Analysis of Chronic Kidney Disease - Case Study Example

Chronic Kidney Disease Case Study Introduction Chronic Kidney Disease (CKD) refers to conditions that damage kidneys and decrease ability to keep healthy of a patient. In order to supplement the failing kidney, kidney replacement therapy that includes dialysis is often prescribed. Failure to supplement the kidney dialysis function leads to accumulation of nitrogenous waste products that causes serious toxicity, multi-organ failure and finally death. Marcia is a typical patient with peritonitis with inadequate dialysis in chronic kidney disease. Her admission conditions of cloudy drainage and abdominal pain affirms complications of the ambulatory peritoneal dialysis she was put under two years ago. Assessment of CHD and Interventions Sighania & Mandalika (2012) state that likes any other patient, assessment of his patient should focus on history taking and physical assessment. Through history taking, numerous findings would be evident, firstly, the patient will complain of skin itching due to deposition of urea, often called uremic frost, fatigue, headaches and pain (Piraino et al., 2010). Although the majority of these findings are general, the laboratory findings would help confirm the diagnosis. On inspection, findings would include generalized edema because of poor kidney excretion function. CKD often presents with generalized pitting edema due to water retention caused by loss of Glomerular Filtration Rate (GFR) that causes sodium retention and subsequently water (Singh 2005). Secondly, the patient will present with weight loss due to protein loss through urine. Loss of kidney function also leads to increased filtration at glomeruli that allows larger particles like albumin to pass through urine. Besides, inspection of the sclera shows the pallor due to anemia. This is because of the release of erythropoietin, which is an important stimulator in red blood cells formation (Arici 2014). On auscultation, the patient will have crackles and shortness of breath. Certainly, in CKD there is a lot of fluid accumulation in the thorax region, causing pulmonary edema. Pulmonary edema creates limited area for lung expansion during breathing leading to shortness of breath and subsequent ventilation-perfusion mismatch (Meurier et al., 2011). However, these assessment findings are seen in the patient with CKD stages four and five. The case presented above represent an ideal end stage of renal disease that fit above clinical findings. Besides, because of the purulent discharge from the access, clinical findings may show elevated body temperature due to possible infections, peritonitis. Proposed Management of the Patient Daugirdas (2011) observes that because the patient has chronic hypertension and CKD, primary interventions should focus on controlling the levels of hypertension. Hypertension is certainly the primary cause and given the extent of this chronic condition; the focus should be on maintaining blood pressure as much as possible. Secondly, electrolyte and erythropoietin treatment should be a fundamental focus of the therapy. Moreover, the excess fluids should be eliminated using diuretic drugs. With compromised cardiac functions, the patient cardiac functions may lead to poor prognosis (El & Levin 2009). In addition, the therapy should focus on treating peritonitis. There should be culture and sensitive test of the cloudy discharge to establish the exact cause and embark on treatment using specific antibiotic (Bernardini et al., 2005). Peritonitis is a common complication of patients with artificial peritoneal dialysis. It shows a lack of patient education in caring the access site. It is proposed that management should include patient and family education on how to care for dialysis access. Ideally, peritonitis should not arise when a patient takes responsibility to ensure aseptic handling of the site (Kavanagh et al., 2004). Pathophysiology of CKD Secondary to Hypertension Singh (2005) notes that hypertension is a major cause of CKD. With high blood pressure, glomeruli vasculature is damaged. Evidently, glomeruli have thin walls and delicate lining that are often destroyed by high blood pressure. Damage exerted on glomeruli causes increased permeability of glomeruli that subsequently leads to increased loss of proteins. Ideally, the proteins are not supposed to be pass through these structures. As a result, many proteins such as creatinine, albumin and traces of other proteins in the urine. More often, microalbuminuria becomes evident and at this stage, the patient can be diagnosed of kidney disease (Klaus 2005). Li et al., (2010) identifies that the relationship of hypertension (HTN) and CKD is often cyclic. Elevated blood pressure as seen in many patients leads to damage of kidney micro-vessels. Increase in damage of kidney micro-vessels leads to increased permeability of the vessels hence subsequent reduction of kidney functions. With chronic and poorly controlled hypertension, the patient will suffer gradual kidney disease that eventually leads to end-stage kidney disease. Based on the GFR, CKD has been classified into five stages. Stage one involves a GFR of less than 90 mL/min/1.73 square meters for more than three months. Irrespective of any evidence of kidney damage, these patients are classified to have CKD. Stage two have GFR of 60-89. Stage three 30-59, stage four 15-29 and stage five has GFR of less than 15 (Bakewell et al., 2002). Notably, the two major outcomes include loss of kidney functions and development of cardiovascular disease. With this case study, it is evident that the primary cause was hypertension. Critically analysis of the stage of this patient, it is likely that the patient was likely at the fourth stage. This is because; she would still ambulate with help of ambulatory peritoneal dialysis. Potential and Actual Risk Factors of CKD Caravaca et al., (1998) observe that there are numerous primary risk factors for CKD; firstly, the case study chronic hypertension has been identified as the actual cause of the CKD. High blood pressure damages micro vessels at glomeruli leading to increasing filtration and subsequent loss of proteins through urine. Besides, damage of these vessels has been implicated in lowering GFR, thus the different stages of the disease. Moreover, HTN is one of the leading causes of fatalities in patients with CKD. Secondly, those above the age of 60 years have been identified as potential risk group. Although the physiological explanation is not clear, many believe that it is caused by a multiplicity of degeneration of structures that affect glomeruli. However, the patient presenting with the disease in this case study is 28 years old female. While the predisposing factors remain unknown, there should be a systematic family history. Because genetically predisposition has been implicated as possible risk factor, any positive family history would be an important hint in understanding the background factors. Thirdly, positive family history of the disease has been implicated as a potential risk factor. Studies have shown that CKD has potential familial inheritance. Smoking has been implicated by some studies as a potential risk factor due to its toxins lodging in the glomeruli thus damaging the vessels. Obesity has been identified as another risk factor though its mechanism is largely unknown. Established cardiovascular diseases and diabetes are primary diseases that have shown to predispose to CKD similar to hypertension. Several studies show a similar pattern of predisposition is majorly seen among majority of cardiovascular diseases shows glomeruli disruption as basis of CKD (Caravaca et al., 1998). Holistic Management of CKD Hurford & Hess (2000) note that studies show that appropriate management of CKD helps in delaying or preventing progression of the disease process. Unlike Acute Renal Disease (ARD), CKD is irreversible and, therefore, requires conservative and clinical interventions to control the devastating effects of the symptoms. It requires multi-disciplinary team ranging from nephrologists, nephrology nurse, dieticians and family. The patient forms the center of care while the various players executed varied, but synergistic roles (Voinescu & Khanna 2002). Moreover, effective management involves psychological domain of the patient and family. In the light of the case presented, it is evident that there are two cases involved, an infection (peritonitis) and CKD. Primarily, peritonitis is a result of poorly managed CKD and sepsis due to poor aseptic technique in caring for peritoneal access site (Segal & Messana 2013). Based on the complaints of cloudy discharge and pain at the abdomen, it indicates there was an infection. The effect has since compromised the dialysis leading to a lower Peritoneal Equilibrium Test (PET) as shown by the findings on admission. Critical analysis of this patient indicates two key clinical lapses. There was poor patient education that led to sepsis. Besides, hypertension management should be emphasized throughout the management. Wang et al., (2003) note that nutritional modification is a cornerstone in managing any kidney pathology. Two important dietary components include sodium and fluid restriction. Based on the physical assessment findings, these patients have generalized pitting edema; this is certainly fluid overload. According to Urden et al., (2006), fluid retention is caused by high sodium retention in the body. In order to reverse adverse effects of excessive fluids and reduce water retention, there should be an elimination of sodium and stringent fluid intake. This is where family and patient education comes in, with clear and precise instructions on diet with rationale for each diet modification; the patient and family will ensure uttermost compliance. The cost of managing CKD is certainly unforgiving psychologically, physiologically and economically. It is the nurses duty to facilitate patient education and family involvement in nutritional management. Anemia Management Management of anemia in CKD with or without dialysis requires treatment of anemia. The successful elimination of anemia entails replacement of iron stores often through intravenous iron especially in patients receiving erythropoietin therapy. As noted earlier, erythropoietin is often lost leading to low synthesis of red blood cells. A successful treatment of anemia requires nephrology nurse to embark on patient and family education on the importance of strict drug regimen. A growing body of evidence indicates that effective patient education leads to compliance and subsequent achievement of desired therapeutic goals. In addition, evidence existing has portrayed beneficial effects of exercise among CKD patients. Because of pulmonary edema and subsequently shortness of breath, exercise should be mild. It has been identified to have benefits in improving cardiac output and thus improved circulation. However, more researches are still ongoing. Certainly, medication is an integral component in the treatment of CKD. Anti-hypertensive drugs are important in managing CKD, although the patient has certainly suffered significant loss of many glomeruli, the antihypertensive regimen at this phase aims at reducing effects on continued high blood pressure. While the condition remains chronic, the clinical staff should ensure patient blood pressure is controlled. Besides, diuretics such as thiazides and potassium-sparing ant diuretics helps in alleviating effects of excessive fluid overload and ensure balanced electrolytes. Unlike the past clinical management of CKD, the recent studies show that these patients suffer huge emotional and psychological devastation (Szeto et al., 2007). When diagnosed with CKD, many people develop the despair, and the journey through kidney disease would be a nightmare. Psychological and clinical counseling ought to go hand in hand to ensure a good prognosis. Some of the reason for hospitalization involves the despair, frustration and inability to act. It is important to understand the background reasons why the patient developed peritonitis. More importantly, it would be crucial to establish whether there are any signs of psychological disconnect or possibilities of despair. Since this is a lifelong disease, many patients have been reported to show negligence in self-care and thus increased cases of complications. One of the areas often overlooked is sexuality. Studies show that CKD causes low sexual urge due to decreased libido. While such issues remain largely unexplored, the effects could harm individual wellbeing. It kills self-image and compromise on the self-worth. Arici (2014) suggests that when patients come with reduced compliance on basic aseptic techniques, nephrology nurse should examine issues beyond physiologic disease. Impact of CKD to Patient Family and Clinical Staff Implications of CKD on Patient CKD present devastating consequences on the patient, family and the clinical staff. Patient is certainly the primary causality that bore greatest brunt of the disease. Patients often suffer from physical ailments that include shortness of breath, puffy face due to edema and psychological stress due to feelings of impending death. Notably, unlike an infection, CKD is a lifetime disease and eventuality is often fatal. With this in mind, patients tend to withdraw from others and often develop the despair. However, effective patient and family education and counseling support helps the patients to navigate these physical and psychological demands positively. Because of fluid retention, they often wake up with a swollen face, sometimes asymmetrically, this causes impaired self-image, and self-esteem goes down. Based on the frustration-aggression theory, many of these patients may resort to aggression. It is important for primary nurse to educate the family on this psychological implication in order to develop a positive environment for these patients. Patient ought to be taught on self-monitoring, care of the access site and sign of complications. Besides, psychological counseling is an important clinical intervention that would help alleviate patient distress. Effects of Family Family suffers the cost of mediation, evidently, when Marca develops purulent discharge from access site coupled with declined GFR; the family is forced to have a patient taken back to the hospital. Besides, there should be periodic clinic follow-up based on severity; this is an additional financial burden to the families. As the patient undergoes severe psychological and emotional liability, the family is the immediate recipient of these aggressive behaviors. CKD is one of the conditions that causes family psychological, social and economic disturbance. The disease process is usually long, frustration to the family. Certainly, the home caregivers bore the biggest burden in managing peritonitis (Bender et al., 2006). Impact on Clinical Staff Clinical staff often develops a clinical and a long-term relationship with the patient. Notably the primary nurses for these patients have to continually ensure the patients adhere to medication while in the hospital and facilitate a successful follow as the need. These patients are often demanding, conducting dialysis and ensuring stringent weight monitoring as an important indicator of the fluid overload parameter is certainly demanding t clinical staff. Based on medication, follow up schedule and long-term partnership with CKD patients, the implication to the nursing and clinical staff has been increased burden of care. Sadly, many of these patients often succumb in the long run, as a primary nurse, losing a long-term patient is a professional challenge and comes with psychological distress. With many patients in need of dialysis coupled with lengthy time needed for successful therapy, there is often frustrating to the clinical staff to have long queues. Limited dialysis equipment and a growing population in need of dialysis pose crucial challenges to the clinical staff. Critical Appraisal of the Management of DKA Fundamentally, collaborative management of these patients with CHD aims at regressing hypertension and other cardiovascular diseases. The current guideline that focuses on a wide range of factors including nutrition, physical and psychological element is perhaps the most definitive intervention that would see increased compliance with drugs and positive health outcome. In recognizing the importance of collaborating psychological and dietary modification into clinical management, it was one of the important steps in ensuring that clinical symptoms management is left on the hands of the patient and home-care givers (Van Diepen et al., 2012). However, there is still a monumental challenge in designing drug regimen. When a patient develops CKD due to hypertension, it has been difficult to balance the drug use and the potential nephrotoxicity. Carvedilol, for instance, remains controversial in controlling hypertension due to its nephrotoxicity defects (El & Levin 2009). The success of drug therapy will largely depend on choosing a combination that while treating symptoms; they do not jeopardize the function of a diseased kidney. Another dilemma in managing CKD is seen when the number of drug regimen are prescribed while all of these drugs are eliminated through kidneys. Although drugs such as thiazides, Lasix and other diuretics are primary in treating edema, they are often cleared so far fast, thus reducing residual effects in the long-term treatment (Argentero et al., 2008). Arici (2014) states that United Kingdom, Europe and the entire globe, there are four integral elements recognized as pillars in managing CKD patients. Firstly, pharmacological therapy, drugs are given in combination to reverse glomeruli destruction, reverse protein loss and treat anemia. While it is important, the clinicians should consider nephrotoxic effects and cardiovascular complications. Secondly, the protocol recommends self-care management, where patient monitors infections, complications and any clinical deviations. Thirdly, referral for nephrologists review and renal diet specialist are important areas of emphasis. Lastly, the current conventional, management is anchored on follow up. Due to the long-term nature of the disease and severity of complications, family and patient education has been identified as the cornerstone in ensuring compliance. Summary and Recommendation Chronic kidney disease is one of the chronic disease whose effects not only not only patient, but also family and clinical staff has felt. The burden of management is overwhelming to all stakeholders. Evidently, dialysis is the ultimate lifetime treatment with nutritional and psychological counseling making important subsidiary clinical management. However, balancing pharmacologic agents remains a challenge in a patient with impaired kidney function. In addition, peritonitis is a common side effect in hemodialysis and peritoneal dialysis. I recommend that in the future, patients with CKDs should be taught on self-dialysis and equipment provided through Community Health Workers (CHW) instead of having long queues in hospitals. References List Argentero, P., Dell’Olivo, B., Ferretti, M.S., 2008. Staff burnout and patient satisfaction with the quality of dialysis care. Am. J. Kidney Dis. 51, 80–92. Arici, M. 2014. Management of chronic kidney disease: A clinicians guide. Bakewell, A.B., Higgins, R.M., Edmunds, M.E., 2002. Quality of life in peritoneal dialysis patients: decline over time and association with clinical outcomes. Kidney Int. 61, 239– 248. 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