I. Introduction Diabetic nephropathy (nephropatia diabetica), also known as Kimmelstiel-Wilson syndrome and intercapillary glomerulonephritis, is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by nephrotic syndrome and nodular glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime cause for dialysis in many Western countries. Discovered by British physician Clifford Wilson (1906-1997) and German-born American physician Paul Kimmelstiel (1900-1970) and was published for the first time in 1936. Causes The exact cause of diabetic nephropathy is unknown, but it is believed that uncontrolled high blood sugar leads to the development of kidney damage. In some cases, your genes or family history may also play a role. Not all persons with diabetes develop this condition. Each kidney is made of hundreds of thousands of filtering units called nephrons. Each nephron has a cluster of tiny blood vessels called a glomerulus. Together these structures help remove waste from the body. Too much blood sugar can damage these structures, causing them to thicken and become scarred. Slowly, over time, more and more blood vessels are destroyed. The kidney structures begin to leak and protein (albumin) begins to pass into the urine. Persons with diabetes who have the following risk factors are more likely to develop this condition: Signs & Symptoms Early signs and symptoms of kidney disease in patients with diabetes are typically unusual. However, a vast array of signs and symptoms listed below may manifest when kidney disease has progressed:
Transcript
I. Introduction
Diabetic nephropathy (nephropatia diabetica), also known as Kimmelstiel-Wilson syndrome and intercapillary glomerulonephritis, is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by nephrotic syndrome and nodular glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime cause for dialysis in many Western countries. Discovered by British physician Clifford Wilson (1906-1997) and German-born American physician Paul Kimmelstiel (1900-1970) and was published for the first time in 1936. Causes
The exact cause of diabetic nephropathy is unknown, but it is believed that uncontrolled high blood sugar leads to the development of kidney damage. In some cases, your genes or family history may also play a role. Not all persons with diabetes develop this condition. Each kidney is made of hundreds of thousands of filtering units called nephrons. Each nephron has a cluster of tiny blood vessels called a glomerulus. Together these structures help remove waste from the body. Too much blood sugar can damage these structures, causing them to thicken and become scarred. Slowly, over time, more and more blood vessels are destroyed. The kidney structures begin to leak and protein (albumin) begins to pass into the urine. Persons with diabetes who have the following risk factors are more likely to develop this condition: Signs & Symptoms
Early signs and symptoms of kidney disease in patients with diabetes are typically unusual. However, a vast array of signs and symptoms listed below may manifest when kidney disease has progressed:
Swelling, usually around the eyes in the mornings; later, general body swelling may result, such as swelling of the legs
Foamy appearance or excessive frothing of the urine Unintentional weight gain (from fluid accumulation) Fatigue Frequent hiccups General ill feeling Generalized itching Headache Nausea and vomiting Poor appetite Weakness, paleness, and anemia Ankle and leg swelling, leg cramps Going to the bathroom more often at night High blood pressure
III. Nursing Health Management
A. Biographical Data
NAME: Mr. A.
ADDRESS: Longos, Malabon
AGE: 9 years old
SEX: Male
NATIONALITY: Filipino
RELIGION: Roman Catholic
BIRTHDAY: June 22, 1939
STATUS: Married
OCCUPATION: Student
ADMISSION DATE: February 19, 2009
ADMISSION TIME: 10:34 am
B. Chief Complaint: fever, abdominal pain
Clinical Diagnosis: Dengue Fever Syndrome
C. History of Present Illness
A week Prior to Admission (PTA), at around 3 in the afternoon, the patient was confined at Tondo General Hospital with a chief complaint of easy fatigability, back pain and swelling of both legs and face and an admitting diagnosis of diabetic nephropathy with severe anemia.
Few hours PTA, the patient suffered chest pain, dizziness and cough while she was doing household chores (Sweeping, washing clothes, etc.). Thereafter, she took a pain reliever medication to ease the pain and an “” applying it unto her chest. Her sleeping pattern was also affected as she could not sleep well. However, easy fatigability, back pain and swelling of her both legs & face worsen her condition. Thus, prompted her family to confine her at said hospital. Several tests (Hematology & Urinalysis) had been made and she was diagnosed with Diabetic Nephropathy with severe anemia. Captropil 25 mg SL 1tab bid & furosemide was given as her initial treatment. However, her condition persisted and she did not
respond to medication and treatment given to her while she was confined on the said hospital. Thus, she was referred by her doctor to Eastern Samar Provincial Hospital for further examination and treatment.
D. Past Medical History
Medical History
Sometime in 1994, as recalled by the patient, she was diagnosed with Diabetes Mellitus Type 2 by a private Medical Doctor. Diamicron was given as her medication for her everyday maintenance but she failed to follow the Doctor’s order. Last year on the month of October she was confined at EVRMC due to swelling of her both legs and was diagnosed with Diabetic Nephropathy. Her condition was temporarily relieved. Thus, her physician permitted her to go home.
Surgical History
No surgery performed.
Obstetric/Gynecologic History
G-6 T-4 Pre-term-2 A-0 L-4
1952, as recalled by the patient, she had her first menstruation. Based on her it is regular and an average of 3-4 days per period. She used 2-3 pads of sanitary napkin per day.
E. Family History
UNRECALLED DM CARDIOVASCULAR
ATTACT TB
DM HYPERTENSIVE
DM ASTHMA A+W
LEGENDS
--- DECEASE PATIENT
---MALE DM--- DIABETES MELLITUS TB----TUBERCULOSI A+W—ALIVE AND WELL
----FEMALE
F. Socio-economic History
Father
Grand Mother
Mother
Grand Mother Grand Father
Sibling Sibling Sibling
DIABETES NEPHROPATHIC
PATIENT
Grand Father
Mrs. A has a small sari-sari store where she spends most of her time. This store is there primary source of income. She’s fond of eating sweet foods. She is a smoker, she begin smoking in her younger years. She can consume 3 sticks in a day just after eating her meals. She also drinks tuba and beer occasionally. However she quitted smoking due to diabetes mellitus.
G. Environmental History
Mrs. A and her husband lives in Tondo Manila. A sari-sari store is in their front yard, this keeps her busy every day. Fruit trees are visible in their vicinity. Water supplies for drinking, cooking, washing are taken from a communal faucet near at their comfort room. Food preparation is usually done by her. They usually store their food in the refrigerator. They have a pail flush type toilet located at the back of their house. They throw their garbage in their compost pit located at their backyard before.
H. Gordon’s Typology of Eleven Functional Health Pattern
Functional Pattern Pre-illness State Illness State Analysis
Health Perception/ Health Management
According to her, health is just how you treated yourself and she managed it by maintaining her personal hygiene.
Health is not only based on taking good care of your hygiene but also maintaining your balance diet.
She realized that her present condition is due to her wrong perception and management of health.
Nutritional/Metabolic Pattern She drinks 3
glasses of water per day.
Break fast:
7:00amAccording to her, she usually eats Pancit and 5pcs of pandesal every morning.
Lunch:
2 cups of rice and viand.
She drinks 4-6 glass of water a day.
Consider her present condition she eats small amount of food.
Drinking of water has been increase. While her eating pattern has been decrease due to her condition.
Dinner:
1 ½ cups of rice and viand.
Elimination Pattern She defecates once a day usually every morning.
She has infrequent urination.
She defecates twice a day usually every morning and/or after eating heavy meal.
Because of her increase fluid in take such as drinking water, she usually urinates 3x a day or more.
Exercise Pattern According to her. She often clean their house every morning
Based on her, she usually jogs at least 2m 3x a week
She is more conscious on her physical fitness.
Cognitive Pattern She is well educated and can speak and understand English fluently
She is well educated and can speak and understand English fluently
Her cognitive was not altered by her decease
Sleep/rest Pattern Mrs. A sleeps ataround 5 – 7 pm andwakes uparound 4 – 6 am
Because of her Condition He cannot sleep well.
Sleepingpattern hasbeen interrupteddue to therecent condition
Self Perception Pattern She perceive her self young appealing woman
According to her, she feels envy to other aged woman who is still physically fit.
She has poor self-esteem due to her condition.
Relationship Pattern She is friendly and social drinker
She quitted drinking
Her relationship to other does not
changeSexual/ReproductivePattern
She perceive her self as a disciplinarian mother and a loving wife
She perceive her self as a disciplinarian mother and a loving wife
Her sexual/reproductive was not altered by her decease
Coping/Stress Tolerance Pattern
Her strength is her family and when they bond she forgot all her problems
She spent most of her time with her family
Her coping stress tolerance was not altered by her decease
Values/Belief Pattern She believe in God but she is not religious.
She value his family and now has a great faith in God.
She Knows that God Can only help Her
H. Review of System
General Survey: “madali akong mapagod, di ko rin makain ang gusto ko lalu na pagbawal” as
verbalized by the patient
Skin:“pawisin ako at paring ang dali kong masugatan” as verbalized by the patient
Head: “madalas sumakit ang ulo ko” as verbalized by the patient
Eyes:“Madalas manlabo ang mata ko” as verbalized by the patient
Ears: The patient denies the onset of hearing problem.
Nose:Colds and itchiness
Throat:“maya’t maya akong lunok feeling ko kasi lagging tuyo ang lalmunan ko.
Malakas ako sa tubig” as verbalized by the patient
Neck:“madalas naakakaramdam ako ng pagsakit ng batok lalo na pag pagod” as
verbalized by the patient
Breast and Axillae: The patient denies the masses or pain on her breast.
Respiratory:“pag sobra akong pagod hinahabol ko ang hininga ko” as verbalized by the patient
Cardiovascular system:“ganon din, sap ago parang aatakin ako ng altrapresyon” as verbalized by the
patient
Gastrointestinal:“parang lagi akong gutom, gusto ko maya maya kain” as verbalized by the
patient
The patient denies difficulty in defcation.
Genitor Urinary:“madalas akong umihi pero minsan patak patak at minsan sobrang dami tapos
nilalanggam” as verbalized by the patient
Musculoskeletal:“naigagalaw ko naman ang mga kamay at paa ko , pwera lang pag my manas” as
verbalized by the patient
IV. Physical Assessment
Note: all of the details below are based upon assessment
General Survey: Mrs. A has a good body build. She has a good posture and gait. Her hygiene was kept. Her voice was not too loud, it is clear and understandable.
Vital Signs:
Temp.: 37.7˚C BP: 180/90mmHgRR: 21bpmPR: 98cpm
Skin:Color is good, warm to touch. Cyanosis is not presence and normal skin turgor.
Lesion or gangrene especially on the lower extremities is absence. Edema on the pedal part w/ pitting of 22.4mm
Hair:Oily thick and evenly distributed.
Nails:The texture is smooth, no clubbing and slight cyanosis. Poor blanch test (return on
original color after 4sec.)
Head: Normocephalic, symmetric, no lesion or lumps.
Eyes:Symmetric eyebrow and eyelashes. No lesion or masses. Reddish conjunctiva and
sclera. Pupils are equally round but unreactive to light and accommodation. Retinal pathology was not able to performed due to lack of instrument.
Ears: Acuity is good to whispered voice. Its texture is smooth and has a good pinna
recoil. Weber Test and Rinne’s Test, tympanic membrane was mot able to assess due to lack of instrument.
Nose:No discharges and lesion. Nasal septum at the medline. Pink nasal mucosa no
sinusitis tenderness.
Oral Cavity:
Lips are pink and moist. No lesion and masses. Oral mucosa is pink an moist. Presence of Kussmaul Breathing (fruity acetone breathing). Uvula at the midline. Good gag reflex and Polyphagia.
Neck:Trachea and Thyroid gland is located at the midline. Lymph nodes are non
palpable except t the submandibular.
Breast and Axillae: No lesion, symmetric and w/o masses. Nipples are w/o discharge and lesion and
masses. Lymph nodes on the axillae are non palpable.
Thorax and Lungs:Symmetric has a good expansion. No lesions and masses are present. Lungs is
resonant, and vesticular breath sound. Diaphragm descend 4cm bilaterally.
Cardiovascular system:The jugular venous pressure is 3cm above the sternal angle. Strong Pulsation on
aortic, pulmonic, erg’s point, tricuspid, mitral. No heart murmur and normal peripheral pulsation.
Abdomen: Absence of lesion. Bubonic auscultation is good. Tympanic percussion is also
good. Masses are not palpable. Liver is 6cm in midsternal line and 10cm in right midclavicular line.
Musculoskeletal:Good ROM on the upper extremities. Edema is present on the lower extremities.
Neurologic:
Level of Consciousness: Upon assessment, Mrs. A is oriented in time, place and her personal identity
Glasgow Coma Scale: she has a total score of 15; it indicates that she is aware and conscious.
Reponses Evaluation Eye Response Mrs. A has a grade of 4. She is
spontaneous and alert. (upon assessment) Verbal Response Mrs. A has a grade of 5. She is oriented
and converse on what is happening. (upon assessment)
Motor Response Mrs. A has a grade of 6. She is alert on verbal command and can follow instruction easily. (upon assessment)
Cranial Nerve AssessmentI - Olfatory Sensory: the patient is able to
differentiate the smell of a perfume and coffee
II- Optic Sensory: the patient has a poor visual acuity. She is nearsightedness prove by 5 inches distance in 12 size Times New roman font
III-Occulomotor Motor: she has a good medial ocular movement
IV-Troclear Motor: she has a good downward and inward deviation
V-Trigeminal Sensory: good blink reflexMotor: good eyebrow resistance
VI-Abducens Motor: she has a good lateral deviation VII-Facial Sensory: good sense of taste by
differentiating the vinegar from soy sauceMotor: she can smile, puff her cheeks and smile
VIII-Acoustic SensoryVestibular: Has a Good balancing base on Romberg’s testCochlear: good hearing acuity and
IX-Glossopharyngeal Sensory: has a good sense of taste on the posterior 1/3 of the tongueMotor: the patient has a good gag reflex
X-Vagus Sensory: the patient has a good gag reflexMotor: the patient has no difficulty in swallowing
XI-Accesory Motor: the patient has a strong resistance on
XII-Hypoglossal Motor:
Motor Reflexes:
The patient as good relflexes
VI- Anatomy and Physiology
THE ENDOCRINE SYSTEM
The nervous system sends electrical messages to control and coordinate the body. The endocrine system has a similar job, but uses chemicals to “communicate”. These chemicals are known as hormones. A hormone is a specific messenger molecule synthesized and secreted by a group of specialized cells called an endocrine gland. These glands are ductless, which means that their secretions (hormones) are released directly into the bloodstream and travel to elsewhere in the body to target organs, upon which they act.
Function
The Endocrine system is an information signal system much like the nervous system. However, the nervous system uses nerves to conduct information, whereas the endocrine system mainly uses blood vessels as information channels. Glands located in many regions of the body release into the bloodstream specific chemical messengers called hormones. Hormones regulate the many and varied functions of an organism, e.g., mood, growth and development, tissue function, and metabolism, as well as sending messages and acting on them.
Role in disease
Diseases of the endocrine system are common, including diseases such as diabetes mellitus, thyroid disease, and obesity. Endocrine disease is characterised by dysregulated hormone release (a productive Pituitary adenoma), inappropriate response to signalling (Hypothyroidism), lack or destruction of a gland (Diabetes mellitus type 1, diminished erythropoiesis in Chronic renal failure), or structural enlargement in a critical site such as the neck (Toxic multinodular goitre). Hypofunction of endocrine glands can occur as result of loss of reserve, hyposecretion, agenesis, atrophy, or active destruction. Hyperfunction can occur as result of hypersecretion, loss of suppression, hyperplastic, or neoplastic change, or hyperstimulation. Endocrinopathies are classified as primary, secondary, or tertiary. Primary endocrine disease inhibits the action of downstream glands. Tertiary endocrine disease is associated with dysfunction of the hypothalamus and its releasing hormones.
Cancer can occur in endocrine glands, such as the thyroid, and hormones have been implicated in signalling distant tissues to proliferate, for example the Estrogen receptor has been shown to be involved in certain breast cancers. Endocrine, Paracrine, and autocrine signalling have all been implicated in proliferation, one of the required steps of oncogenesis.
VII-Pathophysiolgy
Diabetic Nephropathy
Diabetic Nephropathy
Thickening in the Glomerulus
Tissue resistance to insulin
Glucose cannot enter target cell
Insulin production by pancreas/hyperinsulinemia
Impaired insulin Production
Diabetic Nephropathy
Pressure of the blood vessel in the
urine
Ineffective insulin
Chronic kidney Failure
Stress kidney filtration
mechanism
Diminished intracellular Reaction
Peripheral resistance to insulin
Glucose accumulation in blood stream/hyperglycemia
