Hypotension: A Case Study

Cetiner is the primary nurse for four dialysis patients. She tends to all of their complex needs as she strives to improve their outcomes. She delivers care in a manner that preserves patient autonomy, dignity and rights. This is evidenced by all four patients exceeding unit/network benchmarks in adequacy, access and anemia management. She became an advocate for a Veteran who lives in a nursing home and has no family, resulting in improvement of care. She diligently worked with one Veteran to avoid multiple hospital admission for fluid overload. She developed a treatment program along with the Medical Director to manage the patient’s fluid both during and after the hemodialysis treatment. She has provided much support to one of the Veterans with many socioeconomic issues ultimately affecting his treatment. Because of her due diligence with his non- compliance he now stays for his entire treatment on a regular basis

I think that this is normal for me because I have a lot of muscle on my lower body due to performing heavy compound movements at the gym such as squats and deadlifts.

Everyday there are countless admissions to hospitals throughout the world for injuries due to falls. More often than not, patients who suffer falls are elderly patients who have lost their balance. One study states that in the United Kingdom, the number one cause of emergency room admissions to the hospital is for those 65 years and older who have fallen.1 In order for this issue to be addressed and corrected, one must take into consideration the variety of precipitants for falling. One of the major reasons for falls is referred to as orthostatic intolerance. Orthostatic intolerance is defined as “the development of symptoms such as lightheadedness and blurred vision when a subject stands up and clears when sitting back down.”2 There

Hypovolemic shock is the result of whole blood loss, and plasma or interstitial fluid loss in large amounts. Moreover, hypovolemic shock begins when the intravascular volume decreases by approximately fifteen percent. The pathophysiology of hypovolemic shock includes both the heart rate and SVR increasing. As a result cardiac output and tissue perfusion pressures are boosted and interstitial fluid moves into the vascular compartment. Also, both the liver and spleen boost the body’s blood volume by disgorging the stored red blood cells and plasma. In the kidneys, renin prompts the release of aldosterone and also the retention of sodium. Whereas, ADH that is from the posterior pituitary gland surges water retention. In addition, if the initial

Epidemiologically, the exact incidence of hyperkalemia is unknown. However, hyperkalemia is prevalent in patients with predisposing conditions, such as patients with chronic kidney disease (Kovesdy, 2014). Furthermore, there is a higher incidence of hyperkalemia, between 9% and 12%, in patients over 60 years old who receive angiotensin-converting enzyme inhibitors (ACE inhibitors) (An et al., 2012).

In Kidney failure cases urea, creatine, uric acids and electrolytes move from the blood to the dialysate with the net effect of lowering their concentration in the blood. RBC s WBC s and plasma proteins are too large to diffuse through the pores of the membrane. Hemodialysis patient are exposed to 120 to 130 L of water during each dialysis treatment. Small molecular weight substances can pass from the dialysate in to patient’s blood. So the purity of water used for dialysis is monitored and controlled.

It is important to remember the ACEI block the production of angiotensin II altogether, which also block the enzyme kinase. This mechanism allows for vasodilation, decreased blood volume, and the suppression aldosterone: allowing for decreased blood pressure and a slight decrease in edema. While the suppression of kinase can cause an accumulation of bradykinin in the lungs, causing a cough, ACEIs are considered the number one go to drug for hypertension and heart failure. ARBS, working in much the same way as ACEIs, block angiotensin II receptor sites. This allows for kinase to work again bradykinin, and does not produce the adverse cough. Diuretics are a must in most hypertensive patients because they decrease edema, lower blood volume, and decrease the workload of the heart. It is important to watch for adverse side effects such as hypokalemia and hypotension in some patients. By combining all of this knowledge with appropriate lifestyle changes, a clinician can successfully manage a patient’s hypertension and heart

2014). Dialysis treatments partially replaces the filtration properties of the kidney, offer temporary solutions for patients, however, does not address the loss of the hemostatic and endocrine function of the kidney (Sullivan et al. 2012). Furthermore, the outcomes of the patient in dialysis are still disappointing, associated complications which accelerated cardiac disease and infection contribute to an annual mortality rate exceeding 25% (Figliuzzi et al. 2014). Medical therapies has increased survivorship of those with CKD, transplantation remains the only available curative treatment (Song et al.

Research shows that dialysis patients who have problems with fluid management have an increase in hospitalizations, disease processes, and poor clinical outcomes.  Research has also proven that fluid is a strong predictor of mortality and morbidity.

The main role of the kidney in the maintenance of the body mechanisms is to remove excess fluids and toxin from the body as urine. The process through which human beings remove urine from the body entails re-absorption and excretion thus complexity of the process. Kidney focuses on the stabilization of the acid, potassium, and salt content within the body. Kidneys also facilitate operation of various organs in the body through production of Vitamin D and various hormones. In the context of the United States, approximately 26 million patients suffer from the implications of chronic kidney disease. There are five critical stages affecting the operation or functioning of the renal (Sullivan, 2010). The last/final stage results in the eventual failure of the renal.

Since then I have been caring for this patient. The main problem for Mr. Frank is the fluid overload and its related complications. About 30% of the patients above 65 years are fluid overloaded even after dialysis (Lindley, 2009, p. 11). Some patients cannot follow the instructions and gain about 4-5 kg between dialyses and this patient is one among them. The average volume increase necessary for the signs of fluid overload is around 3 kg in a 70 kg patient, which can be sufficient to cause elevated blood pressure (Hoenich and Pearce, 2005, p. 21). Mr.Frank’s dry weight is 71.3kg and his body weight ranges between 75 and 77 kg.

Zyga et al (2009) states that acute renal failure (ARF) remains one of the major challenges of modern medicine. In the intensive care unit (ICU), the uremic complications of ARF aggravate the clinical and hemodynamic status of critically ill patients and impede their clinical recovery. Zyga et al (2009) continues to state that ARF constitutes an additional aggravating factor that increases hospital mortality.

Depending on the dialysis treatment used, protein and other essential electrolytes are either removed or retained. It is essential to monitor laboratory values and to perform proper assessments to assure the patient is receiving the best care possible. Peritoneal dialysis tends to extract protein. Knowing this, a patient who is on peritoneal dialysis would be on a high protein diet to compensate for this loss. Potassium is usually individualized depending on laboratory values and the extent of the disease. A patient undergoing hemodialysis should maintain a daily allowance intake of two to three grams per day, whereas a patient using peritoneal dialysis is not restricted of potassium. Sodium level should be maintained and monitored throughout dialysis. While sodium intake is individualized, considerations must be taken to limit high sodium diets such as processed foods, canned foods, and cured meats. When the kidney function deteriorates, phosphorus is retained causing hyperphosphatemia. Since phosphate is found in many protein food sources, phosphate binders are essential to control

Patients of renal failure undergoing kidney dialysis have some risks and complications associated with it. Risks of kidney dialysis include muscle cramps. Risks of muscle cramps are there in the last half of dialysis session only. Patients of renal failure under treatment with kidney dialysis can also have the risks of hypotension. Hypotension risks are some of the common risks that often occur in women and in people aged above 60. Nausea, headache, vomiting and confusion can also be the possible risks faced by renal failure patients. Some of the possible risks are listed as follows:

Another safety concern in the dialysis unit is the high rate of patient falls. Patient age is a risk factor because most of the dialysis patients are over 65 years or older and are weak and prone to falls. About 82% falls happen at home due to furniture tripping; 40% due to “feeling dizzy or weak” (Marck et al., 2014). Because blood exchange is done during hemodialysis that can cause hypotension and/or weakness, as nurses, safety measures must be followed by ensuring functional while removing unnecessary equipment and keeping the unit free from clutters and by giving high attention to patients to keep them safe. Another prevalent issue in the dialysis unit is the high risk of sepsis. The Centers for Disease Control and Prevention (CDC) “established