Case Study: Plan And Care For The Patient Suffering From Stage- 4 Chronic Kidney Disease

Introduction

Case study -1

This case study is regarding 51 year old Mr. George. In this case study we are going to plan and implement care to the patient suffering from stage- 4 chronic kidney disease along with other health conditions. When the kidneys in the body fail to work properly for a prolonged period of time probably more than month’s period of time, it can be called as chronic kidney disease (Razmaria, 2016). We are going to collect patient information, understand them, find out problems and solution to those problems, implement them and evaluate the outcomes using Levitt’s cycle of clinical reasoning. collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process (Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001). http://www.supportingstudents.org.au/clinical-reasoning-cycle.html

Patient information/ situation

Mr. George, a known case of chronic kidney disease stage-4 with macro albuminuria secondary to diabetes nephropathy. He is 51 years old aboriginal and Torres Strait islander who also have a history of stroke 2 years ago. He is taken care of by his wife and three children. Both the husband and the wife are benefitted by Centre link payment.

Collecting Cues

Mr. George is referred to a nurse practitioner for his deteriorating kidney function, high blood pressure and albuminuria. In addition, Mr. George has a history of stroke 2 year ago. He is obese and has high cholesterol levels. Apart from this Mr. George also has a family history of renal disease. Mr. George is taking medicines perindopril, lercanidipine, furosemide, atorvastatin, metformin, sodium bicarbonate and vitamin-D. But he was not so sure what the medicines were doing to his body and for how long he has to keep taking them.

Process Information

In last 2 years, Mr. George’s weight has increased from 104 kg to 114 kg. His blood pressure was 153/93 mmhg which is higher than the normal value. Mr. George had a history of smoking in the past. Adult Australians who are 60 years or older are at increased risk of developing chronic kidney disease if they have diabetes, are hypertensive, have established cardiovascular disease, have a family history of kidney failure, obese (body mass index ≥ 30 kg/m2), or a smoker of Aboriginal or Torres Strait Islander origin have a history of acute kidney injury (AKI) (Mathew, 2015). His urine albumin is 30mg/mmol which indicate that he has macro albuminuria. The normal value of serum creatinine is 60-100 micromoles per liter. In contrast, Mr. George has the serum creatinine level higher than the normal value which is 237micromol/L. The glomerular filtration rate has to be 90-120mL/min/1.73m2. The glomerular filtration rate is 27mL/min/1.73m2 instead in case of Mr. George. HgbA1c is hemoglobin linked to sugar. https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c.

Identify problems/issues

The list of problems Mr. George was experiencing was

• Signs and symptoms led by the Chronic kidney disease, stage-4
• Deceased GFR rate
• Macro albuminuria and proteinuria
• Obesity
• Hypertension
• hypercholesterolemia
• Fear and anxiety related to the hospital visit
• Doubt and confusion regarding medication regime
• Lack of knowledge regarding names of the medications

There could be various causes for the chronic kidney disease to happen for example diabetes mellitus, hypertension and vascular diseases, acquired obstructive uropathy, glomerular diseases like glomerulo nephritis, adult polycystic kidney disease and reflux nephropathy

Establish goals

Goals should be set in accordance to the idea of patient centered care. Here the main goal of management would be as follows:

• Identification and management of chronic kidney disease, treatment of signs and symptoms and prevention of further complications.
• Maintain the target Blood pressure of 130/80
• Maintain normal body weight and reduce obesity
• Maintain normal kidney functioning
• Treat macro albuminuria
• Active involvement of patient and family members In the whole process

Take action

Mr. George is under pharmacological management of perindopril and lercanidipine, furosemide, atorvastatin, metformin, sodium bicarbonate and vitamin D. Perindopril is a long acting ACE inhibitor used to treat high blood pressure, heart failure or coronary artery disease and lercanidipine is a dihydropyridine calcium channel antagonist which relaxes vascular smooth muscles (NPS Medicinewise)https://www.nps.org.au/medicine-finder/apo-perindopril-tablets https://www.nps.org.au/australian-prescriber/articles/lercanidipine-hydrochlorideThe combination of perindopril and lercanidipine, compared with lercanidipine alone or peindopril alone is effective in mild essential hypertensive patients, and also decrease the incidence of adverse events. (yang, 2015). Mr. George is also prescribed lasix- furosemide which reduces extra fluid in the body reducing edema caused by heart, liver and kidney diseases. https://www.webmd.com/drugs/2/drug-5512-8043/furosemide-oral/furosemide-oral/details metformin had been prescribed to Mr. George in order to prevent complications such as kidney damage, blindness, nerve problems, loss of extremities and sexual functioning that may be caused by diabetes. https://www.webmd.com/drugs/2/drug-11285-7061/metformin-oral/metformin-oral/details. Sodium bicarbonate is used in correcting the metabolic acidosis in chronic kidney disease and slows the disease progression. https://www.medscape.com/viewarticle/914574

Vitamin D deficiency is common in patient with chronic kidney disease (Henrique Franca Gois, Wolley, Ranganathan, & Carlos Seguro, 2018). Hence Mr. George is prescribed with vitamin D supplements.

Evaluate outcomes

After precise and careful completion of each component of clinical reasoning, it is time to evaluate the patient outcomes to know the changes that have been brought about by our action. As we have discussed earlier adult Australians-aboriginals or Torres Strait islander, diabetic, people with history of cardiovascular disease or family history of kidney failure, obesity, hypertensive, smoker or history of acute kidney injury are at increased risk of developing CKD (Mathew, 2015). In case of our patient, he is an aboriginal and Torres Strait islander, has a history of cardio vascular disease, has a family history of kidney disease, and was hypertensive and was a smoker which could have led him to develop chronic kidney disease.

We can say that there have been significant changes in the general condition of Mr. George after his visit to the nurse. In the beginning, he was not so familiar with the names of the drugs he has been taking, he was not sure why he has to take the medicine and for how long it has to be continued. After careful observation of his understanding and level of knowledge, Mr. George was explained in detail the names and the action of all the medication in front of his wife in the language they understood with the help of a translator. He had been explained the importance of taking medicines regularly, importance of exercises, proper diet plan and significance of adherence to it. His target blood pressure of 130/80 mm of hg had been achieved ultimately.

Reflect on process and new learning

After careful consideration of the whole interaction, we can sum up that patient and the family involvement plays a vital role in adherence to treatment regime of the client in accordance with the patient centered care. Major communication barriers in this case were cultural and language barrier. The general condition of Mr. George has been improved to some extent. From the above scenario, we can say that the important aspects

• Patient centered care
• Effective communication to over the communication barriers
• Proper explanation
• Feasible and timely interventions and evaluation
• Follow up

Bibliography

1. Henrique Franca Gois, P., Wolley, M., Ranganathan, D., & Carlos Seguro, A. (2018). Vitamin D Deficiency in Chronic Kidney Disease: Recent Evidence and Controversies. International Journal of Environmental Research and Public Health, 15(8), 1773.
2. Mathew, T. (2015). Chronic kidney disease management in general practise.
3. Razmaria, A. A. (2016). Chronic Kidney Disease. JAMA, 315(20), 2248.
4. yang, z. (2015). efficacy and safety evaluation of perindopril-lercanidipine combined therapy in patients with mild essential hypertention. Current Medical Research and Opinion, 31(1), 183-186.