NUR 133 MED SURG END STAGE RENAL DISEASE CASE STUDY

NUR 133 MED SURG END STAGE RENAL DISEASE CASE STUDY Scenario 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 2 years because of end-stage renal disease (ESRD). 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 turgor, and her mucous membranes are dry. Her vital signs 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 diarrhea. The following blood chemistry results are back. 1. What aspects of your assessment support her admitting diagnosis of dehydration? - Patient’s poor skin tugor, mucous membranes are dry. The patient’s inability to eat or drink for the past two days with severe diarrhea would conclude the patient’s output is higher than the patient’s intake. The patient also appears drowsy. 2. 2. Explain any laboratory results that might be of concern - Patient’s BUN and Creatinine are elevated. Patients Glucose level is elevated. Patient’s Potassium level is elevated. Patient’s Chloride level is low. 3. 3. Identify two possible causes for K.B.'s low-grade fever. - It could possibly be a bacterial or viral infection. - Reaction to medication - It can be the body is beginning to prepare to defense against potential threats 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 4 . What is an AV fistula? Why does K.B. have one? - It is a device that a surgeon will put in a patient who is receiving dialysis. The surgeon connects an artery to a vein. It provides the highest blood flow for dialysis patients. It will last long and the device is less likely to become infected or clotted. It makes a blood vessel wider to allow the flow of blood to circulate while on dialysis. - They use Heparin to keep it from clotting. - Check PPt lab vaules - K.B has end stage renal failure and is currently on dialysis for the past two years. 5.What steps do you take to assess K.B.'s AV fistula, and what physical findings are expected? Explain - Check for Bruit with a Stethoscope, this will determine if it’s patent in the patient's arm. - Assess if the patient has any pain in her left arm, chest or neck. Inspect the site of any redness, edema, warmth or drainage. 6. As you continue the assessment, you notice that a nursing assistive personnel (NAP) comes in to take K.B.'s blood pressure (BP). The NAP places the BP cuff on K.B.'s left arm. What, if anything, do you do? - Stop the NAP. Tell the NAP that the patient has an AV Fistula in her left arm and do not take blood pressure or draw blood from the patient’s left arm. 7. Are these values normal? If not, what are the abnormalities? - The patients RBC count is low - Hbg is low - Hct is low 8. K.B.'s physician notes that she is anemic, which most likely is the cause of her increasing fatigue. Why is K.B. anemic? - Patient RBC and Hgb and Hct are all low. Patient has not been eating and getting a source of Iron. K.B is also in end stage renal failure. Her kidneys are unable to release the hormone Erythropoitein which singles the bone marrow to make more red blood cells. The kidneys are unable to send out the hormone as much as she would need them too. Case Study Progress K.B. is sent for an 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 her 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. It's so hard!" 9. Because K.B. is on HD and has DM, what are her special nutritional needs? Name at least four specific components of the diet recommended for K.B. - Low Carbohydrates - Low Sodium - Iron - Monitor Protein Intake - Beans 10. 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. Five potential problems: - Hypertension: Ace/Arbs , diet low salt intake - Heart Failure: - Metabolic Acidosis: Give Bicarbonate, Monitor electrolyte imbalance. - Cardiac Dysrhythmias: checking vitals, checking apical pulse. - Seizures 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, with the addition of ferrous fumarate oral suspension 100 mg PO tid between meals with water, if tolerated (or with meals if GI distress occurs) and epoetin (Epogen) to be given three times a week intravenously with dialysis. She is also given a prescription for Nephrocaps vitamin supplements to be taken daily. 11. Explain the purpose of the new medications for K. B. - Epogen 12. You spend some time with K.B. to explain the new medications. Which statement by K.B. reflects a need for further teaching? a. "I won't need to take the iron supplements as long as I get the Epogen during dialysis." b. "The liquid iron will cause my bowel movements to turn black or dark green." c. "Hopefully I will feel less tired all the time when these medicines start building up my red blood cells." d. "I should dilute the liquid iron and drink it with a straw so that it won’t stain my teeth." 13. K.B. asks, "Why do I need a prescription for vitamins? I can just take something on sale at the drugstore, right?" How do you respond? - Nephrocaps vitamin supplements. To help increase her intake of Iron. When the dietary intake is not balanced and food intake is not sufficient. The over counter supplements can make them more toxic. 14. The ferrous fumarate suspension comes in a bole that is labeled 100 mg/5 mL. Indicate on the measuring cup how much medication will be used for each dose. At the 5mL margin 15. In monitoring K.B. 's response to the epoetin, what adverse effect would you expect? a. Arthralgia b. Tachycardia c. Drowsiness d. Diarrhea 16. Which vital sign will you monitor carefully while K.B. is on epoetin therapy? Explain your answer. - Blood pressure is the vital sign you would monitor. 17. During the following weeks, which laboratory result is most important to monitor while K.B. is on the epoetin? Explain. - Hbg would be the most important lab value to monitor Case Study Outcome K.B. is discharged to home and goes to the local dialysis center three times a week. She also keeps appointments with the registered dietitian and reports that she is feeling much better