NRS 455 Benchmark – Case Study Mr. D

Sample Answer

Case Study Mr. D.

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span. Evaluate the Health History and Medical Information for Mr. D., presented below.

Health History and Medical Information

Mr. D. is a 65-year-old male nonadherence diabetic with end-stage renal disease receiving dialysis. He is a retired certified public accountant in the last 5years and practices the Muslim faith. He reports that he avoids all pork products.

His complaints included decreased balance, loss of sensation, fear of falling, and decreased endurance during activities of daily living due to the effects of dialysis treatment. Patient’s previous medical evaluation includes end stage renal disease (ESRD) on dialysis and referral for recommendations for initiating exercise program.

Patient comorbidities include obesity with a body mass index (BMI) of 45, type II diabetes mellitus with long-term insulin use, hypertension, sleep apnea, depression with lack of family support and understanding, and diabetic neuropathy. Patient denies suicidal ideation but does report feelings of loneliness and helplessness. Mr. D. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months.

Objective Data

• Height 68 inches; weight 134.5 kg
  
• BP 140/94, HR 84, RR 22
  
• 2+ pitting edema bilateral feet and ankles
  
• Fasting blood glucose 146 mg/dL
  
• Total cholesterol 250 mg/dL
  
• Triglycerides 312 mg/dL
  
• HDL 30 mg/dL
  
• Serum creatinine 1.8 mg/dL
  
• BUN 32 mg/dl
  
• GRF (glomerular filtration rate)-13mL/min

Clinical Manifestations

Describe the clinical manifestations present in Mr. D., focusing on the normal and abnormal findings and how this relates to his current condition.
Subjective Mr. D has the following subjective findings

• Decreased balance
  
• Loss of sensation
  
• Decreased activity endurance
  
• Feelings of loneliness and helplessness
  
• Exertional dyspnea
  
• Sleep apnea
  
• Ankle edema
  
• Pruritus

Objective Mr. D has the following objective findings

• Risk of fall
  
• Morbid Obesity BMI-46.4
  
• Tachypnea
  
• High blood pressure-140/94
  
• Bilateral 2+ pitting ankle and feet edema
  
• Hyperlipidemia
  
• Hyperglycemia
  

Elevated creatinine and BUN levels

Decreased glomerular filtration rate (GFR)
Potential Health Risks for Diabetes WithEnd-Stage Renal Disease
Identify the potential health risks for a diabetic with ESRD and the impacts of nonadherence.

Identify the potential health risks for a diabetic with end-stage renal disease (ESRD) that are of concern for Mr. D. Mr. D has a medical history of Type II Diabetes and ESRD, which puts him at risk of various health risks.
Coronary heart disease This is a significant health risk of ESRD and diabetes. Mr. D has obesity, hyperlipidemia, and HTN, which further increases the risk for Coronary heart disease.

Metabolic Acidosis Mr. D is at risk of developing Metabolic Acidosis caused by the accumulation of phosphates, sulfates, and other organic anions that cause an increase in the anion gap (Zheng et al., 2020).

Hyperkalemia Mr. D is at risk of hyperkalemia, which develops when GFR falls below 20-25 mL/min, as the kidneys’ ability to excrete potassium decreases (Zheng et al., 2020).

How does Mr. D.’s nonadherence to his diabetes self-management plan for DM Type II contribute to ESRD? Non-adherence to diabetic medication contributes to impaired blood glucose control, which leads to long-term hyperglycemia.

Mr. D’s failure to adhere to his medications led to impaired glucose metabolism with constant hyperglycemia, resulting in insulin resistance (Zheng et al., 2020). Insulin resistance is linked with abnormal insulin sensitivity, which contributes to kidney failure.

Describe the common considerations with insulin use for practicing Muslims. The primary care provider (PCP) of a practicing Muslim patient should consider the ritual fasting that Muslims observe during Ramadan. The PCPC should plan for the patient’s care to establish if one can fast and how the blood glucose levels can be managed during the fasting period (Ahmed et al., 2020).

For the practicing Muslim, the PCP should consider the following when planning for the patient’s care Glycemic status; Complications and other comorbidities that may be worsened by prolonged fasting like CKD and Heart conditions; The patient’s diet and meal plan; Possible risks of dehydration and electrolyte imbalance (Ahmed et al., 2020). Furthermore, the PCP should plan whether the patient can fast by assessing renal and hepatic functions, electrolyte imbalance, and infections.

Pathophysiology of Renal Dialysis

Explain the pathophysiology of renal dialysis.

Explain the pathophysiology of renal dialysis.Compare peritonealdialysis and hemodialysis. Renal dialysis replaces the non-endocrine function of the kidney in patients with renal failure. The modalities used in renal dialysis are continuous hemofiltration and hemodialysis, intermittent hemodialysis, and peritoneal dialysis. These modalities exchange serum solutes and remove fluid from the blood through dialysis and filtration across a permeable membrane (Thajudeen et al., 2023).

During renal dialysis, the serum solute diffuses passively between fluid compartments down a concentration gradient, which is termed diffusive transport. During filtration, the serum water passes between compartments down a hydrostatic pressure gradient, drawing solute with it through convective transport.

The two processes are usually used together in a process called hemodiafiltration (Thajudeen et al., 2023).
Hemodialysis entails passing a patient’s blood through an artificial semi-permeable membrane, which takes over the kidney’s filtering and excretion functions.

On the other hand, peritoneal dialysis uses the peritoneum as a natural permeable membrane through which water and solutes can equilibrate (Thajudeen et al., 2023). Unlike hemodialysis, peritoneal dialysis is less physiologically stressful and does not need vascular access.

Describe in detail the pathophysiological explanation and stages of renal disease that leads to ESRD. ESRD is a terminal disease state characterized by a GFR below 15 mL/min. Patients with chronic renal failure undergo five stages that lead to ESRD.

• Stage 1- Kidney damage with normal GFR > 90 ml/min.
  
• Stage 2- Mild reduction in GFR 60-89 ml/min.
  
• Stage 3a- Moderate reduction in GFR 45-59 ml/min
  
• Stage 3b- Decreased GFR 30-44 ml/min
  
• Stage 4- Severe reduction in GFR, 15-29 ml/min.
  
• Stage 5 –Renal failure with GFR < 15 ml/min.

Explain the potential factors that contributed to Mr. D.’s ESRD. The factors that may have contributed to ESRD in Mr. D include
Age (65 years) Advanced age is a risk factor for

• ESRD.
• Obesity
• Hyperlipidemia
• Systemic hypertension
• Uncontrolled diabetes
• Elevated serum creatinine level
• Functional Health Problems
• Evaluate of Mr. D.’s functional health patterns.
• Evaluate each of Mr. D.’s functional health patterns using the information given. Value/Belief Pattern Mr. D observed Islamic religious beliefs and practices.
• Health Perception/Management The patient ineffectively manages diabetes and fails to adhere to medication. Nutrition/Metabolic The patient has morbid obesity, hyperlipidemia, and pruritus.
• Elimination Impaired kidney function with ESRD and a GFR of 13mL/min.
• Activity/Exercise Reports reduced tolerance to activity and exertional dyspnea.
• Sleep/Rest Reports of sleep apnea affecting the quality of sleep.
• Cognitive/Perceptual Reports impaired balance and loss of sensation.
• Self-Perception/Self-Concept Positive feelings of loneliness and helplessness.
• Role/Relationship Lack of family support and understanding.
• Sexuality/Reproductive Reduced tolerance to activity intolerance may affect the patient’s sexual activity and quality of sex.
• Coping/Stress Lack of family support could be contributing to stress and depression.

Discuss at least five actual or potential problems you can identify from the “Functional Health Patterns Assessment Guide,” located in the Topic 3 Resources. Provide a rationale for each. Activity-Exercise Pattern The patient has reduced activity tolerance attributed to a reduced blood supply to the myocardium, as evidenced by reports of increased shortness of breath with activity and decreased activity endurance

Nutritional-metabolic Pattern Altered nutrition, more than body requirements related to a mismatch between energy intake and energy expenditure, as evidenced by morbid obesity. Sleep-Rest Pattern Disturbed sleep pattern related to reduced lung capacity secondary to obesity, as evidenced by sleep apnea.

Coping/Stress Pattern Suicidal risk related to a history of depression. The patient reports feelings of loneliness, helplessness, and lack of family support, which put him at risk of suicide.

Elimination Pattern The patient has impaired urinary elimination related to impaired kidney function. The patient has elevated BUN and creatinine levels, which indicate kidney failure.

Nursing Health Management and Health Promotion

Provide ESRD nursing management and health promotion opportunities.

Provide ESRD nursing management and health promotion opportunities.

Nursing management for Mr. D will include:

• Fluid restriction is to attain fluid balance and prevent fluid overload complications. The nurse should monitor the patient’s intake and output and hydration status and assess for signs of fluid overload. Besides, the nurse should assess the patient’s fluid status by obtaining daily weights (Elendu et al., 2023).
  
• The nurse should administer the prescribed medications for this patient.
  Patients with kidney impairment are often prescribed diuretics to manage fluid retention and control blood pressure.
  Monitoring vital signs, including BP, respirations, heart rate, and temperature. Systolic and diastolic BP and peripheral pulses can be used to assess cardiac output (Elendu et al., 2023).
  
• The nurse should teach the patient to measure his BP daily and identify abnormal findings.
  The nurse should collaborate with a dietitian to assess Mr. D’s nutritional needs. This includes teaching the patient and evaluating his understanding of and adherence to dietary plans (Elendu et al., 2023).

Develop a patient education plan for ESRD that could be offered to Mr. D. for prevention of future events, health restoration, and maintaining renal status. The patient education plan for Mr. D, with regard to the ESRD condition, will include the following:

• Lifestyle modification includes increasing physical activity and decreasing caloric intake to promote weight loss, lower cholesterol levels, and attain optimal blood pressure and blood glucose levels (Chen et al., 2023).
  
• Moderate aerobic and muscle-strengthening exercises should be recommended to improve cardiovascular health, lower blood pressure, and promote weight loss.
  
• Dietary restrictions include adopting a low-sodium diet to lower BP. The patient should be instructed to limit daily protein intake to slow the GFR decline and improve proteinuria (Kim & Jung, 2020).
  
• Education on a renal diet. Mr. D should be educated about the renal diet by avoiding foods high in phosphorus (Kim & Jung, 2020).
  
• Education on avoiding nephrotoxic medications like NSAIDs and aminoglycosides (Chen et al., 2023).

Assume Mr. D. lives in your community. Include community resources and supportive care available for Mr. D. for ESRD care and management at home. The community resources and supportive care available in my community for Mr. D include

• Dialysis locator services
  
• Transplant resources
  
• Community education programs on ESRD, hypertension management, and kidney transplantation

Discuss the nurse’s role in using the holistic multidisciplinary care approach that would be safe and effective for patients like Mr. D., including aspects such as devices, transportation, eligibility for transplant, living conditions, promotion of resiliency, and independence.

As a member of the multidisciplinary team, the nurse has the role of planning, coordinating, and evaluating the patient’s care. The nurse collaborates with the dietitian and social worker to evaluate the patient’s home environment and determine equipment needs before discharge (Ng et al., 2023).

The nurse should provide psychological support for the patient and family and refer them to a psychologist for psychological counseling.

Mr. D may require social services due to the complex process of applying for financial aid to pay for ESRD medical care. Thus, the nurse should collaborate with the social worker to identify these social services and refer the patient (Ng et al., 2023).

References

• Ahmed, S. H., Chowdhury, T. A., Hussain, S., Syed, A., Karamat, A., Helmy, A., Waqar, S., Ali, S., Dabhad, A., Seal, S. T., Hodgkinson, A., Azmi, S., & Ghouri, N. (2020). Ramadan and diabetes A narrative review and practice update. Diabetes Therapy, 11(11), 2477-2520. https //doi.org/10.1007/s13300-020-00886-y
  
• Chen, T. K., Hoenig, M. P., Nitsch, D., & Grams, M. E. (2023). Advances in the management of chronic kidney disease. BMJ (Clinical Research ed.), 383, e074216. https //doi.org/10.1136/bmj-2022-074216
  
• Elendu, C., Elendu, R. C., Enyong, J. M., Ibhiedu, J. O., Ishola, I. V., Egbunu, E. O., Meribole, E. S., Lawal, S. O., Okenwa, C. J., Okafor, G. C., Umeh, E. D., Mutalib, O. O., Opashola, K. A., Fatoye, J. O., Awotoye, T. I., Tobih-Ojeanelo, J. I., Ramon-Yusuf, H. I., Olanrewaju, A., Afuh, R. N., Adenikinju, J., … Yusuf, A. (2023). Comprehensive review of current management guidelines of chronic kidney disease. Medicine, 102(23), e33984. https //doi.org/10.1097/MD.0000000000033984
  
• Kim, S. M., & Jung, J. Y. (2020). Nutritional management in patients with chronic kidney disease. The Korean Journal of Internal Medicine, 35(6), 1279–1290. https //doi.org/10.3904/kjim.2020.408
  
• Ng, M. S. N., Brown, E. A., Cheung, M., Figueiredo, A. E., Hurst, H., King, J. M., Mehrotra, R., Pryor, L., Walker, R. C., Wasylynuk, B. A., & Bennett, P. N. (2023). The Role of Nephrology Nurses in Symptom Management – Reflections on the Kidney Disease Improving Global Outcomes Controversies Conference on Symptom-Based Complications in Dialysis Care. Kidney International Reports, 8(10), 1903–1906. https //doi.org/10.1016/j.ekir.2023.08.025
  
• Thajudeen, B., Issa, D., & Roy-Chaudhury, P. (2023). Advances in hemodialysis therapy. Faculty Reviews, 12, 12. https //doi.org/10.12703/r/12-12
  
• Zheng, L., Chen, X., Luo, T., Ran, X., Hu, J., Cheng, Q., Yang, S., Wu, J., Li, Q., & Wang, Z. (2020). Early-onset type 2 diabetes as a risk factor for end-stage renal disease in patients with diabetic kidney disease. Preventing Chronic Disease, 17. https //doi.org/10.5888/pcd17.200076