Dialysis case study
A 66-year-old black male was seen by his primary provider for complaints of fatigue, anorexia, swelling of hands, face, and ankles, muscles cramps, and increased difficulty breathing. He has a 3-year history of poorly controlled hypertension related to non-adherence to the medical regimen. His B/P routinely runs in the range 155-165/92-102. His B/P today was 170/105. The client does not like to take pills and feels that they are not necessary. He also has been reluctant to modify his diet and likes to eat fried foods. He does not think his eating habits are causing any problems. Because of these symptoms, the client was admitted to the hospital for treatment and further evaluation. His lab values and renal studies confirmed the diagnosis of end stage kidney disease. Because of the severity of his problems, he was started on hemodialysis. What is the likely cause of his kidney failure? Explain your answers
His kidney failure is caused by uncontrolled blood pressure and lack of treatment compliance. When you have uncontrolled high blood pressure it affects the kidneys because the blood vessels narrow and stiffen causing the nephrons in the kidney to work harder. Eventually if hypertension is left untreated it can lead to end stage renal disease because the nephrons in the kidney are no longer able to filter out the toxins such as nitrogen waste which builds up in the blood. They also are unable to maintain fluid or electrolyte balance. Eventually ESRD is demonstrated by decreased glomerular filtration rate less than 15mL/min.
At first, the client refused the dialysis treatments. After further consultation with the medical team and his family, he agreed to start the treatments.
List three common types of permanent access sites that can be used.
Three common types of permanent access sites are:
1. dual-lumen catheter
2. Internal Ateriovenous Fistula (AVF)
3. Arteriovenous Graft
List 2 advantages and 2 disadvantages of each of the sites.
Dual lumen catheter
Advantages
1. Provides quicker access for dialysis doesn’t take as long as a fistula
2. Can still use arms to check blood pressure, draw blood, and administer IV
Disadvantages:
1. Unable to enjoy baths, swimming, or showers
2. Can get clogged or become infected
Internal Ateriovenous Fistula (AVF)
Advantage: 1. there is less chance for infection
2. Can be used long term
Disadvantages: 1. Need to be careful with that arm, (can’t sleep, put pressure, or carry anything heavy. 2. It can take up to four months for the fistula to develop
Arteriovenous Graft
Advantage: 1. you can place it in three different arteries (radial, brachial, and femoral
2. No need to create a fistula, graft can come from human umbilical cord, saphenous vein, or bovine, (cows) carotid artery
Disadvantages: 1. it is not as strong as the fistula 2. Access site might need to be changed more often than fistula
During the hospitalization, he had a permanent hemodialysis catheter (perm- catheter: dual lumen catheter) inserted as an access site. He received dialysis three times each week and his condition improved. Because of the progress he made, he was sent home and was to continue his dialysis treatments as an outpatient.

What does the client need to be taught concerning the permacatheter? Teach the patient how to care for the site such as keeping it cleans, not getting it wet.
Avoid removing the cap on the catheter, only the nurse should be doing this
Avoid swimming or taking baths or showers
Keep dressing dry at all times to reduce the risk of infection
Ensure that gloves and a mask are worn for your protection whenever the dressing is being changed
Report any signs of infection such as, drainage, bleeding, foul order, pain, swelling or redness
Keep all follow up treatment appointments
Call the doctor if he has any questions or concerns regarding the permanent catheter. Educate patient to follow the treatment regimen such as following nutrition plan, taking medications, getting vital signs checked (Wt, BP, Pulse, RR, Temp) and ensuring he maintains his blood pressure under control based on his doctors recommendation.
Ensure that he keep the clamps tight and closed when not the ports are not being used

He was admitted to the hospital 4 weeks later for the creation of an arteriovenous (AV) fistula or graft. Outline the routine home care for these two access sites.

Routine home care for fistula or graft: this information pertains to the arm that has the fistula or graft for dialysis. Please follow guidelines below.

Use your arm for dialysis only.
Don’t allow anyone to check your blood pressure on this arm
Don’t sleep or put weight on your arm
Don’t lift or carry anything heavy and avoid putting pressure on your arm
Don’t allow anyone to take a blood sample from this arm or put in Intravenous fluids in this arm
Be careful not to injure the arm
Report any unusual redness, swelling, pain, heat, to the doctor immediately
Do arm exercises such as putting arms up and then down, out to the sides and down to the sides

The client continued his dialysis treatments and was feeling better. 6 months after the fistula was created, he missed one of his dialysis treatments. When he arrived to his next scheduled treatment, he was feeling worse than usual. He stated that the reason he missed his last treatment was because he was not feeling good. His complaints included the following: difficulty breathing, swelling of hands, face, and legs, weight gain of 7 pounds since the last treatment, B/P readings at home of 175-185/99-110, anorexia, nausea and little urine output since his last treatment. He was worried because these symptoms were similar to the ones he had when he was diagnosed with chronic kidney failure. He stated that he did not call because he did not think missing one treatment would cause that much trouble and he thought he had the flu.

How would you respond to this comment? I would respond by asking him if he understands why he is getting dialysis. I would then educate him on the purpose of dialysis, and the importance of complying with treatments. Finally I would have the patient tell me 2 negative consequences to not getting dialysis treatment.

Describe three problems/complications that can occur during the hemodialysis treatment?
Complications that can occur with hemodialysis treatments are 1. Disequilibrium syndrome can be a complication of hemodialysis which causes increased intracranial pressure ‘and cerebral edema. Can be possibly due to rapid decrease of blood urea nitrogen and blood volume. Can be life threatening, symptoms to look for include headache, nausea, vomiting, restlessness, decreased level of consciousness, seizures, coma, or death may occur. Patient should be assessed for these symptoms and treated with anticonvulsants and barbiturates to prevent life threatening complication.
2. Hypotension may occur if too much fluid is pulled out; treatment is a bolus of fluid re
3. Cardiac dysrhythmias, muscle cramps if too much fluid is taken out
List the routine care for a client before, during, and after a hemodialysis treatment.
Routine care
Before During After
Obtain vital signs( wt, temp, RR, Bp and pulse sitting and standing) Continue monitoring BP, Pulse, level of consciousness Remove all needles
Apply pressure until bleeding stops
Assess access site for signs of infection( redness, swelling, pain, temp, drainage, bleeding) Monitor for signs or changes of chest pain, hypotension, headache, muscle cramps, Perma-cath
After closing catheter clamps remove the blood lines from the catheter
Assess heart, and lung sounds Check dialysis machine for change in dialysate temp, blood leak in dialysate compartment, and check for air in the tubing If blood flow is decreased flush catheter with NS, Heparin and TPA
Assess patency of access site, and onset of new concerns patient may have Before disconnecting the patient from the machine, check Bp, if pt has hypotension administer NS Patient care: check vital signs against pre dialysis readings, check Bp, and Pulse sitting and standing, weigh the patient
Verify all medications patient is taking prior to dialysis treatment Rinse blood from the tubing back into the patient Assess for any new symptoms the patient may be experiencing.
Determine amount of fluid that you will be removing, Administer medications as needed Inform patient to avoid procedures such as blood draws, or injections etc. for the next 4-6 hrs
Prepare access site and connect to machine for dialysis , draw labs give loading dose of heparin Iron, Erythropoietin, Calcitrol, Levocarnitine Schedule patient for next dialysis treatment, reinforce the date, and time to ensure compliance. Inform patient to remove dressings as indicated.

During one of the family conferences, the wife expressed concerns about her husband’s diet. She stated: “He always tells me that I don’t need to cook anything special for him.”

How would you respond to this comment? I would assess what they know about the dialysis diet? I would then help them with their concerns they may have regarding food preparation and requirements. I would assure the patient that we will work with him on incorporating foods he enjoys so he could follow the proper dietary regimen.

What diet information would be appropriate for this client? A meal plan based on foods he enjoys eating and cooking would be the most appropriate. I would educate the patient and his family the importance for meal support. I would then set you up an appointment with a dietician so she can suggest meals based on foods the patient enjoys cooking that meet the dietary requirements needed. Describe the typical diet for a client with chronic kidney failure? A typical diet consists of controlling the amount of potassium, phosphorus, sodium, and liquid in the diet. The diet may need to be modified depending on the patient’s weight, lab work, and other recommendations by the doctor. Include the normal amounts for each of the requirements and give examples of foods to avoid/eat.

It is important to restrict liquids to prevent, swelling, shortness of breath, high blood pressure, and heart failure.

Liquid requirements are 1000mL per day Note that anything room temperature that is fluid is counted as a liquid.

Avoid regular sodas, beer, wine, tea, coffee, fruit flavored drinks with added vitamin c, thirst quencher liquids It is important to restrict sodium to 2-3 grams per day to prevent thirsty, swelling, and high blood pressure Avoid bouillon, broth, consommé, salt free broth, or bullion that are made with a salt substitute
Avoid food, that are high in sodium, table salt, processed foods, smoked meats, broth or bouillon, potato chips, pretzels, salted nuts, pickles, olives, condiments, such as catsup, soy sauce, garlic salt, mustard, barbecue sauce, canned foods, and frozen foods.

The goal for phosphorus is to avoid bone disease; it should be under 1200 mg per day Dietary recommendations

Milk and dairy products: serving size is ½ cups; these foods have 4 gm of protein, 80 mg of sodium, 185 mg of potassium, and 110 mg of phosphorus.
Serving size ½ cup Milk Ice cream
Yogurt
In order for the body to receive the proper nutrition the protein must be kept between 1.0 - 1.2 grams/kg per day 70% of the protein should come from an animal source

Meat/Protein: these foods include 7 gms of protein, 25 mg of sodium, 100 mg of potassium, and 65 mg of phosphorus. DO NOT add salt before or after food has been prepared
The patient may have 1oz of the following proteins.
Beef, pork, lamb chops, poultry, fish, lobster, scallops, canned tuna, shrimp, or clams.
Eggs are considered proteins as well you may have 1 egg, or 2 egg whites or yolks or egg beaters
Avoid the following:
Deli meat such as, roast beef, ham, chicken, or turkey or canned salmon, sardine, cottage cheese
Avoid foods high in sodium, phosphorus, or saturated fats see below: All cheeses except cottage cheese
Sausages, hotdogs such as, Frankfurters, bratwurst, polish, and bacon
Lunch meats, bologna, liverwurst, summer sausage, or loaf salami

Avoid foods high in potassium and phosphorus
Nuts and peanut butter
Dried beans, lentils, and peas

Starches/breads: they contain 2 gms of protein, 80 mg of Na, and 35 mg of potassium and Phosphorus
May eat the following starches/breads:

Serving size: 1 slice, of the following breads
French, Italian, raisin, white sourdough, or light rye
Serving size ½ of the following
Hot dog, hamburger bun, small Danish pastry, sweet roll with no nuts, plain English muffin, or plain bagel

Cereals and grains
Serving size: ¾ cups of ready to eat cereal
2 cups of puffed rice
½ cup of cream of wheat, rice, farina, cooked grits, pasta, or brown/white rice
1/3 cup of oatmeal or oat bran

Crackers and snacks
4 saltine, gram, or butter crackers
1 ½ plain popcorn
9 tortilla chips
Desserts
May have:
2 inch square piece of cake
Ten vanilla wafers
1/8 apple, berry, cherry, or peach pie
1 ½ cup of sweetened jello

Avoid the starches below due to high protein and phosphorus eat them in moderation but not recommended
Bran cereal, muffins, granola bar, or cereal bars.
Avoid prepared boxed, frozen, canned meals, entrees, or side dishes
Avoid whole wheat, oatmeal, rye, and pumpernickel breads
Avoid whole-wheat crackers or cereals

Vegetables: these have 1 gm of protein, 15 mg of sodium, and 20 mg of phosphorus.
May eat the following vegetables low in potassium 0-100mg:
Serving size ½ cup
Green beans, sprouts, raw cabbage, peeled cucumber,
1 cup of alfalfa sprouts
1green or sweet pepper

Medium potassium 101-200 mg
Five spears of asparagus
Serving size ½ cup
Broccoli, cauliflower, eggplant, onions, fresh or canned mushrooms, raw spinach, summer squash

Vegetables high in potassium 200- 350 mg should be consumed in moderation
½ cup of artichoke or cooked celery ¼ of avocado 1 chili pepper Unsalted or regular tomato juice (Reg tomato juice is high in Na) ¼ cup of tomato sauce 1 medium sized tomato ½ cup of Brussels sprouts

Avoid vegetables below due to Very high potassium (> 350 mg) Hash browns Sweet potatoes (> 40 gm of phos per serving) ¼ cup of beet greens ½ medium baked potatoes 1oz of potato chips (14 chips) Cooked spinach has 40 gm or more of phosphorus per serving

Fruits (1/2 gm of protein, 70 calories, and 15mg of phosphorus)

Fruits you could eat: low potassium 0-100mg serving size ½ cups
Applesauce, blueberries, canned pears, or grape juice
1 cup of cranberries or cranberry juice

Medium potassium 101-200mg
1 small apple, or apple juice, pear or tangerine
½ cup of sweet or sour cherries, small grapefruit, or grapefruit juice

Consume fruits below in Moderation due to high potassium (201- 350 mg)
1 cup of canned, fresh apricots or 5 dried apricots
1 medium pear
1/8 of a small honeydew melon or cantaloupe
1 small nectarine
1 medium pear
1 small orange or 1 cup of orange juice

Avoid fruits below they contain more than 350mg of potassium ½ Bananas, prune juice, dried prunes, or canned prunes.

Fats: have very small amount of protein, 45 calories, 55 mg of sodium, 10mg of potassium, and 5 mg of phosphorus
Unsaturated fats
1 tsp of margarine, mayonnaise, oil, or 1 tbs of reduced calorie margarine, low calorie mayonnaise
2 tsp of salad dressing, mayonnaise type or low calorie salad dressing
Saturated fats
1 tsp of butter or solid shortening or powdered coffee whitener
2 tbs coconut

High calorie food: have small amount of protein, 100 calories, 15mg or sodium, 20mg of potassium, and 5mg of phosphorus
Consume in moderation
Candy and sweets, such as 10 jelly beans. 2 Fruit rolls, ¼ cup of cranberry sauce, 5 large marshmallows lemonade, or 2 table spoons of white sugar, jelly, syrup, or honey

Frozen desserts: also count as a liquid
½ of fruit juice bar or 1 three ounce juice bar
It is important to consider eating the right amount recommended of foods high in fiber to prevent constipation, such as oatmeal or whole wheat breads.

The client continued to do well with his hemodialysis treatments. During one of his visits, he asked the nurse what other types of dialysis were available that could be done at home.
How would you respond to this comment? I would inform him that peritoneal dialysis could be done at home, but in order for patients to be considered they need to be compliant with all treatment regimens, including, diet, medications, lab draws, keeping his follow up appointments, and controlled blood pressure. I would advise him to ask the doctor if he is interested and give him information.

Describe two common types of peritoneal dialysis.
Two types of peritoneal dialysis
1. Continuous Ambulatory Peritoneal Dialysis can be done on at home by the patient without using a machine. The patient can continue with their daily activities while the dialysis is taking place in the peritoneal cavity. This process is done because the dialysate remains in the peritoneal cavity over 24 hours, 7 days a week, 3-4 times per day.
2. Continuous Cycling Peritoneal Dialysis is done at home using a machine on a continuous basis during the night while the patient sleeps. It does multiple exchanges automatically, and the last exchange is left in the peritoneal cavity during the day.
Describe how a PD exchange takes place.
Peritoneal Dialysis occurs in the body using the lining of peritoneum to filter out extra fluid and waste products. Dialysate a special solution that contains acid, bicarb, and H2O this solution is inserted into the abdomen through a surgically implanted catheter on the abdominal cavity. As the dialysate sits in the abdomen usually 4 hours it pulls the toxins and waste products from the blood by diffusion across the peritoneal membrane from the body into the dialysate. Once the diffusion is finished the dialysate flows back out from the abdominal cavity through the catheter brining the waste products and toxins with it. Then the process is repeated every night with fresh dialysate. List 2 advantages and 2 disadvantages for peritoneal dialysis.
Two advantages
1. They can do this procedure during the night while they sleep , no machine or needles required
2. They don’t have to go to outpatient center 2-3 times per week, more independence
Two disadvantages
1. Must be done every night
2. May have to do it PD for 30 min, 4 times per day if using the CAPD
Describe three common complications of PD and list the common symptoms.
Three common complications of PD are
1. Peritonitis Infection , sym, Fever, nausea, vomiting, redness, swelling, pain, malaise, abdominal tenderness
2. Perforation of the bladder at time of insertion
Symptoms: positive glucose in the urine with the first bag of dialysate
3. Discomfort from having the dialysis fluid in their stomach
Sym. Bloating, sense of fullness, or back pain
List one age and cultural consideration for this client. Describe one way to modify the plan of care based on these factors. In the African American culture family plays a big role in a patient’s life. One cultural consideration for this African patient is to include his family in his treatment. I would then assess how he views dialysis and his beliefs about the disease. Taking into consideration that the patient enjoys fried foods, I would set up an appointment with the nutritionist so she can suggest alternate ways patient for family to cook healthy without the grease. Also ensure that patient maintains proper dietary requirements for his treatment. I would suggest dialysis support groups within the African American community. In addition, I would educate the patient and his family about dialysis and the important of treatment compliance. Finally, I would address their concerns and answer their questions regarding treatment options.
List 1, 3 part diagnostic statements for this client.
Excess fluid volume r/t compromised regulatory mechanism, secondary to hypertension, ESKD, amb, difficulty breathing, edema, 7 lb weight gain, elevated BP 185/110, decreased urine output

Please return case study with written paper.