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Case Study—Renal Failure

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Case Study Renal Failure 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 ... – PowerPoint PPT presentation

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Title: Case Study—Renal Failure


1
Case StudyRenal 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 (K6.2 BUN 45,
    Creatinine 3.5 Hgb 6.2 Hct 18.6).
  • States that her breathing keeps getting worse
    and worse, cant get around, bones
    breakdecreased appetite but keep gaining
    weightfunny taste in mouthblood sugar real
    highlegs 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 SS 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,
    cant get around, bones breakdecreased appetite
    but keep gaining weightblood sugar real
    highlegs jump at night. States that a doctor
    told her she had bad kidneys.
  • 1. What lab work is typically done? Chem 12 HH
    24 hr creatinine clearance most helpful
    know normals!
  • 2 If ESRD, what lab results would be
    anticipated? BUN, serum creatinine low HH
    K, metabolic acidosis from kidneys inability to
    excrete acid load (especially NH3) and from
    defective reabsorption of bicarbonate.
  • 3. What SS 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,
    etcControl 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
    drugssuch 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
    hemodialysisincluding 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
    hemodialysisincluding 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)

8
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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
_at_ 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?
10
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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 _at_
    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, dont
    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 factorsABO 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 gt 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 Compl
iance!!!
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