Case Study

K.B. is a 32-year-old woman being admitted to the medical floor for complaints of fatigue and dehydration. While taking her history, you discover that she has diabetes mellitus (DM) and has been insulin dependent since the age of 8. She has undergone hemodialysis (HD) for the past 2 years because of end-stage renal disease (ESRD). You initial assessment of K.B. reveals a pale, thin, slightly drowsy woman. Her skin is warm and dry to the touch with poor skin turgor, and her mucous membranes are dry. Her vital signs are 140/88, 116, 18 99.9 F (37.7 C). She tells you she has been nauseated for 2 days so she has not been eating or drinking. She reports severe diarrhea. The following blood chemistry results are back. Sodium 145 mEq/L Potassium 6.0 mEq/L Chloride 93 mEq/L Bicarbonate 27 mEq/L BUN 48 mg/dL Creatinine 5.0 mg/dL Glucose 238 mg/dL What aspects of your assessment support her admitting diagnosis of dehydration? The patient's history supports an admitting diagnosis of dehydration because she told you she has not been drinking for 2 days and reports severe diarrhea. Her skin is warm and dry with poor skin turgor and dry mucous membranes, all of which can be physical assessment findings of a patient with dehydration. Fluid is restricted when the person is on dialysis. Although most of her laboratory findings are elevated, lab values are not a good indicator of dehydration in patients on HD. What is an AV Fistula? Why does K.B. have one? Fistula is a term used to describe the connection of two separate body parts. She has an AV fistula. This fistula is surgically created by connecting an artery with a vein and allows access for HD. What steps do you take to assess K.B.'s AV fistula, and what physical findings are expected? Explain. You would use observation, palpation and auscultation. Observe for any signs of bleeding or infection. AQ functioning AV fistula has a "thrill" evident by palpation and a bruit present with auscultation. The thrill and bruit are present because of the turbulence caused by the mixing of blood between the artery and vein and are considered within normal limits for an AV fistula. K.B.'s admission CBC yields the following results: WBC 7600/ mm^3 RBC 3.2 million/mm^3 Hbd 8.1 g/dL Hct 24.3% Platelets 333,000/mm^3 Are these values normal? If not, what are the abnormalities? Her WBCs and platelets are normal. Her RBCs, Hgb and Hct are all low. This low RBCs, Hgb and Hct are indicative of anemia, which is patients with renal failure. The following day, K.B. is discharged feeling much better with a good understanding of her dietary restrictions. Her iron stores have been evaluated and found to be low. Her physician has instructed her to resume her preadmission medications, with the addition of ferrous fumarate oral suspension 100 mg PO TID between meals with water, if tolerated (or with meals if GI distress occurs) and epoetin (Epogen) to be given three times a week intravenously with dialysis. She is also given a prescription for Nephrocaps vitamin supplements to be taken daily. Explain the purpose of the new medications for K.B. Ferrous furmarate oral suspension is being prescribed for her iron deficiency anemia. The liquid form of iron is better absorbed through the gastrointestinal (GI) tract and will be used by the epoeitin to make new RBCs Epoetin is being prescribed for her anemia. She will receive the medication after her dialysis, and over time it should help increase her blood levels and lessen her fatigue. Other symptoms that respond to erythropoeitin therapy include poor appetite, coldness, disordered sleep patterns, depression, and sexual disinterest. Patients usually require chronic therapy. The Nephrocaps contain a vitamin formulation that is made specifically for patient