Kidney Failure and Transplant: A Case Study 4


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Thecase study covers African-American woman, Jennifer, aged 54 years.She was diagnosed at age 42 with diabetes type 2. According toCartin-Ceba(2012, p34), diabetes is a significant risk for kidney disease.Diabetes injures the small blood vessels in the kidneys, making thekidneys lose the ability to execute its primary function. The primaryrole of the kidneys is to filter the waste products and toxins fromthe blood (Schrier,et al., 2004, p7). Last year April, Jennifer was involved in anautomobile accident, in which she lost her husband. Jennifer survivedbut suffered significant and massive injuries in the lower abdomenand an injured femur. She immediately underwent a surgery to repairscratched left kidney. She consumed two units of blood while undersurgery and another two units in the recovery room. However, thephysician and the helping nurses were forced to withdraw the fifthunit of blood after the patient developed a transfusion complication.

Oneday after the surgery, her urine production reduced to 10-20ml/hr.The physician tried to boost her fluid intake through plasmaexpanders and blood, but the urine output remained low. Several labtests` results revealed a high level of urinary sodium, BUN 70 mg/dland serum creatinine 4mg/dl. Three days after the surgery thepatient`s urine production became stable at 19-26 ml/hr. Further labtest gave a diagnosis of Acute Renal failure. Being diabetic,Jennifer’s level of serum potassium remained high and severehypertension (195/120), dialysis therapy was inevitable. An externalshunt was used to access the patient’s vascular system. An externalshunt is usually used when dialysis must be administered immediately(Lameire, 2005, p.203). The device consists of two lengths of tubing,in which one of the tubing is fitted into a vein and the other in anartery, more often than not in the forearm. The two tubes are linkedby a connector between dialysis therapies. According to Koomans, oneof the advantages of an external shunt in handling kidney failurepatients is that it is readily available for use in an emergency(2001, p222). However, he points out that the device carries highrisks of infection or obstruction with clots. In some cases, if theintegrity of the system is interrupted, rapid and profuse blood lossmay take place. Jennifer was so resentful and emotional of her healthcondition and expressed her willingness to die quickly.

Aimand structure of the case study

Theobjective of this paper is to discuss in detail, the effectiveness ofthe nursing care administered to a 54-year-old African Americanpatient with acute renal failure. The case study will first explainthe pathophysiology of the patient`s renal condition. Next, the paperwill present a critical analysis of the nursing care interventionsadministered to take care of the patient`s needs. The case study willnext discuss in depth, the professional, ethical and legal issuesthat should be considered in providing nursing care to the patient.An evaluation of the efficiency of the nursing care provided to thepatient will be done, and I conclude the paper by presenting aconclusion drawn from the analysis of the patient’s care.

Pathophysiologyof Acute renal failure

Fromthe signs and symptoms portrayed by Jennifer, it is clear that she issuffering from acute kidney failure that is almost leading toEnd-Stage-Renal-Disease (ESRD). Acute renal failure occurs at a pointwhen the kidneys abruptly lose their ability to perform their mainfunction in the human body(Glynne, Allen and Pusey, 2002, p8).The primary role of the kidneys is to sieve the unwanted productsfrom the blood. When kidneys can longer function normally, the wasteproducts accumulate in the blood into harmful levels resulting fromchemical imbalance(Dirkes, p39).This renal condition also referred to as acute kidney injury developswithin a short period ranging from a few hours to a few days.According to Palevskyand Murray, (2006, p74), the renal disease is common amonghospitalized persons or critically ill individuals under seriousmedical care.

Acutekidney failure is a far-reaching condition that calls for intensivenursing care and management (Schrier, et al., 2004, p12). Research byPalevsky and Murray indicate that this condition can be effectivelymanaged back to almost a normal kidney, especially when the patientis in good health (2006, p76). However, Schrier and others point outthat sometimes there are no clear signs of acute kidney injury and isdiagnosed through lab tests done for other conditions (2004, p14).Acute renal injury is manifested by several signs and symptoms suchas:

  • A decline in urine production.

  • Fluid retention resulting in inflammation of legs, feet, and ankles.

  • Tiredness

  • the succinctness of breath

  • General weakness of the whole body

  • Queasiness

  • In severe cases, one may experience convulsions or coma

  • Pain in the chest

Accordingto Lameire (2005, p202) there are several risk factors for acuterenal failure:

  • Liver disease

  • Diabetes

  • Hypertension

  • Heart disease

  • Obesity

Thefact that Jennifer was already suffering from diabetes type 2 andthat her kidney sustained a slight injury during the accidentincreased her risks of developing acute renal failure. According toCartin-Ceba, when a person is suffering from diabetes, there is ahigh risk of the small blood vessels getting injured (2012, p40). Itis clear that the automobile accident that Jennifer was involved leadto the damage of these vessels, and the fact that she was diabetic,acute renal failure was inevitable. The complications that Jenniferportrayed after surgery such as swelling of the ankles and low urineoutput were a clear indicator of kidneys` malfunction. Diabetes mayalso cause damage to nerves in the body causing challenges in bladderemptying (Cartin-Ceba, 2012, p41).

Therenal condition has many complications. According to Palevsky andMurray (2006, p79), acute kidney failure can result in theaccumulation of fluid in the lungs causing difficulties in breathing.The condition also causes swelling of the heart’s linings(pericardium), causing chest pain. Another complication as a resultof renal failure is muscle fatigue making the patient immobile.According to Lameire, Van Biesen and Vanholder (2006, p369), acuterenal failure leads to an imbalance of the blood chemistry, causingmuscle weakness. The condition also may lead to the buildup ofpotassium in the blood, which can lead even to death (Needham, 2005,p1742). Jennifer developed the complication on the third day aftersurgery and later developed a complication that forced the physicianto withdraw blood transfusion.

Accordingto Abosaif and others, another complication of acute renal injury isirreversible kidney damage (2005, p1041). Once in a while, acutekidney failure may cause the permanent loss of the kidney`s abilityto execute its functions, a condition referred to as an end-stagerenal disease. When a patient gets to this level of renal condition,he either permanently survives on dialysis or kidney transplant(Amdur, et al., 2009, p1093). Schrier and others define dialysis asthe artificial mechanical sieving process used to get rid of thetoxins and other waste product from the blood. In other words,Dialysis is a synthetic process used to perform the functions of anormal kidney. It seems that Jennifer is about to enter this stagewith her renal condition, due to the fact the physician haveconsidered putting her under dialysis for her survival.

Acritical analysis of the nursing care implemented to address thepatient’s needs

Onceit was clear to that Jennifer needed to be immediately put ondialysis, the physicians started discussing with her the advantagesand disadvantages of being treated at home and the center. Accordingto Amdur and others, the choice of either being treated at home or inan hospital setting significantly depend on several factors. Thefactors include: convenience, underlying medical problems, homesituation and age (2009, p1095). The fact that Jennifer`s husband haddied, and her only son was already married and living in anothercountry, there was no other person to take care of Jennifer back athome. The physician, therefore, persuaded and convinced the patientto undergo dialysis at the center since it was convenient for her.The physician also influenced her to choose this option since itwould also help in early detection and prompt management of anycomplications arising in the process of the treatment (Abosaif, etal., p1043).

Havingundergone counseling to come to terms with her current healthcondition and the loss of her loving husband, Jennifer agreed toundergo dialysis at the hospital she was admitted after theautomobile accident. At the hospital, one physician and two nurseswere assigned to take care of Jennifer. Jennifer undergoes dialysisthree times a week, and each dialysis session takes around three tofour hours. Jennifer has an access to a television, reads, sleeps,eats, drinks and can receive visitors during the therapy. Accordingto Dirkes (2011, p41), it is important to keep the patient ascomfortable as possible while under treatment to manage theiremotions and prevent other complications.

Beingaware that Jennifer may be forced by circumstances to undergolong-term hemodialysis, the physician educated the patient on theprecautions for preventing challenges associated with the therapy.Jennifer is also being treated with several drugs such asmultivitamins, antihypertensive, antibiotics, antacids and ironsupplements. According to Abosaif and others, it is important for aphysician to explain to the patients the functions of the variousmedications to ensure they comply (2005, 1043). Apart from dialysis,Jennifer is undergoing two other major drugs. The aim of one of themedications is to balance the amount of fluids in the blood. Thephysician discovered in the cause of treating his patient that herlegs, ankles, and arms were getting so much inflamed as a result oftoo much fluid in the body (Cartin-Ceba, 2012, P42). Therefore, herecommended loop diuretics in high doses to force the body toexorcise excess fluids. Jennifer`s potassium level in the blood wasaccumulating to dangerous levels and, as a result, she was medicatedto manage her blood potassium. The physician prescribed calcium toprevent potassium from building up in the blood (Glynne, 2002, p16).According to Needham (2005, p1743), high levels of potassium in theblood can cause uneven heartbeats a condition referred to asarrhythmias and muscle fatigue.

Accordingto Schrier et al., (2004, p25), it is important for physician toregulate and change the diet for their hospitalized patients withacute renal failure. Jennifer diet has been changed by her physicianto ensure it contains the correct amount of protein, calories,minerals, and vitamins. There are restrictions with Jennifer`s dietin terms of sodium, potassium and phosphorus intake. Since put ondialysis, Jennifer has tremendously improved. However, sincelong-term hemodialysis has various challenges, the physician hascommenced counseling sessions with the patient to convince her to geta kidney transplant. There is hope that his son`s kidney, who is awilling donor will be compatible for the transplant once the patientagrees to the option. The major constraint of the transplant remedyis financing, but the son has already enrolled her mother to amedical cover which covers most of her medical expenses including thetransplant.

Professional,legal and ethical aspects to be considered in the care of the patient

Healthprofessionals have several responsibilities while treating patientswith dialysis therapy (Glynne, Allen and Pusey, 2002, p26).&nbspItis the responsibility of the physician to weigh patient`s wishes andthe likelihood of administering a treatment incoherent withprofessional integrity. Professionally, physicians, doctors and otherhealthcare givers are required to consider and make the right andethically correct decisions when the burdens of dialysis outweigh thebenefits (Germain,Davison and Moss, 2011, p135). Jennifer expressed the desire to forgodialysis and wait for her death, but the physician did not respecther wishes. Professionally, the physician did the correct thing byfirst educating the patient about her health condition, and thatdialysis would manage her condition as she awaits a kidneytransplant. It would be ethically and professionally wrong for thephysician to honor Jennifer`s wishes since she was not yet in severedementia or a permanent coma. On the other hand, if the doctor feltthat the type of dialysis chosen by the patient or the family isinappropriate, he had a right not to administer the dialysis.According to Germain, Davison, and Moss, it is not the obligation ofthe physician to administer dialysis in circumstances that are thatdo not meet the standard of care (2011, p136)

Law,ethicsand professional policy require medical professionals not only toavoid administering inappropriate interventions and therapies, butmost importantly support a patient’s capacity to make knowledgeabledecisions (Koomans, 2001,P224: Germain, Davison and Moss, 2011, p137:Needham 2005, p1744). The current policy requires healthprofessionals to discuss with the patients and their families thebenefits, challenges and any other complications that might arise inthe course of the treatment. In the current case study, it is evidentthat the physician observed the professional aspect of informing thepatient the best treatment for her renal condition. The physician isalso highly professional for not withdrawing dialysis that would bean inappropriate action professionally. There are several researchersindicating factors such as age, mental state, congestion of thedialysis centre and financial burden influence a patient to withdrawfrom dialysis intervention (Palevsky and Murray, 2006, p82: Needham,2005, p1745). However, Germain and his colleagues point out that,such factors independently should not be used by medicalprofessionals in withholding dialysis therapy (2011, p138).

Ahealth professional has an ethical obligation and judiciaryresponsibility to make sure that all manageable aspects that may leadto a patient`s decision to forego a dialysis therapy are evaluatedand treated to the best of his or her competency (Glynne, Allen andPusey, 2002, p29). It is, therefore, the duty and obligation of thephysician to ensure that no such factors develop that will influenceJennifer, in making uninformed decisions to forego dialysis before asuccessful kidney transplant is carried out. If Jennifer declines akidney transplant and makes the decision to forego dialysis therapy,it is the professional responsibility of the physician to incorporatea suitable palliative care in the care plan already drawn for her.Ethically, it would be wrong for the doctor to administer long-termhemodialysis against the patient`s will because there are varioushealth complication and financial constraints that come along withit.

Decisionssurrounding dialysis therapy is a topic of educated consent ordecline (Amdur et al., 2009, p1095: Germain, Davison and Moss, 2011,p138). It is the legal obligation of the physician to disclose to thepatient, all the relevant information on his or her health condition,the benefits and shortcomings of the available treatment options.Legally, the physician is required to educate the patient on themanagement of the renal condition without dialysis if the state doesnot require dialysis therapy (Needham 2005, p1745). Patient with themental ability to make decisions or legal agents of the patients in acoma are legally authorized to use the information provided by themedical professional to choose the treatment that best fits theirvalues. Fromthe case study, it is clear that the doctor observed all thedescribed legal aspects before administering dialysis therapy on hispatient. Jennifer has the mental capacity to make decisions and afterbeing educated by the doctor of her renal condition and thesuitability of the available treatment options, she agreed to undergodialysis.

Anevaluation of the effectiveness of the care provided to Jennifer

Someprevious researchers have proposed higher than usual doses as moreefficient, whether dialysis is sporadic, for two to three hours a dayor constant (Abosaif,et al., 2005, p1046). However, Bonventre(2008, p82) has reviewed recentstudies that have challenged this argument. Prolonged dialysis mayappear beneficial for patients with acute renal failure, owing to thelimited capability of the kidney to acclimatize to disruptedmetabolic balance. Prolonged dialysis is also preferred since thereis no substitute therapy can actually function as the normal kidneys(Koomans,2001, p224). More frequent dialysis result in higher risks ofhypertension that later leads to the impairment of intrarenalautoregulation (Bonventre, 2008, p.82) and further result in moreinjury to the already kidney. Dialysis was the only viable option forJennifer wing to the fact that she has been suffering from diabetesfor the ten years and that her kidney was injured during the fatalaccident. Since put under dialysis, Jennifer`s condition has greatlyimproved, and few complications have been noted so far.

Thephysician in charge and his team have been carrying out Jennifer`sblood tests to assess the effectiveness of the dialysis therapy. Thedoctor uses the URR formula to evaluate whether the treatment iseliminating adequate waste products from the blood. The URR testprimary aim is to measure the amount of blood urea nitrogen (BUN),which is a gauge for the all waste products in the body (Lameire,2005, p206). Through this test, the physician has been able to do thenecessary changes with the therapy to keep it useful in managingJennifer`s renal condition. Jennifer is also under medication ofcalcium to control her blood`s potassium level. So far, theintervention has proven to be effective by maintaining her potassiumlevel below 5.5mEq/L. According to Lameire, Van Biesen and Vanholder(2006, p374), oral intake of calcium carbonate is useful forcontrolling potassium level in the blood for people diagnosed with anacute renal injury. The other medication that Jennifer is undergoingis loop diuretics administered in high doses. According to Dirkes,the pharmacokinetic and pharmacodynamic features of loop diureticsmakes them highly efficient in patient with acute renal failure(2011, p44). Jennifer’s ankles and legs swell slightly, in mostcases immediately after a dialysis session indicating that loopdiuretics is an effective remedy in getting rid of excess fluids inthe body.


Fromthe paper, it is clear that dialysis can be an effective therapy formanaging acute renal failure. However, it is clear from the casestudy that not many quickly come to terms with the fact that theyhave to undergo dialysis therapy. However, it is the professional andlegal obligation of the medical professional to educate the patientor the legal agents on the health condition, the treatment optionsavailable and their pros and cons, to assist them in making informeddecision. From Jennifer’s case, the paper points out at the needfor the physician to consider several ethical, professional and legalissues in administering dialysis to ensure it is appropriate, and itsbenefits outweigh its burdens. From the case study, there is enoughevidence that a physician has a legal obligation to involve andsupport a patient in making decisions related to dialysis treatment. The paper also emphasizes the fact that it is professionally wrongfor a medical physician to administer an inappropriate treatment ortherapy, so as to honor a patient’s wishes.

Thepaper has provided evidence from the analysis of patient careprovided to support the argument that, the recovery and survival ofacute renal failure patients greatly depend on the quality of careprovided. From the patient care discussion, dialysis if correctlyadministered can effectively manage acute kidney failure. However,long-term dialysis has various health complications such ashypertension, and this creates the need for the kidney transplant forpeople suffering from the renal condition. When a patient expressesthe need to forego dialysis, and the physician feels the burdens andcomplication of the therapy outweigh the benefits, it is ethicallyright to honor such wishes. However, the paper emphasizes the needfor physicians to integrate quality palliative care in health careplans for the patients who have chosen to forego dialysis.


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