Question

Mrs. A, 53-years-old with a 17-year history of type 2 diabetes, hypertension and hyperlipidemia and a 35-year history of smoking. She presents in the ward with shortness of breath, pruritus, and pitting edema of bilateral extremities. Her blood pressure is 165/92 mm Hg, heart rate 94 beats per minute (regular rate and rhythm), and respiration 26 breaths per minute. She is 153cm tall and weighs 91kg (BMI: 38.9).

Mrs. A is diagnosed with stage 3 chronic kidney disease, with a GFR of 49 mL/min/1.73m² and profound microalbuminuria.

QUESTION:

Based on the the above scenario, organize relevant nursing care and management for Mrs. A in order to maximise her overall health and delay the progression of end stage renal disease (ESRD).

Answer 1

• Based on the serum biomarker results, patient A is diagnosed with stage 3 chronic kidney disease, with a GFR of 49mL/min/ and profound microalbuminuria.
• This diagnosis is substantiated by the noted elevation in random blood glucose levels and HbA1c.
• Patient A is experiencing anemia, with a hemoglobin level of 8.7 g/dl and early signs of a bone and mineral metabolism disorder.
• She is considered at high risk of cardiovascular event due to her long history of diabetes , hypertension,, tobacco use and hyperlipidemia all of which appear to be uncontrolled.

NURSING CARE AND MANAGEMENT

• Patient A attends diabetes self management classes taught by a registered nurse and a registered dietician.
• A 24 hour food recall demonstrated a high protein diet and difficulty complying with a low carbohydrate plan necessary to control her blood glucose levels.
• Over a period of six months, the patient lost and regained 10 pounds.
• She generally does not eat breakfast, had a salad at her desk at work for lunch and typically stops at a fast food restaurant or orders delivery for dinner due to worsening fatigue and loss of energy.
• Goals for treatment includes glucose management, regulation of blood pressure, smoking cessation education, and lowered protein intake.
• The meal plan is created for patient A geared towards weight loss
• The plan is low carbohydrate without being high protein inorder to prevent further damage to the kidneys
• Meal plan is simplified and incorporates homemade quick fix meals or slow cooker recipes that should reduce the fat intake associated with a predominantly fast food diet.
• The need for physical activity is vital for patient A and should help with weight loss, stress control and blood pressure management.
• The patient is encouraged to wear a pedometer and work upto walking 10,000 steps each day.
• She is encouraged to start slowly and increase activity gradually.
• Adherence to medications is an important part of patient a's treatment plan. she is prescribed medications for many of her existing conditions including diabetes, hypertension, anemia and cardiovascular disease.
• Instructions for her diabetes medications include the rationale for maintaining adequate glucose control. Patient A 's history reveals a lack of glycemic control so medication adherence is paramount and patient education includes insulin therapy instructions.
• Patient Ais instructed to monitor her blood pressure at home and to report any high or low reading to her primary care provider.
• To prevent damage related to cardiovascular disease, patient A is started on a ststin to help decrease her lipid levels in conjugation with a low fat diet.
• Patient A is encouraged to conduct self blood glucose monitoring , maintain regular checkups with her healthcare team, and follow up with a nephrologist to further impede kidney disease progression.
• With education and understanding patient A can maintain her current kidney function.