An Anaemia in Haemodialysis Patients - Essay Example

An Audit of Anaemia in Haemodialysis Patients I. Introduction The following is an example of how this (as a nurse) woulddevelop, implement, and evaluate an audit of anaemia in haemodialysis patients. The measures put forth here are consistent with contemporary health policy and the evolving role of the specialist nurse. References will be made to this writer's speciality, management and quality improvement in the literature review. In the development of this topic, first, to be clear, the topic being discussed for the audit is anaemia. The specialist area is haemodialysis. The standards/guidelines used for the audit are the KDOQI as well as the EBPG haemoglobin target. The main idea is to do an audit of haemoglobin results to see if they meet the targets set out by KDOQI. In addition, one of the focuses of the audit is to gain a retrospective collection of data from previous months' blood results. II. Literature Review (Development, 825 words) First of all, in order to know what anaemia is, one must know the definition. According to the NICE guidelines, published by the Royal College of Physicians, "Conventionally anaemia is defined as a haemoglobin concentration lower than[normal as defined by WHO]. This cut-off figure ranges from 11 grams per decilitre (g/dl) for pregnant women and for children between 6 months and 5 years of age, to 12 g/dl for non-pregnant women, and to 13 g/dl for men."1 There is a high prevalency of iron deficiency in CKD patients. "In 2002, Hsu et. al. analyzed data from the Third National Health and Nutritional Examination Survey (NHANES III) (n=15,837) and found low iron indices to be frequently present at all levels of reduced creatinine clearance (CrCl)."2 Additionally, "[m]ore than 50% of CKD patients with an[a]emia were iron deficient, as indicated by serum ferritin 13 g/dl, but that there was no evidence either way for intermediate levels (11.5-13 g/dl) in comparison with higher or lower levels."5 One may wonder if particular medications can cause someone to become anaemic. "Some patients react to drugs because of inherited susceptibility, such as patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. G-6-PD is an important enzyme that buffers the mature red cell against oxidative stress. In individuals who are deficient in G-6-PD, exposure to certain chemicals, drugs, or even some foods will result in the alteration of hemoglobin and breakdown of red blood cells."6 After contraindications have been thoroughly exhausted, next the nurse should decide the necessity or relevancy of any treatment that is suggested for the patient in light of the patient's medical history. Treatments for anaemia vary widely. "The treatment [one] receive[s] will depend greatly on the cause of anaemia. Treatment is usually simple and may be resolved with an improved diet or by taking supplements."7 Treatments, although varying widely, are usually simple. "Treatment for iron deficiency anaemia is usually very effective, and the condition rarely causes any serious complications. [One's] blood may need to be monitored every few months after [one's] diagnosis, to check that [one is] responding to treatment and that [one's] iron levels have returned to normal."8 Sometimes supplements are considered an effective route in treating anaemia. "In most cases, treatments will be Iron supplements or supplements Vitamin B12 or Vitamin B9, Folic Acid. In very severe cases, these vitamins may be injected along with blood fusions or oxygen fusions where required."9 These medications should be taken as prescribed. Otherwise one's health could be in jeopardy. "It will be extremely important to take Iron supplements only as recommended or advised by [one's] doctor. Iron is essential in fighting this condition, but it can also be toxic. [A person's] body has a very difficult time in excreting iron excess so it must be taken only as directed."10 It is a possibility that all one may need are supplements or injections. "If the cause of [one's] anaemia is vitamin B12 deficiency then [one's] doctor may prescribe vitamin B12 injections. These injections will need to be given every 3 months, usually throughout the patient's life. It is also possible to have iron injections but this is not often necessary."11 However, there may be more serious measures that need to be taken. For example, "Ifanaemia has been caused by internal bleeding, e.g. ulcers, then medicines or surgery may be required. If anaemia is severe then [one] may also need to have a blood transfusion."12 III. Implementation Implementation of the audit includes factors like deciding what are the medications the patient will be prescribed. If there are any medications to be prescribed, what are they and what are the proper dosages for a patient If the patient is a child, should these dosages reflect that difference as opposed to if the patient were an adult What about the patient's height, weight, and vital signs If the patient is an elderly patient, should this be taken into special consideration What if the patient has specific secondary or underlying conditions, such as CHF (Chronic Heart Failure), diabetes, stroke, cancer, gastritis, ulcers, Crohn's disease, and so forth The list goes on. Basically, the main idea is that the patient should be evaluated on a case-by-case basis in order to see what kind of strategies should be implemented in order to define more appropriately the best course of action for his or her treatment. Additional factors for the nurse to consider when implementing an audit of anaemia in haemoglobin patients include the method and route of administration of the medications. The way medications are administered can have a big impact on a person's life. For example, let's take an example of a 54-year-old female receiving Gleevec, who also received Actonel and Calcium; this same patient had adverse reactions and side effects of: "bladder neoplasm surgery, wrist fracture, haematuria, anaemia, osteopenia, periorbital oedema, osteonecrosis, arthralgia, joint swelling, diarrhoea, dry mouth, gastrointestinal disorder, wrist surgery, gravitational oedema, bladder cancer, [and] decreased appetite."13 Obviously, some kind of accountability is in order. In order to supervise anaemics, there must be some kind of order established, whether it be in Europe or in developing nations. "Future research priorities should be directed to development of other strategies to effectively improve utilizable iron intakesor to greatly improve compliance in direct supplementation programs, daily or weekly. It is recommended also that the criteria for diagnosis of anaemia and/or for definition of public health problems be reviewed and revised as necessary"14 Monitoring anaemic patients is equally as important. Besides supervision alone, anaemic patients must be monitored. "Treatment with rHuEPO may be a solution for some [patients]. However, optimal haematological benefits will only be produced if a significant bone marrow response can be predicted and iron availability is able to keep pace with the iron demands of erythropoietic state and monitor the iron demand of erythropoiesis from an early stage."15 Regarding implementation strategies for patients who have haemoglobin problems, there are many suggestions for clinical care according to the CARI guidelines. One of the most important pieces of advice is that, "Prior to the commencement of the administration of epoetin analogues, appropriate iron indices and adequate concentrations of Vitamin B12 and folate should be insured."16 Not only this, but it is suggested that certain conditions be avoided. "In addition, efforts should be made to control hyperparathyroidism, aluminium accumulation and/or significant systemic inflammation. Blood pressure levels should be controlled, preferably below 160/100 mmHg."17 Best practices in nursing should consider why a certain treatment is being offered. How is someone affected by the type of treatment being offered If the patient is elderly, will having a monthly injection be more intrusive than, say, taking a pill for instance Is surgery necessarily the best option for a child All of these factors must be taken into consideration when thinking about the patient. Not only must the treatment be genuinely in the best interest of the patient, but it also must be relevant and appropriate to the patient's age, health, sex, life conditions or medical issues, physical well-being, mental state, and religious orientation. Let's take an example. There is a patient named LeAnn who is 9 years old. Her family is composed of Christian Scientists. The problem is, Leann may need a blood transfusion or she could die. However, Christian Science doesn't allow any medical interventions. How does one handle this situation First the nurse must explain to the family that without this crucial blood transfusion, Leann could get even sicker and possibly even die. In this case, the nurse needs to drive home the point that without this blood transfusion, the girl's life is at risk. Religion can definitely play a role in a case like this, so it is important to know the personality of the people with whom one is dealing. Let's take another example. William is an 89-year-old living in a nursing home on the moors. He is encouraged to get injections for his anaemia because his haemoglobin is way too low. Naturally his doctor assumed that William had an iron deficiency and wanted him to get injections on a regular basis every year. However, later it was found that the cause of William's anaemia was not because he had an iron deficiency. William also had Chronic Heart Failure (CHF) as well as stomach ulcers. It was concluded by a doctor whom he went to for a second opinion that he indeed had acidic anaemia, which is an altogether different kind of anaemia. This required a different course of treatment. In any case, if William had suffered from an iron deficiency, would it have been proper for an 89-year-old to receive injections Probably the answer is no. Thus, the nurse must use his or her common sense when looking at patients' charts and trying to distinguish what is the problem, how to develop a solution, implement the solution, and then evaluate if that solution worked correctly. Finally, whatever the outcomes, the nurse must always keep in mind the necessity of obtaining the consent of the patient to continue forth with whatever treatment has been prescribed before it can be administered to the patient in any circumstance. Without the patient's consent, taking any action is considered ill-advised and not best practices. IV. Evaluation The nurse should consider what the health outcomes are for the particular patient that he or she is treating. "For treating the critically ill patient with rHuEPO it is important to know if iron availability for erythropoiesis meets the demands."18 When reading the haemoglobin, one should be cautious in trying to manipulate lab work. It should be duly noted that "targeting of haemoglobin concentrations above 130 g/L has been associated withincreased mortalityand is therefore currently considered inadvisable."19 For the astute nurse, things that he or she will consider when trying to evaluate if a patient's anaemia has improved will consist of four main elements: pallor;20 heart rate;21 fatigue;22 and lab work.23 Usually the anaemic patient's pallor or coloring will be off-usually by quite a bit. The patient will appear drained of his or her color. If coloring improves, this is one soft measure to indicate that the patient is improving. Secondly, the patient's heart rate will be slowed if the person is anaemic. Usually with improvement, heart rate will be more normal, as the heart will not having to be working as hard to pump oxygen with improved circulation. Thirdly, fatigue will be an obvious and key piece of evidence which would point towards anaemia. The patient would be extremely tired much of the time, whereas, with improvement, the patient who is not anaemic anymore will have more energy and spring in his or her step. Last but certainly not least, lab work that comes back with positive results is a key indicator that the patient no longer is anaemic. Obviously, if the haemoglobin levels are too low, the patient is anaemic and the patient's needs must be addressed more suitably in order to combat the problem. V. Conclusion Obviously, treating the anaemic patient comes with a variety of different challenges. The nurse must not only develop strategies to ensure the patient's success, but he or she must implement these strategies and be able to strategically evaluate them. If something is not working, obviously the outcome has not been reached and there was an issue with either the implementation or the development of the strategy. Thus, the nurse must decide at which point something went wrong and reevaluate. Sometimes, it is advisable to take a step back, remove oneself from the situation, and think critically regarding the anaemic patient. What is the patient's lab work telling the nurse Are the haemoglobin levels appropriate Are the patient's pallor, heart rate, and fatigue level acceptable These elements must be evaluated in order to ensure success. REFERENCES Anemia Web Site. http://www.ithyroid.com/anemia.htm. Accessed 28 February 2010. BabyCenter UK Web Site. Anaemia (Iron Deficiency). http://www.babycenter.com.au/pregnancy/complications/anaemia/. Accessed 28 February 2010. Beaton, George, et. al. An Analysis of Experience. Canada: The Micronutrient Initiative, 1999. http://www.foodsecurity.gov.kh/docs/ENG/Cover%20-%20Exec%20Sum%20 -%20Efficacy%20Intermittent%20Iron%20Supplementation-ENG.pdf. Accessed 28 February 2010. Conrad, Marcel. Iron Deficiency Anemia. http://emedicine.medscape.com/article/202333-overview. Accessed 28 February 2010. Drug Lib Web Site. Adverse Event Reports. http://www.druglib.com/adverse-reactions_side- effects/gleevec/seriousness_disabling/reaction_anaemia/. Accessed 28 February 2010. Hsu, et. al. Prevalence of IDA. Journal of American Society of Nephrology, 2002. http://www.feraheme.com/ida/prevalence.html. Accessed 28 February 2010. Locatelli, Francesco, et. al. Anaemia Management in Patients with Chronic Kidney Disease: A Position Statement by the Anaemia Working Group of European Renal Best Practice (ERBP). Nephrology Dialysis Transplantation 2009 24(2): 348-354. http://ndt.oxfordjournals.org/cgi/content/full/24/2/348. Accessed 28 February 2010. McMahon, Lawrence. Haemoglobin. Nephrology 2008; 13, S44-S56. http://www.cari.org.au/DIALYSIS_bht_published/Haemoglobin_Aug_2008.pdf. Accessed 1 March 2010. Medline Web Site. Mortality and Target Haemoglobin Concentrations in Anaemic Patients with Chronic Kidney Disease Treated With Erythropoietin: A Meta-Analysis. http://www.mdconsult.com/das/citation/body/186323857- 2/jorg=journal&source=&sp=17554440&sid=0/N/17554440/1.htmlissn=. Accessed 28 February 2010. NAAC Web Site. Causes of Anemia. http://www.anemia.org/patients/faq/. Accessed 28 February 2010. NHS Direct Web Site. Anaemia, Iron Deficiency. http://www.cks.nhs.uk/patient_information_leaflet/anaemia_iron_deficiency. Accessed 28 February 2010. NICE. Anaemia Management in Chronic Kidney Disease: National Clinical Guideline for Management in Adults and Children. London: Royal College of Physicians, 2006. Sheth, et. al. Anaemia: Conjunctival Pallor Helped Diagnose Anaemia. Journal of General Internal Medicine 1997; 12: 102-106. http://www.eboncall.org/CATs/1886.html. Accessed 28 February 2010. REFERENCES (CONT'D.) Thomas, Christian, et. al. Anaemia in the Critically Ill Patient: Monitoring of Erythropoietin Therapy. Germany: BJU International, 2006. http://www.urotoday.com/prod/pdf/reviews/BJU3_jun2006.pdf. Accessed 28 February 2010. Will, Frank. Anaemia and Supplements. http://ezinearticles.com/Anaemia-and-Supplements&id=2808797. Accessed 28 February 2010. Read More