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Day 1: A 62-year old, recently widowed male Hispanic patient, named Mr. Kevin Ulyses Blanco (K. U. B.) was brought in to the emergency department (ED) by his daughter for progressively worsening shortness of breath, fatigue, a lingering non-productive cough, and generalized edema. One month prior, he noticed dyspnea upon exertion, loss of appetite, nausea, vomiting and malaise, which he attributed to the flu. In the emergency department, he appeared anxious and pale, and had a dry yellow tint to the skin. He denied any chest pain, and he could not recall the last time he urinated. He has history of benign prostatic hyperplasia, diabetes mellitus type 2, hypertension, dyslipidemia, and renal insufficiency for the past two years. His ED assessment findings included: 1+ pedal edema, basilar crackles in the lungs bilaterally, and a scant amount of urine according to a bladder scan. His lab results indicated a glomerular filtration rate (GFR) of 12. Based on his subjective and objective symptoms, he was admitted with a diagnosis of progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD). The plan of care was focused on managing his symptoms and consulting with his nephrologist regarding need for hemodialysis.
Day 3: Mr. K.U.B had an AV graft placed in his forearm to receive dialysis and a dual-lumen hemodialysis catheter for temporary use. His symptoms were worsening despite medical interventions and hemodialysis was needed urgently. The plan was to continue his medications to manage anemia, HTN, diabetes, and renal disease. The nurse identified psychosocial stressors of financial concern and having to live alone with his worsening health condition. With his daughter living far away, he was worried he wouldn’t have support. He stated that he was worried about the financial burden of hemodialysis and struggled with facing the reality of his diagnosis and what his quality of life would be like in the next few years of his life. A recommendation was made for a social worker and psychiatric consult.
Day 8: By the end of day 8, most of his acute symptoms had been relieved and he was stable enough to be discharged. He had been in contact with case management for his follow up appointment had been made with his primary physician and discharge teaching was given.
Questions
- What modifiable factors could Mr. K.U.B. have addressed to slow the progression of his renal disease?
- What collaborative interventions could be used to enhance his care and ensure continuity of care after discharge?
- What affect did uncontrolled hypertension and poor medication compliance have on his disease process?
