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Care of CKD and HD

Gg is a 42 y/o woman being admitted to the medical floor for complaints of fatigue and dehydration.
While taking her history, you discover that she has diabetes mellitus and has been insulin dependent since
the age of 10. She has undergone hemodialysis for the past 3 years. Your initial assessment of Gg reveals
pale, thin slightly drowsy woman. Her skin is warm and dry to touch with poor skin turgor and her
mucous membranes are dry. Her vital signs are 140 / 88, PR – 116, RR – 18 and temp 37.7*C. She tells
you she has been nauseated for 2 days so she has not been eating and drinking. She reports severe
diarrhea. Serum calcium, phosphate, magnesium and complete blood count have been drawn but the
results are not yet available.

Specification Normal Value Result


Sodium 135 – 145 mEq/L 145 mEq/L
Potassium 3.5 – 5.0 mEq/L 6.0 mEq/L
Chloride 98 – 106 mEq/L 93 mEq/L
Bicarbonate 24 – 30 mEq/L 27 mEq/L
BUN 8-21 mg/dL 48 mg/dL
Creatinine 0.8 – 1.4 mg/dL (male) 5.0 mg/dL
0.56 – 1.0 (female)
Glucose 59 – 105 mg/dL 238 mg/dL

1. What aspects of your assessment support her admitting diagnosis of dehydration?


• The patient's history supports an admitting diagnosis of dehydration because she told you she has not
been drinking for 2 days and reports severe diarrhea. Her skin is warm and dry with poor skin turgor and
dry mucous membranes, all of which can be physical assessment findings of a patient with dehydration.
• Fluid is restricted when the person is on dialysis.
• Although most of her laboratory findings are elevated, laboratory values are not a good indicator of
dehydration in patients on HD.
Explain ay laboratory results that might be of concern. Identify (2) possible causes of Gg’s low
grade fever?
 Her lab reports states that the sodium and bicarbonate levels are normal and need no treatment.
While potassium was found to be slightly higher and chloride level was low. However, the levels
of blood urea nitrogen (BUN) and creatinine were very elevated with increased glucose in her
blood. All these results state clearly that the patient is suffering from dehydration, which has
occurred due to the problems of diarrhea, diabetes and nausea.
The rest of physical assessment is within normal limits. You note that she has an arteriovenous fistula in
her left arm.
2. What is AV fistula? Why does Gg have one?
 An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein.
It is surgically created for hemodialysis.
 A vascular access is a surgically created vein used to remove and return blood during
hemodialysis. Gg has one because she is undergoing hemodialysis for the last 3 years.
3. What steps do you take to assess Gg’s AV fistula and what physical findings are expected?
Explain.
 LISTEN to the bruit using a stethoscope at each hemodialysis treatment to assure that the AV
fistula has blood flow. A continuous low-pitched bruit should be present. If it has disappeared or
changed in tone, the attending physician should be notified immediately. The bruit has the same
significance as the thrill and should be continuous and low pitched. A definite diastolic
component should be present.
 FEEL for the thrill. A thrill (purring or vibration) indicates blood flow through the AV fistula. A
continuous thrill should be present, extending through both systole and diastole. It will diminish
in strength as you move farther away from the anastomosis.
 FEEL for a pulse. The anastomosis should be easily compressible. Avoid forceful compression of
the AV fistula with the examining finger. Remember that a strong pulse is not good and suggests
a downstream obstruction.
As you continue the assessment, you noticed that another nurse comes to take Gg’s blood pressure. The
nurse places the bp cuff on Gg’s left arm.
4. What do you think will happen?
 The fistula could be damaged. Fistulas are created surgically. If it is damaged, the patient would
need to have a permacath placed (which may be difficult due to the likelyhood of scarring from
prior permcaths).
 In this case, a new fistula site may need to be selected and the surgery done again. All this time,
the patient still needs to have dialysis. Catheters can last a long time but are also a big risk for
infection.

Specification Normal Value Result


WBC 4.0 – 10.0 X 103/mm3 7600/mm3
RBC 4.0 – 5.2 X 10 6 /mm3 3.2 million/mm3
4.4 – 5.7 X 10 6 /mm
Platelet 130 – 400 X 10 3/mm 3 333,000/mm3
Hemoglobin 8.1 g/dL
Hematocrit 24.3%

5. Are these values normal? If not, what are the abnormalities? Answer utilizing the table.
 RBC value is below normal.
6. Gg’s physician notes that she is anemic, which is most likely the cause of her increasing fatigue.
Why is Gg anemic?
 When kidneys are diseased or damaged, they do not make enough EPO. As a result, the bone
marrow makes fewer red blood cells, causing anemia. When blood has fewer red blood cells, it
deprives the body of the oxygen it needs.
Gg is sent for a hemodialysis treatment. Over the next 24 hours, Gg’s nausea subsides and she is able to
eat normally. While you are helping with her morning care, she confides in you that she doesn’t
understand the renal diet. “ I just get blood drawn every week and meet with the dialysis dietitian every
month – I just eat what she tells me to eat.”
7. What information would you give to Gg about her new medications? Gg asks, “Why do I need a
prescription for vitamins/ I can just take something on sale at the drug store right?” How do you
respond?
 Vitamins are the important micronutrients, which is used by the body for carrying out several
metabolic processes and also in the development of the body. It aids in improving vision and also
strengthens the bone.
 They are also used by certain enzymes as a co-factor to carry out vital reactions of our body. It’s
deficiency can lead to stress, anxiety, trauma and other serious problems. During kidney failure,
the vital balance of nutrients gets affected, which in turn disrupts the vitamin store in the body.
8. Identify (8) potential problems, determine how you would assess the problem and then delineate
nursing intervention and patient education strategies for each.

9. When monitoring Gg’s response to the epoetin, what adverse effect would you expect?
 Headache, body aches, cough, or injection site irritation/pain may occur. If any of these effects
last or get worse, tell your doctor or pharmacist promptly. Epoetin alfa may sometimes cause or
worsen high blood pressure, especially in patients with long-term kidney failure.
10. During the following week, which laboratory result is most important to monitor while Gg is on
epoetin, explain.
 Epoetin is a medication, which is prescribed for the treatment of anemia due to which the red
blood cells decrease abnormally. It is used for the patients who take dialysis treatment to reduce
the need for blood transfusion.
 RBC, Hemoglobin and Hematocrit values are the important laboratory results that should be
monitored while taking Epoetin.
Gg is discharged to home and goes to the local dialysis center 3x a week, she also keeps appointment to
check her laboratory and diet changes.
11. When Gg visits the dialysis center, what is the most accurate indicator of fluid loos or gain?
 Weight is a significant factor that indicates if the patient has loss or gained some weight before
and after dialysis.
Upon Gg’s visit you nursing diagnosis is excess fluid volume RT decreased urine output, dietary excess
and retention of sodium and water. Create your plan of care for Gg. Give at least (5) nursing intervention
and its rationale. What are the expected outcomes?

 Monitor weight regularly using the same scale and preferably at the same time of day wearing the
same amount of clothing. Sudden weight gain may mean fluid retention. Different scales and
clothing may show false weight inconsistencies.
 Monitor input and output closely. Dehydration may be the result of fluid shifting even if overall
fluid intake is adequate.
 Monitor and note BP and HR. Sinus tachycardia and increased BP are evident in early stages.
 Note for presence of edema by palpating over the tibia, ankles, feet, and sacrum. Dependent areas
more readily exhibit signs of edema formation.
 Review serum electrolytes, urine osmolality, and urine specific gravity. All are indicators of fluid
status and guide therapy.
Outcomes

 Patient is normovolemic as evidenced by urine output greater than or equal to 30 mL/hr.


 Patient has balanced intake and output and stable weight.
 Patient maintains HR 60 to 100 beats/min.
 Patient has clear lung sounds as manifested by absence of pulmonary crackles.
 Patient verbalizes awareness of causative factors and behaviors essential to correct fluid excess.
 Patient explains measures that can be taken to treat or prevent fluid volume excess.
 Patient describes symptoms that indicate the need to consult with health care provider.

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