1-2 cups of soda.
1 cup of coffee a day
 FUNTION / HEALTH BEFORE HOSPITALIZATION DURING HOSPITALIZATION ANALYSIS
PATTERN

Elimination Pattern Patient defecates two times a day. Patient defecates once a day when Defecation, normal stool is
Whenever the patient defecates he he got admitted. The patient feels semisolid in consistency.
does not feel any pain. Patient stool pain when he defecates. The The amount and character
color is brown. Semisolid in patient stool color is black (melena) of the stool is determined
consistency. by the amount and kind of
Patient is wearing catheter and
food ingested
He urinates 4-5 times a day without urinate around 120cc per day.
(Fundamentals of Nursing
difficulty. Urine is light amber
pg 321)
yellow
 FUNTION / HEALTH PATTERN Before Hospitalization
Activity / Exercise Patter The patient does military exercises in the
morning for two hours and sometimes
walk as his exercise in the morning.
Cognitive/ Perceptual Pattern The patient can understand and
follow instructions without difficulty,
knows how to read and write. Patient
● Does the person have sensory left eye is unable to see clearly and
defect? has a hearing problem.
During Hospitalization Analysis
Lying on bed most of the time. The patient Copd For exercise to be effective,
has a limited perform ROM exercises it should be regular and
because he experiences difficulty of sustained. Generally, exercising
breathing. He feels pain whenever he at least thrice a week is advised.
moves rated from 6/10.
(Fundamentals of Nursing,
Kozier, pg 104)
The patient can understand and Patient has a problem seeing
follow instructions without difficulty, in his left eye and no sense
knows how to read and write. Patient of taste.
left eye is unable to see clearly and
has a hearing problem.
He has decreased sense of taste.
 FUNTION / HEALTH PATTERN Before Hospitalization
Pattern of Sleep and Rest Usually sleeps around 10:00 pm and wakes up
at 6 in the morning.
7hrs of sleep at night
1:00 – 1:30 pm nap time
Patient described sleep as complete and stated
feeling relaxed after waking up. Before he goes
to sleep he watches the TV to fall asleep
sometimes. Wakes up in the middle of the night complete his total hrs of sleep due to waking up
to urinate, but can easily go back to sleep.
During Hospitalization
Patient can’t sleep easily due to difficulty of
breathing. He describes his sleep as incomplete
because he keeps waking up in the middle of
the night and has a hard time of sleeping. He
feels tired even after waking up. Sleeps lightly
and is easily awaken by disturbances in the
environment.
He sleeps at night at 8:30 or 10 and doesn’t
in the middle of the night
Analysis
The sleep wake cycle is very
important to adults. Usually have an
active lifestyle and are thought to
require 7 to 8 hrs. of sleep each night
by may do well on less.

The patient describes himself as healthy and
strong before getting admitted to the hospital.
Self-Perception
Feels weak all the time and has a big effect on Patient is being a positive thinker
him. He feels the only thing that keeps him despite of what happened to his
going is praying to God to give him strength and health.
feels tired.

Relationship pattern The patient is the head of the family and is
living with his wife and 2 sons. When there is a
decision making or a problem he talks to his
wife and ask what’s better for him and to them.
Always asks his wife for advice and has a good
relationship with his family.
He still is the head of the family and can still The pt is still being a good father to
provide for them. Also, he still consults his wife her kids despite of his current health.
for decision making. He is worried about his kids
if they’re doing well without him.
 FUNTION / HEALTH PATTERN Before Hospitalization
Sexuality
Coping /Stress tolerance Whenever the patient feels stress he talks
to his wife and ask what to do and he said
he talks to God and ask for guidance and
when he feels weak.
Alcohol
Values and Belief He is catholic and goes to church on
Sundays with his family and claims to pray strength from his condition.
every day. He believes in milagro and
albularyo when he feels something is
wrong with him.
During Hospitalization
The patient said he still does the same and Able to describe general coping
prays to God for guidance whenever he
feels stress and weak. Shares his problem
with family
He prays to God every night to give him
Analysis
pattern and effectiveness of the
pattern in terms of stress tolerance.
Hope is the ingredient in life
responsible for a positive outlook in
even’s life bleakest moment. It enables
an individual both to consider a future
and to actively bring the future into
being. Hope originates in imagination
but must become a valued and
realistic possibility in order to energize
the action. Hope has the capacity to
embrace the reality of the individual’s
suffering without escaping from
it(false hope) or being suffocated by it.
(despair, helplessness, hopelessness)
(Fundamentals of Nursing, pg 975.
Carol Taylor)
 Physical Assessment
GENERAL APPEARANCE
Patient is 57 years old male who is awake, conscious, Lying on the bed, looks weak, (+) sign of
distress, medium built, Needs assistance when sitting and doing other physical movement.
Patient is oriented to person, place and time.
Height : 5 Feet 4 Inches
Weight : 96 kilos
 BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
A. HEAD
» Proportional to the size of the
body, round, with prominences in Head is proportional to the size of the body, round with
1. Skull
the frontal area anteriorly and prominences in the frontal area anteriorly and the occipital
NORMAL
the occipital area posteriorly, area posteriorly , symmetrical in all planes and gently
symmetrical in all planes & gently curved.
curved
2. Scalp

» White, clean, free from masses, Scalp is same color as the face and head which is brown, clean
lumps, scars, nits, dandruff, and and free from masses, lumps, scars, nits, dandruff and NORMAL
lesions. lesions.

3. Hair

Black, evenly distributed and covers Alopecia typically causes a few temporary bald
the whole scalp, thick, shiny, free from patches on the scalp. It tends to run in families
split ends. and often strikes in childhood. The hair loss
Black, (+) Alopecia, Shiny and Free from split ends.
» Coarse or fine. seems to be part of an immune system
problem, in which the body's natural defenses
mistakenly attack its own tissue.
 BODY PART NORMAL FINDINGS
4. Face
» Oblong or oval or square or heart
shaped, symmetrical, facial
expression that is dependent on the
mood or true feelings, smooth and
free from wrinkles, no involuntary
muscle movements.
5. Eyes
● Parallel and evenly placed,
symmetrical, non-protruding, with
scanty amount of secretions, both
eyes black and clear.
ACTUAL FINDINGS ANALYSIS
 Nephrotic syndrome may cause your skin to
become dry and fragile, break open easily,
bleed, and become infected.
http://www.webmd.com/skin-problems-and-
Round, symmetrical, facial expression that is dependent on the
treatments/tc/nephrotic-syndrome-skin-care-
mood or true feelings, no involuntary muscle movements.
tips-topic-overview
(+) Dry face
 Wrinkles are a natural part of the aging
(+) Wrinkles
process. As people get older, their skin gets
thinner, drier, and less elastic, and less able
to protect itself from damage. This leads to
wrinkles, creases, and lines on the skin.
Periorbital edema is one of the symptoms of
Nephrotic Syndrome.
(+) Periorbital Edema
Evenly placed, Symmetrical, with scanty amount of secretion in
Periorbital puffiness, also known as "puffy eyes",
both eyes.
or swelling around the eyes, is the appearance of
swelling in the tissues around the eyes, called the
orbits. It is almost exclusively caused by fluid
buildup around the eyes, or periorbital edema.
 BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

Eyebrows ● Black, symmetrical, thick can

Black, symmetrical, thin can raise lower eyebrows
raise lower eyebrows
symmetrically and without difficulty, evenly distributed NORMAL
symmetrically and without
and parallel with each other.
difficulty, evenly distributed
and parallel with each other.
Eyelashes ● Black, evenly distributed and
Black, evenly distributed and turned outward NORMAL
turned outward
Eyelids ● Upper lids cover a small
portion of the iris, cornea and ● Upper lids cover a small portion of the iris, cornea
the sclera (limbus) when the and the sclera (limbus) when the eyes are open.
eyes are open. ● When the eyes are closed, the lids meet
● When the eyes are closed, completely. NORMAL
the lids meet completely. ● Symmetrical, color is the same as the surrounding
Symmetrical, color is the same skin.
as the surrounding skin. ● No palpable mass
» No palpable mass
Lid Margins ● Clear, without scalings or
secretions, lacrimal duct ● Clear, without scalings or secretions, lacrimal duct
openings (puncta) are evident openings (puncta) are evident at the nasal ends of NORMAL
at the nasal ends of the upper the upper and lower lids.
and lower lids.
Palpebral Fissures ● Appear equal when the eyes
● Appear equal when the eyes are open. NORMAL
are open.
 BODY PART NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Lower palpebral
conjunctiva
Pallor Lower palpebral conjunctiva
● Salmon pink, shiny, ● Pallor, shiny, moist and transparent
indicates hemoglobin level is lower
moist and transparent
than the normal range.

Sclera

● White and clear ● White and clear NORMAL

Iris
● Proportional to the size
of the eye, round, ● Proportional to the size of the eye, round,
NORMAL
black/brown, and black/brown, and symmetrical
symmetrical
 Laboratory Results
((HEMATOLOGY UNIT AND REPORT)
EXAMINATION RESULT NORMAL VALUES ANALYSIS
Hemoglobin 77.0 M:140-180 g/L Low hemoglobin count may indicate having anemia.
F:120-160 g/L
NB:136-196 g/L
(HEMATOLOGY UNIT AND REPORT)
Hematocrit 0.24 M:0.40-0.54 A low hematocrit with low RBC count
F:0.37-0.47 and low hemoglobin indicates anemia.
NB:0.50-0.58

WBC Count 6.3 5-10X10 /L Normal

RBC Count 2.45 M:4.5-6.2 x 10 /L Diseases and conditions that cause your body to
F: 4.2-5.4 x 10/L produce fewer red blood cells than normal such as
NB:5.0-7.0 x 10/L Aplastic anemia. Cancer.
Mean Corpuscular Volume (MCV) 96.0 86-96 fl Normal

Mean Corpuscular Hemoglobin (MCH) 31 27-32 pg Normal

Mean Corpuscular Hemoglobin 0.33 0.32-0.36 Normal

Concentration (MCHC)

Red blood cell distribution width (RDWcv) 15.3 12-15% A high red blood cell distribution width (RDW) may
be associated with adverse outcomes in patients
with heart failure and risk of death, and with
previous myocardial infarction.
 EXAMINATION RESULT NORMAL VALUES ANALYSIS
DIFFERENTIAL COUNT

Segmenter 0.64 ADULT: 0.60-0.70 Normal

NB: 0.55-0.65

Lymphocyte 0.27 ADULT:0.20-0.40 Normal

NB:0.30-0.35

Eosinophil 0.09 ADULT:0.01-0.05 High levels of eosinophils in

NB: 0.02-0.04 your blood or in tissues at the
site of an infection or
inflammation.

Platelate Count 179 ADULT:150-450X10 /L Normal

NB:15-93X10 /L
 EXAMINATION RESULT NORMAL VALUES ANALYSIS

U FBS
Creatinine
4.4
724
4.1-5.9
M:62-106
Normal
Abnormally high levels of creatinine thus warn of
F: 44-60 possible malfunction or failure of the kidneys.
R
I Uric Acid 626 M:202-416
F:143-339
A high uric acid level occurs when your kidneys
don't eliminate uric acid efficiently.

N Triglycerides 0.6 < 2.3 There are also some medical problems that can
cause abnormally low triglycerides, such as an
inability to absorb fats or hyperthyroidism.

A HDL 1.2 M: >1.45

F: >1.68
Low HDL levels increase the risk for heart disease

L LDL 1.3 < 2.59 Low level of low-density lipoprotein cholesterol or

a very low total cholesterol level has been
associated with health problems.
Y Sodium 134 136-145 A low sodium level has many causes, including
consumption of too many fluids, kidney failure,
S Potassium 5.0 3.5-5.1
heart failure, cirrhosis, and use of diuretics.
Normal

I Calcium 1.8 2.1-2.6 Low calcium levels in the blood can occur in
kidney failure when there is insufficient Vitamin D

S Albumin 55 39.7-49.5 Increase in albumin can cause kidney damage or

disease
Iron 5.7 M:11-28 Iron deficiency anemia is caused by low levels
F:7-26 of iron in the body.
Total Protein 95 66-87 High levels of total protein can mean that both
albumin and globulin are high.
Anatomy and Physiology
The adrenal glands sit on top of the kidneys and release renin which affects
blood pressure, and sodium and water retention. The bean-shaped kidneys
are about the size of a closed fist. They lie against the back of the abdominal
wall, outside the peritoneal cavity, just above the waistline in the lumbar area.
The right kidney sits slightly higher than the left one because of the position
of the liver. The kidneys are about 4 ½ inches long and 2 ½ inches wide. The
kidneys are highly vascular (contain a lot of blood vessels) and are divided into
three main regions: renal cortex (outer region which contains about 1.25
million renal tubules), renal medulla (medulla region which acts as a
collecting chamber), and renal pelvis (inner region which receives urine
through the major calyces).

The kidneys are protected in front by the contents of the abdomen and
behind by the muscles attached to the backbone. They are further protected
by a layer of fat.
 THE RENAL SYSTEM
Kidneys – collect the body’s waste products
Ureters – muscular tubes that transport urine from each kidney to the bladder.
Urinary bladder – a sac that collects and holds urine that comes from the ureters.
Urethra – a narrow passageway where urine passes from the bladder to the outside of the body, called urination
• Renal Capsule – outer membrane that surrounds the kidney; it is thin but tough

K
and fibrous
• Renal Pelvis – basin-like area that collects urine from the nephrons, it narrows
into the upper end of the ureter

I
• Calyx – extension of the renal pelvis; they channel urine from the pyramids to
the renal pelvis
• Cortex – the outer region of the kidney; extensions of the cortical tissue,

D •
•
contains about one million blood filtering nephrons
Nephron – these are the filtration units in the kidneys
Medulla – inner region of the kidney contains 8-12 renal pyramids. The pyramids

N •
•
empty into the calyx.
Medullary pyramids – formed by the collecting ducts, inner part of the kidney
Ureter – collects filtrate and urine from renal pelvis and takes it to the bladder

E •
for urination
Renal Artery – branches off of the aorta bringing waste-filled blood into the

y
kidney for filtering in the nephrons; the renal artery is further subdivided into
several branches inside the kidney. Each minute, the kidneys receive 20% of the
blood pumped by the heart. Some arteries nourish the kidney cells themselves.
• Renal Vein – removes the filtered blood from the kidneys to the inferior vena
cava
Kidney Function
Every minute 1300 mL of blood enter the kidneys, 1299 mL leave the kidney and 1
mL leaves as urine. The kidneys have many functions. The kidneys are the major
organs that maintain homeostasis (balance of the various body functions) in the
body and help control blood pressure. They maintain balance in electrolytes, acid-
base, and fluid in the blood. The kidneys remove nitrogenous waste from the body
(creatinine, urea, ammonia) and keep essential substances the body needs to
function as it should. The kidneys produce the hormone erythropoietin that
stimulates the production of red blood cells and enzymes.
When the kidneys aren’t working as they should, there is a failure of homeostasis
which can cause death if not corrected. A panel of blood tests, called a Kidney
Function Profile, is used to monitor the kidneys, detect kidney problems or make a
diagnosis.
Nephrotic System Anatomy
• Renal Artery – brings waste-filled blood from the
aorta to the kidney for filtering in the nephron.
• Glomerulus – each glomerulus is a cluster of blood
capillaries surrounded by a Bowman’s capsule. It
looks similar to a ball of tangled yarn.
• Proximal convoluted tubule (PCT)
• Thin descending limb of the loop of Henle
• Thin Ascending limb of the loop of Henle
• Thick Ascending limb of the loop of Henle
• Distal convoluted tubule
• Renal Vein – when filtration is complete, blood
leaves the nephron to join the renal vein, which
removes the filtered blood from the kidney
• Arterioles – blood is brought to and carried away
from the glomerular capillaries by two very small
blood vessels—the afferent and efferent arterioles.
Nephrotic System Function
• Bowman’s Capsule – Surrounds the glomerulus
• Glomerulus – consist of a the cluster of capillaries
• Proximal Convoluted Tubule – nearest the glomerulus; have permeable cell
membranes that reabsorb glucose, amino acids, metabolites and electrolytes into
nearby capillaries and allow for circulation of water
• Loop of Henle – has an ascending and descending limb, these loops along with their
blood vessels and collecting tubes for the pyramids in the medulla. When the filtrate
reaches the descending limb of the loop, water content has been reduced by 70%.
The filtrate contains high levels of salts (mostly sodium). As the filtrate moves further
through the loop, more water is removed which further concentrates the filtrate.
• Distal Convoluted Tubule – farthest from the glomerulus; helps regular potassium
excretion.
• Collecting Duct – collects the filtrate
• Individual nephrons cannot be seen by the naked eye. The nephron is the basic structural and functional unit of the
kidney. Each kidney has about 1 million nephrons. The walls of the nephron are made of a single layer of epithelial
cells. Blood containing urea and metabolic waste products enters the kidney from the liver. The blood is
mechanically filtered to remove fluids, wastes, electrolytes, acids and bases into the tubular system while leaving
blood cells, proteins and chemicals in the bloodstream. The nephrons also reabsorb and secrete ions that control
fluids and electrolyte balance.
• The blood enters the kidney and goes to the glomerulus. Pressure forces fluid out of the blood through membrane
filtration slits creating a cell-free fluid (plasma) of water and small molecules that enters into the renal tubule. Large
cells and proteins stay in the blood. This plasma is taken to the nearest (proximal) convoluted tubule. This runs
down into the medulla into the loop of Henle and then back to the farthest (distal) convoluted tubule to join with
other tubules. In the distal tubule most of the salts are reabsorbed. What is left is further modified until it becomes
concentrated urine which contains urea and other waste products at the end of the collecting duct.

The kidneys collect and get rid of waste from the body in 3 steps:
• Glomerular filtration – Filtrate is made as the blood is filtered through a collection of capillaries in the nephron
called glomeruli.
• Tubular reabsorption – The tubules in the nephrons reabsorb the filtered blood in nearby blood vessels.
• Tubular secretion – The filtrate passes through the tubules to the collecting ducts and then taken to the
bladder.