Case Study—Renal Failure

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Case StudyRenal Failure
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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

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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.

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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?

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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

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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.

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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)

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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?
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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)

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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.

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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.

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• 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

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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?
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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

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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)

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Keys to Renal DX ERSD Treatment
Choices Medication Safety Vascular
Access Bruit Thrill Steal
syndrome Peritoneal dialysis Transplant Compl
iance!!!