INTREGRATED PRACTICE: ASSESSMENT AND INTERVENTIONS (4)

Name: Bhima Devi Poudel Adhikari

Student Number: 220179000

Unit Code: HSNS270

Writing Assignment-1

(Case study)

Unit Co-Ordinator: Sally Bristow

Due Date: 2nd September 2019

Word Count: 2058 words

Introduction:

End stage Kidney disease is a stage 5 chronic kidney disease, particularly high incidence in increasing age

requires renal replacement therapy. RRT is more effective in managing ESKD however preference to

peritoneal dialysis among indigenous Australian is higher in recent years as well as Prevalence of patients

with kidney disease are higher in aboriginal Australian than other Australians (Prakash, 2011). This essay

aims to provide a brief transfer clinical handover for Glenda, reasons of transfer back to Tiwi Island and

an anticipated holistic nursing care plan from Royal Darwin Hospital back to Wurrumiyang Clinic.

Clinical Handover from Royal Darwin Hospital to the Renal Dialysis Unit at Wurrumiyang Clinic:

INTRODUCTION Hi, I am Bhima, a student nurse from the Nightcliff renal unit at Royal

Darwin Hospital and I am calling you to give a clinical handover about a

patient Glenda Kerinaiau.

SITUATION I have a patient aged 56 years old aboriginal women who has end stage

chronic kidney disease due to post streptococcal Glomerulonephritis

(PSGN). Currently, she is on peritoneal dialysis and is tolerated well.

Glenda experiences difficulties to get proper sleep, itchy on face,

breathing difficulties and immune compromised.

BACKGROUND She was admitted to this hospital for haemodialysis in renal outpatient

department 6 years ago. Glenda has a history of recurrent PSGN. After

diagnosis of CKD, Glenda referred to the Royal Darwin Hospital in Nightcliff

Renal Unit for further treatment. Initially, she received haemodialysis and

then moved to peritoneal dialysis from 12 months as per patient’s choice

after consultation with nephrologists. Glenda wants to go back to home at

Kiwi Islands. The Self-care PD training for Glenda was successfully

completed.

ASSESSMENT Currently, patients’ vital signs are Between the Flags. Glenda is on PD and

there might be a chance of developing peritoneal infection as well as

inadequate amount of dialysis. Thus, I would recommend you observe any

signs of infection on peritoneal site and measure dialysis and exchange

dialysis if required. Ensure patients take high protein and fiber rich diet,

low salt intake, nutritional supplements and regular weight measurement.

RECOMENDATION On the bases of her capability of self-care dialysis, access to services with

remote community, the patient’s preferences, family support, our Dialysis

team planned to transfer her back to Tiwi under the care of trained renal

nurse. I would recommend you guide her and ensure correct dialysis is

gained by Glenda.
Identifying reasons why Glenda needs to transfer back to Tiwi

In Glenda’s case, it would be better to transfer her back to the Tiwi Islands. The following are some

concerns which may help to identify best outcomes after transfer;

Patient centered care and cultural consideration: the first priority is acceptance of the patient’s choice

and preferences to improve health outcomes. The patient’s involvement in decision making helps the

health worker to identify patients need and their capability as well as implication of possible holistic care

(Vandecasteele & Tamura, 2014). Furthermore, according to Brown (2012), PD is a good choice of

treatment modalities for elderly person like Glenda (case study) with ESKD who would like to continue

own life style, culture, take care of grandchild, travel as well as socialize with community members. For

senior citizen, the quality of life is more important than the length of life. Prakash (2011) added that

nonindigenous people perceive culturally distinct from other culture and refuse to mingle with them. They

believe that it is unacceptable to stay long term or die at hospital or other’s area. To provide a patient

centered care, it is important to know what the patient’s decisions and connection of their belief are.

Similarly, most of the elderly patients love to stay with family and have a culture of dying in their own

place by selecting PD as Glenda did in this case scenario (Brown, 2012). Glenda will feel better and more

comfortable in her own community, family and home, will gain psychological, spiritual, social and

emotional support from family which won’t get in Darwin although her daughter stays there with her.
Financial implication of remote treatment: treatment in Darwin for Glenda might be more expensive

compared to Tiwi Islands. Brown (2012) acknowledge that Glenda requires to travel to and from each

hemodialysis session while PD does not as PD can be carried out at home. This may reduce the burden of

financial arrangement for transportation and promotes better health outcomes.

Challenges and opportunities of remote treatment: The challenges experience on home dialysis for

patients with ESKD are inadequate medial knowledge of self-care dialysis, patients concern about learning

of home dialysis, fear of being burden on home dialysis, unsure whether patients contact the their

caregivers, difficult to know patients follows all steps like right amount, correct dose and right time of

dialysis (Wallace, Rosner, Alscher, Schmitt, Jain, Tentori & Foo, 2017). As per the case study, Glenda is a

quick learner, understands her condition and has undergone a comprehensive training for self-care

dialysis which may help her and dialysis staff to overcome these challenges.

However, Wallace et al. (2017) also stated that through improvement in patient satisfaction, patient

outcomes and budget savings, remote patient management will provide great opportunity to increase to

uptake and survival of home treatments. Excessive time spends on self-care by Glenda enhances her

independencies and it reduces the burden of performing these activities with health care providers,

improves her satisfaction and quality of life. Instead of face-face contact, telehealth reduces the financial

burden as well as time saving for Glenda as she needs to travel, wait in a waiting room for appointment

in hospital setting (Dey, Jones & Spalding, 2016).

Improved Clinical outcomes: Prakash (2011) mentioned that remote people particularly aboriginal people

have less access to transportation and chance of dropping the treatment in hospital which requires

transportation is high. This situation was clearly explained in the given case study as Glenda’s daughter

mention that Glenda was sick of travelling and attaining the treatment at hospital and willing to give up.

Thus, PD at home setting will increase uptake and patient adherence to treatment and patient

satisfaction. when patient satisfaction to shared decision treatment modalities is improved, Health

workers satisfaction will automatically improve. This intern leads to improve clinical outcomes (Brown,

2012). Furthermore, Health workers regular contact with patients via telephone help early detection of

any risk of PD failure, fatigue, fluid overload, reduction in renal function, sleeplessness, breathlessness,

any signs of infection on peritoneal site and blood pressure. These help early management of symptoms,

reduce worsening of patient health, reduce mortality rate and overflow of patient in hospital (Dey, Jones

& Spalding, 2016).

Anticipated Holistic Nursing Management Plan:

The nursing care plan for Glenda with ESRD to deliver optimal health outcomes and treatment options

followed back in Tiwi Island at Wurrumiyang Clinic are discussed in detail.

Management of End Stage Kidney Disease (stage 5-CKD): According to Schena (2011), 24 hours urinalysis

is required in patients with ESKD to identify proteinuria and provide low protein diet to reduce proteinuria.

Administer ACE inhibitors or angiotensin II β-blockers to reduce proteinuria, reduce aldosterone effect

and blood pressure control. Restricted amount of salt is recommended for patient due to low excretion

of salt. Diuretics such as furosemide is administered for excessive fluid retention in the extracellular space.

Vandecasteele and Tamura (2014) discovered that ESKD patients on peritoneal dialysis have high chance
of weight gain as peritoneal fluid contains sugar and is recommended to do the regular weight check and

maintain balance diet to control weight gain.

Furthermore, ESKD patients may have anemia due to low production of erythropoietin from kidney.

Which may develop cardiac dysfunction, for example, left ventricular hypertrophy. Thus, calculated

erythropoietin dose with body weight is given to treat anemia which may regress cardiac dysfunction. Low

phosphate diet and vitamin D as well as supplementary nutrition are recommended for ESKD patient to

treat hyperphosphatemia, vitamin D deficiency and malnutrition (Turner, Bauer, Abramowitz, Melamed

& Hostetter, 2012).

Treatment: (Schena (2011) provides the treatment options available for ESKD, example, hemodialysis,

peritoneal dialysis and nocturnal dialysis. After provision of treatment options for ESKD, their benefits and

upcoming risk, consultation with nephrologists, Glenda and NT renal dialysis team decided PD as Glenda’s

suitable choice to continue in home setting.

Patient self-management of ESRD and Dialysis: Narva, Norton and Boulware (2016) discovered that

trained nephrology nurses and advance nurses are responsible in providing health education regarding

ESKD and dialysis management for better health outcomes. With the use of innovative education

approaches, self-care and patient centered care is possible through self-management support, shared

decision making, telehealth, and engaging both family and community. Educate the patient regarding

intake of high protein and fiber rich diet for proteinuria and constipation, low salt and phosphate for salt

retention and hyperphosphatemia (Narva, Norton & Boulware, 2016). Johnson, Zimmerman, Welch,

Hertzog, Pozehl and Plumb (2016) suggested that adequate knowledge of CKD improves patient’s

confidence and increase independence leads to improve patient quality of life. Train the patient and family
member regarding self-care dialysis and ESKD to prevent improper dialysis at home (Narva, Norton &

Boulware, 2016). Demonstrate how to do accurate measurement of vital sign and weight at home.

In Glenda’s case, health education regarding the CKD and risk as well as benefits of following home PD

was clearly discussed with Glenda after considering her financial, geographical, emotional and

psychological barriers to continue hemodialysis in Darwin. The informed decision and clear view of the

disease condition along with proper training from trained renal dialysis nurse will help patient for self-

management of both ESKD and dialysis (Chow & Wong, 2010).

Interdisciplinary team: Interdisciplinary care team holds separate disciplines, woks in collaboration and

coordinates within the team to provide patient centered care through common management goals. Team

actively involves patients in decision making process for both short-term and long-term management

goals (Bayliss, Bhardwaja, Ross, Beck & Lanese, 2011). Johns, Yee, Smith-Jules, Campbell and Bauer (2015)

explained the role of each disciplines in management of Glenda’s ESKD and Dialysis. Nephrologist detects

the causative factors of CKD and develop care plans based on the evaluation while Advanced practitioner

provides health education of the condition and explores treatment options as well as facilitates

communication with patient, family and the team members (Fenton, Sayar, Dodds & Dasgupta, 2010).

Similarly, Dietitian provides dietary counseling and fluid management. Pharmacist reviews all

medications, required doses and patient’s adherence along with provision of information regarding the

indication, side effects, duration of medicine and chemical components of medications (Johns, Yee, Smith-

Jules, Campbell & Bauer, 2015). Furthermore, Geriatrician or palliative care directs the need of geriatric

and palliative care as well as ensures treatment plan and disease prognosis in relation to the set goals. On

the other hand, Case management/social work are responsible of assisting patients to achieve preset
goals by offering required resources such as transportation (Fenton, Sayar, Dodds & Dasgupta, 2010).

Transplant team explores available transplant options to patients and helps in selection of treatment

option suitable with ESKD patients. Moist and Al-Jaishi (2016) added that vascular surgeon or general

surgeon in places a surgical fistula and monitors access for dialysis. Interventional radiologist evaluates

the maturity of AVG/AVF for initiation of dialysis and its flow.

Prioritization of care: Improving quality of life for ESKD patients on dialysis is one of the 1st priority of

providing nursing care outcomes due to higher incidence rate of CKD in aging people who may also have

other comorbid disease such as cardiovascular disease or diabetes mellitus (Narva, Norton & Boulware,

2016). For older CKD patients, quality of life is more important than the length of life. When health

practitioners meeting is held with patient and family, their main role of discussion about dialysis should

include its impact on quality of life and actual prognosis. When referring patients to renal clinic, informed

decision should be taken and its implication to the patients’ life should be clearly discussed (Dey, Jones &

Spalding, 2016). Majority of ESKD patients undergo dialysis instead of waiting and worsening their

condition and ended up with long-term PD. Health education regarding the risks of developing peritonitis

and its prevention is provided to patients.

Moreover, provision self-care dialysis training not only helps patient to reduce of burden of expecting

others care and feeling of being burden of life from family, also prevent infection and further complication

(Raman, Middleton, Kalra & Green, 2018). PD has become a best choice of treatment modalities it enables

them to perform daily activity, to continue to job, travel, have active social life and to care of grandchild.

Multidisciplinary workers from renal clinic will help patients in managing dialysis as well as early
identification of peritonitis and medical management which also helps in Optimising quality of life and

patient satisfaction along with survival rate (Brown, 2012).

Care of catheter site and potential risks assessment: dialysis nurse from renal clinic should assess the

catheter and its site for access in flow of fluid, any blockage to the line and any sign of infection. Weekly

3-4 times dressing or bathing the catheter site to prevent infection and other dialysis related

complications (Pluta, Sulikowska, Budnik-Szymoniuk & Basińska-Drozd, 2017). Ensure the patient gains

adequate amount of dialysis fluid and observe for fluid overload. Assess any cardiac dysfunction,

hypertension and metabolic disorder as these are some potential risks of CKD (Wojciechowski, Tangri,

Rigatto & Komenda, 2016).

Conclusion:

ESKD is severe deterioration of CKD (stage 5) requiring kidney transplant. Among aboriginal older adults

with ESKD prefer PD as a best choice of treatment option as it allows patients to continue their previous

activities and is cost effective compared to hemodialysis. Health education and training for self-care

dialysis may help in managing PD at home with involvement of interdisciplinary workers in measuring

adequacy and over load of dialysis fluid.

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