NUR330 Advanced Medical Surgical Nursing

Renal Failure Stage

Abe is at the Renal Failure stage of Chronic Kidney Disease. This is the third stage of chronic kidney disease. At this stage glomerular filtration rate is reduced to 20%-50%. Abe’s GFR is 20 ml/min which is 16% of the normal (125 ml/min/1.73m2). At this point, the kidneys are not able to regulate the normal volume and solute composition. Patient develop oedema, metabolic acidosis, uremia, neurologic manifestation for example convulsions and encephalopathy, nephron destruction occurs leading to decreased phosphate excretion, changes in parathyroid function and lipid clearance noted, intestinal abnormalities are frequent with anorexia, nausea and vomiting.

The pathology test will would best indicate Abe’s renal function is Glomerular filtration rate. This is because it describes the rate of flow of filtered fluid through the kidney. Measure how kidneys are working through concentration of creatinine, urea as well as electrolytes to determine renal function (Webster, Nagler, Morton, & Masson, 2017). Glomerular filtration rate not only helps in detecting presences of renal abnormality but also assist in monitoring those already with or at risk of renal impairment. Moreover, it’s useful in calculating appropriate dose of drugs which can be cleared by kidney.

Educational Points to Prevent Disease Progression

Diet changes, reduce salt (sodium) in diet. Limitprocessed food such as frozen dinner, canned fish rather eat unprocessed food such as lean beef, and avoid the over the counter drugs with sodium bicarbonate. Limit potassium intake. Don’t eat whole-grain breads, wheat and milk. Limit phosphorus and protein rich food. Potassium and phosphorous cause weakness, muscle cramps, and irregular heartbeats while sodium limit reduce high blood pressure (Tomson, & Bailey, 2011). Regular physical exercise also helps lower blood sugar and blood pressure. Achieving a health weight improve heart and lung health.

Good blood pressure control and changes in lifestyle can help manage high blood pressure, for example, quitting smoking, regular body exercise, cutting down on alcohol and appropriate use medications also to control blood pressure. Smoking cause poorly and uncontrolled blood pressure and also affects medicines used to treat high blood pressure. Moreover, smoking slows blood flow to organs like kidney (Go, Chertow, Fan, McCulloch & Hsu, 2014).

Help reduce stress. It may take time to adjust to the disease and patient to keep involved in pleasures, activities and responsibilities of daily life. Share your feelings with family, relatives and close friends or joining support group (Go et al ,2014).

Taking medications as prescribed. Taking medication as prescribe by medical practitioner and avoid over the counter drugs such as anti-inflammatory drugs because they can damage the kidney.

Diabetes control through conservative management, for example, exercise, taking drugs as prescribed, regular check-ups and managing stress. Ensure also that there early management of complications of diabetes especially nephropathy (Tomson, & Bailey, 2011).

Health Improvement Interventions

Diet modification

Early protein restriction (daily intake to be 0.6kg), potassium restriction (Burton, & Harris, 2011). Salt and water restriction, daily water intake be 500mls plus output this slows progression of disease.

Management of complications

i) Anemia, treatment with hematocrit. Rule out iron and vitamin B12 deficiency. Administer recombinant erythropoietin since stimulate red blood cell production (Locatelli et.al 2011).

ii) Hypertension

Use of loop diuretics like furosemide and metformin and angiotensin converting enzyme inhibitor such as Ramipril to reduce blood pressure (Reddi, 2016) and restrict sodium intake.

iii) Hyperkalemia

Dietary restriction of food potassium containing food (Kidney Health Australia, 2012).

iv) Renal osteodystrophy

Reducing serum phosphate by restricting diet, use of aluminum based antacids and oral phosphate binders to bind phosphate. Administer calcium carbonate orally to increase level of calcium for bone formation.

Pharmacological intervention

Administer intravenous calcium to counteract cardiac toxicity, intravenous glucose and insulin to enhance potassium reuptake and also sodium carbonate to correct metabolic acidosis (Kraut, & Madias, 2016).

Emergency dialysis

This is the final recourse for the patient if he is unresponsive to conservative management and also if the glomerular filtration rate decreases to less than 15ml/min, that is, End stage Renal disease.

Compare and Contrast Risk and Benefits of Peritoneal Dialysi and Haemodialysis

Benefits

Peritoneal dialysis is less costly as compared to Haemodialysis because hospitalization rate is lower among the patients thus less cost of paying hospital bill. In Hemodialysis there is less patient responsibility because of hospitalization and patient care is mostly done by nephrology nurse or nephrologist (Levy, Brown, & Lawrence, 2016).

Peritoneal dialysis also enhances patient autonomy and this influence on prevention of peritonitis and offers Patient survival. Moreover, patient satisfaction is well achieved in peritoneal dialysis since the patients are more Involved in their treatment as opposed to haemodialysis. Residual renal function (RRF) is more maintained. This is a major contributor.

In peritoneal dialysis Thrombosis rate is unaffected and catheter- related problems are infrequent as compared to haemodialysis. There is fewer dietary Restrictions in peritoneal dialysis while haemodialysis has more dietary restrictions for it to be more effective (Sinnakirouchenan, & Holley, 2011). Hemodialysis carries a relatively Low risk of infection than that of peritoneal dialysis since it has a better tolerance.

Risks

Peritoneal dialysis has higher technique failure, that is, membrane failure and infection of the abdominal lining (Fento et.al, 2010), it disrupts daily schedule since it is a continuous treatment and all exchanges must be performed 7 days a week. There is weight gain since the dialysate contain sugar (dextrose). Risk of hernia in peritoneal dialysis because holding of fluids for long in abdomen strain muscles. Also patient and care giver burnout happens when there is continuous stress or distress.

Hemodialysis has risk of hypotension particularly in diabetic Patients and also bone disease due to abnormal hormone level which causes calcium and phosphorous level to be out balance. Risk anemia due to blood loss and muscle itching due to high level of phosphorous because phosphorous is not effectively removed during dialysis (Levy, Brown, & Lawrence, 2016).

There is also risk of infection due to catheterization, respiratory compromise such as shortness of breath, pericarditis and inflammation of the membrane around which leads to sudden cardiac death in people undergoing dialysis. Risk of irregular heartbeat likely to also occur due to high level of potassium in blood leading to cardiac arrhythmias.

Recommendation for Appropriate Treatment

I would recommend peritoneal dialysis. It’s a treatment that uses the lining of the abdomen

(peritoneum) and a cleaning solution which is the dialysate to purify blood. Dialysate absorb waste and fluid from the blood. I would recommend this for Abe because it is not done in a dialysis center but he can do it at home so long as it’s done in a clean and dry place. It’s also less costly as compared to haemodialysis and it allows more freedom to work, travel or to do other activities. There is also more freedom of what to eat and drink in peritoneal dialysis than in Hemodialysis. This is because peritoneal dialysis ha fewer dietary restrictions (Sinnakirouchenan, & Holley, 2011). The most important thing that Abe need to be careful is to prevent infection which mostly occurs through the catheter, it happens when the incision is not cleaned well or when he is connecting or disconnecting from dialysate bags.

References

Burton, C., & Harris, K. P. G. (2011). The role of proteinuria in the progression of chronic renal failure. American journal of kidney diseases, 29(7), 765-775.

Collins, A. J., Hao, W., Xia, H., Ebben, J. P., Everson, S. E., Constantini, E. G., & Ma, J. Z. (2011). Mortality risks of peritoneal dialysis and hemodialysis. American Journal of Kidney Diseases, 38(6), 1065-1074.

Fenton, S. S., Schaubel, D. E., Desmeules, M., Morrison, H. I., Mao, Y., Copleston, P., … & Kjellstrand, C. M. (2010). Hemodialysis versus peritoneal dialysis: a comparison of adjusted mortality rates. American Journal of Kidney Diseases, 30(3).

Go, A. S., Chertow, G. M., Fan, D., McCulloch, C. E., & Hsu, C. Y. (2014). Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. New England Journal of Medicine, 355(13), 1296-1305.

Kidney Health Australia. (2012). Chronic Kidney Disease (CKD) Management in General Practice.

Kraut, J. A., & Madias, N. E. (2016). Metabolic acidosis of CKD: an update. American Journal of Kidney Diseases, 67(2), 307-317.

Levy, J., Brown, E., & Lawrence, A. (2016). Oxford handbook of dialysis. Oxford University Press.

Locatelli, F., Aljama, P., Barany, P., Canaud, B., Carrera, F., Eckardt, K. U., … & Cameron, S. (2011). Revised European best practice guidelines for the management of anaemia in patients with chronic renal failure. Nephrology, dialysis, transplantation: official publication of the European Dialysis and Transplant Association-European Renal Association, 20, ii2.

Parfrey, P. S., & Foley, R. N. (2012). The clinical epidemiology of cardiac disease in chronic renal failure. Journal of the American Society of Nephrology, 20(7).

Reddi, A. S. (2016). Renal Pharmacology. In Absolute Nephrology Review (pp. 313-340). Springer, Cham.

Sinnakirouchenan, R., & Holley, J. L. (2011). Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues. Advances in chronic kidney disease, 18(6), 428-432.

Tomson, C., & Bailey, P. (2011). Management of chronic kidney disease. Medicine, 39(7), 407-413.

Webster, A. C., Nagler, E. V., Morton, R. L., & Masson, P. (2017). Chronic kidney disease. The Lancet, 389(10075), 1238-1252.