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Module 8 Case Study Mrs. Belinda Brown 58 years old, CEO San Diego Community Hospital Health Hx: DM2, CAD, CKD, Social Hx: Prior Smoker for 20 years Pt. Report: Came into the ER with C/O Lethargy  N/V  Shortness of breath  Decreased urination  Swelling to BLE

Admitting diagnosis: End-stage kidney disease (ESKD) Objective data:  

VS: BP=150/100, HR=120, RR= 24, T= 99.8F, Spo2= 92% RA

Lab work:      

GFR 10 Cr 3.0, BUN 60 K+ 5.2, Na+ 135 Mg+ 2.1 CXR:Confirmed pulmonary edema Renal US:decreased in size

What risk factors contributed to Mrs. Brown’s development of ESKD? DM Type 2 CAD Prior Smoking Chronic Kidney Disease

Why? DM 2 = ↑ blood sugar accumulates in the vessels, sticks to the vessel walls causing inflammation = damage to the vessels CAD = ↑ lipid levels accumulate in the vessels creating plaques that occlude blood flow Prior smoking = causes vasoconstriction of vessels and decreases blood flow; damage to lung tissue and impaired gas exchange Chronic Kidney Disease= progressive, loss of kidney function

What will be your nursing priorities for Mrs. Brown?(pt. with ESKD)  Fluid Status  Electrolytes  Nutrition

Why?  Fluid Status •

r/t: kidneys ↓ability to

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properly rid body of fluids •

Monitor: I&O, BP, HR closely

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Obtain Daily weight

 Electrolytes  r/t: impaired glomerular function  and retaining electrolytes  Monitor lab work  Monitor for Cardiac dysrhythmias

 Nutrition r/t: need for dietary restrictions

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Protein, Water

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Sodium, Potassium,

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Phosphrous

After another lab draw, Mrs. Brown has the following lab work values.         

BUN 60 Creatinine 3.0 GFR 10 K+ 5.5 Na+ 136 Mg+ 2.3 RBC 3.8 Hgb 10 Hct 37

(7-20) (0.5-1.0) (>90) (3.5-5.0) (136-145) (1.7-2.2) (4.2- 5.4) (12-16) (37-47)

What medical intervention do you anticipate for her and why? Kidney unable to filter electrolytes = ↑ K+, ↑ Mg+, ↓ Na+ Kidney not producing erythropoietin = ↓ RBC, ↓Hgb, ↓Hct Glomerulus is damaged = ↓ GFR, ↑ BUN, ↑ Creatinine All of this = •

Changes in mentation

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Potential for cardiac dysthymias

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Risk for fluid overload

Anemia and ↓ oxygen to tissues

Complications? Infection Dysrhytmias Bleeding Hypotension Disequilibrium Syndrome

List the nursing responsibilities: Mrs. Brown is 4 hours post her 1st HD session and is back on your floor. She c/o: N/V, headache, blurred vision, and is unable to recall where she is. What do you think is happening?  Disequilibrium Syndrome Intradialytic or up 24 hours post-dialysis d/t: brain edema.Can progress to coma and cardiac arrest

What are common medications that may be prescribed for Mrs. Brown’s ESKD?  Erythropoietin  Iron  Vit D  Phosphate binders

Rationales: Erythropoietin- ↓ production of hormone in ESRD = ↓RBC •

want to stimulate production of RBC

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Loss of RBCs during dialysis

Iron- needed to ↑RBC production and ↑ erythropoietin effect Vit D- combat ↓Ca+ and ↑Phosphate •

creates a balancing effect so Ca+ can be reabsorbed into the bone

Phosphate Binders- kidneys unable to get rid of phosphate so it builds up sevelamer, PhosLo (calcium acetate),

Mrs. Brown has been on dialysis for four months and is now being admitted for a kidney transplant.  What is the purpose? Purpose of kidney transplant:

 When kidney function severely impaired and unable to function properly  Quality of life is severely affected  GFR...