Case study - Chronic kidney disease: Nursing

Nurse. Marisol works in a family practice office and is caring for Robert a 55 year old with a history of chronic kidney disease and type two diabetes who's arrived for a follow up appointment in collaboration with a registered nurse RN Ray.

Nurse Marisol goes through the steps of the clinical judgment measurement model to make clinical decisions about Robert's care by recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse Marisol recognizes important cues including mild pitting edema in Robert's lower extremities. A blood glucose of 214 mg per deciliter BP of 145/85 millimeters mercury and a weight gain of 4.5 lbs.

Since his last visit. Nurse Marisol asks about Robert's insulin management at home.

I see that your blood sugar is higher than your last visit. Have you made any changes to your medications or the foods you eat?

Yeah. My blood sugar's been a little high.

Sometimes I get tired and forget to take my insulin at night. I also noticed that your ankles are swollen too.

Can you tell me how much water you've been drinking lately? Well, I've been really thirsty lately, so I've been drinking more than usual anyway, someone told me that drinking water helps to flush out my kidneys.

Next nurse Marisol analyzes these cues. She reviews the electronic health record or E hr and notices that Robert is prescribed 10 units of long acting insulin nightly.

She also notes that he's recommended to follow a 1.5 L fluid restriction daily. She knows that chronic kidney disease is a progressive and irreversible loss of kidney function and that uncontrolled diabetes can worsen damage to nephrons over time.

She also understands that Nephron loss reduces the glomerular filtration rate or GFR leading to decreased fluid output, increased fluid retention edema and increased BP.

Nurse Marisol realizes that Robert needs more effective blood glucose control and fluid management. Now, using the information she's gathered.

Nurse Marisol reports her findings to RNA and together they choose a priority hypothesis of knowledge deficit. Then nurse Marisol collaborates with RNA to generate solutions to promote Robert's understanding of diabetes and its effect on chronic kidney disease.

They establish the expected outcome that after intervening Robert will verbalize two strategies to promote kidney health before the end of his appointment.

Next, nurse Marisol takes action to implement these solutions to achieve better glycemic control and prevent worsening kidney disease.

Nurse Marisol helps Robert program his phone to alarm three times daily and at bedtime as a reminder to check his blood glucose level and take his prescribed insulin.

Then she provides Robert with a logbook to record his blood glucose and daily weight. Nurse Marisol then reinforces the education RNA provided about maintaining Robert's prescribed daily fluid allowance.

First, she reminds Robert that he needs to restrict the amount of fluids he drinks each day because his kidney disease makes it more difficult for his kidneys to filter fluids.

She reassures him that when his glucose is within normal limits, he won't be as thirsty. She also makes sure Robert understands how to measure, calculate and plan his fluid intake throughout the day.

And she encourages him to suck on a sugarless hard candy. When he feels thirsty.

Then she provides Robert with a visual chart of common drink sizes and talks to him about hidden sources of fluid like gelatin and ice.

Lastly, she reminds him to record his daily weight in his logbook and to report to his healthcare provider if he notices a weight gain of 4 lbs or 2 kg because this may indicate fluid retention before the end of the appointment.

Nurse Marisol evaluates the outcome of her actions. Robert verbalizes understanding of his insulin dosing and demonstrates how to document his blood glucose levels and daily weight in the logbook.

Then he demonstrates how to calculate and plan his fluid intake throughout the day. Robert also lets nurse Marisol know that he understands he won't be as thirsty when he keeps his blood glucose from getting too high.

And when he feels thirsty and is nearing his maximum daily fluid intake. He'll suck on a sugarless hard candy.

All right. As a quick recap, nurse Marisol recognized and analyzed cues related to Robert's chronic kidney disease and diabetes and in collaboration with RNA prioritized hypotheses and generated solutions to address this problem.

Nurse Marisol and RNA then took action to implement interventions to address Robert's knowledge deficit and evaluated outcomes by comparing them to the expected outcomes.

Since Robert was able to verbalize two strategies to promote kidney health, they determined that the plan of care was successful.