A patient with chronic kidney disease presents with significant bilateral pitting edema, bibasilar crackles, and hyperkalemia. Which nursing intervention should be prioritized to address these clinical findings?

B) Initiating fluid restriction to manage fluid overload.

A) Administering a potassium-binding resin to reduce serum potassium levels.

B) Initiating fluid restriction to manage fluid overload.

C) Applying emollients to the skin to alleviate uremic pruritus.

D) Starting erythropoiesis-stimulating agents to correct anemia.

A patient with worsening Chronic Kidney Disease presents with hyperkalemia, significant bilateral pitting edema, and bibasilar crackles. Which nursing intervention is the most appropriate to address the patient's fluid overload?

C) Administer a prescribed diuretic and monitor urine output

A) Encourage increased fluid intake to promote renal perfusion

B) Educate the patient on potassium-rich foods to avoid further imbalance

C) Administer a prescribed diuretic and monitor urine output

D) Prepare the patient for immediate dialysis to remove excess fluid

A patient with chronic kidney disease is being treated with a loop diuretic, but now presents with new symptoms of fatigue, dizziness, and hypotension. Which nursing intervention is most appropriate to address the patient's current condition?

B) Administer intravenous fluids to correct intravascular volume depletion.

A) Increase the diuretic dosage to further reduce pulmonary congestion.

B) Administer intravenous fluids to correct intravascular volume depletion.

C) Encourage the patient to increase oral fluid intake to manage hypotension.

D) Hold the erythropoietin therapy until blood pressure stabilizes.

A patient with chronic kidney disease is being treated with a loop diuretic for fluid overload. Recent laboratory results show a serum creatinine of 3.5 mg/dL and hyperkalemia of 5.5 mmol/L. The patient reports dizziness and fatigue, and blood pressure is 92/56 mmHg. What is the priority nursing intervention?

C) Hold the diuretic and notify the healthcare provider about the symptoms of hypotension.

A) Increase fluid intake to improve blood pressure.

B) Administer the diuretic earlier in the day to prevent nocturia.

C) Hold the diuretic and notify the healthcare provider about the symptoms of hypotension.

D) Encourage the patient to ambulate slowly to prevent dizziness.

A patient with chronic kidney disease is experiencing generalized fatigue and dizziness due to intravascular volume depletion from diuretic therapy. The healthcare team reduces the diuretic dosage and initiates erythropoietin therapy for anemia. Which nursing intervention is most appropriate to address the patient's remaining symptoms?

B) Educate the patient on the importance of pacing activities to manage fatigue.

A) Encourage increased fluid intake to manage dizziness and fatigue.

B) Educate the patient on the importance of pacing activities to manage fatigue.

C) Administer additional diuretics to prevent fluid overload.

D) Suggest the use of caffeine to improve energy levels.

A patient with chronic kidney disease is experiencing generalized fatigue, dizziness, and low blood pressure attributed to aggressive diuretic therapy. The healthcare team has adjusted the diuretic dosage and initiated erythropoietin therapy. Despite these interventions, the patient's serum creatinine remains elevated. Which nursing intervention is most appropriate to further optimize the patient's renal function and overall management?

C) Collaborate with the healthcare team to evaluate medication regimens for nephrotoxic drugs.

A) Encourage increased protein intake to improve energy levels.

B) Educate the patient on the importance of adhering to fluid restrictions.

C) Collaborate with the healthcare team to evaluate medication regimens for nephrotoxic drugs.

D) Recommend a high-sodium diet to counteract low blood pressure.

A patient with chronic kidney disease is being treated for hyperkalemia. After administration of sodium polystyrene sulfonate, the patient's potassium level decreases from 5.8 mEq/L to 5.4 mEq/L. Which of the following interventions should the nurse prioritize to further manage the patient's condition?

B) Continue monitoring ECG for further cardiac changes

A) Increase dietary potassium intake to balance electrolyte levels

B) Continue monitoring ECG for further cardiac changes

C) Administer a potassium-sparing diuretic to prevent fluid overload

D) Encourage a high-protein diet to support renal function

A patient with chronic kidney disease is experiencing hyperkalemia with a potassium level of 5.8 mEq/L. Sodium polystyrene sulfonate has been administered, and the patient is on a low-potassium diet. Which additional intervention should the nurse anticipate to manage the patient's condition and prevent cardiac complications?

A) Administering calcium gluconate IV

B) Starting an infusion of normal saline

C) Increasing dietary potassium intake

D) Administering a loop diuretic

A patient with chronic kidney disease is experiencing signs of fluid overload, including increased peripheral edema and dyspnea on exertion. The healthcare team has adjusted the patient's diuretic regimen and reinforced a low-sodium diet. Which additional nursing intervention is most appropriate to help manage the patient's fluid balance and prevent further complications?

B) Restrict the patient's fluid intake as prescribed and monitor daily weights.

A) Encourage the patient to increase fluid intake to promote renal perfusion.

B) Restrict the patient's fluid intake as prescribed and monitor daily weights.

C) Administer an additional dose of antihypertensive medication to lower blood pressure.

D) Educate the patient on the importance of reducing protein intake to decrease creatinine levels.

A patient with chronic kidney disease presents with signs of fluid overload, including peripheral edema, dyspnea, and bilateral lung crackles. The healthcare team is considering adjustments to the patient's diuretic regimen. Which nursing intervention is most appropriate to prioritize in this situation to assess the effectiveness of the treatment plan?

B) Measure the patient's weight daily and monitor trends.

A) Administer oxygen therapy to improve respiratory effort.

B) Measure the patient's weight daily and monitor trends.

C) Encourage the patient to increase fluid intake to dilute electrolytes.

D) Position the patient in high Fowler's position to facilitate breathing.

Chronic Kidney Disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Glomerular Damage - Chronic Kidney Disease (CKD) often begins with damage to the glomeruli, the kidney's filtering units, due to conditions like hypertension or diabetes. This damage reduces filtering efficiency, leading to proteinuria and progressive nephron loss.

• Secondary mechanism: Tubulointerstitial Fibrosis - As glomeruli are damaged, inflammatory responses trigger fibrosis in the kidney's interstitial tissue. This fibrosis further impairs nephron function and decreases kidney ability to concentrate urine and excrete waste products.

• Key complication: Uremia - The buildup of waste products due to reduced kidney function leads to uremia, characterized by symptoms such as fatigue, nausea, and neurological impairment, illustrating the systemic impact of CKD.

Patient Profile

Demographics:

52, female, school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Stage 3 Chronic Kidney Disease

• Current medications: Lisinopril, Metformin, Amlodipine, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Fatigue and swelling in the legs

• Key symptoms: Decreased urine output, nausea, itching, shortness of breath

• Vital signs: Blood pressure 148/92 mmHg, heart rate 88 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, oxygen saturation 94% on room air

Section 1

As the clinical team conducts an initial assessment, they note several key findings that contribute to understanding the progression of the patient's Chronic Kidney Disease. Upon physical examination, the patient exhibits significant bilateral pitting edema in the lower extremities, rated as 3+ on the edema scale, indicating fluid retention likely due to worsening renal function. Auscultation reveals bibasilar crackles in the lungs, suggesting possible fluid overload or early pulmonary congestion, which correlates with the patient's report of shortness of breath. The patient's skin appears dry and exhibits excoriations, consistent with the uremic pruritus she reports.

Laboratory results further clarify the situation. Serum creatinine is elevated at 3.2 mg/dL, up from 2.6 mg/dL noted in her last nephrology follow-up, indicating a decline in glomerular filtration rate. Blood urea nitrogen (BUN) is also increased at 58 mg/dL, reinforcing the presence of uremia. Electrolyte imbalances are present, with hyperkalemia at 5.8 mmol/L, posing a risk for cardiac complications. Her hemoglobin level has dropped to 9.2 g/dL, suggestive of anemia of chronic disease, a common complication in CKD. Proteinuria is noted to be significant, at 2.5 grams per 24-hour urine collection, further supporting the degree of glomerular damage.

The patient's current clinical presentation and laboratory findings necessitate immediate attention to prevent further deterioration. The healthcare team considers adjusting her antihypertensive regimen to better manage her blood pressure and fluid status, potentially adding a diuretic to address fluid overload. They also discuss the need for dietary modifications to manage hyperkalemia and the potential initiation of erythropoiesis-stimulating agents to address anemia. These interventions aim to stabilize the patient's condition and prevent the progression of complications, setting the stage for the next phase of her management plan.

Section 2

Following the initial assessment and the implementation of the revised management plan, the healthcare team closely monitors the patient's response to the interventions. Within 48 hours, notable changes in the patient's status are observed. The addition of a loop diuretic to her antihypertensive regimen shows promising results, as evidenced by a reduction in bilateral pitting edema, now rated at 2+ on the edema scale. The patient's weight has decreased by approximately 1.5 kg, suggesting effective fluid removal. Her shortness of breath has improved, and auscultation reveals decreased crackles in the lungs, indicating reduced pulmonary congestion.

However, despite these positive developments, the patient's laboratory values reveal new complications. Repeat blood tests show a further decline in renal function, with serum creatinine now at 3.5 mg/dL. Although the hyperkalemia has marginally improved to 5.5 mmol/L, likely due to dietary modifications and diuretic therapy, the patient exhibits new symptoms of generalized fatigue and dizziness. These symptoms, coupled with a blood pressure reading of 92/56 mmHg, suggest potential intravascular volume depletion as a side effect of the aggressive diuretic therapy. Additionally, the patient's hemoglobin remains low at 9.0 g/dL, indicating that anemia persists as a concern despite initial plans for erythropoietin therapy.

The clinical team recognizes the need for careful adjustment of the patient's treatment plan to address these evolving challenges. They consider reducing the diuretic dosage to mitigate hypotension while ensuring fluid overload is adequately managed. Concurrently, they plan to initiate erythropoietin therapy to improve anemia and overall energy levels. As the patient continues on her journey, the team remains vigilant, ready to respond to any further changes in her condition and striving to maintain a delicate balance in her complex clinical picture. These developments set the stage for ongoing monitoring and adjustments, highlighting the dynamic nature of managing chronic kidney disease with emerging complications.

Section 3

The healthcare team decides to focus on the new complications, particularly the symptoms of generalized fatigue and dizziness, alongside the low blood pressure, which suggest potential intravascular volume depletion due to aggressive diuretic therapy. To address this, the diuretic dosage is carefully reduced, and the patient is advised to monitor her fluid intake while avoiding excessive restriction. Within 24 hours, the patient's blood pressure stabilizes slightly at 98/60 mmHg, and she reports a marginal improvement in dizziness, though fatigue persists.

Meanwhile, the team initiates erythropoietin therapy to tackle the anemia, aiming to improve the patient's hemoglobin levels and alleviate fatigue. Close monitoring of the patient's hemoglobin and hematocrit levels is established, with follow-up blood tests scheduled to assess the effectiveness of this intervention. After the first dose, the patient begins to report a gradual increase in energy levels over the next few days, suggesting a positive response to the erythropoietin therapy.

Despite these adjustments, the patient's renal function continues to be a point of concern, with serum creatinine remaining elevated at 3.5 mg/dL. This prompts the nephrology team to re-evaluate the patient's overall management plan, considering the potential need for renal replacement therapy if further deterioration occurs. The team also reviews the patient's medication regimen to ensure that it is optimized for renal protection. This careful balancing act underscores the complexity of managing chronic kidney disease with emerging complications, setting the stage for ongoing adaptation and vigilant monitoring as the patient's journey progresses.

Section 4

As the healthcare team continues to monitor the patient, new diagnostic results bring to light additional concerns that require careful consideration. Recent laboratory tests reveal an increase in potassium levels, now at 5.8 mEq/L, indicating the development of hyperkalemia, a common complication in patients with chronic kidney disease. This electrolyte imbalance poses a significant risk and demands immediate attention due to its potential to cause serious cardiac complications. The patient's electrocardiogram (ECG) is promptly assessed, showing peaked T-waves, an early sign of hyperkalemia's effect on cardiac function.

In response to these findings, the medical team swiftly implements a plan to address the hyperkalemia. Sodium polystyrene sulfonate is administered to facilitate the elimination of excess potassium through the gastrointestinal tract. The patient is also advised to adhere to a low-potassium diet to prevent further increases in serum potassium levels. Additionally, the nephrology team considers the possibility of starting dialysis as a more definitive solution should these conservative measures prove insufficient. This situation underscores the complexity of managing chronic kidney disease, where multiple interconnected systems must be carefully balanced to prevent complications.

The patient's response to these interventions is closely monitored. Over the next 48 hours, repeat blood tests show a modest reduction in potassium levels to 5.4 mEq/L, a positive trend that suggests the initial treatment is having the desired effect. However, the team remains vigilant, recognizing that the patient's renal function and overall stability remain precarious. This dynamic situation requires ongoing assessment and adjustment of the treatment plan, highlighting the need for continuous clinical reasoning to navigate the challenging landscape of chronic kidney disease management.

Section 5

Two days later, the healthcare team notes a change in the patient's status that requires immediate attention. The patient begins to exhibit signs of fluid overload, including increased peripheral edema and dyspnea on exertion, which raises concerns about the patient's cardiovascular stability. Vital signs reveal a mild elevation in blood pressure at 150/92 mmHg and tachycardia with a heart rate of 102 beats per minute. Auscultation of the lungs reveals bilateral crackles, particularly at the bases, indicating possible pulmonary congestion. These symptoms suggest that the patient's fluid balance is becoming increasingly difficult to manage, an anticipated challenge in chronic kidney disease due to impaired renal excretion.

In response to these developments, the medical team evaluates the patient's current diuretic regimen and considers optimizing it to improve fluid removal while avoiding further electrolyte imbalances. A low-sodium diet is reinforced to help control blood pressure and reduce fluid retention. The nephrology team also revisits the discussion around the initiation of dialysis, weighing the risks and benefits given the patient's declining renal function and the onset of additional complications. This situation requires a thorough clinical reasoning approach to balance electrolyte management, fluid status, and the patient's overall cardiovascular health.

As the team implements these strategies, they continue to monitor the patient's response closely. Repeat laboratory tests are ordered to evaluate renal function and electrolyte levels, with particular attention to serum creatinine and blood urea nitrogen, which remain elevated. The patient's weight is measured daily to assess fluid retention, and respiratory status is frequently evaluated to ensure that any signs of worsening pulmonary congestion are promptly addressed. This careful monitoring and adjustment of the treatment plan are crucial as the team navigates the complex interplay of factors in chronic kidney disease, aiming to stabilize the patient's condition and prevent further complications.