The purpose of this paper is to utilize the importance of evidence based practice in the clinical setting by incorporating the validity in planning care for the patients whom endure renal disease. Evidenced based practice is such a crucial part in obtaining as much knowledge needed to prioritize and efficiently plan care. This is why it is important for nurses to individualize a patient’s care because nursing care is not universal for all. This paper will review a retired tobacco/dairy farmer. He is an obese, 76 year old white male who was admitted to the hospital with complications from renal failure.
The kidneys play a vital role in the body by removing waste products and excess fluid in the body, which is performed through excretion of urine. This process is necessary to maintain a stable balance of chemicals in your body through excretion and re-absorption. The functions of the kidneys are to; balance the body’s fluids, remove drugs from the body, control the production of red blood cells, remove waste products from the body, and release hormones that regulate sodium and fluid in your body.
If the kidneys are unable to filter the blood by failing to excrete excess wastes and fluids there may be a build up in your body causing other complications. The warning signs for kidney disease are; blood/protein in the urine, high blood pressure (HTN), generalized edema, frequent and/or painful urination, glomerular filtration rate (GFR) of less than 60, and a blood urea nitrogen (BUN) and creatinine test outside the normal range (Moustakas, Bennett, Nicholson, & Tranter, 2012).
Assessment Data On admittance to the hospital, Mr. B was experiencing fatigue and excess weight gain of over 10 pounds in the last few weeks. Upon assessment at a measurement of 5 ft. 8 in. his weight was 219. 1 lbs. with a body mass index (BMI) of 33. 3. He complained of excess fluid accumulating in his upper and lower extremities. Mr. B had +1 pitting edema in his bilateral lower and upper extremities. During the last few weeks, Mr. B has said to be experiencing shortness of breath during exertion and often times at rest. He has had a decrease in urine output of less than 30 ml. an hour during his stay.
His appetite has decreased during his hospital stay due to his increase fatigue and lethargy. He is on a renal/non-concentrated sweets diet and only eats approximately 10%-15% of his meals. His lung sounds were clear in the upper lobes with diminished sounds in the bases of his lungs. His respirations were 22, oxygen saturation (O2 Sat. ) 96% on 2 liters nasal cannula. His blood pressure was 108/43, with a heart rate of 78. Mr. B developed a hematoma on his right arm from a previous fistula that didn’t infuse correctly during his previous dialysis treatment.
A central line was placed in his left chest during his stay due to the failed fistula. He developed a yeast infection in the left central line, which went septic and another central deep line was placed in his right IJ for future dialysis treatments. On admission Mr. B had an ECHO and an EKG done which displayed atrial fibrillation (AFIB) and an ejection fraction (EF) of 55%-65%. Mr. B has a history of atrial fibrillation and is currently on Coumadin therapy for thrombolytic prophylaxis. A chest X-ray was done that showed bilateral interstitial opacities and small pleural effusions.
These findings on the chest X-ray are relevant to renal disease due to excess fluid accumulation within the pleural cavity, which may conclude the diminished lung sounds found during auscultation. A CT Scan of the chest displayed patchy consolidation throughout, which may also support the excess fluid accumulation that can occur during renal failure. Mr. B’s glomerular filtration rate (GFR) was 20 ml/min which is low due to his kidneys not being able to function properly at filtering the blood. Due to his GFR being low, his D-dimer was elevated at 1315 ng/ml.
His blood urea nitrogen (BUN) was 70 mg/dL, and creatinine was 3. 22mg/dL which are both high levels as a result of his kidneys not being able to excrete excess nitrogen and urea, as well as creatinine from the blood. Mr. B’s urine chemistry indicated high protein levels in his urine (100-200) because of the inability of his kidneys to filter protein from the blood therefore excreting proteins as waste. As seen on Mr. B’s complete blood count (CBC), his red blood cells (RBC) are low at 3. 25, with a low hemoglobin (Hgb) at 9. 5 g/dL and his hematocrit (Hct) was also low at 30.2 %.
These findings may play a role in why Mr. B could be lethargic and fatigued. Brain type natriuretic peptide (BNP) was elevated at 33,700. This is likely due to the lack of clearance of BNP from the body due to his renal failure. His BNP may also be elevated due to his congestive heart failure, due to the increase workload on the left ventricle. BNP released by the heart may indicate decreased cardiac output, which may indirectly relate to excess fluid volume within the vascular system. Mr. B’s calcium level was also low at 7. 8.
This is likely due to his loss of appetite since most of the calcium we provide our body is through our diet. Due to his renal failure he is unable to absorb calcium as well, which also leads to low circulating calcium in the blood. Medications Mr. B is on Diflucan, this medication is an antifungal that is used to treat and prevent fungal infections in the body. Some common side effects associated with Diflucan are unusual weakness, fatigue, and loss of appetite. Mr. B experienced all of these symptoms during his stay which could have been a side effect of this medication.
He was on this antifungal for treatment of his yeast infection that he contracted from complications of his central line. Mr. B is also taking hydralazine. Hydralazine is used by relaxing the blood vessels so that the blood can flow through the body more easily which helps lower blood pressure in the body. Mr. B has high blood pressure and is on this medication to help control it. Due to his renal failure, his blood pressure is increased due to the excess fluid volume in his body. Some common side effects that Mr. B experienced during his stay while on this medication were constipation and loss of appetite.
He was prescribed Megace in the hospital to help stimulate his appetite as well as stool softeners to help with his constipation to make it easier for him to have a bowel movement. Mr. B was also given Drisdol during his stay. Drisdol is another name for Vitamin D, which is a fat-soluble vitamin that helps your body absorb phosphorus and calcium. This medication is used primarily to help promote bone density. When calcium levels are low in the body, the parathyroid glands produce increase amounts of the parathyroid hormone which causes the body to pull calcium from the bones to increase the amount of calcium in the blood.
This can happen when the kidneys are not functioning properly. During normal kidney function, the body turns Vitamin D into an active hormone which increases calcium absorption in the intestines which helps increase the amount of calcium that is circulating in the blood. This is why people who have renal failure are at risk for osteoporosis, fractures and other bone disorders because they are lacking in Vitamin D. This is why Mr. B is prescribed Drisdol to help his body absorb calcium. Drisdol is better absorbed in the body when taken after a meal.
However, it can be taken without food if necessary. Since Mr. B had a loss of appetite during his stay at the hospital, he was not getting the proper amounts of calcium in his diet. It is important for him to be on a medication that helps increase his calcium levels since calcium plays an important role in bone growth development. Calcium also plays a role in stabilizing blood pressure due to it being essential for muscular contraction for the heart to pump efficiently and is essential for blood clotting.
Calcium works in the body with vitamin k to help the blood clot and without adequate levels of these nutrients, the body is at an increased risk of bleeding. If someone is on a blood thinner it is important to monitor them more closely for signs of bleeding because they already bleed more than someone who is not on a blood thinner. Since Mr. B has a history of high blood pressure and is on Coumadin for the treatment of chronic atrial fibrillation, he is at risk for bleeding by reducing clot formation so calcium levels are important to monitor as well as his blood panel (Potts, 2012).
Presented with allergies such as; Cephalexin Monohydrate, Hydrochlorothiazide (HTCT), Lisinopril, Pseudoephedrine, Pseudoephedrine HCL, he should not experience any interactions with any of the medications he is taking. Once Mr. B’s renal system stabilizes and regains adequate function he will most likely be placed back on his Lasix which is a loop diuretic. Recent research has shown that loop diuretics are the hallmark pharmacological treatment for excess fluid volume.
To help facilitate optimal fluid status the dose of the loop diuretic may be titrated intravenously to fit specific needs related to fluid excess (Albert, 2012). Health Maintenance and Past Medical History While in the hospital, Mr. B displayed good general hygiene, and is up to date with his influenza, pneumonia, and shingles vaccines. He has been tobacco free for 14 years and denies any use of alcohol. Prior to his health declining in the past few years, he enjoyed being outdoors and remained active by walking at least a mile a day.
At home, his wife stated that Mr.B is pretty good at controlling his blood sugar on a daily basis by eating healthy, exercising, and taking his insulin as prescribed. Mr. B has a past medical history of; congestive heart failure (CHF), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), asthma, hypertension (HTN), anemia, diabetes mellitus, myocardial infarction (MI), hyperlipidemia, gastrointestinal reflux disease (GERD), benign prostatic hypertrophy (BPH), diverticulosis, vitamin D deficiency, skin cancer, renal disease, chronic back pain, right ankle fracture, cataracts, and depression.
He has had a past surgical history of; an angioplasty/stent placement in 2012, and removal of his right cataract, a colostomy, and a colon resection with colostomy reversal. Attributable to the fact that his mother past away of a myocardial infarction at the age of 64, Mr. B is more susceptible to vascular problems himself. On admittance of renal failure to the hospital, Mr. B’s primary diagnosis was excess fluid volume related to his kidney’s insufficient ability to filter out excess fluid from the blood.
His wife mentioned that he has gained about 10 pounds or more weight in fluid over the past few weeks. His chest x-ray showed bilateral interstitial opacities and pleural effusions, which means he has an accumulation of fluid in his interstitial space. He has had a productive cough with clear sputum and his lung sounds were clear in the bilateral upper lobes and then gradually diminished in the bilateral lower lobes. His diminished lung sounds may have been due to the pleural effusions found on the x-ray.
His CT scan displayed patchy consolidation which also could support his excess fluid accumulation. As previously stated, Mr. B’s abnormal lab findings of; a low GFR, increase BUN and creatinine, proteinuria, increase BNP, decreased Hgb, Hct, and decreased RBC are all indicative of renal dysfunction. His intake of fluids for the shift was 425ml and his urine output for the same shift was only 225 ml. which shows he was retaining 200 ml of fluid. As a direct result of his excess fluid retention, Mr. B’s secondary diagnosis was imbalanced nutrition related to inadequate food intake.
Inadequate food intake resulted in less than body requirements that his body needs to stay healthy. His kidneys inability to regulate excess fluid caused increased water retention in his extremities and throughout his body. He had +1 pitting edema in his lower and upper extremities. Excess fluid retention led to Mr. B being short of breath on exertion and fatigued. Being fatigued caused Mr. B to sleep large amounts during the day which caused him to not wake up much to eat his meals regularly resulting in a lack of nutrition. When Mr.B would wake up for meals he stated “this food isn’t like what she (his wife) fixes me.
Expected Client Outcomes The first outcome Mr. B would like to achieve is a urine output of at least 30 ml per hour. Mr. B should also show a decrease in fluid volume retention as evidenced by a decrease in body weight. The second projected outcome is for Mr. B to have normal lung sounds that are clear throughout with no diminished sounds. This will be assessed and evaluated by auscultation of Mr. B’s lung sounds by discharge.
The third important outcome for Mr.B to achieve upon discharge is decreased dyspnea, decrease edema in his lower and upper extremities, and improved activity level of at least walking short distances without getting short of breath. The fourth outcome we would like to see normal lab values pertaining to his kidney function and nutritional status before discharge. Mr. B is on 2 liters nasal cannula for comfort due to the shortness of breath he has been having. One of the outcomes we would like to achieve is to have Mr. B maintain oxygen saturation above 90% without use of oxygen before he leaves the hospital.
Since Mr.B hasn’t been having much of an appetite another projected outcome is for him to eat at least 75% of his meals so that he can get adequate nutrition which will also help improve his strength. Nursing Interventions Due to Mr. B’s kidneys inability to filter out excess fluid from his blood he was placed on dialysis to help filter out the blood and reduce the fluid volume. A foley catheter was placed upon admission to help keep better track of his intake and output. Although, Mr. B’s blood pressure was substantially low at 108/43 on initial assessment, he does have a long history of hypertension.
Evidence based researched presented by Lingerfelt & Hodnicki (2012) displays HTN as the major risk factor in the occurrence and prevalence of chronic kidney disease. This is why it is crucial for Mr. B to not only know, but as well understand and perform how to monitor his BP. Utilizing automatic BP monitor devices are very helpful when monitoring BP at home. Evaluating Mr. B’s weight on a daily basis will help measure how much excess fluid he is retaining and it’s also important before and after dialysis treatments to make sure adequate fluid is being removed (Schick, 2012).
Since Mr. B has had a decrease appetite since he has been in the hospital he was started on Megace, which is a medication that helps stimulate his appetite (Shumaker, 2009). Before discharge Mr. B may need to think more about gradually gaining stability while helping improve quality of life by an argument brought upon by Walsh & Fahy (2011) which argues; that many health care providers overlook the significance in stressing a healthy diet, and as a result neglect the patient’s weight management. Ultimately, setting Mr. B up for complications far more substantial in the future.
With being 5’8 in height and having a BMI at an elevated 33. 3 and weighing in at 219. 1 lbs. Mr. W. over displayed the qualifications needed for further education and reference to dietary. Since Mr. B has been complaining of shortness of breath at times, as previously stated he was started on oxygen to help him feel more comfortable and maintain adequate oxygen saturations above 90%. In addition to the oxygen, he was also given breathing treatments, which consisted of Albuterol-Ipratropium and Pulmicort.
Resulting from Mr.B’s condition he is lethargic and fatigued, it is important that he is given proper rest from daily routines, healthcare workers and as well as visitors. Untreated fatigue may greatly impact quality of life, which may lead to depression, weakness, increased dependency and social withdrawal (O’Sullivan & McCarthy, 2009). Due to the fact that Mr. B had an increase amount of swelling in his extremities, ace wraps were placed on his bilateral lower extremities to help increase venous return. While Mr. B is on hemodialysis and has a central line in place it is important to maintain a clean site.
Using Chlorhexidine soap would help fight against infections by sterilizing the ports used during dialysis. Based on cost of supplies evidence based practice has shown that using the Chlorhexidine soap is the most cost-effective while fighting catheter related infections (Bakke, 2010). Evaluation During the clinical shift, Mr. B did not meet the projected outcome, while still edematous in his upper and lower extremities and his urine output is still less than 30 ml. an hour. Given time, the projected outcomes for Mr. B will be achieved by meeting previously mentioned criteria for the given interventions.
Having an overall goal of decreased fluid volume excess with an increase in Mr. B’s quality of life, as evidence by; decrease in routine assessment of daily body weight, urine output of at least 30 ml. per hour, absent of diminished lung sounds, and maintains adequate oxygenation without episodes of shortness of breath. If the outcomes are not reached in the projected time, it is the nurse’s responsibility to suggest more drastic interventions to help reach the goals stated or develop a more realistic outcome to be reached for Mr. B.