Question

April Holiday,a 54 year old female client ,is going for her first hemodialysis today .The client is scheduled to receive hemodialysis three times weekly and is on a fluid restriction and renal diet.The client's vital signs are T,98 F ,BP,110/70 mm Hg,HR,100 beats/minute;RR,22 breaths /minute.The client has has no pain but stated that she feels very fatigued and has constipation.The nurse notes that the conjunctiva and mucous membranes are pale.The client has a pale sallow coloration of her skin.The hemoglobin is 8 g/dL and hematocrit is 24%.The client is currently taking the following medications to help alleviate anemia.Ferrous sulfate 200 mg. po three times daily ,multivitamins with folic acid,B complex one daily ,and epoetin alfa (Procrit) 50 units/kg/dose subcutaneously on the days of dialysis.The Procrit medication is available in 4000 units/ml.a single dose vial.The nurse weighs the client,noting she is 50 kg..The LPN/LVN needs to provide nursing management for the client's anemia.

a. What dose of Procrit should the nurse provide the client and what are the administration consideration?

b.Explain the nursing management for the clients anemia?

Answer 1

a. What dose of Procrit should the nurse provide the client and what are the administration consideration?

Dose prescribed = 50 units / kg/ dose on the days of dialysis

Dose available = 4000 units / ml

Client’s weight = 50 kg

First we will calculate the required dose of Procrit.

As the prescribed dose of Procrit is 50 units/kg/ dose on the days of dialysis and the client is weighing 50 kg.

So on putting her weight we will get the dose required for her.

Required dose = 50 units X 50 kg

= 2500 units on days of dialysis

She needs a dose of 2500 units of Procrit on days of dialysis.

Now we need to calculate the volume of Injection Procrit required to administer the calculated dose.

The formula is

As the dose calculated as per order is = 2500 units

Dose available = 4000 units

Volume available is = 1 ml

So on putting values dose(volume ) required to administer a calculated dose

=( 2500 / 4000) X 1 ml

= 0.625 ml

So the nurse should administer a dose of 0.625 ml of Injection Procrit to client weighing 50 kg at a prescribed dose of 50 mg/ kg , form a vial of Procrit having 4000 units/ ml on the days of dialysis.

Procrit is used to treat anemia caused by chemotherapy, chronic kidney disease or anemia caused by taking some antiviral drugs used for the treatment of HIV/ AIDS. While administering Procrit to the client nurse should consider the following points:

· Explain the patient about risk of serious heart problems, such as heart attack or heart failure, and stroke or even death may occur on use of Procrit. So this information should be communicated to the patient and administer on the client’s consent only.

· High blood pressure is a common side effect of Procrit in patients with chronic kidney disease. Blood pressure may go up or be difficult to control with blood pressure medicine in a patient already having hypertension while taking Procrit. Or a normotensive patient who never had high blood pressure before may become hypertensive. So nurses should frequently check the blood pressure of the client. If blood pressure is elevated, either new or more doses of antihypertensives are required. So measure blood pressure and do not give Procrit if the client is having uncontrolled high blood pressure.

· It should not be given to the patient having a history of Pure Red Cell Aplasia (PRCA) or developing it after starting treatment. So evaluation of the type of anemia should be done.

· It should not be given if the client is an allergic reaction to Procrit. Also, inform the patient to report if develop symptoms of allergic reaction like rashes all over the body, shortness of breath, wheezing, dizziness and fainting (because of hypotension), swelling around mouth or eyes, fast pulse, or sweating. If such symptoms of a serious allergic reaction occur, stop using Procrit and get medical help right away.

· There is a risk for blood clots formation (thrombosis) on Procrit use and resulting complications. So inform patient to report immediately if experiencing any of these symptoms: chest pain, difficulty in breathing or shortness of breath, pain in legs, with or without swelling, cool or pale arm or leg, sudden confusion, difficulty in speaking, or understanding others' speech. sudden numbness or weakness in the face, arm, or leg, especially on one side of the body, sudden trouble seeing, sudden difficulty in walking, dizziness, loss of balance or coordination, loss of consciousness (fainting) or if hemodialysis vascular access stops working. If other medications like blood thinners are prescribed to help prevent serious side effects. Keep using these medicines for as long as they are prescribed.

· Prescribe the smallest dose of Procrit that is necessary to reduce the chance of needing blood transfusions. Calculate and administer the required dose only.

· Each single-use Procrit vial (bottle) of this medicine is for one use only. Throw it away after one use, even if there is still medicine left inside.

· Store Procrit in the refrigerator and protect it from light. Do not freeze Procrit. The frozen injection should be discarded. Do not use if the medicine has changed color or has particles in it.

· Do not shake a Procrit vial.

· Advise client to follow prescribed diet and medicines, including medicines for high blood pressure, and to measure and record blood pressure. Do not change the dose of Procrit.

· The nurse should teach the client how to prepare and inject Procrit if it has to be done at home, how often it should be injected, and how to safely throw away the used vials, syringes, and needles. If a dose of Procrit is missed then call a healthcare provider right away and ask what to do and in the same way report if more than the prescribed amount is taken.

· Inform the patient to report if having high blood pressure, seizures, unusual tiredness, lack of energy, dizziness, or fainting ( some patients may produce antibodies to Procrit, blocking its action and anemia worsens).

· Common side effects of Procrit include joint, muscle, or bone pain, fever, cough, rash, nausea, vomiting, soreness of the mouth, itching, headache, redness and pain at the site of injection.

· Ensure eight rights – right drug, right patient, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation of drug to drug interaction and right education and information.

QUESTION NUMBER B

Fatigue related to decreased haemoglobin and diminished oxygen-carrying capacity of the blood as evidenced by exertional discomfort, report of fatigue and lack of energy, inability to maintain usual level of physical activity, increased rest requirements.

Nursing intervention	Rationale
Assess the specific cause of fatigue.	The specific cause of fatigue is due to tissue hypoxia from anaemia; which is common in patients with kidney diseases and those on dialysis. Age of the patoient can also compromise activity tolerance.
Assess the client’s ability to perform activities of daily living (ADLs), and the demands of daily living	Fatigue can limit the client’s ability to participate in self-care and perform his or her role responsibilities in family and society, such as working outside the home.
Monitor haemoglobin, haematocrit, RBC counts, and reticulocyte counts.	Hemoglobin is 8 g/dL and hematocrit is 24%. They are associated with decreased oxygen-carrying capacity of the blood. It is critical to compare serial laboratory values progressively to evaluate progression or deterioration in the client and to identify changes before they become potentially life-threatening.
Assist the client in planning and prioritizing activities of daily living (ADL) and spacing of activities with adequate rest period in between.	This will allow the client to maximize her time for accomplishing important activities. Not all self-care and hygiene activities need to be completed in the morning. Likewise, not all housework needs to be completed in one day.
Assist the client in developing a schedule for daily activity and rest. Stress the importance of frequent rest periods	Energy reserves may be depleted unless the client respects the body’s need for increased rest. A plan that balances periods of activity with periods of rest can help the client complete desired activities without adding levels to fatigue.
Educate energy-conservation techniques.	Clients may need to learn skills for delegating task to others, setting priorities, and to use available energy to complete desired activities. Organization and time management can help the client conserve energy and reduce fatigue.
Instruct the client about medications Procrit and other ferrous sulphate and folic acid to production in the bone marrow.	Recombinant human erythropoietin, Procrit increases haemoglobin by increasing production of rbc’s in bone marrow and ferrous sulphate and folic acid are nutrients required for haemoglobin synthesis. They all decreases the need for RBC transfusions.
Anticipate the need for the transfusion of packed RBCs.	Packed RBCs increase oxygen-carrying capacity of the blood and reduces volume over load
Refer the client and family to an occupational therapist.	The occupational therapist can teach the client about using assistive devices according to her need. The therapist also can help the client and family evaluate the need for additional energy-conservation measures in the home setting.

Knowledge deficit about management of anaemia, drugs and diet

Nursing intervention	Rationale
Explain client about increase intake of iron rich foods like meat, liver, green leafy vegetables, raisins, apples etc . And to cook food in iron vessel	It will increase delivery of iron in diet
Take iron tablets daily preferably along with citrus substances like orange juice, lemon, goose berry.	It will increase absorption of iron
Avoid tea, coffee or milk at the same time with tablet , it will decrease iron absorption. Take folic acid regularly.	These substances reduce iron absorption. Folic acid is micronutrient required for dan synthesis.
Explain about constipation and to take high fibre diet and adequate liquids with in the limits imposed by kidney disease to prevent constipation.	Constipation is a common side effect of iron.
Explain about Procrit, its indications, risk associated, signs of complications and to report	Procrit is used to improve anaemia in patients on chronic kidney disease, chemotherapy patients and HIV patients on Zidovudine to avoid need of transfusion.