Renal Failure Case Study Each question is 2 part = total 5 points Correct answer
ID: 244283 • Letter: R
Question
Renal Failure Case Study
Each question is 2 part = total 5 points
Correct answer 2.5 points
Rational 2.5 points
Maria is a 47 year old female with a long history of diabetes mellitus and hypertension. She was recently diagnosed with renal insufficiency 18 months ago. Her medication regimen include a diuretic and an oral anti-diabetic agent. She c/o anorexia and overall fatigue, nocturia and short of breath sometimes. Her current weight is 60 kg. She is being scheduled for sever diagnostic studies to evaluate for the renal disease. Diabetes mellitus is a known risk factor for renal failure.
Define ESRD:
It is the last stage in the progressive clinical syndrome called chronic kidney disease.
What is the best description of chronic kidney disease?
Symptoms are reversible with life- long medication
Condition has a rapid onset with frequent remissions
It is a fatal disorder unless renal replacement therapy is received
There are frequent exacerbations since half of all nephrons are damaged
The following diagnostic tests were performed:
Hemoglobin
Serum creatinine and BUN
Serum calcium
Arterial blood gases
Serum potassium
Serum phosphorus
Urinary creatinine clearance
Which lab value is likely to be decreased in a client with chronic kidney disease?
Serum calcium
Serum creatinine and BUN
Serum potassium
Serum phosphorus
Maria’s hemoglobin level is 7.8. What is the underlying pathology causing this abnormal lab value?
Hematuria results in blood loss
Fewer red blood cells are being formed
Dehydration causes dilutional anemia
Renal waste products destroy red blood cells
Maria’s ABG results: pH 7.35, PO2 96, PCO2 30, HCO3 18. Recall her history – anorexia, weight, diabetes. What is the correct interpretation of these ABGs?
Respiratory acidosis compensated
Respiratory alkalosis compensated
Metabolic acidosis compensated
Metabolic alkalosis compensated
Maria’s findings from the diagnostic test and lab test confirm the medical diagnosis of end stage renal disease. Other assessment findings include, +1 pitted edema, bilateral crackles in the lungs, and clear pale urine. Vital signs: T - 98.8, P - 86, R - 28, and BP - 178/92. Which additional assessment finding is consistent with ESRD?
Yellow gray pallor
Clay-colored stool
Stridor
Fingernail clubbing
Maria’s vital sign was Vital signs: T - 98.8, P - 86, R - 28, and BP - 178/92. Which explanation best describes the pathology resulting in her hypertension?
Irritation of the pericardial lining of the heart due to uremic toxins increases blood pressure
An increase in the excretion of sodium and water from the kidneys causes hypertension
Activation of the renin-angiotensin cycle and excretion of aldosterone causes hypertension
The increase of uremic waste products in the blood stream increases the blood pressure.
Maria’s condition worsens: urinary output low, lab values indicating worsening kidney function. Now she will be placed on dialysis. Maria has to weigh the benefits of hemodialysis versus peritoneal dialysis. Which factor is related to the use of hemodialysis?
High risk of abdominal infection
High risk of air embolus
More easily performed at home
Treatments require more time
Maria is at high risk for the development of which problem while receiving hemodialysis?
Blood clot formation
Ascites
Hepatitis B and C
Hypertension
While assessing Maria’s AV graft site, the nurse palpates a buzzing sensation directly over the graft. Which documentation should the nurse enter into the nurse’s notes?
+4 bounding pulse palpated
Bruit intact and palpated
Thrill present and palpated
Health care provider notified of graft occlusion
Prior to using the AV graft site for hemodialysis, Maria had a tunnel catheter to the right subclavian. Which intervention should the nurse include in her plan of care?
Instruct lab personnel to obtain blood specimens from the dual lumen catheter
Perform sterile dressing changes at the dual lumen catheter site
Empty and record the drainage from the graft tubing regularly
Regularly rotate IV insertion sites above and below the graft site
Maria is scheduled for discharge. The nurse completes discharge teaching for the goal Client will manage her diet effectively while receiving hemodialysis 3 times a week (Monday, Wednesday and Friday). Which expected outcome should be included in the nurse’s teaching plan?
Client will adhere to a low protein diet
Client will select foods high in iron and calcium from a menu
Client will identify the need to avoid fresh fruits and vegetables
Client will identify the need to increase her sodium and fluid intake
What is the maximum amount of weight that Maria should gain between each dialysis treatment?
1.5 kg
2 kg
2.5 kg
3 kg
Maria was receiving dialysis for a year. She is scheduled for a right kidney transplant from her sister. Post-op, Maria is transferred to the ICU. She is drowsy but awakens easily. She is able to swallow sips of water. Her surgical incision site is clean, dry and intact. Which nursing assessment has the highest priority during the first 24 hour postoperative period?
Vital signs
Bowel sounds
Range of motion
Pedal pulses
Maria was receiving dialysis for a year. She is scheduled for a right kidney transplant from her sister. Post-op, Maria is transferred to the ICU. She is drowsy but awakens easily. She is able to swallow sips of water. Her surgical incision site is clean, dry and intact. Where would you expect to find the surgical incision?
Right upper quad
Left lower quad
Right lower quad above and slightly medial to the iliac crest
Left lower quad above and slightly medial to the iliac crest
Which intervention should be included in the plan of care during the immediate postoperative period for Maria?
Monitor her urinary output hourly using an urometer
Assess her surgical incision every shift
Monitor her nasogastric tube every 4 hours
Encourage her to use the incentive spirometer every 4 hours while awake
Which nursing diagnosis has the greatest priority when caring for a client receiving immunosuppressive agents?
Pain
Fatigue
Diarrhea
Risk of infection
Which interventions are important to include in Maria’s plan of care while she is receiving multiple immunosuppressnts?
Restrict Maria’s activity to bedrest with use of the bedside commode
Instruct visitors that fresh flowers should not be taken into the room
Change the IV site daily
Reinforce, but do not routinely change any dressings
A week after surgery, Maria is discharged home. Two days later, she calls the nurse to report that she is experiencing more pain than she thinks she should be having. What is the best initial response by the nurse?
Going home often causes anxiety, which can increase your pain
You may have developed a tolerance to your pain medication
Describe the location and type of pain you are having
The health care provider will need to call you back later if you need more pain medication
One week after surgery, Maria is discharged home. Three days later, she calls the nurse to report that she is experiencing more pain than she thinks she should be having. What is the best initial response by the nurse?
Going home often causes anxiety, which can increase your pain
You may have developed a tolerance to your pain medication
Describe the location and type of pain you are having
The health care provider will need to call you back later if you need more pain medication
Maria states she feels very sore over her kidney area and she cannot remember voiding in the last 24 hours.
Take her prescribed diuretic and analgesic and record when she voids
Increase her fluid intake and report any increase in her weight
Monitor her temperature and report over 101 F
Advise her to come to the clinic right away for further evaluation
Explanation / Answer
1) Its a fatal disorder unless renal replacement therapy is achieved.
Chronic kidney disease is a progressive gradual loss of kidney function that results in irreversible damage of nephron, causing retention of metabolic waste and acid base imbalance. Patient needs renal replacement therapy to sustain life.
2) The lab value to be decreased is serum Calcium.
In renal failure the kidneys stop activating calcitriol, a form of vitamin D and reducing the absorption of calcium. There is also increased phosphorus that leads to remove calcium stores.
3) The cause of low hemoglobin is that only fewer red blood cells are formed.
Kidneys are responsible in secretion of hormone called erythropoeitin which is responsible for formation of red blood cells from bone marrow. In chronic kidney disease due to decreased production of this hormone, there is loe hemoglobin content in blood.
4) Maria has metabolic acidosis.
In metabolic acidosis the acid in blood is increased that leads to decreased pH. Moreover kidneys are unable to produce bicarbonate ions so HCO3 is low.In order to compensate this condition their is hyperventilation leading to removal of CO2 thus decreased PCO2.
5)The additional assessment findings in ESRD is presence of stridor.
Stridor is present that results from accumulation of fluid in the lining of lungs.
6) The reason behind hypertension in CKD is activated renin angiotensin cycle and excretion of aldosterone.
The renin angiotensin aldosterone pathway is responsible for maintaing the blood pressure and fluid balance in body. Decrease in renal perfusion activates the release of renin from the kidneys. This Renin activates the release of angiotensinogen from liver. THis leads to conversion of angiotensin 1 to angiotensin 2that acts on adrenal to excrete aldosterone.
7)The major factor related to choose hemodialysis over peritoneal dialysis the risk of developing abdonminal infection.
Peritoneal dialysis although is convinent as its can be managed in home but still the chances of getting infection is high. An intraperitoneal catheter is placed and diaylasate fluid is cycled to filter out metabolic waste. If not maintained under sterile technique can result in abdominal infection.
8)The high risk during a hemodialysis is blood clot formation.
In hemodiaysis the entire blood of the body passes through the diaysis machine which needs to be correctly heparinised to prevent blood clot. Chances of air embolism is also high as a large bore needle is used and breech in the system can result air embolus.
9) The buzzing sensation over the AV graft needs to be documented as Thrill present and palpated.
Thrill is the term used to identify the buzzing sensation of Av graft and bruit is the term for buzzing sound whwn heard.
10) A sterile change of dressing at the dual lumen site is the priority nursing intervention to be included in nursing care plan. The is to prevent Blood stream infection due to present of a dual Catheter.
11) The client will adhere to low protein diet is the appropriate outcome expected. Increase intake of protein will result in increase of creatinine and urea in blood.
12) Between each dialysis session, Maria can gain a weight not more than 1.5 kg.
13)Vital signs is the priority during the first 24 hrs post transplant. Chances of graft rejection is high during this time therefore its important to check is their is any changes in the vital signs. Pedal pulses can be checked simultaneously while check pulse in vital signs.
14) The Surgical incision will be found over right quad above and slightly medial to illiac crest. This is because the anatomical position of kidneys are retroperitoneal.
15) The immediate intervention during the post operative period includes monitoring the urine output hourly using a urometer. This is done to know if the graft is functioning adequately.
16) The greatest priority intervention while caring for patient receiving immunosuppresants is Risk of infection. As they are alreadyb immunocompromised the chances of developing infection is high.
17) As Maria is receiving multiple immunosuppressants, the plan of care includes Instructing visitors that fresh flowers afre not allowed in patients room.
18) Increase in pain after reaching home can be the result of increased anxiety.
19) The increased pain after reaching home can be the result of tolerance to pain medication.
20)If Maria complaints of not voiding in last 24 hours, she should be advice to come to the clinic right away for further evaluation