End-Stage Renal Disease Treated with Hemodialysis, by Chartease Jackson
Mrs. Enez
Joaquin is a 26-year-old Native American woman of the Pima tribe of Arizona.
Upon graduating high school, she chose to go directly into the work force,
working a 9am-5pm job as a secretary. Mrs. Joaquin is 5’0” and currently weighs
170 lbs, with a body mass index of 34.2kg/m^2. Her ideal body weight is 45.5kg
or 100 lbs., and her usual body weight is 121lb as determined by her past
weight of 140 lbs. and her current weight of 170 lbs. She presents with a
history of hypertension, type-2 diabetes mellitus and renal insufficiency. Her
kidneys have been evaluated for the past seven years. However, her decrease in
glomerular filtration rate began two years ago, at which point she was in the
pre-dialysis stage. Currently, she is being admitted to the hospital for the
placement of an arteriovenous fistula in her forearm to create an alternative
filtration mechanism now that she has reached the final stage of chronic kidney
disease. She was prescribed Glucophage (metformin) at 850 mg bid two years
prior and is still currently on the medication to assist in the control of her
glucose levels. She is also taking vasotec as a new medication prescription,
which is an ACE inhibitor to assist in treating her high blood pressure. She
complains of having symptoms of anorexia, nausea and vomiting, 4kg of weight
gain in the prior two weeks, edema in extremities, face and eyes; malaise;
progressive shortness of breath with three-pillow orthopnea; pruritus; muscle
cramps; and an inability to urinate.
She and
her 26-year-old husband have a seven-year-old daughter who is currently in good
health. However, considering the family history of type-2 diabetes in both Mrs.
Joaquin and her husband, as well as the diagnosis of the disease in both of Mrs.
Joaquin’s parents, it is imperative to continuously monitor the health of the
child, as her family history puts her at increased risk. Along with the child’s
family history, her birth weight of 10 lbs is of concern as studies show that
infants born at a higher birth weight tend to develop the disease at a much faster
rate than those born at a normal weight. Mrs. Joaquin herself was born weighing
11 lbs. and was diagnosed with type-2 diabetes or adult onset diabetes at the
early age of 13, while her husband was diagnosed at the age of 18.
The
National Kidney Foundation states that 44% of all chronic kidney disease
patients are diabetic. This statistic helps with understanding a primary
underlying cause of kidney disease and requires that specific attention is
given to the co-morbidity as it speeds up the progression of the disease to end
stage. In Mrs. Joaquin’s specific case, she has already reached the final stage
of the disease. However, an effective treatment plan is still required to treat
diabetes as well as any other co-existing factors affecting the kidneys. To
properly assess the disease, observing the patient’s diet history is crucial.
Mrs. Enez admits to not sticking with her previous medical nutrition therapy. However,
her lack of appetite or anorexia as well as her nausea and vomiting are factors
in her inability to comply with the treatment plan. Two years ago, when the
patient was admitted and diagnosed with impaired renal function, she reported
that her appetite was normal and that she was not following any specific meal
plan. At that time, her medical nutrition therapy included a 1,200 kcal
exchange list diet that was recommended when the patient was diagnosed with
type-2 diabetes mellitus.
At that
time she presented a 24-hour recall: For breakfast she consumed one fried egg,
three strips of fried bacon, fried potatoes (whole) and one sliced bread with
butter. For lunch she consumed two tamales with chili con carne, fry bread and
one can of Coke with an evening snack of twenty-five potato chips and one can
of Coke. Her dinner included three tacos made with ground beef, chopped
tomatoes, chopped onion, chopped lettuce and three flour tortillas.
Her
current diet history indicates much smaller meals but similar choices. Her
24-hour recall upon admittance for the initiation of hemodialysis included cold
cereal, bread or fried potatoes with an occasional fried egg for breakfast.
During lunch she consumed a bologna sandwich with potato chips and Coke. Her
dinner choices were chopped meat and fried potatoes, and her evening snack
included crackers with peanut butter. Her medical chart shows no indication of
food allergies as well as no use of any supplements at this time. However, she
admitted to drinking a 12 oz. beer daily, which raises concern for the health
of her liver and the potential threat kidney failure poses to damaging other
organs, the liver included. Her physical findings, discussed later, confirms
the possibility of liver damage, which would require specific attention in her
treatment plan. In terms of preventing the initiation and progression of kidney
disease, specific attention is given to diet, weight management, the cessation
of smoking, blood pressure maintenance and limiting alcohol. Because of the
severity of abnormal, very low kidney function, the likelihood of developing
other ailments are significantly high. Taking into account the impact this
disease has on the heart and specifically potassium levels, one can certainly
presume rapid mortality rates in end-stage renal failure if alternative
filtration mechanisms such as hemodialysis were not available.
Overview of the
Disease
According
to the National Kidney Foundation, as of 2016, 26 million U.S. citizens have
been diagnosed with chronic kidney disease (CKD). One who has this condition will experience loss of kidney function,
determined by a decrease in his/her rate of kidney filtration. A disease state
of such severity requires significant attention. Toxins accumulate throughout
the body, potentially causing harm and even possible failure to other organs,
such as the heart and parathyroid gland. The kidneys play a crucial role in
maintaining the body’s homeostasis by way of controlling fluid and electrolyte
balance, pH, blood pressure, filtration of waste products, as well as the
production of enzymes and hormones such as erythropoietin and renin. When these
fist-sized organs are no longer working adequately or do not work at all,
patients will present with signs and symptoms overtly specific to the kidneys’
role in the body.
Filtration
takes place in the glomerulus, housed within each of the millions of nephrons.
It allows for plasma to enter through the afferent tubule and exit back into
the venous system for later use through the efferent tubule. Of the plasma
filtered, 20% is excreted ultimately as urine while the remaining blood plasma
is taken up by the efferent tubules. When diagnosing renal failure, specific
attention is given to the rate at which glomeruli are filtering and to any
abnormal substances visible through a urinalysis. A healthy, functioning kidney
will typically filter out substances at a rate anywhere between 90-120 mL/min.
The most recent means of measuring glomerular filtration takes into account
serum creatinine, BUN and serum albumin levels, as well as race and gender in
an equation that calculates the overall clearance rate of these substances.
Prior to calculating a patients’ GFR, patients will typically present with
other signs and symptoms. The most common precursor to spotting this disease is
often found in the urine, when albumin accompanies the 20% of filtered plasma
that leaves the body in the form of urine. The size of this macromolecule is
reason enough for it to never be seen in urine; however, its presence alone is not
a sole determining factor. Instead it calls for physicians to obtain lab
results, consider other risk factors, and calculate the GFR of the patient to
determine the overall health of the organs.
Those at
increased risk for developing renal failure include individuals who are older,
have diabetes, have hypertension, have a family history of the disease, males,
the obese and/or those who are African American, Native American, Pacific
Islanders and Asians as well as Hispanic Americans (National Kidney Foundation,
2017). Other related causes include inflammation of the kidneys, renal artery
obstruction, nephrotic syndrome, kidney stones, renal tubular disorder, as well
as atherosclerosis. Of these risk factors, the most common co-morbidity is
diabetes. In 2011 alone, “49,677 people of all ages began treatment for kidney
failure due to diabetes” (American
Diabetes Association, 2016). When considering the prevalence of African
American kidney failure patients, it is imperative to consider the prevalence
of the African American population battling diabetes. According to the American
Diabetes Association, 13.2% of the diabetic population are Black, while the ethnic
groups with the highest prevalence of diabetes are of Native American or
Alaskan Native heritage.
Diabetes
affects several organs throughout the body as glucose levels continue to go uncontrolled.
Carbohydrates accumulate around and within organs, making it more complicated
and, in the case of end-stage renal failure, impossible for the organs to
perform their specific functions. The inability of glucose to be taken up into
the cell due to inadequate insulin production or insulin insufficiency creates
an abnormal environment for the glomeruli within the working units of the
kidneys. As glucose continues to accumulate inside of the organ, GFR rates
plummet below their normal value and waste products such as BUN and creatinine
continue to rise to levels of toxicity in the body.
A study in
February of 2017 that focused on 308 patients diagnosed with diabetes and CKD
concluded that “the co-existence of diabetes and CKD has an additive effect on
the development of cardiovascular disease with a substantial increase in risk
of premature mortality” (Lo, 2017). Along with the accumulation of waste
products, patients typically present with hyperkalemia or excessive amounts of
potassium in the blood. This inability to excrete the electrolyte occurs as
filtration rates continue to plummet. As the rate becomes further from normal,
its compensating mechanism becomes completely inadequate, allowing it to be
retained in the body. Abnormal retention of this electrolyte possesses a severe
threat to cardiac function: It increases the rate at which electric conduction
takes place, causing abnormal muscle contractions in the heart. This, in turn,
produces undesired heart rhythms, ultimately leading to cardiovascular disease.
Studies show that “mortality rates increase significantly as levels appear
greater than or equal to 6.0 mEq/l” (Yusuf, Hu, Singh, & Menoyo, 2016).
Chronic kidney disease stage-5 is of primary concern for hyperkalemia and CVD as
the kidney has lost its ability to remove the majority of potassium intake
consumed daily. At this point of the disease, patients will require
hemodialysis treatment. Additional monitoring of potassium is necessary as
potassium is typically found in the dialysis solution. In conjunction with the
potassium found in the solution, studies indicate that “Increased likelihood of
hyperkalemia is associated with the long interdialytic interval between
hemodialysis treatment” (Yusuf, 2016).
Other
nutritional components affected by the kidneys include the active form of
Vitamin D, also known as vitamin D3 or calcitriol. This hormone relies on the
kidneys as the final step in the conversion process occurring first in the
liver before finally becoming a usable form by the body. To add to the severity
of the disease, calcium relies on calcitriol for adequate absorption. So as the
kidneys continue to fail, vitamin D3 is inadequately or not created at all, and
calcium is inadequately or not reabsorbed at all, which leads to the
overproduction of phosphorus by way of the parathyroid hormone (PTH). The body
always has a back-up or compensatory mechanism until it gets exhausted, which
is the case for PTH. This works to reabsorb calcium, eliminate phosphorus and
activate vitamin D in the kidneys. Its primary function entails monitoring
blood calcium levels in the body. The problem comes about, however, when
vitamin D isn’t activated to facilitate calcium reabsorption. As a result,
calcium levels get depleted and PTH tries to counter this abnormality by
secreting phosphorus for an adequate balance of calcium and phosphorus.
Typically, when the body’s internal environment goes into such states of fight
or flight, negative feedback will calm the body back down to a state of normalcy.
Unfortunately, this often does not occur in end-stage renal failure. The
mechanism never gets shut off and phosphorus is continuously secreted to levels
of toxicity, ultimately leading to hyperparathyroidism. Because of this unending
attempt to restore the body’s balance, patients will require supplementation of
vitamin D3 for proper calcium absorption as well as calcium supplementation to
accommodate for the low serum calcium levels. Vitamin D can be supplemented at
DRI levels for hemodialysis patients, while the recommendation for calcium is
up to 2g/day. Also, because of the efforts of the parathyroid gland, its
phosphorus levels are limited to anywhere between 800 to 1,000 mg per day.
Erythropoietin,
another hormone produced by the kidneys, is responsible for red blood cell
formation in cancellous bone. Patients facing this disease typically have to
receive erythropoietin therapy as red blood cell formation continues to
decline. Minimal red blood cell formation means minimal hemoglobin to transport
oxygen throughout the body. To compensate for this abnormality, a dietitian
will ensure supplementation of iron as it aids in the formation of hemoglobin
and fight against the development or occurring anemia in CKD patients.
Supplementation of iron in CKD patients is recommended at DRI levels.
These
concerns are met through implementation of medical nutrition therapy. However,
diet alone is ineffective when treating the final stage of renal failure. At
this point, the kidneys are functioning at a rate of less than or equal to
15ml/min in comparison to the normal range of 90-120ml/min. This severely
abnormal range requires the use of dialysis or an alternative filtering
mechanism in place of the kidneys. Hemodialysis is the most common and requires
a means of access into the venous system for filtration. To allow access,
surgical placement of an arteriovenous (AV) fistula, which is an abnormal
opening required to initiate treatment. This allows toxic substances to be
removed from the body, just as normal kidney function would. However, it also
comes with a few nutritional concerns as it removes necessary water soluble
vitamins and other nutrients with it. Because of this alternative filtration
mechanism, end-stage renal failure patients are required to have a higher
protein intake, at 1.2g/kg, than would be necessary in earlier stages when the
body has no means of ridding itself of excess urea nitrogen. This increased
need of protein is deemed appropriate as it helps the body restore muscle
tissue and facilitates healing after the body has already experienced excessive
muscle wasting. In conjunction with higher protein levels, energy needs will be
significantly higher as well, at 30-35g/kg, in all chronic kidney disease
patients. Fat intake is normal, at 25-35%, while specific attention will be
given to limiting sodium intake. CKD patients are advised to limit their sodium
intake to 2-3g per day due to hypertension and excessive fluid retention.
Excess consumption of sodium in the diet would allow the body to hold on to
more water than necessary, causing unwarranted weight gain, which would be
counterproductive with such patients. In the treatment of hemodialysis, it is
also of concern as it lead could even lead to hypotension.
Nutrition
Assessment
Mrs.
Joaquin is a 26-year-old, 5’0”, 170 lbs. female with a BMI of 34, indicating
that obesity is another risk factor. She appears to be overweight, lethargic,
with her primary complaint of nausea and vomiting. Her vital findings indicate
that her temperature and heart rate are in good standing at 98.6 F and 84 bpm,
respectively. However, her blood pressure and respiratory rate are of concern.
Her blood pressure is 220/80 mm Hg and her respiratory rate is 25 bpm. Decreasing
her respiratory rate to the normal range of 12-20 bpm could possibly be
controlled with more ease as hemodialysis is implemented and toxicity levels
began to decrease. Close attention to fluid intake is also of crucial
importance in controlling her shortness of breath. Her blood pressure, however,
may be decreased with more strenuous effort, taking into account her dietary
compliance, medications prescribed, and hemodialysis treatment. With
hemodialysis treatment, patients can easily encounter hypotension if fluid
intake is not strictly monitored.
Other
findings continued to point to her heart contraction capabilities, indicating
that her heart sounds from auscultation were normal at sound 1, 2 and 4. However,
sound 3 indicated a grade I/VI systolic ejection murmur in her upper left
sternal border. Her head, eyes, ears, neck and throat are all either normal or
would not significantly contribute to understanding her condition. The patient
is neurologically oriented well. However, she has mild jerking movements in her
hand, known as asterixis, which could be related to her abnormal potassium
levels and other levels of toxicity in the body. Her extremities show dry,
yellowish-brown skin, muscle weakness with 3+ pitting edema to the knees. The
patient complained of her abnormal weight gain in the past two weeks, which
explains the abnormal edema in her extremities. Her yellowish skin raises the
question of jaundice, as she admitted to having a 12 oz. beer daily. Though
this is the recommended serving size for women who choose to drink, in Mrs.
Enez’s case of CKD, it is best for her to avoid alcoholic beverages. The
patient’s muscle weakness is indicated in her physical findings in conjunction
with her abnormal creatinine levels, indicating excessive muscle wasting.
Of these
physical findings, her biochemical labs showed direct correlation to many
concerns. These labs indicate that upon her admittance for the placement of an AV
fistula, her albumin levels were normal. Albumin plays a significant role in
identifying CKD as it typically is the first sign, possibly in accompaniment
with blood in the urine. Protein molecules, including many other nutrients, are
typically filtered and then sent back to the body for later use. Spotting any
macromolecule in the urine is alarming as the kidneys do not have a large
enough means to remove them from the body the same way urine gets excreted. As
previously stated, microalbuminuria is typically the first to appear, but not
the sole determining factor in diagnosing this disease. Though these levels are
currently normal, they in fact, did assist in her diagnoses of renal
insufficiency two years prior at abnormal levels of 3.2g/dL.
Her second
biochemical finding indicates a state of hyponatremia with sodium levels
currently at 130 mEq/L. This is relative to her complaint of abnormal weight
gain in the past two weeks as well as her physical findings of abnormal edema
in her extremities and an inability to urine. All of which point to normal
occurrences in CKD as the kidneys continue their progression of damage, a major
function is lost, extracellular fluid balance, naturally, abnormal fluid
retention occurs and the possibility of oliguria or anuria continue to rise
along the progression of the disease.
Normal
serum potassium ranges anywhere from 3.5-5.5, but Mrs. Joaquin is currently
presenting with 5.8 mEq/L. This requires very close attention as excessive
potassium increases the risk of CVD. Potassium is normally through the kidneys:
80-90% of one’s daily intake is consistently removed with urine output. Studies
show that the continuance of Mrs. Joaquin’s serum potassium levels beyond 6.0
mEq/L could increase her chance of mortality significantly.
Her BUN
and creatinine were all high. These are signs that her excretory function has weakened.
The kidneys’ primary function entails excretion of waste products, and this
loss of function will most certainly promote the increase of these substances
within the body. BUN is representative of the body’s ability to excrete urea
nitrogen; normally, only 8-26g/dL should be present. The high levels shown of 69mg/dL
shows not only a loss of excretory function but also that significant interest
should be given to protein consumption. If the patient were in the pre-dialysis
stages, protein intake would be significantly minimal due to the accompaniment
of nitrogen. However, because of the requirement of hemodialysis, which will
remove significant amounts of protein, her allowance can be elevated to 1.2g/kg.
Creatinine levels are also high at 12.0 mg/dL which is also related to protein
and shows signs that her body is experiencing excessive muscle wasting.
Relative
to her co-morbidity of type-2 diabetes mellitus, glucose levels are severely
out of normal range at a level of 282 mg/dL with normal levels anywhere from
70-120 mg/dL. In conjunction with her abnormal glucose levels, her evaluation
of her glucose control over the span of three months indicated that her HbA1c
was high at 8.9%, with normal ranges being between 4.8-7.8%. Diabetes is the
number one cause of kidney disease as glucose accumulation places continuous
stress on the glomeruli, inhibiting its ability to filter normally at a rate of
90-120ml/min.
Other lab
abnormalities indicate that the patient has high levels of PO4 at 9.5 mEq/L,
with normal ranges being anywhere from 2.5-4.5; high magnesium at 2.9 mEq/L
(normally1.6-2.624-30 mEq/L); low carbon dioxide at 20 mmol/L; and high
triglycerides at 200mg/dL. PO4 is an inorganic compound containing phosphorus,
which tends to accumulate in the blood in CKD patients. Negative feedback never
comes around to resolve the body’s compensating mechanism for decreased serum
calcium in response to lack of the active form of vitamin D produced by the
kidneys. Abnormally high levels of phosphorus in the blood raises concern for a
co-morbidity of hyperparathyroidism.
Magnesium,
a mineral typically excreted by the kidneys in renal failure, will typically
follow suit with potassium. As excretory function is lost, both will
accumulate. Typically, however, magnesium levels will only be mildly elevated
in CKD patients, which proves to be the case for Mrs. Joaquin. Her levels
aren’t severely outside of normal range and even begin to decrease with her
hemodialysis treatment to 2.7 mEq/L.
Mrs.
Joaquin’s CO2 levels are directly related to her abnormal respiratory rate,
which could potentially be a result of her state of uremia with toxic
substances in the blood as well as her abnormal fluid retention. As previously
stated, fluid control is the responsibility of the kidneys and pose a direct
threat to the body’s homeostasis when the function of the organs gets lost.
To assist
in the patient’s abnormal physical and lab findings, individualized nutrition
care is required. Chronic kidney disease patients must adhere to a diet high in
calories to prevent the continuous use of protein for energy. This requires
that end stage patients get 30-35g/kg of energy and 1.2g/kg of protein as
patients on dialysis need higher protein levels to accommodate for the already
significant loss of muscle and assist in the repair of tissues. However, prior
to the placement of her AV fistula she was placed on a diet order of 35g/kg of
energy with 0.8g/kg of protein, 8-12 mg of phosphorus/kg and 2-3 g of Na. This
is sufficient as she is not on hemodialysis just yet, so protein levels are
decreased significantly to accommodate for the lack of filtration and need to
use carbohydrates for energy instead of protein.
Medications
ADIME Note
A: Pt. is a 26 y.o. 5’0” female,
170 lbs – BMI 34
·
Biochemical
Data:
o
Sodium
130 mEq/L Potassium 5.8 mEq/L Chloride 91 mEq/L Phosphate 9.5 mEq/L Magnesium
2.9 mEq/L Total CO2 mmol/L Glucose 282 mg/dL BUN 69 mg/dL Creatinine 12.0 mg/dL
Total cholesterol 220 mg/dL Triglycerides 200 mg/dL HbA1c 8.9%
o
Medications:
Glucophage, Vasotec
o
EER:2300-2700kcals
o
Protein:92.4g
o
Medical
Diagnosis: End stage renal disease
D:
·
Altered
Nutrition lab values: Na+, K+,
·
As
related to muscle cramps and asterixis
·
As
evidenced by 5.8 mEq/L Potassium
·
Excessive
fluid intake NI-3.2
·
As
related to edema in extremities, N/V, SOB
·
As
evidenced by 4kg weight gain in the last two weeks
·
Overweight/obesity
NC 3.3
·
As
related to incompliance with previous MNT
·
As
evidenced by a BMI of 34
I:
o
Recommend
2300-2700 kcal
o
Recommend
90g protein
o
Recommend
limiting fluids to 1500ml/day
o
Recommend
no salt substitiutes
o
Recommend
water soluble vitamins at DRI levels
o
Recommend
supplementing zinc at DRI levels
o
Recommend
supplementing vitamin D and E at DRI levels
o
Recommend
frequent small meals daily with snacks
o
Recommend
no alcohol
o
Recommend
30 minute walks 3 times per week
M/E:
o
Monitor
daily fluid intake
o
Monitor
lab values
Date:
4/25/17 Signature___________________________
Alternative Therapies
Though
the use of alternative therapies is rapidly growing in the U.S., sound evidence
for any possible alternative health care option scarcely exists for end-stage
renal failure patients. There is a significant need for more evidence to
support any claims that alternative therapies may be beneficial for chronic
kidney disease. For example, there is information indicating that asparagus
consumption could effectively assist in glomerular filtration rate. However, to
support this claim, one would ignore the potassium content of asparagus and the
potential counter impact it could have, short term or long term.
One
possible alternative option for kidney failure patients is kidney
transplantation. Though this does not fall into the realm of alternative health
care, it gives the option of the patient to heal not only from the condition
itself, but restoration back into a normal lifestyle as hemodialysis tends to
add an additional level of stress to patients, potentially increasing the
occurrence of depression.
Long Term Therapies
Long term
control for end stage renal failure will require paying specific attention to
any existing co-morbidities, such as obesity and diabetes in Mrs. Joaquin’s
case. This will require that she is made aware of the benefits of the exchange
list diet and how it may better help control her glucose levels. In conjunction
with her efforts for proper glucose control, evaluation of her success will be
necessary by evaluating her HbA1c every three months. Studies show that insulin
resistance increases in the presence of obesity, so Mrs Joaquin’s weight
control will be specifically attended to as well. This will not only assist in
proper glucose control, but also ensure that her state of obesity is not a
contributing factor to the onset of more organ failure as well as take any
added stress off of an already failing organ such as the kidneys.
Questions
1.
Describe
the physiological function of the kidneys.
The
kidneys are two crucial organs within the body with specific excretory and
physiological functions. Specifically, these organs are responsible for control
of pH balance, fluid and electrolyte balance, maintenance of blood pressure,
excretion of waste products and the production of hormones. Their primary
functions are to remove waste from the body by way of the glomerulus located
inside of the nephron. As blood flows into the nephron, it is removed from the
glomerulus after filtration either one of two ways, as a small percent of urine
returns to the venous system for later use by the body.
2.
What
diseases/conditions can lead to kidney failure?
Diseases
and conditions that tend to initiate kidney failure included diabetes,
hypertension, nephritis, nephrotic syndrome, kidney stones, and heart disease.
3.
Signs,
symptoms and laboratory abnormalities distinguish disease pathophysiology.What
are the signs and symptoms of chronic kidney failure?
Signs
and symptoms include excessive urination with excessive fluid retention as the
disease progresses, nausea and vomiting, lack of appetite, abnormal phosphorus,
calcium, albumin, potassium BUN and creatinine levels. Patients may also
present with hypertension as fluid levels are continuously retained. Many more
signs and symptoms emerge as the disease state continues to progress, and
possible other co-morbidities present.
4.
Mrs.
Joaquin was diagnosed with type-2 diabetes mellitus when she was 13 years old.
Does she fit the “profile” for someone with type 2 DM? Why or why not?
Type
2 diabetes mellitus is also known as adult onset diabetes, in which case the
patient would not fit the “profile” for someone with this disease. However, her
medical history indicates that she was born weighing 11 lbs. Research indicates
that infants born at higher weights tend to develop type 2 DM much faster than
normal-weight newborns who would develop the disease.
5.
Assess
the patient’s anthropometric values.
The
patient is a 26-year-old, 5’0”, 170 lbs. female with a BMI of 34. Her
anthropometrics raises concern as her height-to-weight ratio is severely out of
range. Ideal body weight for a woman her height is 100 lbs, which means Mrs.
Joaquin is 70 lb overweight, which is considered obese. Her 4kg of body weight
in the past two weeks is of concern as she also presents with 3+ pitting edema
to the knees.
References
About
chronic kidney disease. (2017, February 15). Retrieved from https://www.kidney.org/atoz/content/about-chronic-kidney-disease
American
Diabetes Association®. (n.d.). Retrieved from http://www.diabetes.org/?loc=bb-dorg
Lo,
C., Teede, H., Fulcher, G., Gallagher, M., Kerr, P. G., Ranasinha, S., Zoungas,
S. (2017). Gaps and barriers in health-care provision for co-morbid diabetes
and chronic kidney disease: A cross-sectional study. BMC Nephrology, 18(1).
doi:10.1186/s12882-017-0493-x
Sudha,
M., Salam, H., Viveka, S., & Udupa, A. (2017). Assessment of changes in
insulin requirement in patients of type 2 diabetes mellitus on maintenance
hemodialysis. Journal of Natural Science, Biology and Medicine, 8(1),
64. doi:10.4103/0976-9668.198348
Yusuf,
A. A., Hu, Y., Singh, B., Menoyo, J. A., & Wetmore, J. B. (2016). Serum
potassium levels and mortality in hemodialysis patients: A retrospective cohort
study. American Journal of Nephrology, 44(3), 179-186. doi:10.1159/000448341
This is such an informative paper, Chartease. I learned a lot.
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