Notes for Physical Assessment
General Observations
• Skin:
• Pale, Dry, Scaly Skin: These changes are due to anemia and dehydration, common
in CKD patients because of the reduced production of erythropoietin and inability to
retain moisture.
• Hyperpigmentation: This occurs due to the retention of uremic toxins which can
deposit in the skin, often more noticeable in sun-exposed areas.
• IV Cannula Marks: Indicate frequent need for intravenous access, common in
patients requiring regular medical interventions such as dialysis.
• Rashes: Could be due to allergic reactions or uremic pruritus (itchiness caused by
toxin accumulation).
Neck
• Presence of Internal Jugular Central Venous Catheter (CVC):
• Purpose: Used for hemodialysis to provide a reliable access point to the
bloodstream.
• No Cervical Lymph Enlargement: No signs of infection or malignancy.
• No Jugular Vein Distention: Indicates no signs of fluid overload or heart failure,
which can sometimes accompany CKD.
Trunk and Breath Sounds
• Inspection:
• No Distention or Wounds: Indicates the absence of trauma or surgical interventions.
• Auscultation:
• Normal Breath Sounds: Suggests that the lungs are functioning well, and there are
no signs of pulmonary edema, which can occur in CKD due to fluid overload.
• Quiet, Unlabored Respirations: Indicates no respiratory distress or use of accessory
muscles, which is a good sign of stable respiratory function.
Abdomen
• Suprapubic Fullness with Dullness to Percussion:
• Interpretation: May suggest bladder distention or bowel issues due to fluid retention
or constipation, common in CKD patients.
• Abdominal Distention:
• Interpretation: Could be due to ascites (fluid accumulation in the abdomen) or
bowel distention, which needs to be monitored closely.
Hands and Nails
• Absence of Lunula:
• Interpretation: This could be a sign of anemia or poor nutritional status, both
common in CKD.
• Lindsay’s Nails:
• Proximal White, Distal Brown: Known as half-and-half nails, typically seen in
chronic renal failure due to melanin deposition.
• Capillary Refill Time of 4 Seconds:
• Interpretation: Prolonged capillary refill time indicates poor peripheral perfusion,
often a sign of decreased cardiac output or dehydration.
Upper Extremities
• Inspection and Palpation:
Symmetrical Limbs, Passive Range of Motion: No muscle wasting or joint
abnormalities, suggesting that muscle strength and joint function are preserved.
Lower Extremities
• Feet Can Dangle Without Lesion or Redness:
• Interpretation: No signs of pressure sores or infections.
• Grade 2 Pitting Edema:
• 4 mm Indentation Rebounds in Less than 15 Seconds: This level of edema
indicates significant fluid retention, which is typical in CKD patients due to impaired
kidney function leading to poor fluid management.
Focused Physical Assessment (May 15, 2024)
• Consistency with Previous Findings: The assessment remains consistent over time,
highlighting chronic issues rather than acute changes. This stability helps in managing longterm care and interventions.
Key Points
• Skin Changes: Indicate chronic kidney disease and systemic toxin buildup.
• CVC: Necessary for dialysis, highlighting the severity of kidney impairment.
• Respiratory Function: Remains stable, an important positive sign.
• Abdominal Issues: Suggest fluid retention or constipation, needing regular monitoring.
• Nail Changes: Reflect chronic renal failure and nutritional status.
• Edema: A critical marker for fluid management, requiring consistent assessment and
intervention.
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This comprehensive physical assessment illustrates the multifaceted impact of CKD Stage 5 on the
patient's body, guiding targeted nursing care and medical intervention.
Pathophysiology Explanation
Factors Contributing to CKD
• Modifiable Factors
• Excessive Alcohol Intake: Alcohol can cause direct toxicity to the kidneys, leading
to nephron damage and loss of function.
• Increased Cholesterol Intake: High cholesterol levels can lead to the formation of
atherosclerosis, which can decrease blood flow to the kidneys, impairing their
function.
• Non-Modifiable Factor
• Family History of CKD: A genetic predisposition can increase the likelihood of
developing CKD, as certain genetic factors can affect kidney function and
susceptibility to damage.
Pathophysiological Changes
1. Thickening and/or Increase in Collagen in Basement Membranes
• This structural change in the small vessels of the kidneys can impair their ability to
filter blood properly.
2. Decreased Renal Blood Flow
Reduced blood flow to the kidneys results in a decreased glomerular filtration rate
(GFR), which is a measure of how well the kidneys are filtering blood.
3. Decreased GFR
• Indicators:
• BUN (Blood Urea Nitrogen): 11.97 millimoles per liter (mmol/L) (low levels
indicate reduced kidney function).
• Serum Creatinine: 782.43 mmol/L (high levels indicate impaired kidney
filtration).
Consequences of Decreased GFR
• Dilute Polyuria
• Excessive urination that is diluted, indicating the kidneys' inability to concentrate
urine.
• Leads to Dehydration, which can cause Difficulty in Bowel Movements due to
reduced fluid levels in the body.
• Hypertrophy of the Remaining Nephrons
• Remaining functional nephrons enlarge to compensate for the loss of function, but
this compensatory mechanism eventually leads to further damage.
• Results in an Inability to Concentrate Urine and Further Loss of Nephron Function.
Results of Nephron Function Loss
• Loss of Non-Excretory Renal Function
• Failure to Produce Erythropoietin:
• Erythropoietin is a hormone produced by the kidneys that stimulates red
blood cell production. Failure to produce it leads to:
• Ineffective Erythropoiesis: Poor production of red blood cells.
• Decreased Blood Supply in the Body: Leads to anemia and reduced
oxygen delivery to tissues.
• Immune Disturbances:
• Kidneys play a role in maintaining a healthy immune system. Disturbances
can lead to:
• Infection: Indicated by:
• Neutrophils: 0.820 (neutrophil count, indicative of immune
response).
• Lymphocytes: 0.077 (lymphocyte count, indicative of
immune health).
• Loss of Excretory Renal Function
• Low Residual Renal Function:
• Leads to Fluid Retention and Fluid Volume Overload, causing swelling and
hypertension.
• Electrolyte Imbalances:
• Sodium: 158 mg/dl (elevated sodium levels can lead to hypertension
and fluid retention).
• Potassium: 2.68 mmol/L (imbalanced potassium levels can affect
heart function and muscle control).
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Decreased blood supply in the body:
• This initial condition suggests a systemic issue, such as cardiac dysfunction, leading
to inadequate blood flow to various organs.
Hypoxemia:
Due to the decreased blood supply, there is reduced oxygen (O2) delivery to tissues
(hypoxemia). Capillary refill time of 4 seconds indicates poor peripheral perfusion,
further supporting inadequate blood flow.
Poor circulation of nutrients in the body:
• Reduced blood supply also means that nutrients are not adequately delivered to
tissues, exacerbating cellular dysfunction.
Decreased renal perfusion:
• The kidneys receive less blood flow, impairing their ability to filter blood and maintain
homeostasis. This condition is critical as the kidneys require a constant supply of
blood to function properly.
Acidosis:
• As a result of poor perfusion, metabolic waste products (such as lactic acid)
accumulate, leading to acidosis. The blood gas values (pH 7.16, pCO2 21 mmHg,
HCO3 7.0 mmol/L) indicate metabolic acidosis with partial respiratory
compensation.
Decreased blood flow to the kidneys and nephrons:
• Persistent low blood flow leads to further deterioration of kidney function, as the
nephrons (functional units of the kidney) are deprived of necessary oxygen and
nutrients.
Decreased GFR (Glomerular Filtration Rate):
• GFR is a measure of how well the kidneys are filtering blood. Decreased renal
perfusion leads to a drop in GFR, indicating reduced kidney function.
Thickening and hardening of blood vessels in Bowman’s Capsule:
• Chronic low blood flow and resultant ischemia cause structural changes in the
kidneys. The blood vessels within Bowman’s capsule thicken and harden
(glomerulosclerosis), impairing the filtration barrier.
Ischemic Injury:
• Continued insufficient blood supply leads to ischemic injury to the renal tissue,
causing damage or death of kidney cells.
Irreversible loss of nephrons:
• Nephrons do not regenerate, so ischemic injury results in the permanent loss of these
functional units. Over time, this leads to a significant decline in renal function.
Progressive loss of renal function:
• With ongoing nephron loss, the kidneys progressively lose their ability to perform
essential functions, such as filtering waste, regulating fluid and electrolyte balance,
and maintaining acid-base balance.
Hematuria (RBC: 11.5/μL):
• As kidney damage progresses, the filtration barrier is compromised, leading to the
leakage of red blood cells into the urine (hematuria). The presence of 11.5 red blood
cells per microliter of urine signifies this pathological condition.
Swollen ankles and feet (Grade 2 Edema):
• Edema in the lower extremities is indicative of fluid retention, a common
consequence of reduced renal function. The kidneys' inability to properly excrete
sodium and water leads to fluid buildup in the tissues, manifesting as swelling.
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Overall Impact
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Chronic Kidney Disease results in a progressive loss of kidney function, affecting both
excretory and non-excretory functions. The condition is exacerbated by modifiable and nonmodifiable factors, leading to various systemic complications including anemia, immune
dysfunction, fluid imbalance, and cardiovascular issues. Management focuses on
controlling risk factors, slowing progression, and addressing complications through medical
interventions and lifestyle modifications.
Nursing Care Plan (Decreased Cardiac Output)
Decreased Cardiac Output Nursing Care Plan for a Patient with CKD Stage 5
Assessment:
• Subjective Data:
• Patient reported: "Simula nung nagsimula akong magdialysis parang lagi na mataas
yung BP ko." (Since I started dialysis, my blood pressure has been consistently high.)
• Objective Data:
• Vital Signs:
• Temperature: 36.4°C
• Heart Rate: 116 bpm
• Respiratory Rate: 11 bpm
• Oxygen Saturation: 98% on room air
• Blood Pressure: 130/90 mmHg
• Physical Assessment:
• Weak and irregular pulses
• Pale, dry, and scaly skin
• Capillary refill time: 4 seconds
• Pitting edema (Grade 2) on feet and ankles
• Laboratory Results:
• Abnormal values consistent with CKD complications
Diagnosis:
• Decreased cardiac output related to fluid imbalance affecting circulating volume as
evidenced by weak and irregular pulses and slow capillary refill time.
Planning:
• Short-term Goal:
• After 24 hours of nursing intervention, the patient will demonstrate decreased fluid
overload and improved oxygenation and circulation.
Interventions:
Independent:
1. Check for peripheral pulses.
• Rationale: Weak pulses indicate reduced stroke volume and cardiac output.
2. Perform capillary refill test.
• Rationale: Slow or absent capillary refill time suggests inadequate arterial perfusion
to the extremities.
3. Note skin color, temperature, and moisture.
• Rationale: Assessing these parameters can identify acute and chronic issues with
arterial or venous circulation. Cool skin and diaphoresis can indicate low cardiac
output.
4. Inspect fluid balance and weight gain.
• Rationale: Compromised regulatory mechanisms in CKD can result in fluid and
sodium retention. Monitoring body weight is a sensitive indicator of fluid status.
5. Monitor urine output.
• Rationale: Urine output is a critical indicator of cardiac function. Reduced cardiac
output can decrease renal perfusion, leading to decreased urine output.
6. Elevate the head of the bed.
• Rationale: Elevating the head reduces preload, facilitating easier blood pumping by
the heart.
7. Closely monitor fluid status and restrict fluids as indicated.
• Rationale: Strict fluid management is necessary to prevent complications and
preserve kidney function in CKD.
8. Assist and prepare the patient for dialysis.
• Rationale: Dialysis helps reduce uremic toxins, correct electrolyte imbalances,
manage fluid status, and prevent complications like decreased cardiac output and
hypertension.
Dependent:
1. Administer medications as prescribed.
• Rationale: Medications such as digitalis, diuretics, vasodilators, antidysrhythmics,
ACE inhibitors, and inotropic agents may be necessary based on the patient's
condition to manage cardiac output.
Evaluation:
• Goal not met: The patient's condition requires ongoing monitoring and intervention to
manage fluid balance, optimize cardiac output, and address any emerging complications.
This care plan emphasizes the importance of continuous assessment, fluid management, and
appropriate medical interventions to manage decreased cardiac output in a patient with end-stage
CKD undergoing dialysis.