A patient with stage 3 chronic kidney disease (CKD) presents with increased fatigue, leg swelling, and a serum creatinine level of 1.7 mg/dL. What dietary recommendation is most appropriate for this patient to help manage their condition?

D) Increase potassium-rich foods

A patient with stage 3 chronic kidney disease (CKD) presents with increased fatigue, leg swelling, and slightly elevated blood pressure. Which dietary recommendation should the nurse prioritize for this patient?

C) Increase potassium-rich foods

What is the most important dietary modification the nurse should emphasize to the patient to help manage fluid retention and prevent further hyperkalemia?

B) Limit sodium and potassium intake

What is the primary reason for advising the patient to limit potassium intake in this scenario?

A) To reduce the risk of hyperkalemia

Which of the following findings indicates an improvement in the patient's fluid management after one week of intervention?

A) Bilateral pitting edema in the lower extremities decreased to +2

B) Blood pressure reading of 140/88 mmHg

C) Stable heart rate at 74 beats per minute

Which of the following assessments indicates an improvement in the patient's fluid management?

A) Bilateral pitting edema decreased to +2

B) Blood pressure reading of 140/88 mmHg

C) Serum creatinine level of 1.8 mg/dL

D) Potassium level of 5.1 mEq/L

During a follow-up appointment, a nurse notes a patient's blood pressure has improved to 132/84 mmHg and the patient's pitting edema has decreased to +1. Which nursing intervention has most likely contributed to these improvements?

B) Adhering to dietary guidelines and medication regimens

A) Increasing the dosage of antihypertensive medication

B) Adhering to dietary guidelines and medication regimens

C) Reducing physical activity to prevent fatigue

D) Discontinuing diuretic therapy

What is the primary reason for considering a gradual tapering of the patient's diuretic dosage in this scenario?

A) To completely stop the medication as it is no longer needed.

C) To enhance the patient's energy levels by reducing medication burden.

D) To prevent any further decrease in blood pressure, which has already normalized.

Chronic Kidney Disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Glomerular Damage - Chronic kidney disease (CKD) often starts with damage to the glomeruli, the tiny filters in the kidneys. This can be due to conditions like diabetes or high blood pressure, leading to scarring and reduced filtering ability over time.

• Secondary mechanism: Tubulointerstitial Fibrosis - As the disease progresses, the tubules (small tubes in the kidneys) and surrounding tissue can become scarred. This fibrosis further reduces kidney function by impairing waste removal and fluid balance.

• Key complication: Uremia - As kidney function declines, waste products build up in the blood, leading to uremia. This causes symptoms like fatigue, nausea, and confusion, highlighting the kidneys' crucial role in waste elimination.

Patient Profile

Demographics:

52-year-old male, office worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin

• Allergies: None

Current Presentation:

• Chief complaint: Routine check-up

• Key symptoms: Mild fatigue, occasional leg swelling

• Vital signs: Blood pressure 130/80 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F

Section 1

Initial assessment findings reveal that the patient appears well-nourished and in no acute distress. However, upon closer examination, mild bilateral pitting edema is noted in the lower extremities, consistent with his report of occasional leg swelling. The patient’s skin is warm and dry, and capillary refill is within normal limits. Cardiovascular assessment shows regular rhythm with no murmurs, while lung sounds are clear bilaterally. The abdomen is soft and non-tender, with no organomegaly noted.

Laboratory results from the routine check-up indicate a serum creatinine level of 1.5 mg/dL, slightly elevated from his previous baseline of 1.3 mg/dL, suggesting a mild decline in kidney function. Estimated glomerular filtration rate (eGFR) is calculated at 58 mL/min/1.73 m², classifying him in early stage 3 CKD. Blood urea nitrogen (BUN) is mildly elevated at 25 mg/dL. Electrolytes are within normal ranges, although a slight trend towards hyperkalemia is observed with a potassium level of 5.1 mEq/L. Blood glucose levels are well-managed with a fasting glucose of 110 mg/dL.

The nurse reviews these findings with the patient, emphasizing the importance of blood pressure and blood sugar control to slow the progression of kidney damage. The patient is advised to monitor for any changes in urination patterns, swelling, or fatigue, and to adhere closely to prescribed medications and dietary recommendations. Education focuses on a low-sodium, kidney-friendly diet to manage blood pressure and protect kidney function. The patient is scheduled for a follow-up appointment in three months to reassess kidney function and monitor for any further changes.

Section 2

Three months later, the patient returns for a follow-up appointment. During the initial assessment, the nurse notes that the patient appears well-nourished but reports experiencing increased fatigue and more frequent episodes of leg swelling. Upon examination, there is moderate bilateral pitting edema in the lower extremities. The patient's blood pressure is slightly elevated at 142/88 mmHg, compared to previous readings in the 130s/80s range. Heart rate is regular at 78 beats per minute, and lung sounds remain clear bilaterally. The abdomen is still soft and non-tender, with no changes noted.

The latest laboratory results show a serum creatinine level of 1.7 mg/dL, indicating a further decline in kidney function. The estimated glomerular filtration rate (eGFR) has decreased to 52 mL/min/1.73 m², remaining within stage 3 CKD but showing a worsening trend. Blood urea nitrogen (BUN) has increased to 28 mg/dL. Electrolytes reveal a potassium level of 5.3 mEq/L, continuing the mild trend towards hyperkalemia. The patient's fasting glucose level is 112 mg/dL, indicating stable blood sugar control.

Given these findings, the nurse discusses the importance of more stringent blood pressure management and revisits dietary guidelines to address the patient's sodium intake. The nurse reinforces education on recognizing signs of fluid overload and encourages the patient to continue monitoring blood pressure and weight at home. A referral to a dietitian is made to provide further guidance on dietary adjustments. The patient is advised to follow up with their primary care provider sooner than originally planned to discuss medication adjustments and to prevent further kidney function decline.

Section 3

Two weeks after the follow-up appointment, the patient returns to the clinic for an unscheduled visit, reporting persistent fatigue and a slight increase in the frequency of leg swelling. During the initial assessment, the nurse observes that the bilateral pitting edema in the lower extremities has worsened slightly, now rated as +3. The patient's blood pressure is recorded at 148/92 mmHg, indicating a further increase. Heart rate remains stable at 76 beats per minute, and lung sounds are still clear, with no indication of pulmonary congestion. The patient's weight has increased by 2 pounds since the last visit, suggesting fluid retention.

New laboratory results show a serum creatinine level of 1.9 mg/dL, signifying a continued decline in kidney function. The eGFR has decreased to 48 mL/min/1.73 m², approaching the lower end of stage 3 CKD. The BUN level has risen to 30 mg/dL, and potassium is now at 5.5 mEq/L, which is just above the upper limit of normal and requires close monitoring. The nurse reviews these findings with the patient, emphasizing the importance of adhering to dietary modifications, particularly limiting sodium and potassium intake, to manage fluid retention and prevent further hyperkalemia.

In response to these changes, the nurse contacts the patient's primary care provider to discuss potential medication adjustments, such as the addition of a low-dose diuretic to help manage edema and blood pressure. The nurse also reinforces the need for daily weight monitoring at home and advises the patient on recognizing signs of worsening fluid overload, such as increased shortness of breath or a significant weight gain over a short period. The patient expresses understanding and commits to following the recommended plan, including the upcoming appointment with the dietitian for more tailored dietary advice. The nurse schedules a follow-up appointment for the following week to closely monitor the patient's response to these interventions.

Section 4

One week after implementing the new interventions, the patient returns for the scheduled follow-up appointment. During the initial assessment, the nurse notes some positive changes. The bilateral pitting edema in the lower extremities has decreased to +2, indicating some improvement in fluid management. The patient's blood pressure reads at 140/88 mmHg, showing a slight reduction, but it is still above the target range. Heart rate remains stable at 74 beats per minute, and lung sounds continue to be clear with no signs of pulmonary congestion. Daily weight monitoring shows the patient has lost 1.5 pounds over the past week, suggesting a decrease in fluid retention.

The nurse reviews new lab results, which reveal a slight improvement in serum creatinine, now at 1.8 mg/dL, and eGFR has stabilized at 50 mL/min/1.73 m². BUN levels have decreased to 28 mg/dL, and potassium has returned to a normal level of 5.1 mEq/L, alleviating immediate concerns about hyperkalemia. These results suggest that the dietary modifications and the addition of a low-dose diuretic are having a positive impact on the patient's condition.

During the visit, the patient reports feeling slightly more energetic and has been able to manage fatigue better with regular rest periods. The nurse reiterates the importance of continued adherence to dietary guidelines and medication management. The patient expresses confidence in maintaining these changes and is eager to continue working with the healthcare team to further improve their condition. The nurse and patient discuss the potential for further adjustment in medication if necessary, and another follow-up appointment is scheduled in two weeks to reassess the progress and make any necessary changes to the treatment plan. This consistent monitoring and proactive management aim to prevent any new complications and support the patient's journey toward stable health.

Section 5

Two weeks later, the patient returns for the scheduled follow-up appointment, and the nurse conducts a thorough initial assessment. The patient's vital signs show further improvement: blood pressure has decreased to 132/84 mmHg, inching closer to the target range, while the heart rate remains stable at 72 beats per minute. The nurse notes that the pitting edema in the lower extremities has reduced further to +1, indicating continued success in fluid management. The patient's weight has decreased by an additional 0.5 pounds, suggesting ongoing effective fluid regulation.

The patient shares that they have maintained adherence to dietary guidelines and medication regimens, reporting feeling even more energetic and having an improved ability to engage in daily activities without excessive fatigue. The nurse reviews the latest lab results, which reveal that serum creatinine has further decreased to 1.7 mg/dL, and eGFR has improved slightly to 52 mL/min/1.73 m². BUN levels have stabilized at 26 mg/dL, while potassium levels remain within the normal range at 4.9 mEq/L. These positive trends suggest that the interventions are effectively managing the patient's condition and contributing to improved kidney function.

Given these encouraging results, the nurse and patient discuss the potential for gradually tapering the diuretic dosage to maintain optimal fluid balance while minimizing the risk of electrolyte imbalances. The nurse emphasizes the importance of continued monitoring and regular follow-up appointments to ensure that the patient's condition remains stable and to address any new developments promptly. A subsequent follow-up is scheduled in four weeks to reassess the patient's status and evaluate whether further adjustments to the treatment plan are necessary, reinforcing the collaborative approach to achieving long-term health goals.