HESI Case Study - Chronic Kidney Disease

What is the best initial response by the nurse?

"Describe the location and type of pain you are having." The nurse must always assess first as complete data is needed to determine the nature of the problem and then to intervene appropriately.

Which assessment should the nurse perform to determine if the desired outcome of the losartan has been achieved?

Blood pressure. Losartan is an angiotensin receptor blocker (ARB) used as an antihypertensive agent.

Which assessment data indicates to the nurse that the desired outcome of the epoetin alfa has been achieved?

Conjunctival sac returns to a reddish-pink color. This assessment finding reflects an improvement in the client's anemia. Epoetin stimulates the production of RBCs, resulting in an increase in hematocrit. It is used to treat the anemia common in clients with CKD.

The nurse consults with the healthcare provider (HCP), who becomes angry, and tells the nurse that HCP orders should never be questioned. The HCP instructs the nurse to give the medication as ordered. What action should the nurse take based on the response from the healthcare provider (HCP) phone call?

Document both phone calls and the HCP's prescriptions. The nurse should document the facts of the phone call, including the prescriptions. Notify the charge nurse and activate the chain of command. Unsafe orders must be escalated up the chain of command which starts with the charge nurse. Hold the potassium chloride. It is not safe to give the medication due to the elevated potassium level.

The nurse recognizes that client's family member is grieving with their expression of anger. What is the best nursing intervention for the family member's anger?

Encourage the family member to share frustration regarding the loss of the kidney Allowing the family member the opportunity to verbalize anger will help to work through the anger.

Which intervention is most important for the nurse to implement?

Hold the dose of potassium chloride and contact the HCP to report the serum potassium level. The serum potassium level is elevated, and administering additional potassium in any form is potentially dangerous to the client.

Which intervention should the nurse ensure is included in the plan of care during the immediate postoperative period?

Monitor the client's urinary output hourly using an urimeter. A kidney from a living donor related to the client usually begins to function immediately after surgery and may produce large amounts of dilute urine. Therefore, the output should be closely monitored.

Which additional symptoms should the nurse ask about?

Nausea Ammonia is a breakdown product of urea. When ammonia accumulates in the gastrointestinal tract, it causes irritation, nausea, vomiting, a metallic taste in the mouth, and bleeding. Decreased attention span. Problems ranging from lethargy to seizures or coma, which may indicate uremic encephalopathy. Itching Calcium phosphate crystals and urea accumulate in the skin, causing itching.

Based on the nurse's assessment, which assessment data supports the decision to administer pain medication as the first intervention?

Pain rating of 6/10. Pain was 2/10 prior to transport and is now 6/10. Client is experiencing an increase in intensity of the pain. Heart rate of 102 beats/minute. Heart rate may elevate when acute pain is present Blood pressure of 132/76 mmHg. Blood pressure increased from baseline prior to transfer. May be attributed to acute pain.

The client asks the nurse to clarify what palliative care involves. Which explanation provides the client the best education regarding palliative care?

Palliative care provides relief from symptoms including pain. One of the goals of palliative care is to help clients manage the symptoms of their chronic illness. Palliative care supports holistic care and improves quality of life. One of the goals of palliative care is to support holistic care and improve quality of life.

Which intervention should the nurse ensure has been include in the client's plan of care?

Perform sterile dressing changes at the dual-lumen catheter site. Central vein insertion sites are major sources of nosocomial infection, and they should be cleaned weekly using a strict aseptic technique. Assess the client's distal pulses and circulation in the arm with the access. Ischemia occurs in a few clients with vascular access when the fistula decreases arterial blood flow to areas below the fistula (steal syndrome). Manifestations vary from cold or numb fingers to gangrene. If the collateral circulation is poor, the fistula may need to be surgically tied off and a new one created in another area to preserve extremity circulation.

Nursing Diagnoses and Interventions

The client is admitted to an acute care facility for management of end-stage renal disease (ESRD). The nursing plan of care includes these nursing problems: Excess fluid volume Inpaired gas exchange Decreased cardiac output Inadequate nutrition Risk for infection Risk for injury Fatigue Anxiety Constipation Knowledge deficit

Meet the client

The client is an older adult with a long history of type 2 diabetes mellitus and hypertension. The client record notes a family history of polycystic kidney disease (PKD). The client was diagnosed with stage 4 chronic kidney disease (CKD) two years ago. The client calls the nephrology office to speak to the clinic nurse. The client reports loss of appetite, fatigue, nocturia, and occasional shortness of breath.

Therapeutic Communication: Grief Response

The client returns to the clinic. Vital signs are: temperature 100.6° F (38.1° C), heart rate 88 beats/minute, respirations 24 breaths/minute, blood pressure 178/96 mmHg. Lab work: BUN: 56 mg/dL (19.99 mmol/L) Creatinine: 1.9 mg/dL (144.88 mcmol/L) Hemoglobin 9.6 g/dL (96 g/L) Below therapeutic level of immunosuppression levels. A renal scan is performed. Acute rejection of the kidney transplant is suspected.

Etiology

The client's current medications include a angiotension receptor blocker (ARB), a diuretic, and an oral diabetic medication. The client's most recent lab work (3 months ago) includes: Hemoglobin: 10.5 g/dL (105 g/L) Hematocrit: 30.0% (0.3 proportion of 1.0) Creatinine: 2.25 mg/dL (171.56 mcmol/L) Blood Urea Nitrogen (BUN): 25 mg/dL (8.92 mmol/L) Glomerular Filtration Rate (GFR): 28 mL/min/1.73m2 Sodium: 132 mEq/L (132 mmol/L) Potassium: 3.8 mEq/L (3.8 mmol/L) Calcium: 8.9 mg/dL (2.23 mmol/L) Phosphorus: 4.0 mg/dL (1.29 mmol/L) Parathyroid Hormone (PTH): 98 pg/mL (98 ng/L)

Case Outcome

The client's family member is able to share frustration and anger with other family members. In the meantime, the medical regimen of immunosuppressants is successful in reversing the organ rejection, the client is discharged home with the support of family and the home care nursing agency. The client returns to the transplant clinic in one week for follow up. The client expresses gratitude to have a new kidney. The client plans to take good care of the kidney through careful management of the diabetes and hypertension as well as taking the immunosuppression medications every day as directed. The client verbalizes understanding of the need to continue to follow up with the transplant department and nephrologist.

Immunosuppressive Agents

The client's postoperative medications include immunosuppressive agents, which are used to reduce the risk of organ rejection. Anti-thymocyte globulin (ATG): 4.5mg/kg IV x 1 dose Methylprenisolone sodium succinate: 60 mg IV every 6 hours.

Clinical Manifestation

The client'sdiagnostic tests support the medical diagnosis of end-stage renal disease (ESRD). The client is brought into the clinic to discuss laboratory results. The nurse assesses the client on arrival to the clinic. In addition to the client's report of fatigue, anorexia, dyspnea, and nocturia, the nurse's focused assessment findings include: +3 pedal edema, basilar crackles in both lungs, and clear, pale urine. The client's vital signs: temperature 98.8° F (37.1° C), heart rate 86 beats/minute, respirations 28 breaths/minute, and blood pressure 178/92 mmHg.

Diagnostic evaluation

The nurse contacts the healthcare provider (HCP) regarding the client's symptoms. The HCP orders laboratory testing. The following diagnostic tests are performed and results are as follows: Hemoglobin: 7.8 g/dL (78 g/L) Hematocrit: 30% (0.30 proportion of 1.0) Creatinine: 4.5 mg/dL (397.80 mcmol/L) Blood urea nitrogen (BUN): 100 mg/dL (35.7 mmol/L) Glomerular filtration rate (GFR): 9 mL/min/1.73m2 Sodium: 135 mEql/L (135 mmol/L) Potassium: 5.5 mEq/L (5.5 mmol/L) Calcium: 9.2 mg/dL (2.3 mmol/L) Phosphorus: 5.5 mg/dL (1.78 mmol/L) Parathyroid hormone: 182 pg/mL (182 mg/L) Arterial blood gases: pH 7.35, PO2 96 mmHg, PCO2 30 mmHg, HCO3 18 mEq/L (18 mmol/L)

Management Issues: Priorities and Delegation

When the client is transferred from the SICU back to the Surgical Unit, the nurse receives a report on the client's condition. Report includes the following: Vital Signs: temperature 100.5° F (38.1° C), heart rate 84 beats/minute, respirations 18 breaths/minute, blood pressure 108/76 mmHg. Dressing dry and intact. Pain level 2/10 with last pain medication 4 hours ago. Most recent lab work: BUN: 28 mg/dL (10 mmol/L) Creatinine: 1.6 mg/dL (122.00 mcmol/L) GFR: > 60 mL/min/1.73m2 Hemoglobin: 8.9 g/dL (89 g/L) Potassium: 4.2 mEq/L (4.2 mmol/L) The report includes orders that the client's IV needs to be converted to a saline lock and the urinary catheter needs to be removed after transfer to the Surgical Unit. The nurse on the Surgical Unit does a focused assessment, including vital signs, when the client arrived on the unit. Vital Signs: temperature 100.5° F (38° C), heart rate 102 beats/minute, respirations 20 breaths/minute, blood pressure 132/76 mmHg. The client reports incisional pain rated at a 6/10 from all the activity, and that the tape on the surgical dressing became loose during the transfer.

In response to the nurse's questions, the client admits to pain over the kidney area and cannot remember voiding during the last 24 hours. Which instructions should the nurse give the client?

Advise the client to come to the clinic right away for further evaluation. The client is exhibiting symptoms consistent with organ rejection. The client needs immediate assessment and evaluation for this potentially fatal complication. The nurse should assess for kidney pain, oliguria or anuria, hypertension, lethargy, fever, and fluid retention, as well as increased serum BUN, creatinine, and potassium.

Kidney Transplantation

After receiving hemodialysis for about a year, the client is scheduled to receive a kidney transplant from a family member. Following surgery, the client is transferred to the Surgical Intensive Care Unit (SICU). The client is drowsy but awakens easily. The incision is clean, dry, and intact. Vital signs are as follows: temperature 97.9° F (36.6° C), heart rate 78 beats/minute, respirations 16 breaths/minute, and blood pressure: 144/78 mmHg. Urine output is 50 mL per hour. There is a urinary drainage catheter in place. Point of care glucose level is 127.

After the nurse completes the assessment, what findings are most important to report to the healthcare provider (HCP) ?

Blood pressure of 178/92 mmHg. Blood pressure is elevated. Client may require additional diuretic or antihypertensive therapy to get blood pressure to normal range. Respiratory rate of 28 breaths per minute. Normal respiratory rate is 12-20 breaths per minute. Client has tachypnea and should be reported to the healthcare provider for further evaluation. Bibasilar crackles. Client is experiencing fluid volume overload. Bibasilar crackles are a manifestation of the fluid volume overload. Edema Edema is an abnormal finding and should be reported to the physician.

Based on these problems, which nursing intervention should be included in the client's plan of care?

Encourage the client to ask questions and discuss fears about diagnosis. An open atmosphere that allows for discussion can decrease anxiety. Facilitate discussions with family members about the prognosis and the impact on lifestyle.

The nurse reviews the client's medical history. What part of the medical history should the nurse consider relevant to the client's current history?

Hypertension. Hypertension is one of the primary causes of CKD. The vast majority of clients with CKD have hypertension, which may be either the cause or the result of CKD. Polycystic kidney disease. PKD gene mutation will develop kidney cysts by age 30. Half of these people develop chronic kidney disease (CKD) by age 50 years. Diabetes Mellitus. Uncontrolled diabetes is a leading causative factor in renal disease.

Which interventions are important to include in the client's plan of care while receiving multiple immunosuppressants?

Instruct client to wear a mask when walking in the halls. Since the client is at high risk for infection, activity and mobility should be encouraged to prevent the complications of immobility, such as atelectasis and pneumonia. The client should be assisted with mobility as needed since the client is also at risk for injury. Instruct visitors that fresh flowers should not be taken into the room. Fresh flowers, plants, and fruits are a source of bacteria and should be restricted from the client's room. In addition, visitors should be restricted to healthy adults, and extra precautions should be taken to avoid sharing hospital equipment and to ensure a clean room environment. Monitor immunosuppression drug levels regularly. Too much immunosuppresive medication can result in liver or kidney insufficiency and increased risk for infection. Too little immunosuppressive medication can lead to kidney rejection

Which action can be assigned to the unlicensed assistive personnel (UAP)?

Measure the client's urinary output. This task may be assigned to the UAP.

The client's arterial blood gas (ABG) results are: pH 7.35 PO2 96.0 mmHg PCO2 30.0 mmHg HCO3 18.0 mEq/L (18 mmol/L) What is the correct interpretation of these ABGs?

Metabolic acidosis (compensated). As excessive bicarbonate is excreted, the HCO3 level decreases, causing metabolic acidosis (decreased pH). Compensation occurs when an increased rate and depth of respirations reduce the CO2 levels, returning the pH to low normal.

The nurse determines that the client is demonstrating progression of chronic kidney disease and is uremic. The nurse is teaching the client about progression of chronic kidney disease (CKD). Which evaluation statement documented by the nurse indicates the client's understanding of the disease process?

The client acknowledges that renal replacement therapy will need to be initiated immediately to rid the body of waste and maintain fluid balance. CKD is fatal unless some form of renal replacement therapy such as dialysis or organ transplantation is done.

Based on the client's symptoms, what should the nurse suspect?

The client has uremia and may need to start dialysis. Classic signs of uremia are nausea, vomiting, fatigue, weight loss, anorexia, muscle cramps, pruritis, and a change in mental status.

Client Teaching: Dietary Management

The client is tolerating dialysis and discharge is scheduled. The nurse completes discharge teaching for the goal, "Client will manage diet effectively while receiving hemodialysis three times a week."

Pharmacologic Management

The client receives prescriptions for the following medications: Calcium acetate: 2 gelcaps (667 mg each) by mouth with each meal. Ferrous sulfate: 1 tablet (65 mg) by mouth daily. Epoetin alfa: 3900 units subcutaneously 3 times per week (dosed at 75 U/kg three times a week). Glipizide: 10 mg by mouthdaily 30 minutes before breakfast. Furosemide: 40 mg by mouth twice daily. Losartan: 50 mg by mouth twice daily. Potassium chloride elixir: 40 mEq by mouth three times daily.

Hemodialysis

The healthcare provider (HCP) and nurse discuss types of renal replacement therapy with the client. The HCP discusses the risk and benefits of hemodialysis, peritoneal dialysis, kidney transplantation, palliative care, and no treatment.

Ethical/Legal Considerations: Medication Administration

The nurse notes that the ordered medications include potassium chloride elixir 40 mEq by mouth 2 times a day. Prior to administering the medication, the nurse monitors the client's serum potassium level, which is 6.5 mEq/L (6.5 mmol/L). The nurse reports the serum potassium level to the healthcare provider's (HCP's) office nurse, who calls back and tells the nurse that the HCP wants the dose of potassium chloride reduced by half and changed to an oral tablet, rather than an elixir.

The client is started on a regimen of high-dose immunosupressants. During the acute rejection period, the client's family member states to the nurse, "The client can't be having a rejection; I gave up my kidney. The doctors must have messed up something. I'll sue every one of them if this doesn't work." What is the best response by the nurse?

This is a very difficult time for you and your family." Acknowledgment of the stress being experienced will encourage the family member to continue to express their feelings.

The nurse documents the assessment of the arteriovenous (AV) graft. Which documentation best describes a properly functioning AV graft?

Thrill present and palpated. This buzzing sensation indicates that the graft is patent. In addition to palpating for a thrill, the nurse should auscultate for a bruit, the sound heard at a client's graft site, as well as for intact pulses distal to the graft site.

The nurse assesses the dialysis graft. Which assessment should be reported to the healthcare provider (HCP) immediately?

Yellow, purulent drainage from graft incision site. May indicate infection. Hemodialysis grafts are prone to infection. Absence of a thrill over the graft site. May indicate the graft is clotted. Capillary refill >10 seconds in the hand where the graft is placed. May indicate circulatory compromise or STEAL syndrome.

The nurse is preparing to give the client's medications. The anti-thymocyte globulin (ATG) comes in a vial with 25mg/10mL. the client weighs 132 lbs (60 kg). The Thymoglobulin will be infused over 6 hours. What rate should the nurse program on the infusion pump?

60kg x 4.5mg = 270mg 270mg/25mg X 10ml = 108ml 108ml /6 hours = 18 ml

What complication would the client be most concerned about if choosing peritoneal dialysis?

Abdominal infection/Peritonitis. Peritoneal dialysis places the client at high risk for peritonitis since the catheter and fluid enter the peritoneal cavity. The client must be heparinized during hemodialysis. Therefore, bleeding is a more likely potential complication than thrombosis.

Which action should the nurse implement first?

Administer an analgesic. This intervention will reduce the client's pain and anxiety. It will also reduce discomfort when other procedures such as a dressing change are performed. This is a priority using Maslow's hierarchy.

What assessment data supports the diagnosis of acute organ rejection?

Blood pressure of 178/96 mmHg. Sub therapeutic immunosuppression levels. May indicate the client has not taken the immunosuppressive medications. Acute pain rated 6/10. Correct, pain over the allograft is associated with acute rejection. BUN of 56 mg/dL (19.99 mmol/L) and creatinine of 1.9 mg/dL (167.96 mcmol/L). Correct, even slight elevations of BUN and creatinine post transplant can indicate organ failure. Temperature of 100.6° F (38.1° C). Correct, clients experiencing acu

Which intervention should the nurse implement?

Call and speak directly with the healthcare provider (HCP). The medication prescription is unsafe and requires direct communication with the prescribing healthcare provider (HCP).

Which expected outcome should be included in the nurse's teaching plan?

Client will avoid canned and processed foods. Clients on ESRD should restrict sodium to 2-4 grams per day. Canned and processed foods are high in sodium.

Which lab value would the nurse be most concerned about?

Glomerular filtration rate (GFR) of 9 mL/min/1.73m2. Estimated glomerular filtration rate (GFR) is the best test to measure level of kidney function and determine stage of kidney disease.

The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate the need for further education?

Hemodialysis will help restore kidney function back to a normal level. Hemodialysis removes waste accumulation in the blood. It replaces a function of the kidney, it does not cure the kidney. Bowel or bladder perforation may occur with hemodialysis catheter placement. This is a serious complication associated with peritoneal dialysis (PD).

The nurse is teaching the patient about fluid management between dialysis treatments. Which instruction by the nurse is the most accurate?

Limit fluids in between treatments to minimize the amount of fluid that needs to be removed during dialysis. The goal for hemodialysis clients is to keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg.

The client's hemoglobin level is 7.8 g/dL (78 g/L). What action should the nurse take?

Obtain an order to start an erythropoietin stimulating agent (ESA). Hemoglobin is decreased as the kidneys become less able to produce erythropoietin necessary for the formation of red blood cells. ESA's will replace the erythropoietin levels.

A Complication Occurs

One week after surgery, the client is discharged home. Three days later, the client calls the transplant office to speak to the nurse. The client complains of abdominal pain that has become unbearable in the last couple of hours.

Which assessment finding indicates to the nurse that the desired outcome of the calcium acetate has been achieved?

Serum phosphorous of 4.0 mg/dL (1.29 mmol/L). Calcium acetate acts as a phosphate binder, reducing the high serum phosphorous levels commonly found in the client with CKD.

Vascular Access Devices

The client decides that hemodialysis is the preferred modality of renal replacement therapy. An arteriovenous (AV) graft is surgically placed in the right forearm, and a dual-lumen hemodialysis catheter is placed for temporary use until the permanent AV graft site heals. While assessing the client's AV graft site, the nurse palpates a buzzing sensation directly over the graft.

Which is the priority nursing assessment during the first 24-hour postoperative period?

Vital signs. Vital signs should be monitored frequently to assess for postoperative bleeding, infection, or organ rejection. Assessment for hypotension is essential as it threatens allograft survival.