Chronic Kidney Disease with Hemodialysis - Case Study Example

Dialysis, A Case Study Dialysis, a Case Study Chronic kidney disease represents a progressive destruction of nephrons causing a decline in kidney function. It can be caused by many problems including diabetes, hypertension, glomerulonephritis, and other kidney disease. All forms of CKD (chronic kidney disease) are characterized by a reduction in the GFR (glomerular filtration rate). On average the signs and symptoms of CKD occur gradually and do not become noticeable until the disease is advanced. This paper will discuss Grace (fictitious) as a case study of renal disease, dialysis and care planning. Pathophysiology/ Renal Failure Grace has several reasons for her renal disease which has caused the need for her dialysis. The primary reason for her renal failure is obstructive uropathy which has been further complicated by hypertension and diabetes. Hydronephrosis is a condition that is caused by urine filled dilation of the renal pelvis which is then associated with progressive atrophy of the kidneys due to an obstruction of the urine outflow. The kidney eventually becomes a thin walled cystic structure with parenchymal atrophy, complete obliteration of the pyramids and cortex thinning. Bilateral obstruction will lead to renal failure. Hypertension is one of the major diseases that cause CKD. That is often related to poor control caused because of poor education of the patient and their family. One in three adults in the US and one billion people worldwide have hypertension and 26 million adults in the US have chronic kidney disease (Eskridge, 2010)." The National Committee on Prevention Detection, Evaluation, and Treatment of High Blood Pressure describes the relationship between blood pressure and DVD as continuous, consistent, and independent of other risk factors" (Eskridge, 2010. pg. 55). Hypertension damages the kidneys in a couple of ways. Renal damage causes the activation of the renin-angiotensin system. This can happen from the beginning and then the sympathetic nervous system is activated. As this system continues to be damaged, the damage is measured by the change in the GFR or the serum creatinine. As capillary pressure increases, the endothelial cells are damaged which then activates platelets and interglomerular coagulation (Eskridge, 2010). All of this chronically leads to neprosclerosis. It also accelerates kidney disease caused by other chronic problems such as diabetes. People with diabetes are recommended to keep their blood pressure at 130/80 or below (Porth & Matfin, 2007). In the case of diabetes, diabetic nephropathy is the leading cause of chronic kidney disease and probably accounts of 40% of all new cases. Both type 1 and type 2 diabetes cause this type of renal failure. Diabetic neuropathy points to lesions in the kidney that are created in the diabetic kidney. The glomeruli are affected more than any other structure and there are some other problems such as capillary basement membrane thickening, diffuse glomerular sclerosis and nodular glomerulosclerosis (Porth & Marfin, 2007 pg. 1072). Renal enlargement as well as nephron hypertrophy and hyperfiltration occur early in the disease. This occurs because of the increased work that the kidneys must go through to pick up the excessive glucose . One of the first things that will be seen in diabetic renal failure is albumin in the urine. Hypertension as noted before push this disease forward and the symptoms manifest faster. Treatment Grace is being treated with Dialyzer-Revaclear with treatment time of 4 hours, a blood flow of 350ml/min, Dialysate K 1.5/Ca 1.25/Na (initial Cond 150-Final Cond 135)/ Bicarb 40, Dialysate flow 500ml/min, Dialysate temp 35.5 C, Heparin bolus 1.5u, heparin rate 0.8u/hr, ideal weight 78.5kg, pre weight 79kg, Target wt. 1.0kg. She is being dialyzed three times per week. Though hemodialysis has its own set of problems peritoneal dialysis would not be a good choice for Grace. Grace has a history of infections, she does not get around well, and lives in a retirement home. She is also diabetic and peritoneal dialysis frequently causes hyperglycemia. This would mean that she would be self dialyzing in a less than desirable situation. She does have transportation and the ability to get to dialysis. Pathology of Dialysis There are some major pathologies that dialysis itself can cause. This includes both hemodialysis and peritoneal dialysis. Dialysis does prolong the life of patients with renal disease, there is no question. Hyperphosphatemia is one of these problems. When patients have renal failure they absorb aluminum but it does not happen in normal kidney function. Some patients dialyze against water that is high in aluminum because of where they are and the aluminum accumulates. This can lead to mineralization problems and a decrease in osteoblast function (Freemont, 2002). There may be parathyroid gland problems for the same reason. There are also possibilities of adynamic bone, amyloidosis, encapsulating peritonitis, dialysis associated renal cysts and many complications caused by vascular access sites. Target levels for good outcomes in include dialyzing with an AV fistula, Hemodialysis Kt/V of 1.2 or greater, Hemodialysis URR 65% or greater, albumin of 4.0 g/dl, 5.7% interdialytic weight gain, 11-12 g/dl hemoglobin, intact parathyroid hormone, 8.4 to 9.5 mg/dl calcium and 3.5 to 5.5 mg/dl phosphorus (Keen, 2009). Grace has met all of these parameters for this session. Blood Values The kidneys are no longer able to produce erythropoietin which results in anemia. Grace's Hgb. is 11.5 which is low and she has been low according to history when entering for dialysis. This problem usually results in increased hospitalizations which is true in this case. Morbidity and Mortality may be high based on the fact that this problem has a direct on cardiovascular disease which is already a problem for Grace due to her diabetes and hypertension. When combined with dialysis the numbers of patients with increased mortality and morbidity is significant (Clarkson, & Robinson, 2010) Phosphorus is present in food and is usually screened out of the body in the kidneys but this does not happen with patients that have chronic renal disease. Dialysis is often not able to handle this problem either so most of this issue is handled through a dietary restriction of foods high in phosphorus. If this is not followed, the patient will end up with high phosphorus, low calcium and bone demineralization. At the moment Grace has a normal calcium level. MRSA, VRE, and ESBL are negative and HIV non reactive. Plan of Care Grace will need to achieve and maintain blood pressure within the range set by her physician and she will need to understand why that is important, as will her husband. This will take collaboration between the physician, dietician, nurse and family. She will need to keep her diabetes under control and do what she can to modify her risk factors for cardiovascular disease. She will need to get as much exercise as she can tolerate and take her medications as instructed. She will also need to follow a diet as specifically as possible. Each time she comes in for dialysis or visits her primary providers, she will need BP taken at least 3 times and the average used and compared to her target. She will need to have weight, respiratory rate, heart sounds, breath sounds, peripheral edema, neck vein distention and adherence to instructions assessed. She will also need to keep track of her weight and blood sugars at home and bring that journal with her each time she come. She will need to have a BUN and creatinine level drawn as well as electrolytes. She will also need much patient teaching which must include how to measure and keep records at home of blood pressure, weight, and blood sugar. What hypertension is and how it affects her renal disease, what antihypertensive medications she is on, how they are taken and what the side effects might be as well as what dietary modifications she might need and how that diet affects both her kidneys and her medications (McCarley & Hudson, 2006). Psychological State Patients with renal disease and on dialysis often get less education than some other kinds of patients according to Clarkson & Robinson (2010). This is because with the type of treatment that is going on, the nephrologists have limited time to talk with patients. The nurse gives the patient information but the situation is often the same, the nurse is very much involved in the dialysis itself and the patient may learn task oriented information but not the kind of information that they need to alter lifestyles and do the things they need to do better. This is most likely true of Grace too. She already has some problems including her hypertension and diabetes that will cause some problems with her ability to learn as will her dialysis. She has a cooperative husband but she has become very dependent on him and unable to get around well on her own which causes some depression as well as lack of feeling of independence and self-esteem. Patients who are on renal dialysis have chronic fatigue, dietary and fluid restrictions, major changes in economic status, increased healthcare costs and some embarrassing disfigurement (Clarkson et.al., 2010, pg 30). Family and relationships make the quality of life that these patients now have. Grace has good support from her husband. There is limited amount of physical activity due to muscle cramps, decreased social contact and depression involving the future. Many of these patients need support to continue dialysis as it is cumbersome, time consuming, and uncomfortable.. Medications Grace is on Cardizem CD 18 mg once daily because of her emphysema, prednisone 5 mg every day since 2008, Ventolin 2 puffers QID, Spiriva 180 mcq daily, Lasix as needed, Paxil and Diovan. For hemodialysis, she is on Araresp 20 mcg every Wednesday, Venofer 100 mg every Monday, Amatine 5-10 mg prn and TPA post HD. She is also on Coumadin with a baseline INR of 1.7-2.0 and her present INR is 1.6. Cardizem CD is a Calcium Channel Blocker. Calcium controls the energy storage in the heart muscle. Calcium channel blockers inhibit calcium from moving across the cell membrane which then causes decreased contraction, depression of impulse formation, and a slowing of conduction velocity. All of this has the effect of decreasing the oxygen needs of the heart (Aschenbrenner & Venable, 2007). Cardizem CD can be taken at 180-240 mg/d by mouth for hypertension. Ventolin and Spiriva are both puffers taken to help with bronchial dilation in a patient with emphysema. Lasix is a potent diuretic that is quite effective in reducing peripheral edema from CHF and hepatic and renal diseases including when there is nephrotic disorder. Lasix inhibits the reabsorption of sodium, chloride, and water in the ascending loop of Henle as well as affecting the proximal and distal tubules causing the excretion of excess water. Paxil is taken by Grace because of the devastating effects of dialysis on a patient. It causes depression in most patients. They cannot go anywhere because they have to be near their dialysis clinic and therefore their lives become very restricted. They are limited to how much they can do because their energy level is affected. They have a great deal of difficulty coping with their losses and many patients are not prepared for what life will be like on dialysis (Freemont, 2002). Discussion Grace is very typical of the patient today who is on renal dialysis. She is in her mid-sixties and has been a smoker, is diabetic, and hypertensive. Unfortunately, the average patient is not well aware of what the final effects of this lifestyle may be which is renal failure. Renal failure frequently does not show any symptoms until there is already quite a lot of damage, in fact, the average patient is usually surprised when they find that their kidneys are not working and they need to consider dialysis. Dialysis is extremely life shortening and as many advances as have been made over recent years, the outcomes are still not good. Cardiovascular disease is usually increased due to renal failure and renal failure is then increased because of the cardiovascular disease. Education of these patients is difficult because the lifestyle change is not small but quite large. Many of these patients also lose hope and do not do as well because of that. There is no going back, once dialysis has begun in the case of chronic failure, it has to be continued or the patient will die. This is a hard way to look at things, knowing there will never be a change for the better. Most of these patients are not on transplant lists. Conclusion In conclusion, dialysis is a fundamental treatment for patients with renal failure. There are now many dialysis units throughout the country. Unfortunately many of them are seeing as many patients as they can see. Renal failure has increased with the increased numbers of obese patients with hypertension, hyperlipedemia, and type 2 diabetes. Life is shortened drastically when dialysis begins. Many patients begin dialysis in their mid-sixties. It is a lifestyle that no one wants to lead yet it is difficult to get to these patients in time to save them from this treatment because renal failure is silent until it is too late. Early screening and education by primary care physicians is the only answer at this time and even then, the patient must understand and remain very compliant to prevent this disease. References Axchenbrenner D. & Venable, S. (2007). Drug Therapy in Nursing. 3rd ed. Lippincott: Boston. Clarkson, K., Robinson, K (2010). Life on dialysis: A livid experience. Nephrology Nursing Journal. 37(1). Eskridge, M. (2010). Hypertension and chronic kidney disease: the role of lifestyle modification and medication management. Nephrology Nursing Journal. 37(1). Freemont AJ. (2002). The pathology of dialysis. Seminars in Dialysis 15(4). 227-231 Keen, M. (2009). Modifiable practice patterns and patient outcomes: Implications for nephrology nursing care. Nephrology Nursing Journal. 36(3). Lacson, E. & Levin, N. (2004). C-Reactive protein and end stage renal disease. Seminars in Dialysis 17 (6). 438-448. McCarley, P., & Hudson, S. (2006). Chronic kidney disease and cardiovascular disease- using the ANNA standards and practice guidelines to improve care. Nephrology Nursing Journal. 33(6).. Portth C & Matfin G. (2007). Pathophysiology. 8th ed. Lippincott: Boston. Read More