Case-1.docx

CASE 1: James Brubaker is a 55-year-old man who was diagnosed 2 years ago with end-stage renal disease secondary to hypertension, necessitating treatment with hemodialysis. He is dialyzed at an outpatient clinic three times per week and is restricted to 1000 ml of fluid /day. During the past week, Mr. Brubaker had been feeling ill and was not able to come for his dialysis appointments. In addition to his noncompliance in meeting his scheduled dialysis appointments, Mr. Brubaker omitted his home medications on several occasions. Today, Mr. Brubaker arrives in the Emergency Department extremely dyspneic. Initial Vital signs reflect the following: BP 210/120 Temp 37.6°C HR 108 Weight 178 lbs Resp 36 He is immediately transferred to the Medical ICU. Upon arrival, you asses Mr. Brubaker and find he is lethargic, slightly confused, nauseated, and vomiting. He complains of chest pain, described as moderate in intensity, diffusely located over the precordium and worsened by deep inspiration. Neck vein distention is present. He has rapid, shallow respirations at 36 breaths/min. Auscultation of his lungs reveals crackles scattered throughout the lower 2/3 of his lungs fields. A pericardial friction rub is auscultated in addition to an S3 gallop. Pitting peripheral edema is noted bilaterally in the lower extremities. The ECG monitor shows sinus tachycardia with occasional PVCs. The outpatient dialysis clinic states Mr. Brubaker’s dry (ideal) weight is 160 pounds.Laboratory data reflect the following: Na 132 Hgb 6.5 ABGs (Room Air) K 7.5 Hct 20 pH 7.20 CI 100 RBC 2.9 PaCO2 16 CO2 10 WBC 12,000 PaO2 53 Gluc 100 Plat 200,000SaO2 85% Creat 20 HCO3 10 Ca 7 Mg 1.5 PO4 12 BUN 170 The physician’s order include placement of a 40% face mask. Hemodialysis is initiated immediately via a permanent AV fistula in the left forearm. After 4hrs of intense dialysis, therapy is discontinued and scheduled again for the next morning. Mr. Brubaker is now less restless and more alert with a respiratory rate of 26 breaths/min, BP 140/90, and a post dialysis weight of 166 pounds. After dialysis the next morning, the friction rub is still present. However, Mr. Brubaker’s post dialysis weight is 160 pounds, BP is 118/80, and he denies any discomfort except for the mild pain in his chest with inspiration. Thirty-six hours after admission to the ICU, Mr. Brubaker is transferred to the telemetry floor with daily hemodialysis treatments scheduled. 1. What is chronic renal failure? 2. Why was hemodialysis initiated so emergently upon Mr. Brubaker’s arrival? 3. Mr. Brubaker had a primary AV fistula in his left forearm. What are important concepts related to dialysis access? 4. What are typical laboratory findings in a chronic renal failure patient? 5. What is the relationship between calcium and phosphate and how is this relationship altered in chronic renal failure? 6. What electrolyte imbalances did Mr. Brubaker had and how those imbalances occurred? 7. What fluid and ABG imbalance did he manifest? 8. Mr. Brubaker’s treatment modality for ESRD was hemodialysis. What are the main differences between hemodialysis and peritoneal dialysis? 9. What complications did Mr. Brubaker manifest? 10. What nursing diagnoses apply in this case?