Case studies: Renal system
Case Study: Acute Glomerulonephritis
Angie Kilgore, 33 years of age, kept a scheduled appointment with the nurse practitioner for
routine follow-up after the delivery of her infant son six months before. Assessment of her
vital signs indicated that she had a slightly elevated blood pressure and physical examination
revealed tenderness in the costovertebral angle area. The nurse practitioner learned
that Mrs. Kilgore had had an episode of flulike symptoms with a sore throat and fever several
days earlier, which caused her to feel feverish and have a slight headache. Routine urinalysis
revealed the presence of blood and albumin in her urine. Although her symptoms had receded, Mrs. Kilgore
complained of not feeling very well and of some facial swelling
and flank pain. The nurse practitioner referred her to the physician who explained that her
symptoms required a more in-depth evaluation. Mrs. Kilgore was advised to make arrangements
for admission to the hospital for further testing and treatment of acute glomerulonephritis.
Case Study: Nursing Care of Individuals with Nephrotic Syndrome
Directions: To complete this section, read the situation and answer the questions that follow.
Doris Winter, 39 years of age, had been controlling her diabetes with insulin for 23 years. She
was admitted to the hospital for evaluation of weight gain associated with dependent edema.
She complained of puffy eyes and intermittent headaches that were moderately severe. She was tired and
felt irritated because she needed to make arrangements for the care of her
two children while she was hospitalized. Routine laboratory findings specific for nephrotic
syndrome showed that she had proteinuria, hypoalbuminemia, and hyperlipidemia.
1. What are Mrs. Winter’s highest priority nursing diagnoses and why?
2. What are the recommended nursing interventions for Mrs. Winter?
3. How will the underlying pathophysiological process in Mrs. Winter’s case be managed?
Case study: Nursing Care of Individuals with Polycystic Kidney Disease
Martin Miller, 40 years of age, was admitted to the hospital for evaluation of his increasingly
troublesome symptoms, which began several years before. He had a distended abdomen,
flank pain, and palpable kidneys that were tender when touched. He explained that he had
hematuria, loss of appetite, nausea, and had vomited the previous evening. Mr. Miller said
he was familiar with these symptoms because he remembered that his father had had an
illness that required a nephrectomy when his father was in his early fifties. His father had
been treated with analgesics and antibiotics until he died at 63 years of age.
1. Complete the following statements of nursing diagnoses, which were identified as high
priorities in his care:
a. Fluid volume excess related to
b. Anticipatory grieving related to
c. Pain related to
d. High risk for ineffective individual coping related to
2. What are the nursing interventions related to each?
3. How are the nursing diagnoses arranged in order of their priority?
Case Study: Chronic Renal Failure and Hemodialysis
Lisa Whitman, 44 years of age, was admitted to the hospital for a renal transplant. She
was diagnosed with chronic renal failure (CRF) after being diagnosed with type 1 diabetes
mellitus when she was seven years of age. Her diabetes was controlled on bid dosing of
insulin until a few months before when she began complaining of increasing lethargy. Her
systolic blood pressure was elevated to over 200 mm Hg. Her diminishing urine output
and fluctuations in her blood sugar level, which had previously been under control, were
worrisome signs of renal failure. During the previous winter she had begun complaining
of flu-like symptoms. She experienced anorexia, nausea, and vomiting. Her serum glucose
level rose over 800 mg/dL. Ms. Whitman was admitted to the hospital in diabetic
ketoacidosis (DKA) and severe fluid overload. Her current urine output was approximately
“2 cups” a day. Hemodialysis was begun: An arteriovenous (AV) shunt was created in her
left forearm and she was maintained on a schedule of dialysis three times a week. Ms.
Whitman’s condition was stabilized and she was discharged home on hemodialysis.
Case study: Nursing Care of Individuals with End-Stage Renal Disease and
Undergoing Continuous Ambulatory Peritoneal Dialysis
Pam Kelly, an active 52-year-old woman, requested continuous ambulatory peritoneal dialysis
(CAPD) as her treatment of choice for end-stage renal disease. She wanted to be able to
have her treatment at home and control the procedure herself.
Questions
1. What are the principles of physics that guide the action of CAPD?
2. Compare hemodialysis and peritoneal dialysis in each of the following categories:
HEMODIALYSIS
PERITONEAL DIALYSIS
Number of treatments a week
Number of hours for a
treatment
The semipermeable
membrane is
Access for fluid and solute
exchange
Care of the access
Complications
Case Study: Renal Calculi
Phyllis Wagner, 66 years of age, noticed a dull, aching, constant pain in the lumbar region of
her back. During the night, she noticed that the pain changed somewhat, radiating toward
her groin. She was nauseated and vomited moderate amounts of stomach contents twice. In
addition, she complained of diarrhea and intermittent abdominal pain. Mrs. Wagner felt the
urge to void, but was only able to pass small amounts of blood-tinged urine. Her temperature
was 101°F. Renal ultrasonography showed stones in the pelvis of her left kidney. A urine
specimen was sent to the laboratory for culture and sensitivities. Her physician ordered
meperidine hydrochloride (Demerol) 100 mg IM, q4–6h prn for relief of pain.
Case Study: Urinary Incontinence
Mrs. Worthington, 73 years of age, is 5 ft tall and weighs 150 lb. She raised three children
and is the grandmother of eight children. She lives on the ground floor of an apartment
house within walking distance of the grocery stores and restaurants in her town. Her children
live within several miles of her home. Recently Mrs. Worthington noticed that small amounts
of urine escaped each time she sneezed or coughed. This led to her needing to change clothing
during the day because of the dampness in her perineal area. She felt that the main reason
for her incontinence was that she could not reach the bathroom in time. After a complete
evaluation of the problem by her doctor, she was told that she was infection-free. She
was not taking any medications that would cause this problem. The nurse practitioner suggested
weight reduction and an exercise intended to strengthen her pubococcygeal muscle.
The nurse taught her to strengthen this muscle by stopping urine flow several times during
voiding. Mrs. Worthington found this a difficult exercise in the beginning, but with time and
persistence, she succeeded at it.
The exercise and weight reduction were successful in reducing her incontinence. However,
approximately three years later, the problem returned insidiously. Her physician suggested
surgery to correct the problem and she consented.
Class Activity: Nursing Care of Individuals with Renal Transplantation
Marge Young, 53 years of age, was maintained on hemodialysis for several years. She had discussed
the prospect of renal transplant with the nurse and physician. When given the option,
she agreed to transplant because she believed that a transplant would enable her to lead a normal life,
whereas the three times weekly schedule of hemodialysis was limiting. Her name
was placed on a list awaiting an appropriate kidney donor. Finally, she received a call from
her physician’s office informing her that she could be admitted for renal transplantation.
Questions
1. Plan Mrs. Young’s preoperative care, including explanations of the assumptions you made for
each of the
interventions you planned.
2. What do you think Mrs. Young will be most concerned about in the postoperative period? Why?
3. What are the goals of care for Mrs. Young in the postoperative period?
4. What is a main therapy after a kidney transplant?
5. How is kidney rejection identified?
6. How is renal function monitored?
7. What are the patient teaching considerations for the individual who is discharged home?
Class Activity: Nursing Care of Individuals with Urinary and Renal Dysfunction
Directions: The following are common nursing diagnoses of adults with urinary and renal
dysfunction.
Relate each to a potential patient situation and identify appropriate interventions. Provide the
rationale for using each intervention.
1. Fluid volume excess related to decreased renal blood flow.
2. Fluid volume excess related to lack of information about dietary restriction.
3. Altered renal perfusion related to obstruction of renal blood supply.
4. Potential sexual dysfunction related to treatment or surgery.
5. High risk for body image disturbance related to weight gain and edema.
6. Social isolation related to fear of incontinence.
7. Pain related to obstruction.
8. Altered patterns of urinary elimination related to incontinence.
9. Powerlessness related to perceived lack of control over the situation.
10. Sleep pattern disturbance related to interrupted sleep.
11. Potential for injury related to presence of catheter, shunt, and/or peritoneal access.