Benchmark – Case Study: Mr. D.
Case Study: Mr. D.
Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit this completed template to the assignment dropbox.
Case Study: Mr. D.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the lifespan.
Evaluate the Health History and Medical Information for Mr. D., presented below.
Health History and Medical Information
Mr. D. is a 65-year-old male non-adherence diabetic with end-stage renal disease receiving dialysis. He is a retired certified public accountant in the last 5years and practices the Muslim faith. He reports that he avoids all pork products. His complaints included decreased balance, loss of sensation, fear of falling, and decreased endurance during activities of daily living due to the effects of dialysis treatment. Patient’s previous medical evaluation includes end stage renal disease (ESRD) on dialysis and referral for recommendations for initiating exercise program. Patient comorbidities include obesity with a body mass index (BMI) of 45, type II diabetes mellitus with long-term insulin use, hypertension, sleep apnea, depression with lack of family support and understanding, and diabetic neuropathy. Patient denies suicidal ideation but does report feelings of loneliness and helplessness. Mr. D. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months.
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Objective Data:
- Height: 68 inches; weight 134.5 kg
- BP: 140/94, HR 84, RR 22
- 2+ pitting edema bilateral feet and ankles
- Fasting blood glucose: 146 mg/dL
- Total cholesterol: 250 mg/dL
- Triglycerides: 312 mg/dL
- HDL: 30 mg/dL
- Serum creatinine 1.8 mg/dL
- BUN 32 mg/dl
- GRF (glomerular filtration rate)-13mL/min
| Clinical Manifestations Describe the clinical manifestations present in Mr. D., focusing on the normal and abnormal findings and how this relates to his current condition. | |
| Subjective | Decreased balance Loss of sensation Risk of fall Decreased tolerance to activity Dyspnea with exertion Swollen ankles Pruritus Feelings of loneliness and helplessness |
| Objective | Class 3 obesity: BMI-46.4 Tachypnea Elevated blood pressure of 140/94 2+ pitting ankle and feet edema bilaterally Hyperlipidemia Hyperglycemia Elevated creatinine and BUN levels |
| Potential Health Risks for Diabetes WithEnd-Stage Renal Disease Identify the potential health risks for a diabetic with ESRD and the impacts of non-adherence. | |
| Identify the potential health risks for a diabetic with end-stage renal disease (ESRD) that are of concern for Mr. D. | Diabetic nephropathy is a potential health risk for a diabetic patient with ESRD. Patients develop microvascular complications caused by damage to the small blood vessels that supply the kidney’s glomeruli (Natesan & Kim, 2021). The patient develops thickening of the glomerular and tubular Basal Membrane. Another risk is arteriosclerosis and hyalinosis of afferent and efferent arterioles and tubulointerstitial fibrosis (Natesan & Kim, 2021). |
| How does Mr. D.’s non-adherence to his diabetes self-management plan for DM Type II contribute to ESRD? | Diabetes mellitus is a leading cause of chronic kidney disease and ESRD. The patient’s medication non-adherence led to chronic hyperglycemia and abnormal glucose metabolism, which contributed to insulin resistance (Natesan & Kim, 2021). Insulin resistance contributes to impaired insulin sensitivity, which leads to kidney failure. |
| Describe the common considerations with insulin use for practicing Muslims. | The clinician should consider safe insulin use in Muslims who are fasting. This is because prolonged strict fasting increases the risk of hypoglycemia and diabetic ketoacidosis in people with diabetes (Ochani et al., 2023). Insulin therapy should be continued when fasting, provided there is proper titration of insulin to the patient’s needs. The patient should be advised to assess blood sugars regularly through finger pricking (Ochani et al., 2023). If the patient has symptoms of hypoglycemia, dehydration, or acute illness, the fast should be broken. |
| Pathophysiology of Renal Dialysis Explain the pathophysiology of renal dialysis. | |
| Explain the pathophysiology of renal dialysis. Compare peritoneal dialysis and hemodialysis. | Renal dialysis is a therapy initiated in patients with ESRD. It takes over the kidneys’ regulatory and excretory functions but not the kidneys’ endocrine function. Renal dialysis removes excess fluids and waste products and restores chemical and electrolyte balance (Bello et al., 2022). The principles used in dialysis include: Diffusion: Removes waste products, including BUN and creatinine, from the blood Filtration: Filtration is controlled by hydrostatic pressure. Fluid moves from an area of higher pressure to an area of lower pressure and helps to regulate fluid balance in the blood. Ultrafiltration: Involves controlled fluid removal by manipulating hydrostatic pressure using both positive and negative pressure (Bello et al., 2022). In peritoneal dialysis, the peritoneum is used as a semi-permeable membrane for diffusive removal of solutes (Bello et al., 2022). Hemodialysis entails passing the patient’s blood through an artificial semi-permeable membrane to carry out the filtering and excretion functions of the kidney. |
| Describe in detail the pathophysiological explanation and stages of renal disease that lead to ESRD. | ESRD occurs following the progressive, irreversible loss of kidney function. It is diagnosed when there is kidney damage or GFR of less than 60ml/hr for three months or longer (Gupta et al., 2021). A patient with kidney failure undergoes five stages to reach ESRD: Stage 1: Kidney damage with normal or increased GFR; GFR ≥ 90ml/min (Gupta et al., 2021). Stage 2: Kidney damage with mild reduction in GFR; GFR 60-89ml/min. Stage 3: Moderate reduction in GFR; GFR of 30-59ml/min. Stage 4: Severe reduction in GFR; GFR15-29ml/min. Stage 5: This stage is regarded as ESRD. It is marked by Kidney failure with GFR ˂15ml/min (Gupta et al., 2021). |
| Explain the potential factors that contributed to Mr. D.’s ESRD. | The risk factors for ESRD include advanced age, African American race, overweight/obesity, high blood pressure, diabetes mellitus, diabetes mellitus, a history of heart disease, proteinuria, hyperlipidemia, elevated serum creatinine level, a history of smoking, drug abuse, and family history of ESRD (Gupta et al., 2021). The potential factors that led to ESRD in Mr. D include: Aging-65 years Obesity and hyperlipidemia History of hypertension High serum creatinine level. |
| Functional Health Problems Evaluate Mr. D.’s functional health patterns. | |
| Evaluate each of Mr. D.’s functional health patterns using the information given. | Value/Belief Pattern- The patient follows Islamic religious beliefs and does not consume pork products since it is against his beliefs. He does not value Diabetes treatment interventions as he does not adhere to medications. Health Perception/Management: The patient has a deprived state of health based on his history of ESRD, obesity, type II diabetes mellitus, hypertension, sleep apnea, and depression. Nutrition/Metabolic: The patient has severe obesity and high cholesterol levels. He reports having pruritus. Elimination: Mr. D has kidney failure and is on dialysis with a GFR of 13mL/min. Activity/Exercise: The patient cannot tolerate activity and exercise. Sleep/Rest: The patient has sleep apnea, which could affect his sleep quality. Cognitive/Perceptual: Mr. D reports having a decreased balance and loss of sensation. Self-Perception/Self-Concept: The patient’s comorbidities have affected his self-concept, leading to reports of loneliness and helplessness. Role/Relationship: Mr. D has no family support, and his family fails to understand him. Sexuality/Reproductive: The patient’s health, including activity intolerance, may affect his sexual activity and level of sexual satisfaction. Coping/Stress: The patient lacks family support, which affects his ability to cope during his illness. His poor health is a major stressor leading to depression. |
| Discuss at least five actual or potential problems you can identify from the “Functional Health Patterns Assessment Guide,” located in the Topic 3 Resources. Provide a rationale for each. | 1. Activity/Exercise: Activity intolerance, as evidenced by diminished endurance when carrying out activity. This can be attributed to altered cardiopulmonary tissue perfusion secondary to decreased blood supply to the myocardial tissue due to a decreased cardiac output (Ansari et al., 2020). 2. Nutritional/Metabolic: The patient has severe obesity with a BMI of 45.0, caused by energy intake being greater than energy output. 3. Sleep/Rest pattern- The patient experiences sleep disturbance from sleep apnea, usually contributed by reduced lung capacity in obese persons (Ansari et al., 2020). 4. Elimination: The patient has an impaired kidney function evidenced by ESRD requiring dialysis and lab results showing high BUN and creatinine levels and a GFR of 13mL/min. 5. Coping/Stress: The patient reports having depression with a lack of family support and understanding. He also reports feelings of loneliness and helplessness, which increases the risk of worsening depression and suicidal thoughts/ideas (Rahman et al., 2020). |
| Nursing Health Management and Health Promotion Provide ESRD nursing management and health promotion opportunities. | |
| Provide ESRD nursing management and health promotion opportunities. | Correction of extracellular fluid volume overload through water restriction. Nutritional therapy: Restriction of protein, phosphate, sodium, and potassium (Naber & Purohit, 2021). Restriction of vitamin-rich foods due to their high potassium levels (Naber & Purohit, 2021). The nurse should advocate for adjusting drug doses to the patient’s degree of renal function. Health promotion opportunities: Lifestyle modification in diet and physical exercises (Lambert et al., 2022). |
| Develop a patient education plan for ESRD that could be offered to Mr. D. for prevention of future events, health restoration, and maintaining renal status. | The patient education plan for Mr. D’s ESRD will target lifestyle modification to delay the progression of kidney damage and improve the quality of life. 1. Diet- The patient will be educated to modify his diet by taking a low-protein diet for adequate protein metabolism and to prevent proteinuria (Naber & Purohit, 2021). 2. Diet- A DASH diet will be recommended to lower his BP and prevent further kidney damage. The DASH diet also helps in weight loss and lowering blood glucose levels. 3. Physical activity- The patient will be educated to gradually increase his physical activity levels to the level he can tolerate. He can engage in low-intensity exercises like walking, bicycling, swimming, and rowing and gradually increase the intensity based on tolerance levels (Lambert et al., 2022). 4. Medication adherence: The patient should be educated on the importance of medication adherence to achieve optimal BP and blood glucose control. Lowering BP will slow the progression of kidney damage. |
| Assume Mr. D. lives in your community. Include community resources and supportive care available for Mr. D. for ESRD care and management at home. | Community resources and supportive care for ESRD patients include: Kidney transplant coordination services Dialysis locator services Palliative care networks Organ Procurement and Transplantation Network Financial assistance resources Caregiver assistance programs Food programs-Meal on Wheels Community Support Groups- Online and face-to-face meetings (Rahman et al., 2020). |
| Discuss the nurse’s role in using the holistic multidisciplinary care approach that would be safe and effective for patients like Mr. D., including aspects such as devices, transportation, eligibility for transplant, living conditions, promotion of resiliency, and independence. | The nurse has a role in ensuring Mr. D receives holistic multidisciplinary care and refers the patient to the appropriate specialists or professionals to meet his different healthcare needs (Collister et al., 2019). The nurse should coordinate a team of healthcare professionals to support and counsel the patient and meet his health needs. The nurse collaborates with the dietitian to evaluate the patient’s nutritional needs (Collister et al., 2019). The nurse collaborates with the social to help the patient access resources such as Organ transplantation services, financial aid, housing, and transportation (Rahman et al., 2020). The nurse also collaborates with the palliative care nurse to address the patient’s palliative care needs, discuss his prognosis, and ensure treatment plans support the treatment goal (Collister et al., 2019). |
References
Ansari, S., Haboubi, H., & Haboubi, N. (2020). Adult obesity complications: challenges and clinical impact. Therapeutic Advances In Endocrinology And Metabolism, 11, 2042018820934955. https://doi.org/10.1177/2042018820934955
Bello, A. K., Okpechi, I. G., Osman, M. A., Cho, Y., Cullis, B., Htay, H., Jha, V., Makusidi, M. A., McCulloch, M., Shah, N., Wainstein, M., & Johnson, D. W. (2022). Epidemiology of peritoneal dialysis outcomes. Nature Reviews. Nephrology, 18(12), 779–793. https://doi.org/10.1038/s41581-022-00623-7
Collister, D., Pyne, L., Cunningham, J., Donald, M., Molnar, A., Beaulieu, M., Levin, A., & Brimble, K. S. (2019). Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review. Canadian Journal of Kidney Health and Disease, 6, 2054358119882667. https://doi.org/10.1177/2054358119882667
Gupta, R., Woo, K., & Yi, J. A. (2021). Epidemiology of end-stage kidney disease. Seminars in vascular surgery, 34(1), 71–78. https://doi.org/10.1053/j.semvascsurg.2021.02.010
Lambert, K., Lightfoot, C. J., Jegatheesan, D. K., Gabrys, I., & Bennett, P. N. (2022). Physical activity and exercise recommendations for people receiving dialysis: A scoping review. PLOS ONE, 17(4), e0267290. https://doi.org/10.1371/journal.pone.0267290
Naber, T., & Purohit, S. (2021). Chronic Kidney Disease: Role of Diet for a Reduction in the Severity of the Disease. Nutrients, 13(9), 3277. https://doi.org/10.3390/nu13093277
Natesan, V., & Kim, S. J. (2021). Diabetic Nephropathy – a Review of Risk Factors, Progression, Mechanism, and Dietary Management. Biomolecules & therapeutics, 29(4), 365–372. https://doi.org/10.4062/biomolther.2020.204
Ochani, R. K., Shaikh, A., Batra, S., Pikale, G., & Surani, S. (2023). Diabetes among Muslims during Ramadan: A narrative review. World Journal of Clinical Cases, 11(26), 6031–6039. https://doi.org/10.12998/wjcc.v11.i26.6031
Rahman, M., Jager, K. J., Andreoli, S. P., Van Biesen, W., García García, G., Walker, R. C., … & Hemmelgarn, B. (2020). Supportive care for end-stage kidney disease: An integral part of kidney services across a range of income settings around the world. Kidney International Supplements, 10(1), e86-e94. https://doi.org/10.1016/j.kisu.2019.11.008