Anatomy, physiology and pathophysiology.
Clinical assessment using a system-based approach.
Nursing management related to medical management.
Role of an interdisciplinary team..
Primary healthcare strategies.
Medical management and treatment.
Ethical and legal issues.
Education of the patient and the family.
The case study which was presented was of a male who was 80 years of age. He goes to Port Augusta hospital three times a week for haemodialysis. For the purpose of his haemodialysis, he has arteriovenous fistula on his right arm. With that, he was allergic to sulpha drugs. He had to take multiple medicines because of his condition. He had to administer an ascorbic acid tablet which is 500 mg after his dialysis. With that, he also took calcitriol which is of 0.25mg on alternate days. He also had to acquire epoetin lambda 10,000 unites after dialysis. 500 mg of a folic acid tablet is also taken by him after the procedure. With that, loperamide 2mg capsule is sometimes required by him for the occasion of diarrhoea. In addition to all of this, he has to obtain metoprolol tablet of about 0.25 mg every morning and mega B1 tablet after every dialysis. He was also recommended to take calcium carbonate 500mg tablet three times a day with pantoprazole of 40 mg one time daily. Additionally, he was also suffering from Type 2 Diabetes mellitus and hypertension. He was also diagnosed with the cancer of rectal/bowel in the year 1975. He underwent an operation in 1985 for the removal of the large bowel. With that, he had a history of kidney cancer in the year 2005. Cancer has spread to his both of the kidney and because of which he has to undergo a surgery to remove his right kidney in the year 2010. In the recent year that is in 2015, he also has to remove his left kidney and prostate. And because of that, now he is on haemodialysis. Currently, he is living with his wife who is very supportive.
The kidneys are present as a pair in the human body and are in the shape of a bean. They are brown in colour and their size is generally the size of the fist of the person. They are enveloped by renal capsules which are made up of very strong fibrous connective tissue. The layer of fat is also connected to the kidneys which aid in cushioning them. However, there is an asymmetry in both of the kidneys. The right kidney is lower than the left kidney and sits under the liver's posterior side and diaphragm. Also, the left kidney sites below spleen's posterior side and the diaphragm. The kidney is divided into three major parts. They are renal cortex, renal pelvis and renal medulla. The kidney is also connected by renal arteries, renal veins and renal plexus (Muller et al., 2017). The kidneys in the body perform major bodily functions. They maintain the homeostasis of the body by regulating the electrolytes and by managing the acid-base functions. Kidneys also play role in plod pressure by checking the water and salt balance. With that, they serve the role of filtering the blood of the body so that wastes could be removed via urine. In addition to that, kidneys in humans are also responsible for water, amino acids and glucose reabsorption. With that, they also make hormones in the body such as calcitriol and erthropoitin (Muller et al., 2017).
Cancer is a disease which is caused due to uncontrolled proliferation of the cells. The cells of the body lose their property of contact inhibition and monolayer formation and thus start to spread within the system which disturbs the normal functioning of the body (Barata&Rini, 2017). Cancer in the kidney is one of the most common cancers which are found in both women and men. Most of the cases which are reported generally have cancer due to changes in the gene of non-Hippel-Lindau (VHL). This is a gene which is a 2-hit tumour suppressor and the first allele of this gene is turned off via intragenic mutation and the other allele is usually deleted because of a large deletion. In the cancerous cells, VHL inactivation results in hyperactivity of hypoxia-induced factor (HIF) which in the end leads to overexpression of growth factors which are platelet-derived and vascular endothelial growth factors (VEGF). Therefore, it can be said that cancer activity is initiated because of the activity of growth factors which are platelet-derived, vascular endothelial growth factors, receptors and mTOR inhibitors in addition to AXL and MET tyrosine-protein kinase receptors (Barata&Rini, 2017).
Clinical assessment of the patient could be done by nurses with the help of head to toe approach. It is a way of collecting relevant information about patient health status (Anderson et al., 2018). This kind of assessment requires critical thinking and clinical judgment and also information about the patient's condition. Physical examination is done by using a variety of techniques such as inspection, percussion, palpation and auscultation. Head to toe assessment includes a complete system of the body and a systemic method for data collection (Anderson et al., 2018). The nurse is provided with a full understanding of the patient. Priority assessment is also an important part of this approach. For a nurse, it is crucial to know about body systems. They should also know on which system they need to focus which is based upon the presentation of the client and the nursing knowledge, pharmacology and pathology. Unusual findings should also be considered in the health history of the patient. The sections which are included in the head to toe assessment are neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal and integument assessment (Anderson et al., 2018).
Management of the patient who has to undergo haemodialysis is a very complicated task. The major areas of concern in their management are controlling hypertension in patients. Hypertension needs to be controlled because it is associated with hemodynamic stability of the person while dialysis is going on. Hypertension in patients can increase the danger of a cardiovascular disease which in turn could cause problems in the health of the person. Because of hypertension, the patient could also die (Khan at al., 2016). With that, chronic inflammation should also be monitored in the patient. In the normal condition, inflammation is good for the body but during disorder which is related to kidney, inflammation can become uncontrolled, persistent and maladaptive. Systemic inflammation can also cause cardiovascular diseases, depression, frailty and protein-energy wasting in patients. Therefore, it is necessary to reduce inflammation in patients (Cobo, Lindholm&Stenvinkel, 2018).
The patient could be provided with help from various members of the healthcare community. He could be assisted by physicians, nurses, dietitians and social workers. A physician can provide the patient with appropriate knowledge and education about his health condition. He could also help in knowing what is beneficial for him and how he can manage his situation. Physicians could also tell him about the complications which could occur in his case and thus can give the guidance (Johns et al., 2015; Duru et al., 2018).Nurse, in this case, could help in follow-ups with the patient so that regular monitoring of the patient's condition could be done. The nurse can further educate the patient on self-management and could also help with medication managing. The role of the dietician is to give counselling to the patient about the dietary components in the food and to tell him about the management of the fluids. Social workers can also help the patient by assisting with supplying the resources which are important to the patient. They can also help with the health care proxy completion. They could also aid in providing support to the family of the patient (Johns et al., 2015; D’Onofrio et al., 2016).
Haemodialysis is a procedure which helps in life-saving but it also causes multiple problems for the patient and the family. One of the problems which are faced by the patient is the economic burden. In the case study which has been presented also stated that the patient has to undergo haemodialysis thrice a week. The expenditure on the treatment is too much for the patient and it kept on increasing. For this, health policies should be made so that less burden is faced by the patients and their families. Some public health strategies could also be put in place for the patients who are living with hemodialysis so that their quality of life could be enhanced (Abdul Manaf et al., 2017). With that, the focus should also be given towards patient accessibility. In the case of hemodialysis, travelling of the patient generally restricted. The healthcare facility should be near to the patient location of living. This would help him with coming and going problem. The patient would reach out to the facility anytime and also when he is facing some kind of problem which needs immediate attention of the nurse or any other healthcare practitioner. This would directly impact the patient’s quality of life (Dąbrowska-Bender et al., 2018).
In the management of haemodialysis patients, it is important to focus on inadequate nutrition especially the lack of ascorbic acid in the body. Intake of ascorbic acid could lead to change in kidney disease mineral disorder and thus could affect the patient in a positive way. Therefore, the patients are provided with a tablet of ascorbic acid after the dialysis is done so that the level of the ascorbic acid could be maintained (Ke et al., 2018). With that, haemodialysis patients are also be provided with vitamin D supplements because its deficiency can cause alteration in bone and hyperparathyroidism. Therefore, calcitriol is given to the patients to limit the deficiency of vitamin D in them (Parikh et al., 2015).
Pain management is important in the people who undergo haemodialysis because most of the time it is poorly managed and it cause severe discomfort to the patient. It can also lead to poor quality of life and usage of excessive healthcare (Davison, 2019; Hain et al., 2019). Pain can cause psychological distress, limitation in work, social life and family. With that, it can cause depression in patients with decreased satisfaction in life. Hospital visits also increase and this causes troubles for the patients. For the management of the pain, analgesics are given. This is a pharmacological approach which is used for reducing the chronic pain of the patient. Another approach which could be used is the non-pharmacological treatment which consists of aerobic exercise, massage, acupuncture, stretching andacupressure. In addition to these behavioural therapies could also be used. They are cognitive behavioural therapy, relaxation techniques, guided imagery, biofeedback, counselling and mindfulness-based reduction of stress (Davison, 2019; Hain et al., 2019).
Diagnosis of kidney problem can be done by looking at the glomerular filtration rate (GFR). This test is done to monitor the functioning of the kidney. Its normal range is 100-120mL/ min/ 1.73m but if it is less than 60mL/ min/ 1.73m then attention should be paid to the patient as it can cause chronic kidney diseases and further complications. Blood tests need to be done for this diagnosis. Assessment of proteinuria could also be done checking early morning sample of the urine and quantifying albumin-creatinine ratio. Proteinuria monitoring is important because it can tell about the progression of kidney failure. The diagnosis could also be made by imaging of the kidneys (Vaidya&Aeddula, 2019).
Psychosocial aspects that could affect the patient could be depression as haemodialysis affect the quality of life of the patient which could negatively affect his social, psychological and economic wellbeing. Other than this, the self-esteem of the person can also diminish as he faces many problems in doing daily life activities such as taking part in social and sports events. He may also face a problem in transportation to the hospital and his body appearance could change. He could also experiences episodes of anxiety due to chronic pain which is related to his condition. Nursing intervention could be given so that they can adapt to the situation and support and help could be provided to them. The nurse could also encourage the patient and could help him with his needs and requirements (Gerogianni, S. K., &Babatsikou et al., 2014).
Ethical issues that should be kept in mind by the nurse while working with a patient who is receiving his haemodialysis can be beneficence, autonomy, non-maleficence and justice. Beneficence means that nurse would take decisions which will promote the well being of the patient. By non-maleficence, the nurse has to avoid any harm that could be done to the patient and that will cause the patient some problems. Autonomy means the patient's own decision will be regarded and his decision will be given importance for his own health. Justice means that nurse or the healthcare provider will be fair and equitable and will perform the correct treatment which will not involve unjust or wrongful acts (Stone, 2018). A legal issue can be raised if patient safety is risked by the nurse. For that nurse needs to give proper attention to the service which has been provided to the diseased individual (Kadivar et al., 2017).
Education of the patient and the family is necessary in the case of haemodialysis because it can result in the better following of the treatment plan which will reduce the complications of the condition (Bahramnezhad et al., 2015). Nurses could play an important role in addressing the patient family and telling them about the patient situation and his health status. Nurses could also give training to the patient and the family members to manage the condition. They can also highlight the risk factors that can cause complex troubles for the patients. By providing knowledge about the haemodialysis, nurses could encourage the patients to take their medicines on time and can also make them more responsive towards the follow-ups. Patient family members would be made more aware of their role in managing the patient condition (Bahramnezhad et al., 2015).
Discharge planning of the patient includes changes in the diet. The diet which needs to be administered should be altered in terms of intake of salt that is sodium and potassium. Protein and phosphorus need also be changed. Other than this, the patient should take care of his medicines and should be available for follow-ups. The patient should always be present for his medical examination and appointments. He should come regularly for his haemodialysis and should not miss them. With that, he should also manage his Type 2 diabetes mellitus and hypertension (Stads et al., 2013).
In the conclusion, it can be said that the kidney's function is very much important for the proper functioning of the body. It maintains the homeostasis and discards the waste product from the blood. Cancer in the kidney generally occurs due to alteration in a gene. The assessment could be made with the help of a head-to-toe approach by the nurse. Nursing management involves managing hypertension and chronic inflammation in the body. Moreover, multiple healthcare practitioners could help the patient with their services. They are physicians, nurses, dietitians and social workers. Primary healthcare strategies that can be used are creating policies which will reduce the economic burden and increasing the accessibility. Pharmacological and pain management interventions could be provided to the patients. Diagnosis of the condition can be done by looking at GFR, by assessment of proteinuria and by kidney imaging. The patient could also suffer from depression and anxiety and could face ethical and legal problems. Educating the patient and the family members is also necessary and it is important that a proper discharge plan should be created for the patient.
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