A patient with stage 3b chronic kidney disease presents with anemia, hyperphosphatemia, and signs of fluid overload. Which nursing intervention should be prioritized to address the patient's current symptoms effectively?

C) Initiate fluid restriction to control fluid overload.

A) Administer erythropoiesis-stimulating agents to manage anemia.

B) Educate the patient on a low-phosphate diet to address hyperphosphatemia.

C) Initiate fluid restriction to control fluid overload.

D) Adjust antihypertensive medication to optimize blood pressure control.

A patient with chronic kidney disease (CKD) stage 3b presents with worsening symptoms, including shortness of breath and edema. Lab results indicate anemia and hyperphosphatemia, while a chest X-ray shows mild pulmonary congestion. Which nursing intervention should be prioritized to address the patient's current condition?

A) Administer a diuretic to reduce fluid overload and manage pulmonary congestion.

B) Initiate erythropoiesis-stimulating agents to correct anemia.

C) Provide phosphate binders to manage hyperphosphatemia.

D) Adjust antihypertensive medications to optimize blood pressure control.

A patient with chronic kidney disease has been experiencing increased fatigue, mild dizziness, and muscle cramps after a recent change in her antihypertensive regimen. Her blood pressure has decreased, and laboratory tests reveal a decrease in hemoglobin and elevated serum phosphate levels. Which nursing intervention should be prioritized to address her current symptoms and lab findings?

C) Collaborate with the healthcare provider to adjust the antihypertensive medication dosage.

A) Administer a bolus of intravenous fluids to increase blood pressure.

B) Educate the patient on the importance of adhering to dietary phosphate restrictions and reassess her understanding.

C) Collaborate with the healthcare provider to adjust the antihypertensive medication dosage.

D) Supplement her diet with high-iron foods to manage her anemia.

A patient with chronic kidney disease (CKD) presents with increased fatigue, mild dizziness, and a drop in blood pressure after a change in her antihypertensive regimen. Laboratory results indicate stable renal function but persistent anemia and hyperphosphatemia. Which of the following nursing interventions is most appropriate to address the patient's current symptoms and lab findings?

C) Collaborate with the healthcare provider to adjust the antihypertensive medication to prevent further hypotension.

A) Increase the dose of the erythropoiesis-stimulating agent to improve hemoglobin levels.

B) Counsel the patient on the importance of strict dietary phosphate restrictions and adherence to her phosphate binder regimen.

C) Collaborate with the healthcare provider to adjust the antihypertensive medication to prevent further hypotension.

D) Recommend immediate intravenous iron supplementation to address potential iron deficiency anemia.

A patient with chronic kidney disease presents with worsening fatigue, increased shortness of breath, decreased urine output, and peripheral edema. Laboratory results reveal a hemoglobin level of 8.8 g/dL, serum potassium of 5.8 mEq/L, and serum phosphate of 5.4 mg/dL. Which nursing intervention should be prioritized to address the patient's current condition?

C) Administer loop diuretics to manage fluid overload.

A) Administer erythropoietin-stimulating agent to address anemia.

B) Initiate oxygen therapy to improve oxygen saturation.

C) Administer loop diuretics to manage fluid overload.

D) Start a low-potassium diet to address hyperkalemia.

A patient with chronic kidney disease presents with worsening fatigue, increased shortness of breath, and decreased urine output. Laboratory findings indicate hyperkalemia and pulmonary edema. Which nursing intervention should be prioritized to address the patient's current condition?

C) Administer diuretics as ordered to manage fluid overload

A) Administer oral potassium supplements to correct electrolyte imbalance

B) Initiate oxygen therapy to improve oxygen saturation

C) Administer diuretics as ordered to manage fluid overload

D) Provide a high-protein diet to address anemia

A patient with chronic kidney disease has been started on diuretic therapy. She presents with a serum potassium level of 5.5 mEq/L and elevated serum phosphate level of 5.3 mg/dL. Which nursing intervention should be prioritized to address the current electrolyte imbalance and prevent potential complications?

C) Restrict high-potassium foods and monitor cardiac rhythm closely.

A) Administer potassium supplements to stabilize potassium levels.

B) Encourage a diet high in phosphorus to manage electrolyte balance.

C) Restrict high-potassium foods and monitor cardiac rhythm closely.

D) Initiate intravenous calcium supplementation to manage hyperphosphatemia.

A patient with chronic kidney disease (CKD) is being managed with diuretics and demonstrates a modest increase in urine output. However, she continues to experience dyspnea and her chest X-ray indicates persistent pulmonary congestion. Her serum potassium is 5.5 mEq/L and hemoglobin is 8.9 g/dL. What is the most appropriate next step in managing this patient's condition?

A) Increase the dose of diuretics

C) Administer a blood transfusion

D) Restrict fluid intake further

A patient with chronic kidney disease presents with elevated serum phosphate levels and fluctuating blood pressure, including episodes of hypotension. The patient is experiencing persistent pulmonary congestion and dyspnea with minimal exertion. Which nursing intervention should be prioritized to address the patient's immediate clinical needs?

B) Initiate fluid restriction to manage pulmonary congestion and prevent fluid overload.

A) Administer prescribed phosphate binders to manage elevated serum phosphate levels.

B) Initiate fluid restriction to manage pulmonary congestion and prevent fluid overload.

C) Educate the patient and family on the importance of dietary phosphate restrictions.

D) Monitor blood pressure closely and prepare for potential initiation of dialysis.

A patient with chronic kidney disease is experiencing episodes of hypotension and pulmonary congestion. The clinical team is considering initiating dialysis. Which nursing intervention is most appropriate to address the patient’s current condition?

C) Position the patient in a high Fowler's position to alleviate pulmonary congestion.

A) Encourage the patient to increase fluid intake to manage hypotension.

B) Administer prescribed phosphate binders with meals to manage hyperphosphatemia.

C) Position the patient in a high Fowler's position to alleviate pulmonary congestion.

D) Restrict dietary sodium intake to manage fluid overload.

chronic kidney disease - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic kidney disease (CKD) primarily results from prolonged damage to the nephrons, leading to sclerosis and fibrosis. This reduces the kidneys' ability to filter waste, balance electrolytes, and regulate fluid levels, causing accumulation of toxins in the body.

• Secondary mechanism: Glomerular hypertension and hyperfiltration occur as compensatory mechanisms for nephron loss. While initially maintaining GFR, they eventually exacerbate nephron damage, accelerating progression of CKD due to increased pressure and workload on remaining nephrons.

• Key complication: As CKD progresses, reduced erythropoietin production leads to anemia, while impaired phosphate excretion causes mineral and bone disorders, collectively increasing cardiovascular risk and impacting quality of life.

Patient Profile

Demographics:

52-year-old female, school teacher

History:

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

• Current medications: Lisinopril, Metformin, Amlodipine, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and swelling in legs

• Key symptoms: Shortness of breath, decreased urine output, loss of appetite

• Vital signs: Blood pressure 150/95 mmHg, heart rate 88 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, oxygen saturation 93% on room air

Section 1

New Diagnostic Results:

Following the initial assessment, additional diagnostic tests were ordered to further evaluate the patient's condition and pinpoint the underlying causes of her worsening symptoms. The lab results revealed a serum creatinine level of 2.1 mg/dL, indicating a decline in renal function compared to her last check-up. Her estimated glomerular filtration rate (eGFR) had decreased to 38 mL/min/1.73 m², confirming the progression of her chronic kidney disease from stage 3a to stage 3b. Blood tests also showed anemia, with a hemoglobin level of 9.8 g/dL, and hyperphosphatemia, with a phosphate level of 5.2 mg/dL. These findings align with the anticipated complications of CKD, such as erythropoietin deficiency and impaired phosphate excretion.

In addition to the laboratory data, a chest X-ray was performed due to the patient's shortness of breath, which revealed mild pulmonary congestion indicative of fluid overload. This corroborates the physical findings of peripheral edema and suggests that her volume status needs to be carefully managed. Furthermore, a 24-hour urine collection showed a significant decrease in urine output, supporting the clinical impression of worsening renal function. These diagnostic results highlight the need for adjustments in her management plan, including potential modifications to her antihypertensive regimen and initiation of treatments to address anemia and electrolyte imbalances.

Given these developments, the clinical team is tasked with re-evaluating her treatment strategy to slow the progression of CKD and manage her current symptoms. The focus will likely involve optimizing blood pressure control, possibly introducing erythropoiesis-stimulating agents, and considering phosphate binders to mitigate her mineral imbalance. These interventions must be carefully balanced with the patient's existing medications and her overall health status, emphasizing the importance of comprehensive, multidisciplinary management in the context of chronic kidney disease.

Section 2

Change in Patient Status:

A week after the initiation of the revised management plan, the patient returns to the clinic for follow-up, presenting with new symptoms of increased fatigue and mild dizziness. Her blood pressure, previously well-controlled at 130/80 mmHg, has now dropped to 110/70 mmHg, suggesting possible overtreatment with her adjusted antihypertensive regimen. Her weight, indicative of fluid status, remains stable; however, the peripheral edema persists, albeit slightly reduced. The patient also reports experiencing muscle cramps, which may be related to her electrolyte imbalances.

Repeat laboratory tests show a slight improvement in serum creatinine, now at 2.0 mg/dL, and eGFR stable at 39 mL/min/1.73 m², indicating a modest stabilization of renal function. However, her hemoglobin level has decreased further to 9.5 g/dL, despite the introduction of erythropoiesis-stimulating agents, suggesting a need for further investigation into her anemia, possibly considering factors such as iron deficiency. Serum phosphate levels remain elevated at 5.1 mg/dL, despite dietary phosphate restriction and the use of phosphate binders, necessitating re-evaluation of her current medication regimen and dietary adherence.

These findings prompt the clinical team to reconsider the patient's antihypertensive therapy, potentially reducing dosages to balance blood pressure without exacerbating her renal condition. Additionally, the persistence of anemia and hyperphosphatemia highlights the need for a more aggressive or alternative approach, possibly involving iron supplementation and a review of her phosphate binder therapy. This nuanced situation underscores the importance of continuous monitoring and tailored adjustments in managing chronic kidney disease, emphasizing the need for a patient-centered approach to address evolving complications effectively.

Section 3

A few days after her follow-up clinic visit, the patient presents to the emergency department with new complaints of worsening fatigue, increased shortness of breath, and a noticeable decrease in urine output. On examination, her vital signs reveal a blood pressure of 100/65 mmHg, pulse rate of 88 beats per minute, respiratory rate of 22 breaths per minute, and oxygen saturation of 92% on room air. The physical exam is notable for increased peripheral edema and mild jugular venous distention, suggesting fluid overload, despite her earlier stable weight. Auscultation of the lungs reveals bilateral basal crackles, indicative of possible pulmonary congestion.

Laboratory tests show a further drop in hemoglobin to 8.8 g/dL, raising concerns about worsening anemia, potentially exacerbated by the ongoing renal dysfunction and inadequate erythropoietin response. Her electrolyte panel reveals persistent hyperkalemia with a serum potassium level of 5.8 mEq/L, alongside a slight increase in serum phosphate to 5.4 mg/dL, despite previous interventions. Chest X-ray confirms pulmonary edema, correlating with her respiratory symptoms and signifying the need for prompt management of her fluid status and electrolyte imbalances.

These developments prompt the clinical team to initiate diuretic therapy cautiously to address fluid overload while reassessing her current medication regimen, particularly her antihypertensive and phosphate binder treatments. Consideration is given to the potential need for dialysis initiation, given the risk of acute decompensation in her renal function. The team also plans to investigate further the cause of her anemia, possibly addressing iron deficiency with intravenous iron supplementation, and to evaluate alternative phosphate binders or dietary measures to manage hyperphosphatemia more effectively. This scenario underscores the complexity of managing chronic kidney disease with concurrent complications, requiring a multifaceted approach to stabilize the patient's condition and prevent further deterioration.

Section 4

Following the initiation of diuretic therapy, the patient's fluid status shows initial signs of improvement. Over the next 24 hours, the urine output begins to increase modestly, and there is a slight reduction in peripheral edema. However, her respiratory status remains a concern, as she continues to experience dyspnea with minimal exertion. A repeat chest X-ray suggests persistent pulmonary congestion, indicating that while the diuretics have begun to take effect, there is still significant fluid overload that needs to be addressed.

Laboratory results from the subsequent day reveal that the serum potassium level has decreased to 5.5 mEq/L, showing some improvement yet remaining above the normal range. This warrants continued monitoring and careful adjustment of her treatment regimen to avoid potential cardiac complications associated with hyperkalemia. Her hemoglobin remains low at 8.9 g/dL, prompting the clinical team to proceed with intravenous iron supplementation, which they hope will aid in ameliorating her anemia and improving her overall energy levels. The team also evaluates her dietary intake to ensure adequate nutrition while managing her electrolyte disturbances, especially focusing on phosphorus restriction given the elevated serum phosphate level of 5.3 mg/dL.

The patient's clinical response to the initial interventions is mixed, necessitating further adjustments and close monitoring. The consideration for potential dialysis becomes more pressing, as the risk of acute decompensation persists despite current measures. The healthcare team discusses the possibility of initiating dialysis, weighing the risks and benefits, and preparing the patient and her family for this potential next step in her care. This situation highlights the necessity for ongoing reassessment and flexibility in the management plan for patients with chronic kidney disease, especially in the face of evolving complications.

Section 5

Over the next 48 hours, the patient's condition evolves, revealing new diagnostic results that require the clinical team's attention. A repeat set of laboratory tests indicates that while the serum potassium level has further decreased to 5.2 mEq/L, closer to the normal range, the serum phosphate level has risen to 5.8 mg/dL, necessitating urgent dietary and pharmacological interventions to prevent complications such as vascular calcification and secondary hyperparathyroidism. The increase in phosphate levels prompts the clinical team to intensify phosphate binder therapy and reinforce dietary phosphate restrictions.

Additionally, the patient's blood pressure readings have become more variable, with episodes of hypotension, measured at 95/60 mmHg, occurring in the early mornings. This fluctuation raises concerns about the patient's cardiovascular stability, particularly in the context of ongoing fluid management challenges. The persistent pulmonary congestion, as evidenced by the repeat chest X-ray, and the patient's continued dyspnea with minimal exertion, suggest that fluid overload remains inadequately controlled. These findings heighten the consideration for initiating dialysis, as there is an increasing need to manage fluid balance more effectively and prevent further cardiac strain.

The clinical team convenes to discuss the potential shift towards dialysis, considering the benefits of improved fluid and electrolyte management against the risks and lifestyle implications for the patient. This decision-making process involves a multidisciplinary team, including nephrologists, dietitians, and nursing staff, to ensure a comprehensive approach. The patient's family is engaged in these discussions, ensuring they are informed and prepared for the possible transition to dialysis. As the team weighs these options, they continue to monitor the patient's response to current interventions closely, emphasizing the importance of adaptable care strategies in managing chronic kidney disease with emerging complications.