A nurse is reviewing Mr. Johnson's lab results and clinical presentation. Considering his current condition and risk of complications, which nursing intervention should take priority?

C) Preparing to administer sodium polystyrene sulfonate to address hyperkalemia

A) Administering a potassium-sparing diuretic to manage fluid overload

B) Encouraging increased oral fluid intake to prevent dehydration

C) Preparing to administer sodium polystyrene sulfonate to address hyperkalemia

D) Increasing his antihypertensive medication dose to better control his blood pressure

A nurse is caring for Mr. Johnson, who has worsening chronic kidney disease with symptoms of fluid overload and electrolyte imbalance. Which intervention should the nurse prioritize to address Mr. Johnson’s current clinical status?

B) Administer the prescribed diuretic to reduce fluid overload.

A) Increase Mr. Johnson's oral fluid intake to manage dehydration.

B) Administer the prescribed diuretic to reduce fluid overload.

C) Encourage Mr. Johnson to consume foods high in potassium to correct the imbalance.

D) Withhold antihypertensive medication to prevent further hypotension.

Given Mr. Johnson's current health status, which nursing intervention would be most appropriate to address his hyperkalemia and prevent cardiac complications?

B) Administer a potassium-binding agent as prescribed and monitor ECG changes.

A) Encourage increased fluid intake to dilute serum potassium levels.

B) Administer a potassium-binding agent as prescribed and monitor ECG changes.

C) Increase dietary potassium intake to balance electrolyte levels.

D) Withhold all antihypertensive medications to reduce potassium retention.

Mr. Johnson, a patient with chronic kidney disease, is showing some improvement in his condition but continues to have elevated blood pressure and persistent hyperkalemia. The healthcare team plans to initiate low-dose diuretics and consider a potassium-binding agent. As a nurse, what is the priority action to ensure patient safety in this situation?

D) Arrange for frequent electrolyte monitoring to detect any changes in potassium levels promptly.

A) Monitor Mr. Johnson's blood pressure hourly to assess the effectiveness of antihypertensive medications.

B) Educate Mr. Johnson on the importance of adhering to a low-potassium diet to manage hyperkalemia.

C) Evaluate Mr. Johnson's fluid output and weight daily to assess the effectiveness of diuretic therapy.

D) Arrange for frequent electrolyte monitoring to detect any changes in potassium levels promptly.

Mr. Johnson, who is experiencing persistent hypertension and metabolic acidosis, is currently on low-dose diuretics and a potassium-binding agent. Which nursing intervention is most appropriate to address the risk of cardiac complications in this scenario?

C) Monitor serum potassium levels and ECG for signs of arrhythmias.

A) Administer a daily dose of calcium channel blockers.

B) Encourage an increase in fluid intake to improve renal perfusion.

C) Monitor serum potassium levels and ECG for signs of arrhythmias.

D) Increase the dose of diuretics to further reduce blood pressure.

A nurse is reviewing Mr. Johnson's care plan and notes his persistent hypertension despite the use of low-dose diuretics. Which of the following interventions should the nurse anticipate to address his elevated blood pressure while considering his renal dysfunction?

B) Initiating an angiotensin-converting enzyme (ACE) inhibitor.

A) Increasing the dose of diuretics to further reduce fluid overload.

B) Initiating an angiotensin-converting enzyme (ACE) inhibitor.

C) Restricting sodium intake to less than 1 gram per day.

D) Adding a beta-blocker to his current regimen.

A patient with chronic kidney failure is experiencing premature ventricular contractions (PVCs) and has a serum potassium level of 5.2 mEq/L. Which of the following interventions should the nurse prioritize to address the patient's current condition?

C) Review and adjust the patient's electrolyte management, focusing on potassium levels

A) Increase the dosage of the current beta-blocker to control PVCs

B) Administer sodium bicarbonate to correct metabolic acidosis

C) Review and adjust the patient's electrolyte management, focusing on potassium levels

D) Initiate potassium-sparing diuretics to stabilize potassium levels

Mr. Johnson, who has chronic kidney failure, has shown improvement in the management of PVCs with adjusted beta-blocker therapy. However, he now presents with mild peripheral edema and a slight weight gain. Which of the following is the most appropriate nursing intervention to address these findings while considering his overall condition?

B) Restrict fluid intake and monitor daily weights.

A) Increase the dosage of his potassium-sparing diuretic.

B) Restrict fluid intake and monitor daily weights.

C) Administer an additional dose of beta-blocker to reduce fluid retention.

D) Encourage increased dietary sodium to balance electrolyte levels.

Mr. Johnson is experiencing mild peripheral edema following adjustments in his medication regimen while managing chronic kidney failure. Which nursing intervention is most appropriate to address his fluid retention and prevent further complications?

B) Educate Mr. Johnson on reducing sodium intake in his diet.

A) Increase Mr. Johnson's fluid intake to promote renal clearance.

B) Educate Mr. Johnson on reducing sodium intake in his diet.

C) Encourage Mr. Johnson to engage in moderate exercise to enhance circulation.

D) Withhold his diuretic medication to prevent dehydration.

chronic kidney failure - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic kidney failure often begins with nephron damage, reducing the kidneys' ability to filter blood effectively. This leads to the accumulation of waste products like urea and creatinine, causing uremia and systemic toxicity.

• Secondary mechanism: Persistent nephron damage triggers compensatory hyperfiltration in remaining nephrons. Over time, this increases glomerular pressure and accelerates nephron loss, further impairing renal function and exacerbating waste accumulation.

• Key complication: As kidney function declines, the ability to regulate electrolyte and fluid balance is compromised, resulting in complications like hypertension, edema, and metabolic acidosis, which can further stress cardiovascular and systemic health.

Patient Profile

Demographics:

65-year-old male, retired factory worker

History:

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

• Current medications: Lisinopril, Metformin, Furosemide

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and swelling in the legs

• Key symptoms: Nausea, decreased appetite, nocturia, mild shortness of breath

• Vital signs: Blood pressure 150/95 mmHg, heart rate 92 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, oxygen saturation 95% on room air

Section 1

As the nursing team continues to monitor Mr. Johnson, they notice a change in his clinical status. Over the past couple of days, Mr. Johnson's fatigue has worsened, and he has developed increased swelling in his lower extremities. Upon examination, the edema is now pitting and extends to the mid-calf. His blood pressure remains elevated at 155/98 mmHg despite adherence to his antihypertensive medication regimen. He reports persistent nausea and a further decrease in appetite, leading to unintended weight loss. His respiratory rate has increased to 22 breaths per minute, and his oxygen saturation has decreased to 92% on room air, indicating a potential compromise in respiratory function.

Lab results reveal a rise in serum creatinine to 2.8 mg/dL from a previous 2.0 mg/dL, and blood urea nitrogen (BUN) has increased to 35 mg/dL, suggesting worsening renal function. Electrolyte imbalances are evident, with hyperkalemia at 5.8 mEq/L and mild hyponatremia at 134 mEq/L. Arterial blood gas analysis indicates a metabolic acidosis with a pH of 7.32 and bicarbonate level of 18 mEq/L. These findings suggest that Mr. Johnson's chronic kidney disease is progressing, and he is at risk for developing more severe complications, such as cardiac arrhythmias or pulmonary edema.

In response to these changes, the healthcare team considers adjusting Mr. Johnson's treatment plan. The priority is to manage his fluid overload and electrolyte imbalances while addressing his hypertension more aggressively. A consultation with a nephrologist is warranted to evaluate the need for potential interventions such as dialysis or further medication adjustments. In the interim, dietary modifications, including potassium restriction, are advised, and close monitoring of his vital signs and laboratory values continues to be essential. The team also educates Mr. Johnson and his family about recognizing signs of further deterioration and the importance of adhering to follow-up appointments, setting the stage for ongoing management and potential escalation of care.

Section 2

As the healthcare team implements the adjustments to Mr. Johnson's treatment plan, they monitor his response closely. Over the next 48 hours, the nursing team observes that Mr. Johnson's edema has slightly decreased, now extending just above the ankles, indicating some improvement in fluid management. However, his blood pressure remains elevated at 150/95 mmHg, suggesting that his antihypertensive regimen still requires optimization. His respiratory rate has stabilized at 20 breaths per minute, and his oxygen saturation has improved to 94% on room air, reflecting a slight improvement in respiratory function. Despite these positive trends, Mr. Johnson continues to experience significant fatigue and nausea, impacting his overall quality of life.

New diagnostic results further inform the clinical picture. A follow-up serum creatinine level indicates a slight decrease to 2.6 mg/dL, while BUN remains elevated at 33 mg/dL. Hyperkalemia persists, with potassium levels at 5.6 mEq/L, necessitating ongoing dietary potassium restriction and consideration of medication adjustments. Electrolyte rebalancing efforts have stabilized sodium levels at 135 mEq/L, and repeat arterial blood gas analysis shows a pH of 7.34 with bicarbonate at 19 mEq/L, indicating marginal improvement in metabolic acidosis. These results suggest that while there is some stabilization, the risk of severe complications remains, and further intervention may be required.

The clinical team concludes that Mr. Johnson's current trajectory, albeit slightly improved, still poses a risk for complications such as cardiac arrhythmias due to persistent hyperkalemia. As a result, discussions with the nephrologist lead to a decision to initiate low-dose diuretics to address fluid overload more effectively and consider the introduction of a potassium-binding agent. The team continues to emphasize the importance of dietary compliance and medication adherence, while also planning for regular follow-up to assess the need for more invasive interventions, such as dialysis, should his condition not improve satisfactorily. This careful balance of ongoing monitoring and timely intervention underscores the complexity of managing chronic kidney disease, setting the stage for further adjustments in Mr. Johnson's care plan.

Section 3

Response to Interventions:

Over the following days, Mr. Johnson's response to the recent adjustments in his treatment plan is closely monitored. The introduction of low-dose diuretics appears to be effective, as evidenced by further reduction in edema, now localized to his feet. This improvement suggests better fluid management and provides some relief to Mr. Johnson, who reports feeling slightly more comfortable. However, his blood pressure remains elevated at 148/92 mmHg, indicating the need for ongoing optimization of his antihypertensive therapy. Despite the diuretics' success in managing fluid overload, Mr. Johnson continues to experience fatigue and nausea, which are likely exacerbated by the ongoing metabolic imbalance.

A repeat set of laboratory tests reveals that Mr. Johnson's serum potassium has decreased to 5.2 mEq/L, reflecting a positive response to dietary restrictions and the potential initiation of a potassium-binding agent. However, his serum bicarbonate remains at 19 mEq/L, and his pH is stable at 7.34, suggesting that metabolic acidosis, while not worsening, still requires careful management. These lab values highlight the importance of balancing electrolyte stability while avoiding the risk of cardiac arrhythmias. Meanwhile, Mr. Johnson's serum creatinine and BUN levels remain relatively unchanged, underscoring the chronic nature of his kidney dysfunction.

Despite these challenges, the healthcare team is encouraged by the incremental improvements. They remain vigilant in monitoring for any signs of cardiac complications, particularly given the persistent hypertension and potential for arrhythmias. Discussions with Mr. Johnson and his family continue to emphasize the critical role of medication adherence and dietary management in preventing further deterioration. The team plans to reassess the need for more aggressive interventions, such as dialysis, should his renal function decline further. As Mr. Johnson navigates this complex phase of his treatment, the focus remains on preventing complications and enhancing his quality of life through comprehensive, individualized care.

Section 4

New Complications:

As Mr. Johnson's treatment progresses, a new complication arises, prompting immediate attention from the healthcare team. During a routine check-up, Mr. Johnson reports experiencing episodes of palpitations and a sensation of an irregular heartbeat. Concerned, the team performs an electrocardiogram (ECG) which reveals occasional premature ventricular contractions (PVCs). These findings, along with the elevated blood pressure and persistent metabolic acidosis, raise concerns about potential cardiac complications. The team is particularly aware of the risk factors associated with his chronic kidney failure, including electrolyte imbalances and hypertension, which could exacerbate cardiac issues.

In response to these developments, the healthcare team prioritizes a comprehensive review of Mr. Johnson's medication regimen, focusing on optimizing his antihypertensive therapy and re-evaluating his electrolyte management. They consider adjusting his current beta-blocker dosage to better control his blood pressure and potentially minimize the frequency of PVCs. Additionally, they are mindful of the need to maintain a delicate balance in Mr. Johnson's potassium levels to prevent further arrhythmias. With his serum potassium at 5.2 mEq/L, the team deliberates on the cautious use of potassium-sparing agents to ensure stability without precipitating hyperkalemia.

To address the ongoing metabolic acidosis, the team discusses the possibility of initiating sodium bicarbonate therapy to help improve Mr. Johnson's serum bicarbonate levels and provide relief from his symptoms of fatigue and nausea. These interventions are carefully considered, with the team emphasizing the importance of close monitoring and regular follow-up. Mr. Johnson and his family are involved in these discussions, ensuring they understand the potential risks and benefits of the proposed changes. As Mr. Johnson's clinical picture evolves, the team remains committed to a proactive approach, aiming to mitigate complications and improve his overall quality of life.

Section 5

Response to Interventions:

Following the adjustment of Mr. Johnson's medication regimen, the healthcare team closely monitors his response to the interventions. Within a week, Mr. Johnson reports a noticeable reduction in the frequency of palpitations, which suggests that the modifications in his beta-blocker dosage may be effective in managing the premature ventricular contractions (PVCs). His blood pressure readings have stabilized, with recent measurements showing an average of 130/85 mmHg, indicating improved control. However, the team remains vigilant, aware that Mr. Johnson's chronic kidney failure continues to pose challenges to maintaining cardiovascular stability.

Laboratory tests are conducted to assess the impact of sodium bicarbonate therapy on Mr. Johnson's metabolic acidosis. Results reveal a modest improvement in his serum bicarbonate levels, which have increased from 18 mEq/L to 21 mEq/L. Mr. Johnson's symptoms of fatigue and nausea have diminished, enhancing his overall comfort and quality of life. However, his serum potassium level remains at 5.2 mEq/L, prompting careful monitoring to avoid the risk of hyperkalemia due to the potassium-sparing agents in use. The team underscores the significance of a balanced electrolyte profile, conducting regular tests to ensure stability.

Despite these positive responses, Mr. Johnson begins to experience mild peripheral edema, noted during a physical examination. His weight has increased slightly by 1.5 kg over the past week. The team attributes this to fluid retention, possibly linked to adjustments in his medication regimen and the ongoing challenges of managing his chronic kidney failure. In response, they explore further modifications in his diuretic therapy to address the edema while preventing electrolyte imbalances. Mr. Johnson and his family are informed of these developments, and they continue to be active participants in care planning, with the goal of optimizing his treatment outcomes and minimizing complications.