Chronic Kidney Disease Late Symptoms Assessment
(Picmonic)
Chronic Kidney Disease Early Symptoms Assessment
(Picmonic)
Outline
Mr. Stinson is a 52-year-old male with a history of HTN, DM Type II, CKD, and CHF. He presented to the Emergency Department (ED) complaining of severe itching, nausea, and vomiting. He appeared pale and is lethargic. He reported shortness of breath and the nurse notes crackles in his lungs. He has now been admitted to your unit.
Critical Thinking Check
Bloom's Taxonomy: Application
What additional nursing assessments should be performed?
Complete metabolic panel (electrolytes, renal function, etc.
Complete blood count
Possibly an ABG to assess for acidosis
Possibly a BNP to assess volume overload and its effect on the heart
Upon further questioning, the patient reports he normally gets dialysis Monday, Wednesday, Friday, but that he skipped dialysis yesterday because he was “not feeling well”. He has +2 pitting edema in his legs. Vital signs are as follows:
HR102RR24
BP153/97SpO290%
The patient’s labs result and show the following:
BUN62 mg/dLNa134 mg/dL
Cr3.9 mg/dLCa7.8 mg/dL
GFR13 mL/min/m2Phos5.0 mg/dL
K6.3 mEq/LMg1.6 mg/dL
Gluc224 mg/dLH/H8.2 / 30%
pH7.32pCO232HCO3–16
BNP247 pg/mL
Critical Thinking Check
Bloom's Taxonomy: Analysis
Interpret these lab results and explain their meaning.
The BUN/Cr and GFR indicate the patient is definitely in kidney failure as his glomerulus is not filtering the blood like it should and the waste products are building up
His electrolyte abnormalities (hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia, and hypomagnesemia) are all indicative of kidney disease and acidosis. The kidneys would normally retain sodium and excrete potassium. In kidney failure, they do the opposite and potassium levels can get very high.
He is in metabolic acidosis, likely because his kidneys are not able to retain the bicarb buffer like they normally would – this also contributes to the hyperkalemia. As the body tries to balance the H+ ions, it kicks K+ out into the bloodstream.
His BNP is also elevated, indicating volume overload – this is probably caused both by the kidney failure and not getting dialysis and by the heart failure
He is anemic – chronic anemia is common in chronic kidney disease patients due to the lack of erythropoietin.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is going on with Mr. Stinson physiologically?
Because of his CKD, Mr. Stinson requires dialysis to perform the normal functions of the kidneys, since his aren’t working. He likely felt sick because his potassium was elevated and because of the azotemia (toxins building up in his blood).
He missed dialysis and therefore he is now even more volume overloaded and azotemic
This will cause a risk to his heart and lungs because of the overload and the hyperkalemia
The nephrologist is consulted and determines that the patient needs hemodialysis. As soon as possible. The charge nurse of the dialysis unit is working to create a bed for him and will call back as soon as one is available, hopefully within the hour.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What do you, the nurse, need to consider and assess for Mr. Stinson PRIOR to sending him to dialysis?
Importance of hemodialysis – he likely didn’t feel well because he NEEDED dialysis.
Reasons to “skip” dialysis typically involve severe infections and fevers, in which case he should go the following day whenever possible or notify his nephrology team
Should also reinforce teaching regarding nutrition – foods to avoid (high in potassium) and when to take medications with or without food (especially Phos-Lo and Calcium supplements)
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 