Case Study: Chronic Kidney Disease NR 324: Adult Health I, Study Guides, Projects, Research of Nursing

Download Case Study: Chronic Kidney Disease NR 324: Adult Health I and more Study Guides, Projects, Research Nursing in PDF only on Docsity! 2 Case Study: Chronic Kidney Disease NR 324: Adult Health I Patient Natasha Williams is a 45-year-old African American female who came into the emergency room on Tuesday, May 28, 2019, at 1800 with a chief complaint of swelling in both feet and ankles. N.W. says that the swelling has been present for the past three days. Health History During the interview process it was discovered that Natasha Williams past medical history includes obesity, hypertension, diabetes (diagnosed five years ago), and chronic kidney disease (diagnosed within the last year). N.W.’s family health history includes her mother, who has hypertension, and her father, a non-compliant diabetic who died last year. Mrs. Williams states she has no known allergies. When asked how she felt about her overall health she stated, “I feel more tired than usual these days.” N.W. denies any history of surgery or blood transfusion. Her current home medications include Glipizide 10 mg once daily by mouth to manage diabetes, and Tylenol 650 mg by mouth every 4 hours as needed for pain. The patient states that she currently works as a marketing technologist, which requires her to spend most of her days on the computer and making phone calls. N.W. has a history of smoking a pack of cigarettes a day for the past twenty-five years, and drinks alcohol three nights out of the week to relax from work when she gets home. N.W. is married with two children, ages five and seven. She says her husband does most of the cooking at home, but with her busy schedule she normally picks up fast food. Focused assessment findings: patient is alert with some confusion. Vital signs: Temp 97.7 F, Pulse rate: 116 bpm, Respirations: 20, Blood pressure: 142/92. Lung sounds are clear in all lobes, tachycardia noted with cardiac sounds, no murmur auscultated, no JVD noted, upper extremity skin color appropriate to race, lower extremity skin color is ashen, no hair is present on 3 lower extremities (patient reports using Nair hair removal), 2+ moderate pitting edema on left and right lower extremities, grade 1+ dorsalis pedis pulse, capillary refill > 2 seconds, legs cool to touch. As per doctor orders, patient labs will be drawn, results are pending until the morning. Laboratory and Diagnostic Testing Patient Natasha Williams laboratory tests results at 0630 on Wednesday, May 29, 2019. Creatinine Clearance: 14 (Normal: 60+ mL/min) GFR: 17 (Normal: 90-120/min/1.73 m2) BUN: 30 (Normal: 7-20 mg/dL) A1C: 8.5 (Normal: <5.7%) Creatinine: 3 (Normal: 0.5-1.1 mg/dL) Hgb: 11 (Female Normal: 12-16 g/gL) Sodium: 149 (Normal: 135-145 mEq/L) Hct: 35 (Female Normal: 36-46%) Potassium: 7 (Normal: 3.5-5 mg/dL) Glucose: 136 Normal: Fasting: <100 Before meal: 70 - 130 After meal: (1-2 hrs) <180 A1c: Less than around 7.0% Laboratory tests used to diagnose and monitor chronic renal failure include blood studies, arterial blood gas analysis, urinalysis, imaging, renal biopsy, and Electroencephalogram. In order to diagnose Chronic Kidney Disease, a creatinine clearance test is performed to determine the Glomerular filtration rate (GFR). Age affects creatinine clearance value; it decreases by 10% every 10 years after age 40. In a healthy adult, a normal creatinine clearance rate ranges from 75- 125 mL/min/1.73m2. GFR less than 60 for more than 3 months is diagnostic for chronic kidney disease (Levey, Inker & Coresh, 2015). Injury or damage to kidneys with a duration of 3 months 6 according to their liking (“Stages of chronic kidney disease”, n.d.). The patient has a surgeon, who will be performing an arteriovenous fistula surgery in order to get the patient ready for hemodialysis. The transplant coordinator will work with the nephrologist to get the patient approved to be put on the kidney transplant list (“Stages of chronic kidney disease”, n.d.). The nurse will provide care for the patient based on the plan of care given by the nephrologist. The nurse is to monitor the patient’s overall status while providing care. The nurse is responsible for monitoring the patient’s vital signs throughout their shift to determine if the patient’s status is worsening. The patient’s blood sugar will have to be taken every shift to determine if the blood sugar levels are within normal limits. The nurse will notify the doctor if the blood sugar is abnormally high. The daily input and output will be taken in order to monitor kidney function and fluid retention. The patient will be weighed every day to determine how much fluid is being retained in the body. The patient will receive education about smoking and alcohol cessation, because these factors will worsen her condition very rapidly. Since the patient has Stage 4 CKD the treatment plan is to preserve any existing kidney function in order to prolong the need for renal replacement therapy. However, it has been found that the patient’s condition is deteriorating, therefore the patient is preparing for hemodialysis and a potential kidney transplant. The patient is currently taking hydrochlorothiazide 20 mg once daily, which will help remove excess fluid in the body by preventing sodium absorption and reducing the blood pressure levels (Vallerand & Sanoski, 2019). Additionally, she is taking Captopril 25 mg twice daily, which will widen the blood vessels and lower blood pressure (Vallerand & Sanoski, 2019). The patient’s third medication is Glipizide 10 mg once daily, which lowers the blood sugar level with the production of insulin by the pancreas (Vallerand & Sanoski, 2019). The 7 patient has dietary restrictions on sodium, potassium, phosphate, and fluid because the kidneys are unable to excrete excess waste (Lewis, Bucher, Dirksen, & Heitkemper, 2017). The patient should avoid canned and pickled foods, condiments, and cured meats since these items can contain high amounts of sodium (Razmaria, 2016). Foods that contain high amounts of potassium such as bananas, avocados, peanut butter, potatoes, and yogurt need to be avoided as well (Lewis, Bucher, Dirksen, & Heitkemper, 2017). With increasing function deterioration, the kidneys are unable to eliminate phosphate. Therefore, foods high in phosphate, such as meat and dairy products, need to be avoided. A fluid restriction of 1500 ml per day has been placed since the patient is experiencing fluid retention. The patient currently has a pending procedure for arteriovenous fistula, which will be surgically created. This site will be used during dialysis treatment. During dialysis, two needles will be inserted into the arteriovenous fistula. One needle will remove the blood from the body and filter it in the machine (Lewis, Bucher, Dirksen, & Heitkemper, 2017). Once the blood has been filtered, it will be returned to the body with the other needle. The patient will be scheduled for dialysis three times a week, with each visit lasting around two to three hours. Nursing Management Physiological Nursing Care Plan The patient came into the ER presenting with swelling in both feet and ankles, which have been present for 48 hours. The swelling in the patient’s extremities can be attributed to the fact that she has been living with Chronic Kidney Disease for over six months now. Given the information that we have the patient’s priority nursing diagnosis would be excess fluid volume retention, as evidenced by swelling in her feet and ankles. The short-term goal for the patient would be for her to explain how to further prevent the accumulation of excess fluid. In order to achieve this goal, the nurses will educate the patient on 8 how to modify her diet, with the help of a dietician, and stick to her medication regimen, which will help decrease fluid retention. The long-term goal for the patient will be for her to remain free of edema while in the hospital. In order to achieve this goal, the patient will be put on hydrochlorothiazide, a diuretic, to help remove excess fluid from the body. Along with medication therapy, the patient will be placed on a low sodium diet and fluid restrictions to minimize fluid retention. Nursing Intervention #1 w/ rationale Evaluative Statement #1 Teaching Consideration #1 ● Elevate the patient’s edematous ankles and feet and handle them with care. ● The rationale for elevating the edematous extremities is to help move the extra fluid back to the heart. In turn, the extra fluid will return to circulation in the body. ● After elevating the patient’s edematous extremities, the patient will notice less fluid occupying the feet and ankles, leaving them with a feeling of relief and less pressure. ● When educating the patient about edema care or prevention, make sure they are in an alert and ready state of mind. If possible, include family members in the teaching process in order to have multiple people be able to properly care for the patient. Nursing Intervention #2 w/ rationale Evaluative Statement #2 Teaching Consideration #2 ● Keep the patient on a fluid and sodium restriction until their edema has been controlled. Since water follows sodium, the patient will be placed on a low sodium diet to prevent more water from being retained. ● By having water intake restricted and being placed on a low sodium diet, the patient will report that there has not been an increase of fluid being retained in the lower extremities. ● Recommend that the patient speak and work with a dietician in order to help the patient make the necessary adjustments they need to their everyday diet and eating habits. 11 others. In the case of these out their frustrations their depression, a patients writing in a journal without having to rely on recommendation should be put may help to alleviate some of someone to listen to them. in for the patient to be seen by a the negative feelings they are The patient will come to therapist. The therapist will experiencing. Reason being, rely on the journal as a work with the patient to explain writing in a journal gives the form of therapeutic the importance of receiving care patient an opportunity to put communication with while treating the patient for down what they are feeling. It themselves. The journal can their own feeling of allows them to explore more also be used to document hopelessness. meaningful ways to deal with their progress as they go their current situation on their through treatment. own time. Conclusion Natasha Williams is an African American woman with a history of obesity, diabetes, hypertension, all of which are risk factors for CKD. The patient’s chief complaint was swelling of both feet and ankles for three days. The nurse primary goal was to decrease and prevent more swelling from occurring. The doctor ordered specific labs to be drawn to assess the patient’s overall kidney function. GFR lab value of 17/min/1.73 m2) is critical because this means that the patient is about to reach end-stage renal failure and will need to start dialysis as soon as possible. The patient will be receiving surgery for arteriovenous fistula that would be used as an access point for dialysis. The transplant coordinator is working with the patient’s nephrologist to approve the patient to be put on the transplant kidney list. The nurse will continue to reinforce education on diet and the risk for not staying compliant with medications and treatment. 12 13 Reference Levey, A., Inker, L., & Coresh, J. (2015). Chronic Kidney Disease in Older People. JAMA, 314(6), 557–558. https://doi.org/10.1001/jama.2015.6753 Lewis, S., Bucher, L., Dirksen, S., & Heitkemper, M. (2017). Medical-surgical nursing: assessment and management of clinical problems (10th ed.). St. Louis, Mo.: Elsevier, Inc. Razmaria, A. A. (2016). Chronic kidney disease. Jama Network. Retrieved June 10, 2019, from: https://jamanetwork.com/journals/jama/fullarticle/2524193. Schub, T. B., & Pilgrim, J. R. B. M. (2018). Renal failure, chronic: psychological factors. CINAHL Nursing Guide. Retrieved From: https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=nu p&AN=T703355&site=eds-live&scope=site Stages of chronic kidney disease (CKD). (n.d.). Retrieved From: www.kidneyfund.org/kidney- disease/chronic-kidney-disease-ckd/stages-of-chronic-kidney-disease/ The A1C test and patients with chronic kidney disease. (2019). Retrieved from https://www.davita.com/education/kidney-disease/risk-factors/the-a1c-test-and-patients- with-chronic-kidney-disease Understanding your lab values. (2018). Retrieved from https://www.kidney.org/atoz/content/understanding-your-lab-values Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Davis's drug guide for nurses. Philadelphia, PA: F.A. Davis Company.