Case Study—Renal Failure

1. Case Study—Renal Failure

2. Case Study • Ms. Garcia, a 54 yr old Hispanic female, dx with IDDM for 10 years. Admitted to the hospital with CHF, ESRD, altered lab values (K+=6.2; BUN 45, Creatinine 3.5; Hgb 6.2; Hct 18.6). • States that her “breathing keeps getting worse and worse, …can’t get around, bones break…decreased appetite but keep gaining weight…funny taste in mouth…blood sugar real high…legs jump at night”. States that a doctor told her she had “bad kidneys”. • 1. What lab work is typically done? • 2 If ESRD, what lab results would be anticipated? • 3. What S&S of ESRD does Ms. Garcia display and WHY? • 4. What conservative measures might have delayed ESRD? Discuss dietary, fluid, medications, etc…

3. Case Study • Ms. Garcia…, a 54 yr old Hispanic female, dx with IDDM for 10 years. Admitted to the hospital with CHF, ESRD, altered lab values (K+= 6.2; BUN 45, Creatinine 3.5; Hgb 6.2; Hct 18.6). States that her “breathing keeps getting worse and worse, …can’t get around, bones break…decreased appetite but keep gaining weight…blood sugar real high…”legs jump at night”. States that a doctor told her she had “bad kidneys”. • 1. What lab work is typically done? Chem 12; H&H ; 24 hr creatinine clearance most helpful; know normals! • 2 If ESRD, what lab results would be anticipated? ^ BUN, serum creatinine; low H&H; ^ K+, metabolic acidosis from kidneys inability to excrete acid load (especially NH3) and from defective reabsorption of bicarbonate. • 3. What S&S of ESRD does Ms. Garcia display and WHY? Metabolic Acidosis due to decreased ability to excrete acid metabolites therefore Kussmauls breathing in effort to blow off excess CO2. musculoskeletal system affected with renal osteodystrophy as GFR dec., kidney cannot eliminate phosphate; high phosphate binds with Ca which is drawn from bone; in CRF, kidneys do not metabolize vitamin D to its active form which is required for reabsorption of Ca from intestinal tract; weight gain from Na and water retention; uremic damage causing peripheral neuropathy..plus other symptoms including anemia from decreased production of erythropoietin; and HTN.. • 4. What conservative measures might have delayed ESRD? Discuss dietary, fluid, medications, etc…Control HTN usually by Na and fluid restriction and antihypertensives, esp by ace inhibitors; restrict phosphate intake and use phosphate binders and give with meals; inc. Ca levels by adm. of active Vit D; monitor K levels; adm erythropoietin; avoid use of nephrotoxic drugs…such as aminoglycosides; protein restriction in diet.

4. Ms.Garcia, 54 yr old Hispanic female, dx with IDDM for 10 years, is admitted to the hospital with CHF, ESRD, altered lab values (elevated K, serum creatinine and decreased Hgb and Hct. The physician inserts a temporary catheter for immediate hemodialysis. • What is the Priority intervention for Ms. Garcia? • 2. Explain how dialysis works (principles of osmosis, filtration, etc.) • 3. What is removed during dialysis and what is not removed?

5. The physician inserts a temporary Quinton catheter for immediate hemodialysis. • What is the Priority intervention for Ms. Garcia? Lower life threatening K; correct any life threatening fluid overload • 2. Explain how dialysis works (principles of osmosis, filtration, etc.)Osmosis move fluid from area of lesser to an area of greater concentration of solutes; addition of glucose to dialysate bath creates an osmotic gradient across membrane to remove excess fluid from the blood; ultrafiltraton is water and fluid removal that results from pressure gradient across the dialyzer membrane due to increased pressure in blood compartment or a decreased pressure in dialysate compartment; diffusion is movement of solutes from an area of greater concentration to an area of lesser concentration with renal failure, urea, creatinine, uric acid and electrolytes as potassium and phosphate move from the blood to the dialysate to lower concentration in blood. • 3. What is removed during dialysis and what is not removed?Solutes as above and fluid removed; RBCs, WBCs and large plasma proteins are too large to diffuse across membrane

6. The physician has determined that Ms. Garcia has ESRD and requires hemodialysis 3 times a week . A fistula is created using synthetic grafting material and is placed in her left forearm. • 1. Describe the different types of fistulas and access devices and their related nursing implications both immediate post-op and long term • Permacath • Primary fistula • Fistula using synthetic grafting material • 2. What are the complications associated with hemodialysis…including disequilibrium syndrome, hepatitis, etc. • 3. Explain the importance of weighing before and after dialysis.

7. The physician has determined that Ms. Garcia has ESRD and requires hemodialysis 3 times a week . A fistula is created using synthetic grafting material and is placed in her left forearm. • 1. Describe the different types of fistulas and access devices and their related nursing implications both immediate post-op and long term • Permacath involves use of tunneled catheter, is cuffed to prevent infection, can be used immediately • Primary fistula; the best, creation of connection of artery and vein; requires time to mature, maybe 6-8 weeks, some never mature; least likely to clot. • Fistula using synthetic grafting material; requires healing, can be used in 1-2 weeks, easy to clot, more difficult to remove; distal ischemia (steal syndrome) • 2. What are the complications associated with hemodialysis…including disequilibrium syndrome. (hypotension, muscle cramps, blood loss, sepsis, disequilibrium syndrome) • 3. Explain the importance of weighing before and after dialysis (important in determining amount of fluid to remove, dry wt)

9. Case study continued… Ms. Garcia is receiving 70/30 Humulin 20u sq q am; Procardia XL 60 mg. po bid; Oscal 500 mg po @ 10 am and 2 pm; Niferex 1 tab po daily; Basaljel 600 mg tid 1 hr ac; Epogen 5,000u sq 3 X a week. 1. What is the primary use for each of these medications and what considerations regarding dialysis? 2. What is the purpose of each of these medications?

11. Case study continued… • Ms. Garcia is receiving 70/30 Humulin 20u sq q am; Procardia XL 60 mg. po bid; Oscal 500 mg po @ 10 am and 2 pm; Niferex 1 tab po daily; Basaljel 600 mg tid 1 hr ac; Epogen 5,000u sq 3 X a week. • What is the primary use for each of these medications and what considerations regarding dialysis? insulin to control BS ; Procardia for control of BP, hold on dialysis day; Oscal for Ca supplement, Niferex for Fe replacement, don’t give with Ca as it binds; Basaljel to bind with phosphate and given before meals, can be given on dialysis days; Epogen to increase RBCs. • 2. What is the purpose of each of these medications? (as above)

12. Ms. Garcia has been on hemodialysis for almost a year and states that she is tired of going to dialysis, hates the fluid and dietary restrictions and wants to try peritoneal dialysis. • 1. Explain how peritoneal dialysis works. • 2. What are the primary advantages and disadvantages of peritoneal dialysis? • 3. What are the complications associated with peritoneal dialysis? • 4. What actions would you take if the dialysate return looks cloudy? What action if Ms. Garcia becomes short of breath when dialysate fluid is being instilled? • 5. Explain the dietary needs for Ms. Garcia while she is on peritoneal dialysis.

13. Ms. Garcia has been on hemodialysis for almost a year and states that she is tired of going to dialysis, hates the fluid and dietary restrictions and wants to try peritoneal dialysis. • 1. Explain how peritoneal dialysis works. Involves placement of permanent catheter into peritoneal cavity; peritoneum acts as semipermeable membrane, involves process of diffusion, osmosis and ultrafiltration; amt fluid removed depends upon glucose concentration in dialysate solution; dialysate solution warmed to body temp to increase peritoneal clearance, prevent hypothermia. • 2. What are the primary advantages and disadvantages of peritoneal dialysis? Advantages: Fewer dietary and fluid restrictions; person not tied to dialysis machine for 3 days a week for 4-5 hours; better control of BP; less complicated system, less cardiovascular stress. Disadvantages: potential for peritonitis, requires special training and personal compliance, more time consuming, daily process- several cycles per day.

14. 3. What are the complications associated with peritoneal dialysis?(as above, especially peritonitis, etc) • 4. What actions would you take if the dialysate return looks cloudy? What action if Ms. Garcia becomes short of breath when dialysate fluid is being instilled? (Possible infection, report to MD; if SOB, elevate HOB and drain dialysate fluid) • 5. Explain the dietary needs for Ms. Garcia while she is on peritoneal dialysis. Fewer restrictions, increase protein intake, increase K+, increase PO4 intake

15. Ms. Garcia, 54 yr old Hispanic female,dx with IDDM for 10 years. She has tried hemodialysis and peritoneal dialysis. Now she wants a kidney transplant so that she can really feel “good” again! 1. What factors would be considered prior to a decision to transplant Ms. Garcia? 2. Assuming that Ms. Garcia receives a kidney transplant, what nursing care is most important in the immediate post-op period? 3. Differentiate among the different types of rejection. 4. Describe the “usual” anti-rejection drugs including prednisone, cyclosporin (CYA), Cellcept, Atgam, Imuran, and OKT3 and the common side effects. 5. What teaching is Priority for the person with a transplant?

16. Ms. Garcia, 54 yr old Hispanic female,dx with IDDM for 10 years. She has tried hemodialysis and peritoneal dialysis. Now she wants a kidney transplant so that she can really feel “good” again! • What factors would be considered prior to a decision to transplant Ms. Garcia? • Transplant factors:ABO compatibility; HLA (human leukocyte antigens for histocompatability (match as many as possible); no infection; good surgical candidate; medication compliance. • 2. Assuming that Ms. Garcia receives a kidney transplant, what nursing care is most important in the immediate post-op period? • Immediate post-op- period care: accurate I & 0 urine output, replace fluids cc per cc; monitor respirations; fluid and electrolyte balance, have ATN and require careful monitoring; for donor; care for nephrectomy

17. Kidney Transplant • 3. Discuss the signs and symptoms of kidney rejection. decrease urine output tenderness over kidney weight gain fever > 100 • 4. Describe the “usual” anti-rejection drugs including prednisone, cyclosporin (CYA), Cellcept, Atgam, Imuran, and OKT3 and the common side effects. CYA (cyclosporin) Cellcept, Prograf Atgam Imuran OKT3 (only acute rejection, anaphylactic reaction) • 5. What teaching is Priority for the person with a transplant? (avoid infection, take meds, monitor for rejection)

18. Keys to Renal DX ERSD Treatment Choices Medication Safety Vascular Access Bruit Thrill Steal syndrome Peritoneal dialysis Transplant Compliance!!!