A Comprehensive Nursing Assessment for Renal Hemodialysis - Term Paper Example

TITLE: A COMPREHENSIVE NURSING ASSESSMENT FOR RENAL HEAMODIALYSIS (NAME) (COURSE NAME) (INSTITUTION NAME) 17TH APRIL, 2009 Introduction Nursing assessment is the collecting of information about a patient's physiological, mental and sociological status. The gathering of health data concerning a patient is important as it forms the basis for diagnosis and eventual administration of treatment by health practitioners. Renal heamodialysis is essentially used to offer an artificial alternative for the failed kidney function. It is also called renal replacement therapy. Dialysis as a treatment for renal disease uses the principle of the diffusion of solutes across a semi-permeable membrane. Kidneys regulate the body's internal balance of water and minerals such as sodium and potassium. Healthy kidneys eliminate from the blood the daily metabolic fixed hydrogen ions. The concentration of solutes in the blood such as potassium, phosphorus, and urea is undesirable and may lead to a patient collapsing. This paper gives a comprehensive nursing assessment for a patient with the problem of kidney failure. Techniques of nursing assessment A number of techniques have been employed in nursing assessment. These methods have to establish the history and carry out a physical examination of the patient. Some assessment techniques only centre on a specific feature of the patient's care. For instance, a Waterlow score looks at a patient's risk of developing a Bedsore (decubitus ulcer), a Glasgow Coma Scale assesses the conscious state of a person and pain scales which measure the "fifth vital sign" (Bookman, 2007). Of the existing techniques the Index of independence in activities of daily living (ADLs) as an assessment method is reviewed in this paper. ADLs Activities of daily living (ADLs) are things that people usually do in daily living for the purpose of self-care such as eating, showering, putting on cloth and grooming. The activities also include working, homemaking and leisure. Health practitioners normally explain that the capability or incapability of performing ADLs is an assessment of the functional status of a person. The ADLs measurement is helpful in assessing the elderly, the psychologically ill and persons with chronic illness so as to determine the type of health attention a person may require. The essential activities of daily living involve self-care errands such as using the toilet and feeding. An individual who has stable health conditions should be able to carry out the above daily tasks with much ease. However, persons that cannot carry out any or all of the above tasks on their own may be having critical malfunctioning of one or more of their body tissues. Therefore, such individuals require examination and fast diagnosis of their conditions. Instrumental activities of ADLs are not obligatory for basic functioning, but allow a person to live autonomously within a community such as light house work and shopping. Persons who are unable to undertake the above tasks may be starting to develop medical complications in their body parts and therefore need to be examined closely to prevent any further complications. A critique of the renal heamodialysis assessment tool (see appendix) The assessment tool chosen for the assessment of kidney failure is based on quality indicators. The first part involves the assessing the adequacy of the dialysis and incase of any change the reasons for the trend. The second part is about the access function and tests aspects such as haemostatic changes in the body of a patient. Other parts test on issues that are related to the blood such as anemia, diabetes and nutrition. The assessment tool then ultimately allows for physical testing of the patient on skin, tongue, hair among others. The tool meets the basic requirements of nursing assessment techniques as it has a section on physical examination of the patient. The tool also seeks to find out the intervention measures that have been employed to correct certain issues that led to the current kidney failure of the patient. The tool however falls short of building rapport between the nurse and the patient and family. Such a rapport is important as it helps to establish the health history and expectations of the patient. The assessment tool also lacks the testing the conditions of the patient in relation to independence in activities for daily living (ADLs). Kidney failure affects the way one carries out the daily activities. Therefore, it is important to establish the extent of ability or inability of a renal patient to perform such activities like using the toilet. Framework for carrying out a renal heamodialysis assessment To carry out a nursing assessment, it is necessary to develop a framework within which the process will take place. The framework has three stages namely; the initial stage of nursing process, Elements of a nursing assessment and lastly recording of the assessment. Pre- nursing assessment stage In the first stage of nursing assessment a nurse carries out a comprehensive nursing evaluation of a patient's needs not necessarily considering the current condition of the patient. The rationale of this stage is to find out the patient's nursing problems. The patient’s nursing concerns are expressed as either real or probable. For instance, a person who has been rendered motionless by a road traffic accident may be assessed as having the "probable for impaired skin related to immobility". This stage is important as it enables the nurse to predict before hand the likely outcomes of one’s condition. Components of a nursing assessment Examining the history of a person is the first component and helps the nurse to establish a rapport with the patient and their family. The nurse seeks to find out the events that precede the physical examination of the patient. The nurse finds out the health status of an individual and determines the course of current diseases including the symptoms. The nurse finds out how the patient’s conditions are being managed. The nurse examines the past medical history and at this stage, the family’s medical history is also taken into consideration. The other issues that the nurse seeks to find out in the patient’s history are the patient’s social history and how they perceive their illness. The second component of nursing assessment involves psychological and social examination. The nurse examines the client’s perception. The patient is asked to state the reason why they think they are being assessed and what they look forward to benefiting from the assessment. The emotional health of an individual is also examined at this stage to determine how the patient is coping with the disease. Another important aspect to test during this stage is the social health of a patient and involves assessing the status of a patient in terms of finances, relationships, job status and support networks. The nurse then assesses the physical health of the patient by asking the patient or family about general health, previous illness history, appetite, sleep pattern, alcohol and tobacco. The also nurse assesses the spiritual health of the patient by finding out whether to them religion is important. The third and last component of nursing assessment is the actual measurement of the condition of the patient that made them to be referred for examination. The actual testing allows the nurse to use the nursing assessment tool is the physical examination. The nurse observes and/or measures signs and symptoms such as nausea which in the patient. The nurse uses techniques such as palpation, Auscultation and Percussion. The nurse also measures other body variables like temperature, blood pressure and respiratory rate Documentation of the assessment The last stage of a nursing assessment involves recording and putting together the gathered information that when analyzed, conclusions can be drawn and recommendation made which allows for diagnosis and treatment of the patient. The assessment is stored in the patient's nursing records on paper or in digital medical records that can be accessed by others in healthcare team. Application of the nursing assessment framework in renal heamodialysis The above framework has been applied in the assessment of kidney failure. The following aspects are tested on a monthly basis in the assessment: An examination of the need for special diet nutritional supplements for the managing of renal failure. The assessment tool has a section on nutrition and examines whether a dietician has been involved in the nutritional managing of the patient’s health. An examination of the renal failure related anemia and the suitable treatment. The assessment also determines fluid overload, establishes an ideal dry weight and determines the need for antihypertensive medication. The renal heamodialysis involves a review of the dialysis records during which the records are updated. The monthly check up present a major strength of this assessment. The monthly assessment of the renal failure of an individual allows the nurse to keep track of all the changes in the health status of a patient and provide advice accordingly. The carrying out of a physical examination that involves laboratory testing and interpretations helps to establish the patient’s response to treatment. The assessment addresses both the physical and social concerns of the renal failure conditions which help to determine the motivation levels of the patient in seeking for the medical attention. In applying the above framework in the renal heamodialysis the assessment has failed to carry out examinations on psychological and spiritual aspects of the patient as far as their condition is concerned. The paper recommends that the assessment should be modified so that it is more interactive with the patient. The nurse should be in a position to establish the history of the patient and move with the patient until the cause for the current condition is established and appropriate curative measures carried out. References Bookman, A et al. Family Caregiver Handbook. Cambridge, MA: Massachusetts Institute of Technology, 2007. Appendix: Renal Heamodialysis Assessment Tool Month…………. Patient’s name…………. Year……… …. MRN…………… Primary Monthly Nurse Summary Quality indicators Adequacy of dialysis URR>65% Result…….. Have the values decreased? Yes… No…. (Reasons……………………………….) NOTES: Interventions……………………………… ………………………………………… Access function: Cannulation problems Yes…No... Arterial Inflow problems Yes….No… Welling of the access arm Yes….No… Homeostasis time increased Yes….No… URR decreased Yes….No… NOTES: Interventions……………………………… ………………………………………… Patient teaching on access care…………… Anemia: EPO dosage…………….Hypochromic cells(MVC)……..(80-98) MCHC…….(310-360) Energy level…………………..Haemoglobin level……………..(Target Hb 120 gm/L) Medication Review…………Se Ferritin……………………..(Target 300-800μg/L) Transferrin……………….(Target transferrinnSat 20-50%) Exercise participation……Yes…No….Type………………. Assess for Causes of Hypo-Response to EPO: Blood loss…. Renal bone disease……… Infection…… Hospitalizations………… Nutritional status Malignancy…………….. Dialysis prescription…… Hyperthyroidism………. Aluminum toxicity……….. Hematological disease… Nutrition: Albumin>40g/L Result………… Bone Disease Management: Serum CA (Corr) =2.2-2.6 Result…….. PTH Result…….. Counseling by Dietitian Yes…No… Medical Review………………. Teaching reinforcement by nurse Yes..No.. Notes: Problem list/Nurse Notes: Physical concerns:…………………………………………………………………………. ……………………………………………………………………………………………… Social Concerns……………………………………………………………………………. Diabetes Management: Patient diabetic Yes…No… . Medical Officer involved in care? Yes….No… Is patient aware of the need to see a foot specialist? Yes… No… Is patient aware of the importance of yearly optical check ups? Yes…No… Physical Assessment Skin Colour: Pink…Pale…Cyanotic…Sweaty…Uraemic frost…Perfused… Skin: Normal…… Dry…..Clammy… Oedema: Nil….Ankles…Lower legs… Tongue: Dry…Moist Uraemic oduor: Yes…No…. Gait: Steady…Assisted….Unsteady Mental status: Alert…Vague….Confused…Disoriented.. Respiratory: Normal….Productive coughs….Breathless….Wheeze….Dry cough… Access: Thrill….Bruit…..Bruising…. Hair loss: Yes…No… Wounds Yes …..No… Leg Ulcers….Abrasions…Scratch Marks….Skin grafts…Permanent Access… Swabs attended: Yes…No…. Hepatitis B Vaccination Status:……………………………… Completed….Refused…..Course: initial…2 month…4month…8 month….Booser…. BP control: Target Weight:…………………….. Target Systolic BP 130 mmHg Yes….. No….. Target Diastolic BP 85 mmHg Yes….. No….. Estimated target weight is correct Yes….. No….. Weight gain Read More