CASE STUDY (Nephro)

Case Scenario

K.B. is a 62-year-old woman being admitted to the medical floor for complaints of
fatigue and dehydration. While taking her history, you discover that she has diabetes
mellitus (DM) and has been insulin-dependent since the age of 8. She has undergone
hemodialysis (HD) for the past 3 years. Your initial assessment of K.B. reveals a pale, thin,
slightly drowsy woman. Her skin is warm and dry to the touch with poor skin turgor, and
her mucous membranes are dry. Her vital signs (VS) are 140/90mmHg, 116 bpm, 18 cpm,
37.7° C. She tells you she has been nauseated for 2 days so she has not been eating or
drinking. She reports severe diarrhea. A complete blood count (CBC) has been drawn but
the results are not yet available. The following blood chemistry results are back:

Laboratory Test Results

Blood Chemistry

 Sodium 145 mEq/L

 Potassium 6.0 mEq/L
 Chloride 93 mEq/L
 Bicarbonate 27 mEq/L
 BUN 48 mg/dL
 Creatinine 5.0 mg/dL
 Glucose 238 mg/dL
Complete Blood Count
 WBC 7600/mm3
 RBC 3.2 million/ mm3
 Hgb 8.1 g/dL
 Hct 24.3%
 Platelets 333,000/ mm3
LEARNING TASKS:

1) What aspects of your assessment support her admitting diagnosis of dehydration?

Patient stated she has not been drinking for 2 days and her skin is warm and
dry to the touch with poor skin turgor, and her mucous membranes are dry.

2) Explain any lab results that might be of concern.

Elevated BUN and creatinine levels and elevated potassium level indicates
renal failure. Elevated glucose indicates diabetes mellitus.

3) Identify two possible causes for K.B.'s low-grade fever.

Dehydration and an infection.

The rest of K.B.'s physical assessment is within normal limits. You note that she has an
arteriovenous (AV) fistula in her left arm.

LEARNING TASKS:

1) What is an AV fistula? Why does K.B. have one?

A fistula is usually created in the forearm or upper arm with an anastomosis
between an artery and a vein. KB has it because it allows assess for
hemodialysis.

2) What steps do you take to assess K.B.'s AV fistula, and what physical findings are
expected? Explain.

Palpation, and auscultation. A thrill can be felt by palpating the area of

anastomosis and a bruit can be heard with a stethoscope.

3) As you continue the assessment, you notice that a nursing assistive personnel (NAP)
comes in to take K.B.'s blood pressure. The NAP places the blood pressure cuff on K.B.'s
left arm. What, if anything, do you do?

KB’s fistula is on his left arm and taking the blood pressure on that site could
damage the AV fistula and cause circulation problem. Call NAP to the side and
advise not to take blood pressure on left arm.
Case Progression:

K.B. is sent for a hemodialysis (HD) treatment. Over the next 24 hours, K.B.'s nausea
subsides, and she is able to eat normally. While you are helping her with her morning care, she
confides in you that she doesn't understand the renal diet. “I just get blood drawn every week
and meet with the dialysis dietitian every month—I just eat what she tells me to eat.”

LEARNING TASKS:

1) Because K.B. is on HD, what are her special nutritional needs?

Protein restriction, phosphate restriction, limiting fluid intake and decrease

in sodium and potassium and ensuring adequate calorie and vitamin and
mineral intake.

2) Based on the case, identify at least three (3) relevant nursing diagnosis, and develop a
comprehensive nursing care plan for the patient with emphasis on gerontologic
considerations.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Imbalanced After nursing  Monitor the client’s  To determine the After nursing
“I was been Nutrition: Less interventions the food intake. amount of food intervention the
nauseated for 2 than body client will have an that is consumed. client had increased
days.” as verbalized requirements increased nutritional intake
by the patient. related to nausea nutritional intake  Provide a diverse  This will and absence of
as evidenced by and absence of diet according to his stimulate the nausea and vomiting
Objective Data: inadequate food nausea and needs. appetite of the
T: 37.7° C intake. vomiting client.
PR: 116 bpm
RR:18 cpm Refer to a dietitian  Collaboration
BP: 140/90mmHg if indicated. with the dietician
in order to guide
the client about
proper nutrition.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Fluid volume After nursing  Assess skin turgor  The skin of After nursing
“I have severe deficit related to interventions the and oral mucous elderly patients interventions the
diarrhea.” as severe diarrhea client membranes for signs losses elasticity; client had
verbalized by the demonstrates of dehydration. hence skin turgor demonstrated
patient. lifestyle changes should be lifestyle changes in
to avoid assessed over the avoiding progression
Objective Data: progression of sternum or on the of dehydration.
T: 37.7° C dehydration. inner thighs.
PR: 116 bpm Longitudinal
RR:18 cpm furrows may be
BP: 140/90mmHg noted around the
tongue.
 Monitor fluid status
in relation to dietary  Most fluid comes
intake. into the body
through drinking,
water in food, and
water formed by
the oxidation of
foods. Verifying
if the patient is on
a fluid restraint is
necessary.
 Note the presence of  These factors
nausea, vomiting, influence intake,
and fever. fluid needs, and
route of
replacement.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Fatigue related to After nursing Discuss with the  Education may After nursing
“I am feeling fatigue decreased interventions the patient the need for motivate to interventions the
and dehydrated.” as metabolic energy client can activity. Plan increase activity client verbalized
verbalized by the production verbalize increase schedule with the level even though increase in energy
patient. in energy level patient and identify the patient may level and displays
and display activities that lead feel too weak improved ability to
Objective Data: improved ability to fatigue. initially. participate in desired
T: 37.7° C to participate in  Alternate activity  To prevent activities.
PR: 116 bpm desired activities. with periods of rest excessive fatigue.
RR:18 cpm and uninterrupted
BP: 140/90mmHg sleep.
 Discuss with the  Education may
patient the need for motivate to
activity. increase activity
level even though
the patient may
feel too weak
initially.
 Alternate activity  Prevents
with periods of rest excessive fatigue.
or uninterrupted Indicates
sleep. physiological
levels of
tolerance.
 Provide comfort  To be free from
and safety injury during
measures. activity.