HLT51612 Nursing

The current topic focuses on the concept of nursing practices and implementation strategies which helps in the redressal of the health condition of a patient suffering from chronic kidney disease. The assignment also takes into consideration end of life palliative care strategies which helps in easing the pain or alleviated health symptoms faced by the patient. The assignment emphasizes upon the nursing policies which are relevant in providing long-term care.

The study conducted help in analysing the pathophysiology of the patient and the relevance of the medical treatment and diagnostic process in comprehending the current problem situation of the patient. The assignment focuses on Lucy who is a 66-year-old patient and had been living with her husband and four children.

However, Lucy had been restricted to Darwin owing to her deteriorating health condition. She has to be on constant haemodialysis and repeat the sessions three times a week. The assignment further emphasizes upon designing daily activities log which helps in the management of the present condition of the patient. The reflections also help in understanding the outcomes of the nursing care and designing of alternate methods.

Medical history and present status of the patient: 

In this context, the patient had a plethora of medical conditions and history. Some of these were coronary artery disease, gout, and type 2 diabetes mellitus. The patient here was on constant haemodialysis for the past three years owing to end-stage renal failure. The patient had also undergone thrombectomy and fistuloplasty in the year 2006. The patient had also rejected graft failure due to immunosuppression and had repeated admission to hospital owing to cryptococcal meningitis.

 Additionally the past medical condition of the patient required for collaboration from a number of medical channels. Therefore, the only measure which could be undertaken for controlling the progression of the CKD in the patients was to put the patient on haemodialysis.  In the present context, Lucy had been admitted to the hospital owing to infection caused by Cryptococcus group of bacteria. The microbial agent had been seen to cause opportunistic infections in solid organ transplants.  Lucy had been admitted to the hospital with the relapse of the infection every time. Though, the rate of the infections could be controlled by calcineurin-inhibitor immunosuppressive agents.

 However, the incidences of relapse are often associated with immune reconstitution inflammatory syndrome. Lucy also had a past history of haematoma which could be attributed to relapse of microbial infection caused by the formation of a right brachiobasilic fistula. Therefore, the only avenue left to Lucy over here was undertaking regular heamodyalysis. However, for conducting dialysis the openings or the fistula needs to be created through which the purification of the blood is channelized. This could become the site of new infections by permitting the entry of microbes.

Pathophysiology of the patient:  

The patient Lucy had been suffering from end-stage renal disease owing to diabetic neuropathy. Therefore, the patient had to be on haemodialysis three times a week which limited her travelling to the countryside to meet her children. The patient had been suffering from end-stage renal disease also called Chronic Kidney Disease (CKD). At this stage, the kidneys fail to meet the sufficient filtering requirements of the body. The loss of the filtering capabilities leads to accumulation of harmful and toxic waste substances in the body of the patient. There are ways for the management of the chronic kidney disease in patients such as kidney transplant or haemodialysis.

The incidents of transplants are often related to the occurrence of secondary infections in the body of the receiver.  The infections are lethal in origin and often arise as a result of the rejection of implants which triggers secondary immune reactions in the body (Sinclair, Day, Levett?Jones & Kable, 2017).

The progression of the disease occurs slowly and exhibits a number of symptoms in the patients ranging from fatigue, loss of appetite, frequent need to urinate or difficulty in producing sufficient quantity of urine. Sometimes the condition of CKD is confused with the presence of other disturbances such as hepatobiliary disturbances (Vann et al., 2015). The signs and the symptoms of the kidney diseases vary considerably among different age groups of people. The problem situation is often aggravated in the presence of other chronic sicknesses such as diabetes.

One of the most common symptoms which had been noticed in the ones affected with progressive disorder of the kidney is Proteinuria. It is characterised by the presence of excess or elevated levels of protein in the urine of an affected individual. The presence of diabetic neuropathy in the patient over here could be related to the occurrence of foamy urine, renal oedema and hypertension. The same could be attributed to excessive sodium retention due to lack of proper kidney functions and hyperglycaemia.

In this context, Lucy developed end-stage renal disease owing to diabetic neuropathy. Thus, diabetic neuropathy is often characterised by the presence of a number of clinical conditions at the same time such as proteinuria, high blood pressure and renal oedema being some of the few(Sim et al., 2015). The Diabetic Kidney Disease (DKD) develops in 30-40% people with diabetes and, out of which one third may develop kidney failure (Harvey et al., 2015).  Particularly in patients with type 2 diabetes often experience atherosclerotic kidney changes.

The presence of chronic kidney disease has often been related to other co-morbidities such as cardiovascular disease as impaired ultrafiltration also affects the rate of circulation. Additionally, decreased reabsorption of important nutrients from the fluids within the renal distal convoluted tubules leads to a deficit of some of the important constituents such as calcitriol. The less concentration of calcitriol further stimulates the synthesis of parathyroid hormones which leads to increased absorption of calcium from the bones leading to osteoporosis or other bone-related disorders.  Additionally, the presence of co-morbidities such as diabetes further increases the risk of progressive neuropathy in the patient manifold times (Sinclair et al., 2017).

Medications and special considerations prescribed for the patient:

Lucy had been suggested with a number of different medications for controlling the different co-morbidities faced by the patient. Some of the medicines which had been suggested to the patient are aspirin, Calcitriol, 1250 mg oral calcium tablets. Additionally, the patient was also given folic acid for the restoring and maintaining the blood haemoglobin level. The patient was also given omeprazole 20 mg oral daily along with daily doses of insulin. The aspirin was suggested for the prevention of the development of cardiovascular disease in an individual.

 As asserted by Hayes, Douglas & Bonner (2015), the presence of chronic kidney disease in an individual could be related to the development of disease of the coronary arteries. This could be attributed to the impaired blood ultrafiltration, which also affected the rate of blood circulation. Lucy had also been substituted with high doses of Calcitriol as the decreased functioning of the proximal tubules of the kidney lead to less absorption of calcitriol.

The reduction in the amount of calcitriol leads to stimulation of the parathyroid gland leading to over secretion of para thyroxine.  The para thyroxine selectively absorbs calcium from the bones to restore blood calcium level. This results in the weakening of bones leading to conditions of osteoporosis in the patient. Therefore, Lucy had reportedly been showing symptoms of gout which had made the activities of daily life difficult for her.

In this context, a number of medical tests were conducted for understanding the pathophysiology of the patient. The normal creatinine is supposed to be within the range of 45-90 µmol/L, whereas in the case of Lucy the creatinine was recorded at 486 µmol/L. The presence of high amount of creatinine is evident of the fact the process of ultrafiltration does not occur properly (Fried et al., 2013). Additionally, the haemoglobin per ml of the blood of the patient is 86 g/L which is much below the normal range of haemoglobin specified for a female that is 115-165 ml. Though the sodium is present in an amount less than the normal concentration, the calcium is within range. However, as argued by Zwar et al., (2017), the normal levels of calcium could be due to the supplementary doses.

 In this respect, some of the tests conducted such as the Hematocrit measures a number of red blood cells present per ml of the blood. The clinical records of Lucy show that she has less Haematocrit volume pointing towards the loss of blood in urine due to impaired ultrafiltration. The friction and the TSAT tests were conducted to measure the amount of iron or haemoglobin present in the blood of an individual. The iron concentration was relatively low pointing at impaired ultrafiltration. The presence of high amount of urea and creatinine points at the low or reduced glomerular filtration rate.

Rationale justifying the present case: 

The present section focuses on the concept of chronic kidney disease which is a present health debacle affecting people globally. The stressful lifestyle of people along with unhealthy habits such as increased tendency to smoking, drinking can produce serious impact upon the kidney filtration rate (Davy et al., 2015). Additionally, there seems to exist a correlation between There has been a gradual rise in the numbers of chronic kidney diseases and requires immediate medical intervention and policies. However, the chronic kidney disease is mentioned as a silent killer in medical literature and is seldom exhibited in symptoms (Reilly et al., 2016). The only way to check or measure the presence of a kidney disease is through measurement of estimated glomerular filtration rate.  A decreased GFR often points towards the presence of a progressive kidney disease and needs medical intervention.

In the present case study, the patient had been suffering from a number of clinical and co-morbid conditions at the same time. The patient had been a long-term condition of diabetes mellitus or type 2 diabetes. The patient here Lucy had reportedly also shown symptoms of gout and coronary artery obstruction.

These could be related to the presence of hyperglycaemia in the patient which had resulted in neuropathy damaging or obstructing veins and arteries, blocking the normal flow of blood. In the present circumstances, the chronic diabetic condition of the patient resulted in the development of chronic kidney diseases. The presence of high glucose in the blood causes the kidney to filter in an excess amount. This perpetually builds pressure on the kidney filters affecting the normal filtration power of the kidneys. The filters gradually lose their retention powers resulting in leakage where the body is not able to hold on to the vital proteins. The excess proteins are then released in the urine resulting in the situation of proteinuria.

Discussion of the diagnosis and the treatment methods: 

The current study focuses on the concept of relevant nursing practices implemented for the treatment and care provider of a patient suffering from end-stage renal progression. Here, the patient Lucy had been receiving haemodialysis three times a week and is also affected with a number of co-morbidities. Some of the additional clinical ailments which had affected Lucy include type 2 diabetes along with coronary artery disease and gout. The patient had also been provided with grafts sessions which had resulted in severe immunosuppressant in the patient.

The patient had also developed cryptococcal meningitis which leads to recurrent hospital administration of the patient. In this respect, one needs to mention that the presence of a number of co-morbidities could lead to confusing result regarding the treatment and intervention plans which need to be provided to the patient. The present medication routine followed with the patient includes administration of high doses of aspirin for the prevention of future cardiovascular diseases.

However as argued by Thirsk, Moore, & Keyko  (2014), the incorporation of such high doses of aspirin could lead to corrosion of the walls of the stomach or even lead to severe pain in case of overdose. The haemodialysis could be followed up with a holistic care regimen. The implication of such methods helps in controlling high levels of glucose in the blood of the patient.

Some of these activities include following a diet which is rich in minerals as impaired ultrafiltration results in loss of the important nutrients from the blood of an individual. The present health condition of the patient possesses a number of restrictions pertaining to the health of the patient.  Therefore, the support from the care professionals serves an important purpose. However, some of the effective measures which could be implemented for controlling the deterioration in the present health condition of the patient are monitoring the diet of the patient strictly.

Additionally, provision of supplements such as Calcitriol can also help in maintaining the blood calcium level. However, the patient here had been provided with acid suppression therapy by providing with 20mg of omeprazole daily. The consequences of which are debatable as acid suppression therapy have been seen to increase the risk of kidney injury in an individual by triggering the formation of polycystic kidneys.

The screening of chronic kidney disease involves a number of screening and investigation procedures. Some of these methods are conducting a thorough physical examination, conducting laboratory tests and conducting other imagery tests such as ultrasonography for detailed analysis. The test is further conducted based upon the past health records of the patients such as past or family history of nephritic diseases along with obesity and other co-morbid conditions such as diabetes are some of the other factors. As commented by Wu, Hsieh, Lin, & Tsai (2016), the age of the patient often serves as a governing factor for the screening and analysis process

Some of the imaging methods and techniques which could be employed over here are conducting an ultrasound with Doppler effects. The assessment of the size and the echogenicity of the kidney can have important diagnosis value (Di Marco et al., 2014). Thus, conducting the test reveals some of the abnormalities such as the presence of kidney stones, hydronephrosis (Carolan, Smith, Hall, & Swallow, 2014). The presence of these symptoms should point at the need of referral to a urologist. For patients like Lucy with a number of clinical conditions and associated co-morbidities, conducting the colour Doppler test would have been instrumental in finding out the pathophysiological condition of the internal organs.

Additionally, some of the laboratory tests could be conducted over here which includes estimation of the glomerular filtration rate, urine analysis and measurement of spot albumin-to-creatinine ratio. In this context, as Lucy is suffering from an end-stage renal disease which calls for regular follow up through imaging and clinical tests. She needs to be followed with the urine dipstick test which helps in the analysis of the presence of abnormal levels of proteins and other components within the urine of an individual.

Generation of daily activities log in relation to nursing care:

The nursing care in order to provide sufficient support and required medical interventions of patients like Lucy had been discussed over here. In this context, Lucy had been suffering from a number of chronic ailments and co-morbidities at the same time. One of the major concerns here has been the chronic kidney disease for which the patient had to be on dialysis three times a week. Additionally, the patient had also been affected with some other co-morbidity such as coronary artery disease and arthritis.

A past attempt in establishing as successful graft in the patient had led to subsequent hospital administration due to cryptococcal meningitis. Therefore, the only option left for looking after the cause of the patient is to provide her with the smooth or painless end of life care. However as argued by Gansevoort et al., (2013), one of the complications associated with chronic kidney disease is the management of effective medication. In this context, the patient had been suffering from a number of co-morbidities which effective documentation and data recording of the medicines given to the patient throughout the day.

The deteriorating health condition of the patient had also resulted in restriction of the daily activities of the patient.  In this respect, the comprehensive screening process is required as the CKD develops in gradual stages. Some of the symptoms need to be taken into consideration for effective management and treatment of chronic kidney disease such inefficiency in emptying the bladder, nocturia, recurrent urinary tract infections, history of nephrolithiasis. One of the most common diagnostic methods which could be employed is an assessment of the fluid status of the patient. The measurement of signs of dehydration and fluid overload helps in analysing the current status of the nephritic ultrafiltration rate of the patient.

In the context of Lucy, repeating the spot urine albumin-to-creatinine ration helps in the estimation of the permissible levels of creatinine within the urine of an individual. Thus, obtaining values between 30-300 mg the test needs to be repeated within a week. However as argued by Thompson-Martin, McCullough, & Agrawal (2015), the measurements of the tests are often misleading. This is because exercise, fever or severe emotional stress can also adversely impact the albumin-to-creatinine ratio.

A physical examination could be followed by a thorough abdominal analysis for noticing the presence of renal enlargement, tenderness or presence of renal bruits.  Here, Lucy owing to her current medical condition had been restricted to Darwin and could not travel or meet her children.  Additionally, she had been suffering from other associated conditions such as diabetes and coronary artery disease. Thus, undertaking a holistic process would have been beneficial in providing the patient with sufficient mobility and self-managerial skills (Krum et al., 2014).

The daily activities records could be maintained in the form of checklist and log book. This is particularly useful in the context of Lucy who had a number of co-morbidities. As commented by Stevens & Levin (2013), the nursing profession needs to maintain a safe record keeping of the health history of the patient. This is particularly useful in providing the patient with the exact medication and doses. Further, the checklist helps in keeping track of the important medications which had already been provided to the patient as erroneous medication administration could be fatal for patients like Lucy.

In order to access the current situation of Lucy, a number of observatory methods could be employed by the nursing profession.  Some of the methods include conducting urine analysis of the patient on a fortnightly basis. In this context, as the patient had reached towards end-stage renal failure, therefore constant assessment methods could help in preventing severe outcomes in the patient.  The urine analysis would help in estimating some of the important factors such as albumin to creatinine ratio (Angeli et al., 2015). The analysis of the ratio helps in estimating the presence of excess proteins in the blood. A detailed analysis of the medical reports of Lucy pointed towards a slight rise in the level of potassium.

Management of CKD:

The management or the methods of treatment of a chronic kidney disease mainly emphasizes upon rennin angiotensin aldosterone blockade (RAAS) and blood pressure control. For the provision of optimum care and support to patients such as Lucy management of common co-morbid conditions such as cardiovascular disease and diabetes needs to be taken into consideration. One of the most common methods which could be employed over here for the management of chronic kidney disease in an individual is the Rennin Angiotensin Aldosterone Blockade (RAAS) therapy.

The therapy could be designed with either an Angiotensin Converting Enzyme Inhibitor (ACEI) or angiotensin receptor blocker (ARB). The ACEI or the ARB is the preliminary antihypertensive treatment employed for patients with chronic kidney disease and is recommended for patients with albuminuria (Edvardsson et al., 2014).  The angiotensin results in greater amount of vasoconstriction of the efferent arteriole than the afferent arteriole leading to glomerular hypertension (Toussaint et al., 2015).  As commented by Dwarswaard, Bakker, Staa, & Boeije (2016), the process leads to prolonged hyperfiltration resulting in structural and functional glomerular deterioration.

As asserted by Goraya, Simoni, Jo, & Wesson (2014), implementation of ACEI methods has also been seen to increase the levels of potassium and serum creatinine levels. However, as argued by Ikizler et al., (2013), dual RAAS therapy has been seen to worse the signs of the chronic kidney disease and result in hyperkalemia. Though, some additive anti-proteinuric effects are observed when both the RAAS agents are used together.

Therefore, dual RAAS therapy should only be suggested to patients with severe albuminuria, which is less than 1mg/day (Han et al., 2013). Additionally, spironolactone has been seen to reduce albuminuria. Several studies have been conducted pointing towards the use of combination therapy of albuminuria and one of the RAAS therapies. However, there are a number of restrictions for the application of such process in the ones with concomitant heart or coronary artery disease.

As mentioned by Roth et al. (2013), a level exceeding the saturation amount signals towards the inculcation of more haemodialysis sessions. This helps in the sieving of excess proteins and urea which gets accumulated in the blood.  Additionally, the patient Lucy here being affected with long-term type 2 diabetes or diabetes mellitus needs to be under constant monitoring and supervision. The constant assessment helps in monitoring the excess blood glucose level which helps in the prevention of other alleviated symptoms such as gout or arthritis (Delanaye et al., 2016).

Reflections on the outcomes of the nursing care:

In my role as a nursing professional looking after the care needs of patients like Lucy, I had faced a number of difficulties pertaining to the assessment and management of the multiple co-morbidities of the patient.  Thus, maintaining an e-health record would have helped me in maintaining the severe complications faced by Lucy. However, lack of sufficient funds and support from additional medical channels restricted my objectivity and efforts. The severe arthritic condition had also made it impossible for her to go and meet her children residing in the countryside.  Additionally, the patient also reported of diabetes and coronary artery disease.

Therefore, inculcation of holistic approaches within the daily schedule of the patient such as light and brisk walking along helped me in the management of patient health.  Here, the patient had been undergoing end-of-life care and treatment process. Therefore, the aim of the nursing profession should provide the patient with sufficient autonomy and enough space for decision making. For this purpose, the family members of the patient should also be involved in the care and decision-making process. This helps in maintaining a positive care culture around the patient.  In my role of catering to the complex health concerns of Lucy, i felt that maintaining a record or a log book helped me in maintaining a list of the important medications to be administered to the patient.

Conclusion:

The current assignment focuses on the nursing procedures and policies which had been implemented over here for catering to the complex health concerns of Lucy.  The lady here had been receiving the end of life care and treatment process owing to renal failure and had to be on haemodialysis three times a week. The management of the complex health conditions of the patient required intervention and support from a number of healthcare channels. Thus, inculcation of regular testing methods along with holistic care regimen can help in controlling the deterioration of the health status of the patient. Additionally, incorporation of important policies such as patient autonomy and informed decision making can help the patient and their respective families have sufficient amount of say in the care planning.

The assignment also helps in understanding the importance of the tests in understanding the current health status of the patient and the scope of opportunities held by the test in analysing the health of the patient.

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