K.B. 32-Year-Old End-Stage Renal Disease
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages
K.B. is a 32-year-old woman being admitted to the medical floor for complaints of fatigue and dehydration. While taking her history, you discover that she has diabetes mellitus (DM) and has been insulin-dependent since the age of 8. She has undergone hemodialysis (HD) for the past 3 years. Your initial assessment of K.B. reveals a pale, thin, slightly drowsy woman. Her skin is warm and dry to the touch with poor skin tur-gor, and her mucous membranes are dry. Her vital signs (VS) are 140/88, 116, 18, 99.9° F (37.7° C). She tells you she has been nauseated for 2 days so she has not been eating or drinking. She reports severe diar-rhea. Serum calcium, phosphate, magnesium, and a complete blood count (CBC) have been drawn but the results are not yet available. The following blood chemistry results are back:
- Chart View
Laboratory Test Results
Sodium 145mEq/L Potassium 6.0mEq/L Chloride 93mEq/L Bicarbonate 27mEq/L BUN 48 mg/dL Creatinine 5.0 mg/dL Glucose 238 mg/dL
- What aspects of your assessment support her admitting diagnosis of dehydration?
- The patient’s history supports an admitting diagnosis of dehydration because she told you she has not been drinking for 2 days and reports severe diarrhea. Her skin is warm and dry with poor skin turgor and dry mucous membranes, all of which can be physical assessment findings of a patient with dehydration.
- Fluid is restricted when the person is on dialysis.
- Although most of her laboratory findings are elevated, labs are not a good indicator of dehydration in patients on HD.
- Explain any lab results that might be of concern.
HD patients routinely have an elevated BUN and creatinine level. The elevated potassium reflects K.B.’s renal failure. The elevated glucose reflects her history of diabetes mellitus, but keep in mind that these results might not be fasting. Patients with end-stage renal disease might have elevated BUN and creatinine levels, which are caused by the renal failure and not the dialysis.
- Identify two possible causes for K.B.’s low-grade fever.
- Viral illness, which could also explain her complaint of nausea
CASE STUDY PROGRESS
The rest of K.B.’s physical assessment is within normal limits. You note that she has an arteriovenous (AV) fistula in her left arm.
- What is an AV fistula? Why does K.B. have one?
Fistula is a term used to describe the connection of two separate body parts. K.B. has an AV fistula.
This fistula is surgically created by connecting an artery with a vein and allows access for her HD.
- What steps do you take to assess K.B.’s AV fistula, and what physical findings are expected?
You would use observation, palpation, and auscultation. Observe for any signs of bleeding or infec-tion. A functioning AV fistula has a “thrill” evident with palpation and a bruit present with auscul-tation. The thrill and bruit are present because of the turbulence caused by the mixing of blood between the artery and vein and are considered WNL for an AV fistula.
- As you continue the assessment, you notice that a nursing assistive personnel (NAP) comes in to take K.B.’s blood pressure. The NAP places the blood pressure cuff on K.B.’s left arm. What, if anything, do you do?
Discretely stop the NAP from taking the blood pressure on the left arm. Doing so could cause damage to the AV fistula and alter the circulation of that arm. Point out that the BP can be taken in K.B.’s right arm. Ensure that a sign specifying, “NO BP/VENIPUNCTURE IN LEFT ARM” is placed over K.B.’s bed; some facilities place a special armband over the restricted extremity. Outside of the patient’s room, in private, review the reason you asked the NAP to change arms for the BP.
CASE STUDY PROGRESS
K.B.’s admission CBC yields the following results:
- Chart View
Laboratory Test Results
WBC 7600/mm3 RBC 3.2 million/mm 3 Hgb 8.1 g/dL Hct 24.3% Platelets 333,000/mm3
- Are these values normal? If not, what are the abnormalities?
K.B.’s WBC and platelets are normal. Her RBC, Hgb, and Hct are all low. The low RBC, Hgb, and Hct are indicative of anemia, which is a common condition in patients with renal failure because the kidney does not make sufficient levels of erythropoietin. Erythropoietin stimulates the production of red blood cells.
252 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
CHAPTER 5 GENITOURINARY DISORDERS CASE STUDY 56
- K.B.’s physician notes that she is anemic, which most likely is the cause of her increasing fatigue. Why is K.B. anemic?
- Anemia is common in ESRD and occurs because the diseased kidney is unable to synthesize an adequate amount of erythropoietin. Erythropoietin stimulates the bone marrow to produce RBCs.
- HD can result in hemolysis of RBCs during the dialysis process, further decreasing Hgb and Hct values.
CASE STUDY PROGRESS
K.B. is sent for a hemodialysis (HD) treatment. Over the next 24 hours, K.B.’s nausea subsides, and she is able to eat normally. While you are helping her with her morning care, she confides in you that she doesn’t understand the renal diet. “I just get blood drawn every week and meet with the dialysis dietitian every month—I just eat what she tells me to eat.”
- Because K.B. is on HD, what are her special nutritional needs?
- The renal diet is adjusted based on the lab data obtained on a weekly or monthly basis. The RN needs to refer any medical nutrition teaching to a renal dietitian. Because of the complexity of renal diets and nutritional needs, make certain K.B. receives a renal RD consultation.
- Common adjustments in the diet for a renal patient include restriction of protein intake, limiting fluid intake, restricting phosphorus, sodium, magnesium and potassium intake, and ensuring adequate calorie and vitamin and mineral intake.
- Protein is restricted, based on the degree of renal function impairment (i.e., reduced glomerular filtration rate). It is a delicate balance between restricting protein intake so that the kidneys are not overwhelmed and yet preventing protein-calorie malnutrition. The patient receiving HD requires more protein because dialysis causes some protein loss. Regular BUN and albumin levels are drawn to monitor whether protein intake is adequate. Poor protein intake is indicated by decreased albumin levels and might lead to muscle wasting and negative nitrogen balance.
- Fluids are restricted to 500 to 1000 mL plus the amount equal to the previous day’s urine output. Excess fluid leads to HTN, cardiac enlargement, tachycardia, shortness of breath, and fluid collection in the lung bases. If large amounts of fluid are gained between dialysis treatments, hypertension might occur. A fluid is anything liquid at room temperature such as ice, gelatin, milk, juice, coffee, tea, soup, popsicles, or ice cream.
- Phosphorus intake is limited to 800 to 1000 mg/day to maintain serum phosphorus between 3.5 and 5.5 mg/dL and to prevent osteodystrophy. Increased phosphorus levels affect bone health. Dialysis removes limited amounts of phosphorus; drugs that assist with removing phosphorus might be given. Phosphorus is found in most foods, especially milk, meat, cheese, chocolate, whole-wheat products, peanut butter, and colas.
- A high Na intake increases thirst and leads to edema. Therefore, Na intake is usually limited to 1 to 3 g/day. It is important to teach your patients not to use salt substitutes because they usually contain potassium chloride instead of sodium chloride.
- Mg is excreted by the kidney and also accumulates in persons with ESRD. K.B. should be cautioned about taking additional Mg. Mg is most commonly found in vitamins, some antacids, and cathartics.
- Potassium intake is usually restricted to 60 to 70 mEq/day. High blood potassium levels can cause dangerous cardiac dysrhythmias. High-potassium foods include citrus fruits, prunes, dried fruit, potatoes, nuts, chocolate, milk, legumes, beans, meat, and vegetables. Not all fruits and vegetables have K. In addition, seasoning products might contain high levels of potassium and sodium.
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 253 Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
PART 1 MEDICAL SURGICAL CASES
- Caloric intake should be between 30 and 35 kcal/kg body weight/day to avoid endogenous protein catabolism. If the patient has DM, the renal RD will make renal and CHO modifications to provide for adequate blood glucose control. To obtain enough calories, the patient might need to eat sugar-type foods as CHO servings such as jelly beans, hard candies, or gum drops. These provide calories but no phosphorus, K, or fluid.
- Vitamin and mineral supplementation is needed on a daily basis. Diets that are low in protein are also low in vitamins and iron; in addition, HD removes water-soluble vitamins from the blood. Calcium and vitamin D supplements might be needed if the patient’s serum calcium levels are low.
- Patients in renal failure have the potential to develop comorbid conditions. Identify five potential problems, determine how you would assess the problem, then delineate nursing interventions and patient education strategies for each.
- Problem: Cardiac dysrhythmias as a result of electrolyte disturbance
Assessment: Monitor serum K levels for hyperkalemia. Assess for subjective weakness in legs, obtain a recent dietary history, and determine whether K.B. is adhering to the dialysis regimen.
Intervention(s): Refer to a renal RD for medical nutrition therapy regarding potassium content of foods. Notify physician of any abnormal findings (abnormal labs, leg weakness); get ECG if K.B. reports any palpitations or you detect irregular heart rate; initiate emergency measures as needed. Monitor weight over time—this is done at the dialysis center with every visit to the dialysis treatment center, both before and after the treatment.
Patient education: Review potassium intake, high-potassium foods, and S/S and consequences of hyperkalemia. Again, refer to renal RD.
- Problem: Hypertension
Assessment: Monitor BP over time, review antihypertensive medications, and ask K.B. whether she is taking the medications. Monitor weight over time.
Intervention(s): Document target BP. Encourage K.B. to adhere to fluid restrictions and take medications as prescribed. Consult physician if BP is above stated goals.
Patient education: Teach and reinforce daily BP monitoring, S/S of fluid overload, and consequences of uncontrolled HTN. Review medication (indications for, use, side effects). Review the importance of following fluid restrictions as part of managing hypertension.
- Problem: Anemia
Assessment: Monitor Hct and Hgb levels; low Hgb might cause shortness of breath and fatigue. Assess effectiveness of erythropoietin-stimulating medications by monitoring Hgb levels over time. Assess for bleeding. Monitor vitamin B12 and folic acid levels; both B vitamins are necessary for the synthesis of DNA. Monitor ferritin, transferrin saturation, iron, and TIBC levels. Iron is an important component of the RBC and needed for the erythropoietin to work.
Intervention(s): Check dialysis record to see that erythropoietin-stimulating medications were ordered and administered as ordered. Administer vitamin B12, folic acid, and iron as prescribed. If albumin is low, refer to renal RD for MNT. If dietary protein is increased, PO4 binders might need to be increased or the dialysis prescription changed. Albumin can be low because of anemia or overhydration. The renal RD will know how to interpret the lab data and make appropriate dietary interventions.
Patient education: Discuss special instructions, purpose, dose, schedule, and side effects of folic acid, vitamin B12, and oral or parenteral iron preparations.
- Problem: Inadequate iron level
Assessment: Monitor iron, TIBC, and ferritin and transferrin saturation levels. Iron is absorbed from the diet and is bound to transferrin in the blood; normal transferrin saturation is 20% to 50%. Adequate ferritin, the iron storage protein in the body, is necessary for the erythropoietin stimulating proteins, such as epoeitin alfa, to work. Iron deficiency anemia is characterized by a decreased serum iron level, elevated TIBC, and decreased transferrin saturation.
Intervention(s): Report low iron, elevated TIBC, serum ferritin less than 100 ng/mL, and transferrin saturation less than 20%. Administer iron preparations as ordered.
254 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
CHAPTER 5 GENITOURINARY DISORDERS CASE STUDY 56
Patient education: Teach side effects of iron preparations.
- Problem: Ca–phosphorus–vitamin D–PTH imbalance
Phosphorus, Ca, vitamin D, and PTH all play a part in controlling serum phosphorus levels and bone health. The kidney synthesizes vitamin D into calcitriol, which helps increase Ca absorption from the GI tract. When serum Ca is low, serum phosphorus is elevated, thereby causing the PTH to increase and Ca to be pulled from the bone into the blood. Too much PTH causes bones to become weak and fracture more easily (renal osteodystrophy).
- Monitor serum Ca levels; observe for S/S of elevated Ca (joint pain) or decreased serum Ca (muscle twitching, muscle cramps, bone fractures, joint pain).
- Monitor serum phosphorus levels; observe for S/S of elevated serum PO4 (itching and elevated PTH). High phosphorus levels pull Ca out of the bones. Elevated PTH level causes bone disease.
- Report abnormal Ca and phosphorus levels. Take PO4 binders with meals and snacks to minimize phosphorus absorption. PO4 binders must be taken with food to be effective; they will not be as effective if taken 30 minutes after meals. Calcium carbonate can be used as a PO4 binder; do not give with iron supplements.
- If vitamin D is required, give the analog form—calcitriol (Rocaltrol). Get a nutrition consult.
- Patient education: Stress the importance of taking PO 4 binders as ordered and complying with dietary restrictions. Teach patients that Ca can be taken with calcium channel blockers calcium channel blockers do not block the absorption or uptake of Ca.
- Problem: Seizures
Assessment: Document any history of seizures or seizure-like activity. Record current and past anticonvulsant therapies. Monitor BP over time, as well as Hgb levels and rate of Hgb change.
Intervention(s): Notify physician of history of seizures, current uncontrolled HTN, and any precipitous increase or decrease in Hgb levels.
Patient education: Teach the patient about importance of controlling BP and complying with antihypertensive and anticonvulsant meds. Consult physician about ESP dose when there is a sudden change in Hgb level.
- Problem: Fluid volume deficit or overload
Assessment: Monitor for S/S of inadequate dialysis: weakness, insomnia, impaired sense of taste (dysgeusia), and anorexia. Monitor actual home dialysis records if applicable.
- Fluid volume deficit: Has the patient lost weight? Does the dry weight need to be adjusted? This would cause too much weight to be removed during dialysis, leading to volume deficit.
- Fluid volume overload: Is the patient drinking too much between treatments, missing
treatments, or shortening time on the dialysis machine?
Intervention(s): Dialysis nurses oversee or administer dialysis as prescribed. Consult about changes in dialysis prescription. Monitor weight and labs over time.
Patient education: Teach the patient about the importance of performing or attending dialysis as prescribed.
CASE STUDY PROGRESS
The following day, K.B. is discharged feeling much better and with a good understanding of her dietary restrictions. Her iron stores have been evaluated and found to be low. Her physician has instructed her to resume her preadmission medications, except for the addition of ferrous sulfate elixir 5 mL PO tid with meals and epoetin (Epogen) to be given three times a week IV with dialysis. She is also given a prescrip-tion for Nephrocaps vitamin supplements to be taken daily.
Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 255
PART 1 MEDICAL SURGICAL CASES
- What information would you give K.B. about her new medications?
- Ferrous sulfate elixir is being prescribed for her iron deficiency anemia. The liquid form of iron is better absorbed through the GI tract and will be used by the epoetin to make new RBCs.
- Epoetin is being prescribed for her anemia. She will receive the medication after her dialysis, and over time it should help increase her blood levels and lessen her fatigue. Other symptoms that respond to erythropoietin therapy include poor appetite, coldness, disordered sleep patterns, depression, and sexual disinterest. Patients usually require chronic therapy.
- The Nephrocaps contain a vitamin formulation that is made specifically for patients with renal impairment.
- K.B. asks, “Why do I need a prescription for vitamins? I can just take something on sale at the drug store, right?” How do you respond?
It might be tempting to take an over-the-counter vitamin preparation, but the Nephrocaps and other similar preparations are made specifically for patients who have impaired renal function. The OTC vitamin preparations might contain items that are dangerous for a patient in renal failure.
- When monitoring K.B.’s response to the epoetin, what adverse effect would you expect?
- Drowsiness d. Diarrhea
Adverse effects include hypertension, possible seizures, pruritus, and bone pain. Keep in mind that K.B. already has hypertension as an effect of her renal disease, so her blood pressure must be monitored carefully while she is on epoetin therapy.
- During the following weeks, which laboratory result is most important to monitor while K.B.
is on the epoetin? Explain.
K.B.’s hemoglobin level must be monitored carefully. Epoetin is given to maintain the Hgb to a range of 10 to 12 g/dL. When the Hgb approaches 12 g/dL, the dose of epoetin will be reduced; if the Hgb continues to increase, the epoetin will be temporarily discontinued. If the Hgb level increases greater than four points in 2 weeks, the epoetin should be reduced. Deaths have been reported if the Hgb levels go above 12 g/dL while on epoetin.
CASE STUDY OUTCOME
K.B. is discharged to home and goes to the local dialysis center three times a week. She also keeps appoint-ments with the registered dietitian and reports that she is feeling much better.