Joint CPMP/CVMP Quality Working Party
1.
Colciencia: Domingo Pérez Ruiz C/ Jerónimo Santa Fe, no 5, 3o C 30800 Lorca Murcia
1.
We report the case of a male patient with IRT on regular dialysis twelve hours a week, with a 1.9 m2 surface PS capillary, 2.5 mmol calcium bath, anticoagulation with continuous sodium heparin.
His medical history shows:
History of explosive renal lithiasis since the age of two, without controls since the age of 10, although periodic explosive nephritic colic persisted.
The patient’ s previous renal function is unknown.
One year before admission, laboratory tests performed for ocular trauma revealed a creatinine level of 1.9 mg/dl. No known drug allergies, hypertension or diabetes.
Moderate tonus
One week before admission, the patient complained of nausea, vomiting, dizziness, and muscle contracture.
Your doctor observes left kidney stone image, sending you to urology, where very important renal failure is detected without urinary obstruction, reason why you are admitted.
The patient, who at that time was 26 years old, was admitted in a situation of advanced renal failure (serum creatinine 43.2 mg./dl), urea 384 mg./dl, requiring periodic dialysis of femoral catheters urgently at discharge.
NURSING DEVELOPMENT
The study performed on her first admission showed the existence of bilateral corticomedullary nephrocalcinosis in plain abdominal X-ray and renal ultrasound; the patient's relatives denied administration of vitamin D 6.8 mg in childhood.
In subsequent controls, a progressive increase in bone density was observed at all levels not justified by PTH changes, extraosseous calcifications, partial resistance to EPO, and intolerance to UF intradialysis.
3.8 mg./dl was confirmed with strong College-GT activity suspicion that the underlying disease was a primary hyperoxaluria. Liver biopsy was performed at the next May-GTA 19.1 mmol/GTh negative University Hospital.
These results are compatible with the diagnosis of primary hyperoxaluria type 1.
As the disease progresses, more dialysis is needed, reaching 20 hours per week in five sessions.
Over the years on dialysis has the following complications:
• Hyperparathyroidism. • Intermittent claudication clinic. • Calcinosis cutis • Calciphylaxis • Thrombopoietinitis • Malnutrition • Anemia secondary to chronic hyperparathyroidism
This clinical situation establishes the nursing care plan5 described below:
NURSING ASSESSMENT
The following data were obtained from the nursing assessment:
A 32-year-old single man lives with his parents and does not work.
Currently in daily dialysis program due to worsening of the underlying disease (primary hyperpoxaluria) according to medical diagnosis, through femoral catheter for thrombosis in previous AF.
• Requires repeated nursing care to maintain the patency of the venous catheter. • You have difficulty chewing gum pain (appearing slightly inflamed) and lack of medical advice showing a negative nitrogen balance.
In laboratory tests the values of serum albumin and protein are decreased. • Generally comes to the Unit with fluid overload > 2000 cc. • presents limitation of physical movement due to muscle-skeletal impairment that manifests in lower limb flexion and strength
Frequent physical resistance occurs when the catheter is activated in the unit. • The patient begins to show signs of rigidity, discomfort when the patient is sick due to loss of consciousness, lack of cooperation due to skin irritation, need for dialysis
In the last sample presented transfusion reaction with skin rash, pruritus, urticaria and edema in lips and eyelids, requiring treatment with steroids. • Little communication, usually focus the conversation on your disease, sometimes show fear of future treatment.
This makes you have mood swings • Don’t feel like going out of the house because of the difficulty you face to challenge yourself and the deterioration of your body image (genu-valgus foot, hands, catheter).
Receive visits and phone calls from family and friends. • Tell you to have trouble sleeping and stay asleep because of restlessness and pain. • Ask for information about your disease.
The most important problems observed in this patient and the care plan are described below.
The diagnoses were made according to NANDA6 taxonomy.
1- Desettlement nutritional deficiency due to defect r/c inadequate or uncontrolled diet and difficulty chewing and m/p signs of malnutrition
Objectives:
• Increase in protein intake in the diet.
Establishment plan
• Assess the nutritional status • not to mention laboratory test abnormalities. • Inform the patient about his diet, protein-rich. • Advise semi-small mucosa while remaining oral hygiene after eating disorders.
Consultation with the dentist • Coordinate the diet according to their preferences and nutrients allowed.
2. - Impaired physical mobility r/c lack of muscle strength and m/p limitations of movement or ability to move in their environment.
Objectives:
• To prevent complications of decreased mobility. • To create optimal levels of mobility and resistance. • To design methods to adapt to mobility difficulties.
Establishment plan
• Perform passive exercises 2 or 3 times a day. • Perform hydrotherapy and massage of the affected limbs. • Facilitate transfers with mechanical means. • Evaluate changes in strength, pavilion, pain relief.
3. – Deterioration of sleep pattern r/c pain and restlessness and m/p of prolonged unveiling and interlinked sleep.
Objectives:
• Provide comfort measures to induce sleep. • Reduce or prevent circumstances that may interfere with your rest.
Establishment plan
• Reduce environmental distractors (light, telephone) • Recommend soft music, night baths, clean clothing, massage, reading, etc., • Seek a comfortable posture.
Use elements of lower limb accommodation. • Physical causes. • Advise pharmacological treatment when needed.
4. – Self-care deficit r/c muscle damage and handicap m/p inability to dress, fix and sit.
Objectives:
• Help the patient adapt to the situation; • Inform the family about role changes.
Establishment plan
• Providing safety in activities by adapting space as possible. • Providing opportunities to adapt. • Involving the family in care.
5. – Risk of impaired skin integrity r/c calcinosis cutis and dry skin and m/p pruritus and skin irritation.
Objectives:
• Maintain skin integrity. • relieve symptoms.
Establishment plan
• Keep your skin hydrated using a cleaner limestone less often than after removing a catheter with cold water. • Keep your nails clean and short to avoid injury and infection. • Protect your skin.
6.- Deterioration of social interaction r/c changes in physical appearance and m/p impairment, poor communication and social isolation.
Objectives:
• Increase self-esteem of the patient. • Teaching ways to cope.
Establishment plan
• Promote conversations about their aphids. • Incentivizing training activities: days that do not come to the unit. • Focusing on verbal skills, conduct of positive experiences. • Teaching techniques social modification
7.- Fear r/c and m/p changes in behavior pattern: irritation, depression.
Objectives:
• Identify emotional response: irritability, worry, anguish. • Knowing attitude and coping resources to face your disease.
Establishment plan
• Giving information related to the control and prognosis of your disease. • Reducing or eliminating threatening stimuli. • Teaching behavior modification techniques: relaxation, thought stopping, emotional self-control. • Establishing a trust relationship.
8.- Risk of infection r/c invasive procedures.
Objectives:
• Maintain access ways to perform the dialysis technique. • Identify infection-promoting procedures.
Establishment plan
• Carry out the care of the arteriovenous fistula and catheters according to unit standards and follow-up of the maturation of the arteriovenous fistula. • Assess signs of infection. • Maintenance of the necessary permeability of the femoral catheter using when it has been done.
Interdependent processes related to dialysis and common to IRT patients:
• Intolerance to dialysis technique a high vascular access. • Anemia secondary to erythropoietin and blood loss. • Anaphylactic reaction dyspnoea/ blood transfusion. • Intolerance to dialysis technique
DEVELOPMENT
Despite daily dialysis, the disease continued its course and physical deterioration was increasing.
After the rehabilitation sessions and the patient's effort, a slow difi cient ambulation started to be adapted.
He began short and light walks, sometimes he went out to friends' houses, although his limitations and physical appearance still prevail over him.
There were no signs of infection of the catheter or irritated skin areas.
Although protein intake increased considerably, even reaching fattening, protein malabsorption continues.
He has received all the information he has requested and now he is more collaborating and shows more hopes in the transplant.
Keep having mood swings, but now she even makes some joke about the problems that arise from her.
Although she feels supported by her future, she comments that she feels safe for all the people she receives from both her family and health personnel.
In January 2003, he underwent an urgent mixed hepatorenal transplant.
Currently, she is not on dialysis program, regularly attending the reference hospital to assess its evolution.
1.
Acknowledgements
Our thanks to Dr. D. Eladio Lucasllén, head of Nephrology section, for her help and collaboration.
Due to its constant incentive and valuable suggestions we want to thank the supervisor of the dialysis unit, Dña.
Montserrat Pérez Robles.
Special thanks to Dña.
Paqui Pérez Robles, professor and head of studies of the School San Juan de Dios in Barcelona, who gave us his time and knowledge.
