Chronic Kidney Disease - Clinical Issues Identified within the Clinical Scenario on Patient, Care Provision for the Top 3 Clinical Issues - Case Study Example

Case Study: Chronic Kidney Disease Name Institution Date Case Study: Chronic Kidney Disease Introduction Joe Thomas is faced with multiple challenges that involve ill health. This discussion paper will focus on three major clinical issues existing in the case study from a holistic perspective and this will encompass the respiratory distress which is the first priority, hypertension and hyperglycaemia. Additionally, the analysis of the case study will demonstrate how a community nurse is able to identify the priorities of care through a holistic and comprehensive client assessment and how to link the issues to care provision by using critical analysis to improve Mr. Thomas’s well- being. Clinical Issues Identified within the Clinical Scenario on Patient 1. Chronic kidney disease The patient was diagnosed with the condition two years ago and his renal function has deteriorated significantly 2. Diabetes The patient has type 1 diabetes, bilateral diabetic retinopathy, deteriorated eyesight and a left leg ulcer (Curhan, 2006). 3. Circulation Issues (Hypertension) This is indicated by the patient’s prolonged history of hypertension as well as the currents signs of strong pulse indicated by BP: 195/120 and edema indicated by very swollen legs (Berall, 2011). 4. Ego Integrity This is indicated by the patient’s stress factors such as financial problems and relationships with other individuals. Financial problems can be indicated by the fact that he is supported by Disability Support Pension while relationship problems are indicated by him living alone and has not seen his children since 2006. The fact that he has problems with the normal daily activities and cannot drive can lead feeling of helpless and hopeless. 5. Elimination Issues (Proteinuria) This is indicated by his current eGFR which is approximately 36 mL/min/1.73m2 6. Food/Fluid Issues This is indicated by edema and the patient being overweight because he weighs 110kg 7. Neurosensori Symptoms This can be indicated by falling, decreased eyesight, cellulitus in his lower left leg, soles of feet, and inability to carry out normal activities 8. Respiratory Symptoms The patient suddenly developed respiratory distress, SaO2: 91% on room air. 9. Social Interaction Symptoms Difficulty lowered condition, for instance the patient is not able to do his normal and does not maintain the function of roles in the family 10. Counseling Issues The patient has inadequate knowledge about his condition and treatment. For instance, the patient is reluctant to undertake regular BGL monitoring and does not take his insulin at a consistent dose or time. Additionally, the patient needs to be educated about his condition, his dietary intake, and usage of nephrotoxic antibiotics (Kerri, 2007). 11. Cultural Issues The patient is an Indigenous Australian and hence it is important to understand and take into consideration his cultural values during the entire treatment regimen (Dudgeon, 2010). Concept Map Care Provision for the Top 3 Clinical Issues 1. Controlling Respiratory Distress Controlling respiratory distress is the first priority for the patient because the patient suddenly developed respiratory distress, SaO2: 91% on room air and this is a life threatening state. Respiratory distress refers to inability of a patient to adequately oxygenate and is characterized by outwardly evident, physically labored respiratory efforts. The patient got respiratory distress when he was being administered with cephazolin. Basically, cephazolin results to adverse effect for patients with severely impaired renal function. Additionally, dyspnea which is breath shortness is an adverse reaction of the drug and thus the patient’s respiratory distress could have resulted from the reaction of cephazolin (Tams, 2009). Re-establishment of sufficient arterial oxygen tension and removal of excess CO2 are the most important immediate treatment for the patient. The most effective way of achieving this is through establishing a patent airway, establishing or assisting ventilation as well as maintenance of adequate oxygen tension through administering supplemental oxygen in order to maximize oxygen delivery (Kersten, 2008). In this case, the nurse will ensure that to create a patent airway by ensuring that patient’s airway is open and maintain an open airway through the head tilt-chin lift. To carry out a head tilt-chin lift maneuver, take one hand and place it on the forehead, pushing a little upward and backward. Lay the fingers of your other hand under the bony part of the chin and lift up. This will lift the chin far-off enough from the neck to move the tongue, therefore creating a patent airway. Oxygen therapy can be achieved through mouth-to-mask ventilation. The nurse will position herself at the head-side of the patient. While positioned at the head, the mask will be encircled with both hands at the same time trying to tilt the head back. The mask should then be held on the face to make sure there is adequate seal and then give the patient breaths into the filter mask (Limmer, & O’Keefe, 2009). The patient should also be placed in high-Flower’s position and the cardiac rate and rhythm should be monitored as well as monitoring the vital signs, consciousness level, in addition to pulse oximeter readings every 5 minutes until the patient is transferred to outside facility. The nurse will also prepare to transfer the patient to an outside facility that can provide a higher level of care (Limmer, & O’Keefe, 2009). Since patients with respiratory distress are normally acutely and most are in life-threatening states, it is important for the nurse to offer psychological to the patient care because there is a probability that the patient is frightened, anxious and distressed. Good psychological care will assist the patient in breathing more easily and effectively. Additionally, because oxygen can dry airways, it is appropriate to humidify the patient and keep the patient’s lips moist with a lubricant (Kersten, 2008). 2. Blood Pressure Control Strict blood pressure control is a high priority in the care of the patient because his BP is 195/120 and the blood pressure control is supposed to be less than 130/80 mm HG in all patients with chronic kidney disease. ACE inhibitors or angiotensin-receptor blockers (ARBs) can be used to achieve blood pressure control for the patient although a multidrug regimen is necessary. The patient has a history of hypertension and this contributed to the development of the patient’s CKD condition. The patient’s high blood pressure is a major risk factor for him and this can also be treated through dietary sodium cutback as well as fluid control. Additionally, the patient needs weight control and physical activity which can also contribute to the patient’s blood pressure control (Berall, 2011). Diuretics will be necessary for the patient due to the hypertensive effect of volume overload. Even though the goal blood pressure should be less than 130/80 mm/HG, the patient call for a more stringent goal where his blood pressure should be less than 125/75 mm HG because the patient has chronic kidney disease and substantial proteinuria as indicated by his current eGFR being approximately 36 mL/min/1.73m2 (NISHCE, 2008). Achieving the blood pressure goals is important in avoiding further kidney damage for the patient as well as slows the patient’s chronic kidney disease. In addition, in order to control the blood pressure of the patient, the following measures are necessary for the patient: Monitoring and recording of his blood pressure as indicated to provide objective data to monitor the patient’s blood pressure where increased levels might illustrate non-adherence to the therapy regimen Administration of antihypertensive medication as per the prescription because antihypertensive medications contribute greatly to the treatment of high blood pressure allied to chronic kidney disease The patient will be encouraged to comply with the dietary and fluid restriction treatment because adhering to diet and fluid restrictions plays a big role in preventing excess fluid as well as sodium accumulation The patient will also be taught how to report signs and symptoms of fluid overload, changes in vision, seizures, headaches and edema as well since these signs and symptoms indicate inadequate control of high blood pressure and hence there is need to change treatment (Collins, et al, 2005). The expected outcome in blood pressure control will be to have the patient’s blood pressure within the normal limits, the patient to report no headaches, visual problems or seizures and to ensure the patient does not have edema as it is indicated by his swollen legs (Hebert, 2003). 3. Glycemic Control due to the Patient’s Diabetic Condition (hyperglycemia) Tight glycemic control for the patient should be achieved because of diabetic condition. The aimed glycated hemoglobin level for the patient should not be less than 7.0 because the patient has diabetes (National Kidney Foundation 2002). Insulin lispro can be used to control the patient’s hyperglycemia. However, care should be taken during insulin administration and blood glucose level should be monitored regularly to regulate dosing and prevent hypoglycemia (Kerri, 2007). Since the patient has insulin-managed diabetes, he requires adjustment of his regimen to: Prevent escalating hyperglycaemia Lower risk of hyperosmolar hyperglycaemic state (HHS) Counter increased infection risk allied to hyperglycaemia Decrease symptoms of hyperglycaemia and boost general well-being. Insulin management should also be an aim in order to prevent increasing blood glucose levels. If there is not sufficient insulin supply, elevated production of counter-regulatory hormones lead to a rise within blood glucose levels such that it becomes more difficult to manage an infection. In addition, hyperglycaemia makes the patient to be more venerable to various sequelae and this includes elevated risk to infection, endothelial cell dysfunction as well as oxidative stress and this predisposes the patient to tissue damage (Kerri, 2007). Blood glucose of the patient should be monitored regularly to give the appropriate information to establish the insulin requirements of the patient. The chronic kidney disease the patient has may make his blood glucose levels to increase and thus monitoring the patient’s blood glucose levels regularly will provide information regarding dose adjustments with the aim of maintaining blood glucose levels or to return blood glucose to acceptable levels (Kerri, 2007). Conclusion Chronic kidney disease is a common disease affecting a larger percentage of population. Diabetes and hypertension are the major underlying cause of the disease and from the case study the patient has a history of both diabetes and hypertension. The patient requires drug regimens which include glycemic control, control of blood pressure, controlling proteinuria, as well as dietary intake adjustment. According to the indentified clinical issues, the patient requires multidisciplinary care which will include collaboration among doctors, nurses, pharmacists, dietitians, and social workers, and provision of the optimal system for maximizing the care for the patient. 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