NCLEX

NCLEX Case Study: Nursing Care of the Patient With Renal Disease

By March 17, 2018 No Comments

Renal Disease:

Fran, a 36-year-old mother of three, has had two urinary tract infections (UTIs) over the past few years, both occurred during pregnancy. She now has symptoms of a UTI again. Medical history includes:

Allergy: penicillin
Lifestyle: cigarette smoking—1.5 packs/day since age 16 years
Alcoholic beverages: beer on weekends
Past medical history: eczema on arms and legs, frequent UTIs

The nurse at the clinic understands that clinical manifestations are related to the loca- tion of the UTI.

Matching:

Match the clinical manifestations in Column A with the types of urinary tract infections (UTI) in Column B:

Fran has interstitial cystitis. The nurse instructs Fran to drink more fluid because this will dilute the urine and make the bladder less irritable. It will also increase the frequency of urination, which will help to flush out bacteria.The nurse also instructs Fran to apply a heating pad to the suprapubic area at the lowest setting. Finally, the nurse discusses dietary changes that may prevent bladder irritation.

Select all that apply:

The nurse is providing Fran with information about bladder irritants. Fran would be instructed to avoid:

A. Caffeine
B. Alcohol
C. Milk
D. Chocolate
E. Spicyfoods
F. Legumes

The nurse understands that UTIs can cause symptoms related to the emptying or storage of urine.

Fill in the blanks:

What four questions would the nurse ask to determine whether Fran has problems with urinary emptying?
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________

What four questions would the nurse ask to determine whether Fran has problems with urinary storage?
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________

Since Fran has had three UTIs, it would be important to teach her health-promotion activities that could decrease the incidence of infection.

Select all that apply:

What health-promotion activities could the nurse teach the patient?
A. Empty the bladder every 6 hours
B. Evacuate the bowel regularly
C. Wipe the perineal area from front to back
D. Urinate before and after intercourse
E. Drink cranberry juice daily
F. Shower rather than bathe in the tub

Hot spot:

What area would the nurse percuss to assess for kidney infection?

assess for kidney infection

assess for kidney infection

Six months after her visit, Fran is taken to the ED in the middle of the night with nau- sea, vomiting, hematuria, and abdominal pain. Her skin is cool and moist. She said that she had been out in the sun doing yard work for the previous 2 days.A renal ultrasound indicates that she has urinary calculi.

Select all that apply:

Fran asks the nurse what causes urinary calculi. Which of the following answers from the nurse are correct?
A. Low fluid intake
B. Decreased uric acid levels
C. Warmclimate
D. Family history for renal calculi
E. Immobility
F. Frequent urination

Intense colicky pain may be present when the stone is passing down the ureter. Lithotripsy is sometimes recommended to break up the stones if they are too large to pass. Hematuria is common after lithotripsy. A stent is usually inserted to facilitate passage of the stones and decrease stenosis.The stents are removed after about 2 weeks because they pose an increased risk of infection. The ultrasound results can determine whether the stones are small enough to pass through the ureter into the bladder.

KEY POINTS:

Urinary Tract Infections (UTIs)

■ Upper UTIs (pyelonephritis, renal abscesses, interstitial nephritis) are less common, but may be more severe than lower UTIs (cystitis, prostatitis, and urethritis).
■ In most hospital-acquired UTIs, the cause is frequently instrumentation of the urinary tract or catheterization.
■ Clinical manifestations include dysuria, burning on urination, frequency, urgency, nocturia, incontinence, hematuria, and suprapubic or pelvic pain.
■ Diagnosis is made by urine culture and sensitivity (C&S).
■ Medical treatment involves antibiotics; pyelonephritis usually requires a longer course of treatment.
Preventive measures include showers rather than tub baths, females cleaning from front to back, liberal intake of fluids, avoidance of urinary tract irritants (coffee, tea, colas, alcohol), void every 2 to 3 hours and after intercourse, and acidify the urine with vitamin C or cranberry juice.

Renal Calculi

■ Stones form more often in dehydrated persons.
■ Clinical manifestations depend on the location of the stone, presence of obstruction, infection, and edema, but can include pain and discomfort, hematuria, nausea, vomiting, and diarrhea.
■ Diagnosis is made by x-rays of the kidneys, ureters, and bladder (KUB); ultrasound; or urography/pyelography.
■ Medical treatment involves opioid analgesics and stone removal.
■ Most patients can pass a stone 0.5 to 1 cm in diameter; larger stones can be removed through
ureteroscopy,extracorporeal shock wave lithotripsy (ESWL),or endourologic methods.
■ Urine should be strained and stones sent for analysis; calcium-based stones are the most common.

Preventive measures for all stone types include increasing fluid intake to avoid dehy- dration, drinking two glasses of water at bedtime, maintaining a urine output of greater than 2 L/d, and possible diet restrictions based on stone type.


Joe, 62 years old, has a history of smoking and is being examined for a bladder tumor. Bladder cancer is most common in men 60 to 70 years of age and is three times more common in men than in women.

Fill in the blanks:

What information in Joe’s history suggests an increased risk for bladder cancer?

________________________________________________________________________________________________________________________________________________________________________________________________________________

Select all that apply:

Identify risk factors associated with bladder cancer:
A. Contaminated drinking water
B. Dehydration
C. Recurrent or chronic urinary tract infections (UTIs)
D. Exposure to environmental carcinogens
E. Diabetes
F. Pelvic radiation therapy

The clinical manifestations of bladder cancer are intermittent hematuria that is not accompanied by pain, frequency, and urgency.

Cystoscopy will be scheduled to determine whether the tumor in the bladder is cancer. Most bladder cancers are superficial; that is, they do not invade the wall of the bladder. These tumors respond well to treatment; however, the risk of recurrence is high. Before cystoscopy, the nurse checks to make sure that the patient has completed the consent form. Joe states that the procedure was explained to him and that he has no additional questions.

Select all that apply:

What are the responsibilities of the nurse when the patient returns from cystoscopy?
A. Monitor for bright-red blood in the urine
B. Encourage the patient to change position slowly
C. Irrigate the catheter daily
D. Provide warm sitz baths
E. Monitor for signs of urinary tract infection (UTI)
F. Strain all urine for stones

After the procedure, Joe is told that treatment is necessary but also that the tumor is superficial and small. Joe is scheduled for a transurethral resection of the tumor followed by intravesical administration of bacillus Calmette–Guérin (BCG).

Multiple-choice:

Joe is receiving his first treatment with Bacillus Calmette–Guérin (BCG). It is evident that further teaching is needed when Joe states:
A. “I will have to have a catheter inserted to receive the treatment.”
B. “I will need to retain this solution for 1.5 to 2 hours before voiding.”
C. “I should drink large amounts of fluid before and during the treatment.”
D. “I should change my position every 30 to 45 minutes during the treatment.”

KEY POINTS:

Bladder Cancer

■ Risk factors are cigarette smoking; exposure to environmental carcinogens; recurrent or chronic urinary tract infections; bladder stones; high urinary pH; high cholesterol intake; pelvic radiation therapy; and cancers in the colon, prostate, or rectum of males.
■ The most common symptom is painless gross hematuria; changes in voiding or urine may also occur.
■ Diagnosis is made by cystoscopy and biopsy.
■ Simple, superficial tumors can be removed by transurethral resection or fulguration;
invasive or multiple tumors require a cystectomy, removal of the bladder.
■ Bacillus Calmette–Guérin, which is an attenuated live strain of Mycobacterium bovis, is an effective treatment for recurrent bladder cancer; it works by enhancing the body’s immune response.


Rachel, a recent graduate from nursing school, is trying to provide safe and effective care for patients. Lynn, her mentor, is very helpful and understanding. However, Rachel must make many independent decisions because the unit is so busy.

Multiple-choice:

Rachel has received reports on four patients. Which patient should be assessed first?
A. Sarah—blood pressure (BP): 88/60 mmHg, pulse: 124, respiratory rate (RR): 30; had a 100-mL urine output for more than 8 hours.
B. Coleen—temperature: 101°F (38.3°C); has blood in the urine with each void.
C. Theresa—blood urea nitrogen (BUN): 36 mg/dL, creatinine: 0.8 mg/dL; vomited 200 mL of undigested
food 6 hours earlier.
D. Tyra—BP: 112/78 mmHg, pulse: 88, respiratory rate (RR): 24; is on diuretics and became slightly dizzy when getting up to void.

Fill in the blanks:

After reading Sarah’s laboratory results in the left column, complete the laboratory interpretation in the middle column and the intervention in the right column.

Laboratory results

Laboratory results

Sarah is diagnosed with acute renal failure (ARF) related to dehydration.The health care pro- vider (HCP) explains to Sarah the seriousness of her condition and the necessary treatment.

Multiple-choice:

As her intravenous (IV) is being inserted, Sarah asks again why her kidneys are not working well. The nurse’s best response is:
A. “This has occurred because you declined to have your IV reinserted.”
B. “This has occurred because of damage to the glomeruli of the kidneys.”
C. “Dehydration has decreased blood flow to the kidneys, resulting in damage.”
D. “The high heart rate you are experiencing is detrimental to the kidneys.”

Matching:

Match the categories of acute renal failure (ARF) in Column A with the different causes of ARF in Column B:

categories of acute renal failure

categories of acute renal failure

Sarah remains acutely ill. Her most recent labs are:

Renal Failure lab results

Renal Failure lab results

Multiple-choice:

After reviewing the laboratory results, the nurse prepares to call the health care provider (HCP). What is a priority for the nurse to communicate to the HCP?
A. Potassium: 5.9 mEq/L
B. Creatinine: 3.6 mg/dL
C. pH:7.30
D. Hemoglobin: 9.6 g/dL

TIP: Situation, background, assessment, and recommendation

The situation, background, assessment and recommendation (SBAR) technique has been recognized as the best practice for standardized communication in health care by The Joint Commission. The SBAR technique provides an effective method for stan- dardizing communication and bridging gaps in situations such as hand-offs, patient transfers, critical communications, and telephone calls. SBAR promotes quality and patient safety by improving communication efficiency and accuracy.
■ Situation—The patient has abnormal lab values.
■ Background—The patient was admitted with a 5-day history of vomiting and she is
now in ARF.
■ Assessment—Her lab values are as follows: potassium 5.9 mEq/L, creatinine 3.6 mg/dL, and pH 7.30.
■ Recommendation—I suggest a consult with nephrology and a line placement for dialysis; consider administering Kayexalate.

KEY POINTS:Acute Renal Failure (ARF)

■ ARF is the abrupt loss of kidney function over a period of hours to days, but it is usually reversible.
■ The major categories are prerenal caused by hypoperfusion, intrarenal caused by parenchymal damage, and postrenal caused by obstruction; acute tubular necrosis is the most common cause of ARF in hospitalized patients.
■ Clinical manifestations include olguria (less than 500 mL urine output/d) or anuria (less than 50 mL urine output/d); increased creatinine, BUN, and other nitrogenous waste products; hyperkalemia; metabolic acidosis; calcium and phosphorous imbal- ances; fluid volume excess; failing blood pressure regulation; and anemia.
■ Preventive measures include providing adequate hydration, preventing/treating hypotension promptly, monitoring urine output in hospitalized patients, monitoring renal function, preventing/treating infections promptly, catheter care with removal of catheter as soon as possible, and monitoring drug levels of nephrotoxic medica- tions (such as gentamicin).
■ Medical treatment includes identifying the underlying cause, treating fluid and elec- trolyte imbalances, and hemodialysis if needed.
■ Nutritional therapy includes a high-carbohydrate diet with restriction of foods high in protein, potassium, and phosphorous.

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