ESRD Secondary to Diabetes and Hypertension - Essay Example

Patient Report and Nurse Care Plan Introduction and Background Patient pseudonym: Smith Alison Patient demographic data: Age: 76 years Gender: Male Ethnicity: Macedonian orthodox Chief complaints : History of fever since 3 days, nausea and vomiting since 2 days, decrease in appetite since 2 days and shortness of breath since few hours. Wife complaints stale smell of urine near him. History of presenting complaints: Fever since 3 days, intermittent and high grade, not associated with chills or rigors. History of mild cold and cough present. No history of altered sensorium, seizures,loose stools or burning micturition. Past history: Alison is a known patient of End-Stage Renal Failure or ESRF secondary to hypertension and type-2 diabetes mellitus. He has been on hemodialysis 3 times a week. The patient was diagnosed to have ESRF one year ago. He has history of hypertension for 25 years and history of type-2 diabetes mellitus for 22 years. Other than these, the patient is also a known case of ischemic heart disease diagnosed 12 years ago and for which he underwent GAGs in 1999. He also has mild Parkinsons disease, diagnosed 6 years ago. he suffers from dementia too. There is history of recurrent falls, but with no eventful fall so far. He has a pressure ulcer on his right toe. Alison is irregular with his medication and follow-up. Despite appropriate education on dialysis, he refused the treatment initially. The patient is not allergic to any known medication. He lives with his wife and requires assistance for activities of daily living. There is history of episodic fecal and urinary incontinence which are managed by his wife. In this report, the pathophysiology, clinical interventions, medications, diagnostic tests and nursing care plan will be discussed with reference to the clinical condition of the patient. Examination: On admission to the hospital, Alison appeared conscious, alert and oriented to time, place and person. His Jugular Venous Pressure was not elevated. His temperature was high (35.3 deg.C), blood pressure was slightly on the lower side (120/60mmHg), respiratory rate was very high (78 per minute) and oxygen saturation in room air was 96 percent (normal limits). Examination of the cardiac region revealed ejection systolic murmur. Auscultation of the chest revealed basal crackles in the lower part of the lungs with reduced breath sounds in the right base. Abdominal examination and examination of central nervous system were unremarkable except for few tremors due to Parkinsonism. Alison has a permcath in situ for dialysis. He has a pressure ulcer on his right big toe. Diagnosis: Known patient of end-stage renal disease secondary to type-2 diabetes mellitus and hypertension with ischemic heart disease, parkinsonism and pressure ulcer, currently admitted for right lower lobe pneumonia and worsening uremia. Differential diagnosis for acute condition: 1. Right lower lobe pneumonia: Most likely in view of tachypnoea, decreased breath sounds and crackles. 2. Congestive heart failure: Unlikely because of normal jugular venous pressure. 3. Fluid overload: Possible because of chronic renal failure. Clinical intervention needed: Management of pneumonia and uremia Pathophysiology of the chief complaint and significant comorbidities, and review of laboratory investigations: 1. Pneumonia Inflammation of the alveolar tissue of the lungs is known as pneumonia. There are several causes to pneumonia, of which the most common is bacteria. Pneumonia occurs due to presence of virulence factors and due to decreased immunity secondary to chronic disease as in Alison. Pneumonia causes accumulation of fluid and inflammatory mediators resulting in ventilation-perfusion defect, impaired gas exchange and inadequate oxygenation of tissues resulting in increased respiratory rate and increased work of breathing. (Stephen, 2010). Chest X-ray of Alison at the time of admission revealed congested lungs, focal consolidation in the basal segment of the right upper lobe , probably infective in origin. The X-ray also confirmed presence of right internal jugular permacath that was inserted for dialysis, with the tip lying within the right atrium. The X-ray also showed osteopenic bones and sternotomy wires in situ. 2. End-stage renal disease or ESRD and uremia ESRD is a condition in which the patient is in chronic renal failure and requires transplantation or dialysis. The most common causes of ESRD are diabetic nephropathy, followed by hypertensive nephropathy. Alison has both these causes. ESRD affects all organ systems. The symptoms begin to appear when the glomerular filtration rate falls to less than 120ml per minute. The signs and symtoms depend on the organ system involved. It is common for patients with ESRD to beseen frquently in emergency rooms either due to metabolic complications like hyperkalemia or due to complications secondary to dialysis. other common causes of admission include anemia and infection. In Alison, the cause of emergency admission is right lower lobe pneumonia. Alison is on frusemide, a loop diuretic useful in chronic renal failure to prevent fluid accumulation. Alsion is also on Aranesp or darbepoietin alpha, an analogue of erythropoietin (Singh et al, 2006), from anemia due to chronic renal faliure, caltrate of calcium supplementation, calcitriol or 1, 25- dihydroxycholecalciferol for supplementation of Vitamin D deficiency due to chronic renal failure and ostelin or ergocalciferol to enhance calcium absorption (Teng et al, 2003). Another drug Alison is on is esomeprazole, a proton pump inhibitor to prevent erosive gastritis related to ESRD and also drug-induced. Alison is on salbutamol, a short acting beta-2 adrenergic receptor agonist for shortness of breath. Alison has a permacath in situ as confirmed by the chest X-ray. Upper limb vein mapping was nonsignificant. Uremia may be defined as "a clinical syndrome associated with fluid, electrolyte, and hormone imbalances and metabolic abnormalities, which develop in parallel with deterioration of renal function" (Alper and Shenava, 2010). Under normal circumstances, kidney is the site for production and secretion of various hormones like aldosterone and erythropoietin, homeostasis of acid-base, regulation of fluid and electrolytes and elimination of waste products. In ESRD, the kidney is unable to function properly resulting in acidemia, anemia, hyperparathyroidism, hypertension and malnutrition (Muscaritoli et al, 2009). Development of uremia occurs when creatine clearance falls below 10ml/min. Clinical manifestation of uremia include nausea, vomiting, anorexia, fatigue, muscle cramps, pruritus, weight loss and change in mental status (Alper and Shenava, 2010). The ultimate treatment for uremia is dialysis which Alison is already on. In patients with diabetes like Alison, dialysis must be initiated when creatinine is 6mg/dL or the creatinine clearance is 15ml/min (Alper and Shenava, 2010). 3. Diabetes mellitus type-1 Alison is a known case of type-2 diabetes mellitus for the past 22 years. Type-2 diabetes mellitus is the most common type of diabetes and occurs in older people with hereditary factors or predisposable factors like obesity and sedentary lifestyle (Votey, 2005). It occurs due to a combination of peripheral resistance to insulin action and an inadequate secretory response by the beta cells (Kumar et al, 2007). Decreased ability of the peripheral tissues to respond to insulin and inadequate secretion of insulin by beta cells of pancreas are the main metabolic defects in type-2 diabetes. The factors which probably lead to insulin resistance are increased non-esterified fatty acids, inflammatory cytokines, adipokines, and mitochondrial dysfunction (Stumvoll et al, 2005). Beta-cells of pancreas are the only source of insulin production in the body. Impaired insulin secretion by beta-cells occurs due to failure of beta cells to adapt themselves for the long-term demands of peripheral insulin resistance and increased insulin secretion (Kumar et al, 2007). This occurs due to glucotoxicity, lipotoxicity, and amyloid formation for beta-cell dysfunction (Stumvoll et al, 2005). The dysfunction is both quantitative and qualitative.In the long-term, diabetes leads to 3 main conditions, disease of the eyes (retinopathy), nerves (neuropathy), and kidneys (nephropathy) (Kumar et al, 2007). These effects are due to the damaging effect of hyperglycemia on the blood vessels in these tissues. Tissues like nerves, lenses, kidneys and blood vessels do not require insulin for transport of glucose. Hence blood glucose can enter the cells without insulin. Hyperglycemia leads to increased intracellular glucose which is then metabolized by aldose reductase to sortibitol and then fructose. This process uses NADPH which gradually gets depleted resulting in oxidative stress in the cells. Thus damage to the organs occurs (Kumar et al, 2007). In the retina, increased intracellular glucose stimulates the de novo synthesis of diacyl glycerol from glycolytic intermediates which further causes activation of protein kinase C. Protein C causes revascularization in retina and diabetic retinopathy, increased depositon of extra cellular matrix, fibrinolysis and production of pro-inflammatory cytokines (Kumar et al, 2007). Thus various tissues in the body are damaged as a result of blood hyperglycemia. In Alison, long-standing diabetes is one of the causative factors for the development of ischemic heart disease, foot ulcer and end-stage renal disease. Alison is on oral hypoglycemic drug gliclazide 120 mg. Glycosylated hemoglobin levels are 5.8 which indicated excellent glycemic control. The microvascular complication is nephropathy and the macrovascular complications are ischemic heart disease and foot ulcer. 4. Hypertension Alison is a known patient of hypertension for 25 years. His blood pressure without medication is 170/110 mmHg. Elevation of blood pressure above the normal for age and sex is known as hypertension. According to the Joint National Comission (cited in Dreisbach and Sharma, 2010), systolic blood pressure of more than 159mmHg and diastolic blood pressure of more than 99mmHg is catogorised under as stage-2 hypertension. Hypertension may occur due to many causes. Basically, there are 2 types of hypertension- essential hypertension and secondary hypertension. Hypertension is considered as essential when a recognizable secondary cause is absent. In Alison, the hypertension is essential. This type of hypertension mainly results from decrease in the peripheral vascular resistance and simultaneous adrenergic hyperactivity. Calcium homeostasis is also altered. Persistent hypertension leads to target organ damage. The main organs which are affected as a result of prolonged hypertension are heart, kidneys, aorta and small arteries, central nervous system and retina. Hypertension is chronic and mandates lifelong therapy. Most often than not, patients do not adhere to treatment regimens and advice because of vague symptomatology or absence of symptoms (Lojuri and Rahimi, 2007). Elevated blood pressure which has been uncontrolled for a prolonged duration of time can lead to many changes in the structure, blood vessels and the conducting system of the heart. These changes can lead to the development of various conditions of the heart such as coronary artery disease, left ventricular hypertrophy, cardiac arrhythmias and congestive heart failure. The pathophysiology of hypertensive heart disease is a complex interplay of various structural, neuroendocrine, hemodynamic, molecular and cellular factors (Riaz, 2007). In Alison, long standing hypertension is one of the contributing factors for development of ischemic heart disease and end-stage renal disease. Alison is on metoprolol, a betablocker, useful to control blood pressure. The ideal choice of antihypertensive in Alison in view of ESRD would be ACE inhibitor (NICE, 2008). 5. Ischemic heart disease Alison is a known patient of ischemic heart disease for 12 years. Ischemic heart disease or IHD or coronary heart disease is a condition in which there is oxygen deprivation to the muscles of the heart as a result of decreased blood flow and perfusion and is accompanied by inadequate removal of the products of metabolism (Zevitz, 2006). The hallmark feature of this condition is imbalance between the supply and demand of oxygen of the myocardium which can occur either due to increased myocardial oxygen demand or decreased myocardial oxygen supply or both. It can manifest as one of these: anginal discomfort, ST-segment deviation on ECG, decreased uptake of technetium 99 or thallium 201 in images of myocardial perfusion and ventricular function impairment (Zevitz, 2006). Ischemia to the myocardium results from disease in the coronary arteries. The disease is most often due to formation of atheroma and its consequences like thrombosis. Atheroma, also known as atherosclerosis is nothing but patchy focal disease of the intima of the artery (Maseri et al, 1992). The beginning of these plaques occurs in the second or third decade and gradually progresses. Initially, the circulating monocytes migrate into the intima of the arteries and take up oxidised low density lipoprotein from the plasma. These cells then become lipid-laden foam cells (Zevitz, 2006). Once these foam cells die, the contents of the cells are released which are mainly lipids. These form fatty streaks. Smooth muscles cells of the artery migrate in and around the fatty streaks and proliferate to form a plaque. The plaque encroaches into the lumen and also erodes the media layer of the artery. Gradually a thick collagen -rich fibrous tissue encapsules the plaque which is then called mature fibrolipid plaque. Mature plaques can rupture or fissure creating a pathway for blood to enter. The blood then disrupts the arterial wall. Disruption of arterial wall compromises the vessel lumen and precipitates thrombosis and vasospasm, all of which cause decrease in the blood flow through that vessel. Sometimes, the rupture itself can cause occlusion of the vessel or can cause rapid growth of the plaque which occludes the vessel resulting in acute coronary syndrome (Zevitz, 2006). There are many risk factors for the development of ischemic heart disease. Advanced age, male sex, genetic factors, smoking, hyperlipidemia, hypertension, diabetes mellitus, sedentary lifestyle and heavy consumption of alcohol are risk factors (Zevitz, 2006). In Alison, advanced age, hypertension, diabetes mellitus and male sex have contributed to the development of ischemic heart disease. 6. Dementia The most common cause of dementia is Alzheimer disease which may be defined as "an acquired cognitive and behavioral impairment of sufficient severity that markedly interferes with social and occupational functioning" (Anderson, 2010). Age related development of neurofibrillary tangles, senile plaques and cerebrocortical atrophy, especially in the medial regions of the temporal lobe are the main pathological features of Alzheimer disease. However, the exact cause of Alzheimer disease is unknown. The risk factors for the development of this disease are advancing age, obesity, dyslipidemia, diabetes, hypertension and elevation of inflammatory markers (Anderson, 2010). These risk factors have contributed to the development of dementia in Alison. One associated feature with dementia is depression which is present in 30 percent cases of dementia (Anderson, 2010). Alison also suffers from depression. His chronic illnesses also have contributed to depression. Alison is on citolapram which is a selective serotonin reuptake inhibitors useful for depression. 7. End-stage renal disease or ESRD ESRD is a condition in which the patient is in chronic renal failure and requires transplantation or dialysis. The most common causes of ESRD are diabetic nephropathy, followed by hypertensive nephropathy. Alison has both these causes. ESRD affects all organ systems. The symptoms begin to appear when the glomerular filtration rate falls to less than 120ml per minute. The signs and symptoms depend on the organ system involved. It is common for patients with ESRD to be seen frquently in emergency rooms either due to metabolic complications like hyperkalemia or due to complications secondary to dialysis. other common causes of admission include anemia and infection. In Alison, the cause of emergency admission is right lower lobe pneumonia. Alison is on frusemide, a loop diuretic useful in chronic renal failure to prevent fluid accumulation. Alsion is also on Aranesp or darbepoietin alpha, an analogue of erythropoietin , from anemia due to chronic renal faliure, caltrate of calcium supplementation, calcitriol or 1, 25- dihydroxycholecalciferol for supplementation of Vitamin D deficiency due to chronic renal failure and ostelin or ergocalciferol to enhance calcium absorption. Another drug Alison is on is esomeprazole, a proton pump inhibitor to revent gastritis related to ESRD and also drug-induced. Alison is on salbutamol, a short acting beta-2 adrenergic receptor agonist for shortness of breath. Alison has a permacath in situ as confirmed by the chest X-ray. Upper limb vein mapping was nonsignificant. 8. Parkinson disease Alison is suffering from mild Parkinson disease since 6 years. The condition is a neurodegenerative disease that is progressive and is associated with loss of dopaminergic nigrostriatal neurons (Hauser and Pahwa, 2010). The main pathological features of this condition are lewy bodies and typical loss of dopaminergic neurons in the ventrolateral substantia nigra. The cardinal features of Parkinson disease are rigidity, tremors and brdaykinesia (Hauser and Pahwa, 2010). The fourth important feature is postural instability. It is because of this that Alison has tendency to fall often. Though the exact cause of Parkinson disease is not known, many believe that a combination of genetic and environmental factors is a cause in most cases. Alison has mild hydrocephalus and the Parkinson-like features are probably because of that. Also, uremia due to chronic renal failure can cause tremors. The standard symptomatic treatment is a combination of levodopa with peripheral decarboxylase inhibitor (Sinemet). Alison is on this combination drug. The drug decreases tremors and other symptoms of Parkinson disease and has minimal side effects except for development of dyskinesias and fluctuations in long term use (Hauser and Pahwa, 2010). Summary of findings or problem statement 76 year old Alison, a known patient with ESRD secondary to long standing diabetes mellitus and hypertension was admitted with complaints suggestive of right lower lobe pneumonia and uremia. Though he was placed on regular dialysis, he was nor compliant on treatment which resulted in uremia. Chest X-ray confirmed right lower lobe consolidation and serum creatinine and blood urea nitrogen confirmed uremia. Blood pH and serum electrolytes were within normal limits. Hemoglobin was 7g/dL. Other problems in Alison are ischemic heart disease, parkinsonism, dementia, right toe ulcer and depression. Nursing Care Plan Goals of treatment 1. Treat pneumonia and improve ventilation and oxygenation of tissues (Nettina, 2006). 2. Conserve renal function and maintenance of kidney function as much as possible (NICE, 2008). 3. Improve hemoglobin to 11- 13g/dL (NICE, 2008). Nursing assessment Careful history of the patient was taken, including past history and drug history. The respiratory rate, work of breathing and oxygen saturation were assessed besides auscultation of chest and chest X-ray review. This included elucidation of appropriate history pertaining to the chronic disorders and the health status of Alison. The degree of renal impairment was assessed using tests like serum creatinine, Blood Urea Nitrogen, urine creatinine clearance, glomerular filtration rate, blood pH, and serum electrolytes. Detailed physical examination including general physical examination and systemic examination was done along with review of laboratory results. The psychosocial response to the disease was reviewed along with resources available and the social support network present. During nursing assessment it was found that BUN and serum creatinine levels were very high. But electrolytes and blood pH were within normal limits. Alison did not have enough social support. he only support was his wife who was also fragile and weak. Alison was depressed because of the chronic state of his disease and dependence on others for day-to-day activities. The nurses looked for presence of sputum, accumulation of secretions and chest pain and dyspnea. The sputum secretions were sent for culture. Hemoglobin level, serum electrolytes, blood urea nitrogen urine specific gravity, urine electrolytes and daily weight were evaluated. Nursing diagnoses 1. Impaired gas exchange due to decreased ventilation secondary to inflammation and infection of the alveolar spaces. Short term goal: Restoration of normal respiratory rate, control of temperature and infection and improvement in oxygen saturations. Long term goal: Prevention of repeat epidoses and prevention of accumulation of fluid. 2. Ineffective airway clearance secondary to increased tracheo-bronchial secretions and accumulation of fluid secondary to chronic renal failure and fluid overload (Nettina, 2006). Short-term goal: Restoration of normal respiratory rate and improvement in oxygen saturation Long-term goal: Prevention of accumulation of fluid in the lungs 3. Excess fluid volume secondary to disease process 4. Pallor and low hemoglobin due to anemia of chronic renal failure and poor nutrition Short term goal: Increase in hemoglobin to 11g/dL Long term goal: Maintain hemoglobin between 11-13g/dL 5. Imbalanced nutrition as a result of restricted dietary intake, anorexia, vomiting and nausea Short term goal: Control symptoms related to uremia like nausea and vomiting Long term goal: Maintain kidney function as much as possible but prevent malnutrition 6. Risk of injury secondary to parkinsonism, and calcium deficiency Short term and long term goal: Safe ambulation 7. Ineffective therapeutic regimen management related to restrictions imposed by chronic renal failure and its treatment Short term goal: Dialysis with consent Long term goal: Compliance with treatment regimens 8. Accumulation of metabolites and other wastes due to inappropriate clearance by kidney resulting in uremia Short term goal: Control of uremia and restoration of normal fluid and electrolyte status Long term goal: Prevention of metabolic and fluid and electrolyte derangements Nursing interventions and rationale 1. Oxygen was administered through mask or other means as needed based on respiratory rate, oxygen saturations and arterial blood gas analysis. The aim of oxygen saturation was more than 92 percent. The patient was placed in semi-reclined position for maximum aeration and maximum lung expansion. The conscious level of the patient, tachypnoea and restlessness was monitored. The rationale behind this intervention was that pneumonia causes poor ventilation and ventilation-perfusion mismatch leading to decreased oxygenation of tissues and accumulation of carbon-di-oxide (Nettina, 2006). 2. Fresh sample of sputum, especially the early morning sample was sent for gram stain and culture. The patient was encouraged to cough, retained secretions were suctioned out, humidified oxygen was provided and chest wall percussion and postural drainage were provided to loosten and mobilize secretions (Nettina, 2006). 3. Managing fluid and electrolyte imbalance: Since regulating capacity of the kidneys is inadequate, signs and symptoms for hypovolemia or hypervolemia were monitored based on daily weight, urinary output, urinary specific gravity, serum and urine electrolytes, blood pressure, auscultation of lungs for rales, inspection of neck veins for engorgement and evaluation for signs and symptoms of hyperkalemia like tall T waves in ECG, etc (Nettina, 2006). Acid-base status was monitored using arterial blood gas analysis and, bicarbonate and fluid therapy were given accordingly. 4. Treatment of anemia: The patient was transfused with one unit of packed red blood cells to acutely rise hemoglobin (Drueke et al, 2006). This is important because the patient has poor ventilation due to pneumonia and anemia could worsen the oxygenation of the tissues (Nettina, 2006). 5. Treatment of infection: The patient was started on antibiotics for pneumonia. Since most often than not, bacteria is the cause and broad spectrum antibiotics like cephalosporins or augmentin were initiated intravenously even before the culture reports came. Once the culture reports were available antibiotics were changed accordingly. To control fever and discomfort paracetamol was given round the clock. 6. Management of chronic renal failure: This included low protein diet supplemented with essential aminoacids to prevent development of uremia, malnutrition and wasting; treatment of anemia using erythropoietin derivatives and blood transfusions as needed, treat acidosis with replenishment of bicarbonate stores with oral sodium bicarbonate; restriction of dietary potassium and administration of cation exchange resin to prevent and manage hyperkalemia; prevention of retention of phosphate by decreasing dietary phosphorus and by administration of phosphate-binding agents which bind phosphorus to the intestine. Since dialysis or kidney transplantation must be done when conservative management is no longer useful, dialysis was initiated (NICE, 2008). 7. Ensuring safe activity levels: This was done by monitoring the patients serum calcium and phosphate levels, inspecting the gait, range of motion and strength of muscles of the patient, administering analgesics like paracetamol as and when needed, increasing activity as tolerated by the patient, providing calcium supplements between meals to increase levels of serum calcium and by administering Vit D to increase the absorption and utilization of calcium (NICE, 2008). 8. Increasing the understanding of the treatment and compliance with treatment regimens: The patient was prepared for dialysis. He was offered hope that was tempered by reality. the patients understanding of the treatment regimen was assessed and the fears and concerns evaluated. Patient was provided adequate time for rest after dialysis. the meals were provided in small parts to prevent nausea and vomiting. Social support network was encouraged and a social worker was entrusted for the job (Nettina, 2006). A psychologist was asked to intervene to provide psychotherapy for depression. Holistic care Alison received person-centered care and the care and treatment took into account his needs and preferences. He was provided opportunity to make informed decisions about his treatment in partnership with his physicians and other health professionals. It is very essential to establish good communication between health professionals and Alison and the communication must be supported by information that is evidence based and tailored to his needs (NICE, 2008). The treatment provided was in accordance with his culture and spirituality. His wife and other dear ones were also be involved in the decision-making. His wife was provided appropriate support as needed (NICE, 2008). Expected outcomes 1. Stable blood pressure 2. Absence of excessive weight gain 3. Ambulation without fall 4. Asks questions, reads education material about dialysis and adheres to treatment regimens. 5. Decrease in fever and respiratory rate 6. Decrease in oxygen requirement and normalization of saturations 7. Improvement in blood urea nitrogen and serum creatinine levels 8. Rise in hemoglobin Conclusion 76 year old Alison is a know patient of ESRD secondary to diabetes and hypertension. He was admitted to emergency in view of right lower lobe pneumonia and worsening uremia due to poor compliance to treatment. Appropriate nursing assessment, diagnosis, interventions according to best practice guidelines caused improvement in the clinical status of the patient. Alisons expected outcome measures were met and he was discharged in 10 days time. References Anderson, H.S. (2010). Alzheimer Disease. Emedicine from WebMD. 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