Question

Case Study: 22 year old with ESRD DB is a 22 yo male who developed ESRD Secondary to glomerulonephritis as an IGA nephropathy. His comorbitidies include anemia secondary to chronic disease and HTN. He also suffers from chronic UTI's and does not feel well on some days. He states he is chronically tired but must work full time. He is an undocumented worker whose primary language is Spanish. He speaks and understands some English but processes information slowly and reads only Spanish. He works as a cook in a diner and supports and lives with his elderly father. He has very few friends and no girlfriend currently. He has an AV fistula in his left lower arm which is patent and has a positive thrill and bruit. He is scheduled to receive dialysis 3 times a week for 4.5 hrs but sometimes misses appoints and often leaves early (after 1.5 hrs of treatment). He is afraid to miss work or be late for work. He usually eats 1-2 meals a day at the diner and often forgets to take his Renvela with his meal at work. He has been given a free supply of Renvela and advised to take this with every meal but compliance is poor. As an alternative he is advised to carry Tums with him and take this if he does not have his Renvela with him. His current Vs are BP 170/100, P 104, R 18, T100 orally. EKG: Sinus Tachy CXR: Clear Current Labs: Serum albumin 3.4, Creatinine14.8, Hgb 5.2, Ca 6.8, PO4 10.9, K.5.8, WBC 12.2 Orders are as follows: 1. Diet 85 GM Protein 2 GM NA 2 Gm Kand 1140 mg Phosphorus 2. Fluid restriction 1000ml/24 hrs 3. Procardia XL 90 daily 4. Lisinopril 20 mg daily 5. Coreg 25mg every 12 hrs 6. Renagel 800mg TID 7. Phoslo 1 packet TID 8. Kayexalate 15 gms TID 9. Clonidine 1 mg BID 10. Labetalol 200mg BID

Answer 1

C. Since DB is already having end stage renal disease he was advised on fluid restriction. Excess fluid intake will pose risk of excesz fluid retention which may suddenly cause Hyperyemtion or sudden hypotension, Heart will be enlarged and shortness of breath. Since he is on dialysis, he will feel co.fortable before during and after dialysis. There is a limit of ffluid volume that can be dialysed more than that we need to schedule one more dialysis.

Diet restricted with Potassium & phosphorus:

Normal kidneys will maintain a balance of the minerals, but failed kidneys make minerals levels flutuate leading to muscle weakness, cramps, brittle bones etc.

Excess sodium in his diet will tend to absorb more water leading to swelling of legs.

D. Care plan

CNS : Patients with ESRD may have dementia, delirium, depression. So we need to educate them and screen yhem for the same.

GIT: Already discussed above in diet

Cardiac : HTN need to aim at lowering the hypertension. beta blockers, ARBs, ACE inhibitors, calcium channel blockers, Diuretics to be taken. weight reduction is a target.

E. Prioritization;

Acute glomerulonephritis - cause for ESRD

Anemia- Ocygen supply impact

Hypertension- Cardiac illnesses

AV fistula - not much systemic complications

UTIs - not serious