Case study: End stage renal failure

End Stage Renal Failure

Presented by Jacynta F. Pepin (RN)

CASE STUDY

• Madam O, 78 years old, Chinese

• history of dyspnea and lethargy

TRIAGE• Temperature: 37.1 Celsius

• Blood pressure: 102/49mmHg

• Heart rate: 51 beats per minute

• Respiratory rate: 35 per minute

• SPO2: 95%

• Dyspnea• Lung crepts • Lethargic• Pale• Bilateral pedal edema• Disorientated to time,

place and people

• DM and HPT for more than 10 years

• Hemoglucose: 20.3mmol/L

• Ultrasound abdo: chronic renal parenchymal disease

• CXR: suspected basal pneumonia with pulmonary congestion

• Blood Test (Package B)

Potassium: 6.0mmol/L

Urea: 64.9mmol/L

Creatinine: 924µmol/L

• ABG: (with oxygen5L/min)pH 7.173PCO2 25.9 mmHgPO2 81.7mmHgHCO3- 12.8mmol/L

End Stage Renal Failure

Definition:

• The final stage of CKF when kidneys are unable to excrete metabolic wastes and regulate fluid and electrolyte balance adequately .

Causes• Diabetic• Hypertension• Chronic glomerulonephritis• Polycystic kidney disease• Others :

PyelonephritisInfectionMedicationToxins

• Filtration• Reabsorbtion• Secretion

Pathophysiology

GFR equation

• formula to calculate GFR:

= 186 × (serum creatinine[mg/dL])-1.154 × (age [years])-0.203× 0.742 (if female) × 1.210 (if African-American)

Alteration and Manifestation

•

NEUROLOGICAL SYSTEM

RESPIRATORY SYSTEM

CARDIOVASCULAR SYSTEM

GASTROINTESTINAL SYSTEM

RENAL SYSTEM

Treatment and Medicine• IV NaHCO3 8.4% (1 mEq/ml) in 50 ml • 1 ampoule of calcium gluconate 0.7 g in 10 ml• Actrapid subcutaneous injection TDS• Flagyl 500mg TDS and Meropenem 500mg

TDS• IV Atropine 0.5mg (PRN)

Treatment Option

• Dialysis :HemodialysisPeritoneal dialysis

• Transplantation

• Double lumen• Right jugular vessels• The tip should lie in the

superior vena cava just above the right atrium

Hemodialysis

• Each treatment takes about 4 hours and is done 3 times each week.

Management

• 3hours,ultrafitration of 1000mL • 2unit of plasma transfusion• oxygen via nasal cannula at 4L/min, • cardiac monitoring • insertion of a peripheral intravenous

catheter and an indwelling Foley catheter• 1000 mL fluid restriction • low protein diet

Nursing Care Plan

• Excess fluid volume related to failure of kidneys to eliminate excess body fluid and risk of volume deficit related to extraction from dialysis.

• Risk for infection related to invasive catheters and impaired immune function.

Excess fluid volume related to failure of kidneys to eliminate excess body fluid and risk of volume deficit related to extraction from dialysis.

Goal: maintain hydration

• Assess skin characteristic, signs of bleeding respiratory efforts and vital signs.

• Daily weight, I&O• Diuretics and antihypertensive medicines are withheld

during dialysis• Verify continuity of shunt and dialysis circuit• Assess for oozing or frank bleeding• Administer IV solution eg. Normal saline or volume

expander eg. Albumin.• Monitor serum sodium level and restrict sodium intake• Restrict fluid intake

Risk for infection related to invasive catheters and impaired immune function.

Goal: Prevent infection

• Assess for signs and symptoms of infection.

• Maintain asepsis with the catheter during dialysis.

• Avoid usage catheter for any purpose but hemodialysis.

Health Education• Teach about medications and

lab results.

• Self-monitoring BP andblood glucose levels.

• Interaction with members of the interdisciplinary team, eg. Dietician, social worker for financial information and support.

• Educate in preparation of AV fistula and dialysis.

Outcome

• transferred out from ICU• VS improved but she require a permanent

dialysis access ; arteriovenous fistula• refuse dialysis • dialysis treatment was abandoned• DIL, AMA

• On the fourth day, dyspnea ,wheezing , restless and drowsy

• chest X-ray obtained shows worsening of congestive cardiac failure

• condition deteriorating with falling blood pressure and heart rate

• unconscious and severe dyspnea• no urine output after 80mg of IV Lasix• confirmed death with caused of death of

Cardiac Failure

Conclusion

• Assessment of all body systems is essential.

• Education of patients about the management of ESRF.

• It is not easy to prepare patient for dialysis.

• Early prevention

Thank You