Case study - Chronic kidney disease (CKD): Nursing

Nurse Marisol works in a family practice office and is caring for Robert, a 55-year-old male with a history of chronic kidney disease and type 2 diabetes, who's arrived for a follow-up appointment.

After settling Robert in the exam room, 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/dL, blood pressure of 145/85 mmHg, and a weight gain of 4.5 pounds since his last visit.

Nurse Marisol asks about Robert’s insulin management at home. Nurse Marisol: 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? Robert: Yeah, my blood sugar’s been a little high.

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

Can you tell me how much water you’ve been drinking lately? Robert: 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 EHR, and notices that Robert is prescribed ten units of long-acting insulin nightly.

She also notes that he’s recommended to follow a 1.5-liter 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 blood pressure.

Nurse Marisol realizes that Robert needs more effective blood glucose control and fluid management. Now, using the information she's gathered, Nurse Marisol chooses a priority hypothesis of knowledge deficit.

Then, she generates solutions to promote Robert’s understanding of diabetes and its effect on chronic kidney disease. She establishes 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 levels. Nurse Marisol then provides education about maintaining his 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 harder for them to filter fluids.

She reassures him that when his glucose is within normal limits, he won’t be as thirsty. She also explains 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 health care provider if he notices a weight gain of 4 pounds, or 2 kilograms, 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.

Alright, as a quick recap...Nurse Marisol recognized and analyzed cues related to Robert’s chronic kidney disease and diabetes, prioritized hypotheses, and generated solutions to address this problem.

Nurse Marisol 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, Nurse Marisol determined that the plan of care