Mr. Stinson is a 52-year-old male with a history of HTN, DM Type II, CKD, and CHF. He presented to the Emergency Department (ED) complaining of severe itching, nausea, and vomiting. He appeared pale and is lethargic. He reported shortness of breath and the nurse notes crackles in his lungs. He has now been admitted to your unit.
Critical Thinking Check
Bloom's Taxonomy: Application
What additional nursing assessments should be performed?
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Full set of vital signs
Auscultate heart and lung sounds, as well as peripheral pulses
Assess skin turgor and edema
Assess the patient’s dialysis access site for functionality or bleeding
Critical Thinking Check
Bloom's Taxonomy: Analysis
What diagnostic or lab tests would you expect the provider to order?
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Complete metabolic panel (electrolytes, renal function, etc.
Complete blood count
Possibly an ABG to assess for acidosis
Possibly a BNP to assess volume overload and its effect on the heart
Upon further questioning, the patient reports he normally gets dialysis Monday, Wednesday, Friday, but that he skipped dialysis yesterday because he was “not feeling well”. He has +2 pitting edema in his legs. Vital signs are as follows:
HR102RR24
BP153/97SpO290%
The patient’s labs result and show the following:
BUN62 mg/dLNa134 mg/dL
Cr3.9 mg/dLCa7.8 mg/dL
GFR13 mL/min/m2Phos5.0 mg/dL
K6.3 mEq/LMg1.6 mg/dL
Gluc224 mg/dLH/H8.2 / 30%
pH7.32pCO232HCO3–16
BNP247 pg/mL
Critical Thinking Check
Bloom's Taxonomy: Analysis
Interpret these lab results and explain their meaning.
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The BUN/Cr and GFR indicate the patient is definitely in kidney failure as his glomerulus is not filtering the blood like it should and the waste products are building up
His electrolyte abnormalities (hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia, and hypomagnesemia) are all indicative of kidney disease and acidosis. The kidneys would normally retain sodium and excrete potassium. In kidney failure, they do the opposite and potassium levels can get very high.
He is in metabolic acidosis, likely because his kidneys are not able to retain the bicarb buffer like they normally would – this also contributes to the hyperkalemia. As the body tries to balance the H+ ions, it kicks K+ out into the bloodstream.
His BNP is also elevated, indicating volume overload – this is probably caused both by the kidney failure and not getting dialysis and by the heart failure
He is anemic – chronic anemia is common in chronic kidney disease patients due to the lack of erythropoietin.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is going on with Mr. Stinson physiologically?
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Because of his CKD, Mr. Stinson requires dialysis to perform the normal functions of the kidneys, since his aren’t working. He likely felt sick because his potassium was elevated and because of the azotemia (toxins building up in his blood).
He missed dialysis and therefore he is now even more volume overloaded and azotemic
This will cause a risk to his heart and lungs because of the overload and the hyperkalemia
The nephrologist is consulted and determines that the patient needs hemodialysis. As soon as possible. The charge nurse of the dialysis unit is working to create a bed for him and will call back as soon as one is available, hopefully within the hour.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What do you, the nurse, need to consider and assess for Mr. Stinson PRIOR to sending him to dialysis?
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ALWAYS hold antihypertensives before HD (obtain provider order)
Hold any medications that may be dialyzed off as they will not have their therapeutic benefit (confirm with pharmacist and obtain provider order)
May require potassium-lowering medications before dialysis if the wait is going to be too long – hyperkalemia can be deadly
Determine if any medications should be held prior to HD
Assess full set of vital signs
Obtain a weight, preferably on a standing scale
Assess heart and lung sounds, as well as skin/edema
Mr. Stinson goes to hemodialysis, where they are able to pull of 3 L of fluid. He tolerates the procedure well and returns to his room.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What would you need to assess for Mr. Stinson AFTER he returns from Dialysis?
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Obtain a weight, preferable on a standing scale, to compare to the pre-HD weight. This helps determine how much fluid was pulled off (1 kg = 1 L)
Obtain a full set of vital sign
Re-draw a renal function panel as ordered to ensure electrolytes are not in a dangerous range (requires provider order)
Critical Thinking Check
Bloom's Taxonomy: Application
What are some important patient education topics for Mr. Stinson before discharge?
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Importance of hemodialysis – he likely didn’t feel well because he NEEDED dialysis.
Reasons to “skip” dialysis typically involve severe infections and fevers, in which case he should go the following day whenever possible or notify his nephrology team
Should also reinforce teaching regarding nutrition – foods to avoid (high in potassium) and when to take medications with or without food (especially Phos-Lo and Calcium supplements)
