Adventist University of the Philippines

Course In Care of Clients with Problems

Third year 1ST Semester, AY 2021-2022

Name: Ellayza Rb D. Operaña Date: October 6, 2022

Section: B Sir Maki Samson

Perfect Score Score

Questions 28
Checklist 44

Managing a Patient with End Stage Renal Disease

Mr. DJ is a 26-year-old student, a male, who was diagnosed with Sickle Cell Anemia (SCA) in
childhood. He was adherent to his routine medications and regular to follow up. He presented
with 2 weeks history of oliguria and passage of frothy urine. This was preceded by swelling of
the leg and face a week prior to presentation. This was associated with anorexia, weakness of the
body, early satiety, abdominal fullness, and nausea. There was no fever, vomiting, jaundice, or
change in bowel habit. He had cough productive of frothy sputum but no hemoptysis or chest
pain; however, he had dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.

1. What is the role of Sickle Cell Anemia in this case? 2pts

➢ Sickle cell anemia is an inherited blood disorder in which the red blood cells
(RBCs) take on a sickle or crescent shape. This causes the patient to get a lot of
infections, like getting swollen legs and faces, and it was also linked to body
weakness.
Upon admission he was conscious but in respiratory distress. He had anasarca, pallor, and
asterixis but no cyanosis. The pulse was 108 beats/minute, full volume, and regular, the blood
pressure was 160/90 mmHg, the precordium was hyperactive, and apex beat was displaced and
heaving. The heart sound heard were S1, S2, and S3 gallop with pansystolic murmur maximal at
the apex. Further investigations results revealed that urinalysis showed proteinuria 3+. The total
and differential white blood cell count was normal, and ESR was 94 mm/hr. The serum sodium
was 132 mEq/L, potassium was 4.1 mEq/L, bicarbonate was 13 mEq/L, creatinine was 7.2
mg/dL, urea was 98 meq/L, calcium was 4.6 mEq/L, total protein was 59 mg/dL, albumin was
28 mg/dL, total cholesterol was 5.2 mmol/L, LDL was 3.2 mmol/L, and HDL was
1.1 mmol/L.The abdominal ultrasound showed bilateral shrunken kidneys, hepatomegaly, and
ascites. Other viscera were normal. Chest X-ray showed marked cardiomegaly, pulmonary
edema as abnormality. Echocardiography revealed marked 4-chamber dilatation and
biventricular failure. The diagnosis of sickle cell nephropathy with congestive cardiac failure
was given.

2. Upon knowing the patient diagnosis, what explains his:

a. Pulmonary manifestations? 2pts

➢ Early stage, characterized by pulmonary edema, weakness of the body, abdominal
fullness, early satiety, nausea, swelling of the leg and face

b. Cardiovascular manifestations? 2pts

➢ Cardiomegaly

3. Provide the implication (high or low and possible complication or effect on patient) of
the following lab values based on the patient’s case: 2 pts each

a. Na and K
➢ Na = 132 mEq/L (low) = Hyponatremia causing the patient to become
fatigue/weakness of the body
➢ K = 4.1 mEq/L (normal) = no complications on patient

b. Bicarbonate
➢ 13 mEq/L (low) = may cause metabolic acidosis, or too much acid in the body.

c. Creatinine
➢ 7.2 mg/dL (high) = kidneys aren’t working well

d. Urea
➢ 98 mEq/L (high) = kidney failure and heart failure problems
He was advised on low salt diet, care on protein intake, and was commenced on tabs Ramipril,
hydrochlorothiazide, furosemide, digoxin, and erythropoietin. He was also on twice weekly
hemodialysis. He was transfused with 2 units of packed red blood cell.
4. Going back to the patient’s manifestations, what could be the indication for the
following medication? (Base your answer on the patient’s list of manifestations, ex.
Ramipril for hypertension) 1 pt each

➢ a. Ramipril (for hypertension)

➢ b. Hydrochlorothiazide (for hypertension)
➢ c. Furosemide (for edema)
➢ d. Digoxin (for heart failure)
➢ e. Erythropoietin (for red blood cell production)
 5. The patient’s next dose of furosemide is due in your shift. The doctor’s order reads,
Furosemide 40 mg IV push, STAT.

a. What precaution is observed prior to administration of furosemide? 2 pt

➢ Initiate saline administration before the first dose of furosemide to avoid volume
contraction which may limit the desired calciuric response.

b. How much will be given to your patient if the available dose is this: (show
your formula) 5 pts

➢ D = is the desired dose

➢ H = is the on-hand dose
➢ V = is the vehicle (drug form: liquid)
➢ A = is the amount calculated to be given to the client

The hemodialysis including ultrafiltration and medication was regular; however, the
breathlessness and ascites persisted. Weekly therapeutic abdominal paracentesis for symptomatic
relief was then instituted. Results of further investigations revealed sterile exudative ascitic fluid.
Chest CT scan revealed enlarged heart, mild pericardial effusion, and prominent main pulmonary
artery. Abdominal CT scan revealed bilateral small kidneys, gross ascites, hepatomegaly,
cholelithiasis, dilatation of the portal vein, and prominent collaterals seen at the porta hepatis.
The managing team then was expanded and included nephrologists, infectious disease physician,
cardiologist, gastroenterologist, and hematologist.

The frequency of hemodialysis was increased to daily. The patient improved progressively, and 4
weeks later he had a successful and live-related kidney transplant. There was no operative or
immediate postoperative complication.

6. What could have prompted the need for renal transplant? 2 pts

➢ This is the location that requires a kidney transplant due to the abdominal CT scan
showing bilateral small kidneys, gross ascites, hepatomegaly, cholelithiasis, portal vein
dilatation, and prominent collaterals at the porta hepatis.
 7. Perform proper wound care to a patient post-renal transplantation. Study the
checklist (https://youtu.be/RtpRuXnIfXQ only the first part) and create a short (6 to
8 min) video of your return demonstration.

RETDEM LINK: https://drive.google.com/drive/folders/1MT6mbtPFqGNt-

xMAZ4wbYrncGNZ1Qtr2

Case adapted and modified from https://www.hindawi.com/journals/crin/2012/406406/

Wound Cleaning and Dressing Checklist

Procedure Done (2 Needs Not Done
points) Improvement (0)
(1 points)
Preparation:
1. Check doctor’s order and gather all
equipment (verbalize)
• Materials needed:
a. Plastic bag (to act as biohazard bag)
b. Newspaper or any paper big enough to
create a sterile field (assumed sterile)
c. Cotton balls (assumed sterile)
d. 4x4 dressings at least 10 pieces
(assumed sterile)
e. Cleansing agent (not to be used)
Note: place newspaper, cotton balls,
dressing, and cleansing agent in a box
(assumed sterile)
f. 2 pairs of clean gloves
g. A pair of sterile gloves
2. Perform hand hygiene and ensure patients
privacy
3. Introduce yourself and verify patient’s
identity
4. Explain procedure and assess pain level.
5. If with pain administer analgesic 30 min
prior to dressing change (verbalize)
6. User proper PPE if needed (verbalize)
Removal of old dressing:
1. Prepare a biohazard bag
2. Apply clean gloves
3. Remove the tape by pulling it parallel to the
skin towards the dressing. Holding down
the uninjured skin and if necessary towards
the hair growth.
 4. Remove layer of dressing one layer at a
time and assess dressings.
5. If we drains, conceal if from the sight of the
patient and fold the dressing to contain it.
6. Do not put pressure on draining tubes
(verbalize).
7. Peel of gloves and perform hand hygiene.

Wound Assessment:
1. Put on new pair of clean gloves and assess
wound (verbalize)
2. Peel of gloves and perform hand hygiene
Wound cleaning and dressing:
1. Create a sterile field and prepare sterile
materials within it: cotton balls, gauze, tape
2. Put on sterile gloves.
3. Clean the wound, circularly starting at the
least contaminated (wound itself) to most
contaminated. Do this at least 3 times.
4. Blot the wound dry with gauzed
5. Dress the wound by placing 2 folded 4x4s
and then layered with 2 4x4.
6. Secure dressing with tapes.

Document findings (verbalize)

Perfect Score: 44 Passing Score: 37 Student

Score:

Checklist from https://youtu.be/RtpRuXnIfXQ