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Nursing Process Paper: Atherosclerosis of renal arteries

Tobias Cerillo Delaware Technical Community College

Author Note Submitted to the Faculty of Delaware Technical Community College Nursing Program In Partial Fulfillment of the Requirements for Nursing 122: Human Needs in Health & Illness II

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Abstract The aim of this nursing process paper is to document how the nursing process was applied to a patient with the medical diagnosis of atherosclerosis of renal arteries and the subsequent perioperative course of treatment during my clinical rotation. An overview of the nursing process and the pathophysiology of atherosclerosis of renal arteries will be briefly discussed. A complete medical and nursing assessment will be discussed. The assessment will then be distilled into prioritization of nursing care by using the nursing process format of nursing diagnosis, plan of care (with interventions), actual implementation of care, and the patients responses. Finally, a summarization of the patient care during this brief encounter in clinicals will be provided. Keywords: atherosclerosis of renal arteries, nursing process paper, nursing care plan Tobi, since your NP paper was late, returning it to you in a timely manner was not possible for me. You need to redo it ASAP. This time, lets not brag about how you whipped the paper off without much effort because it shows. I am more concerned about this NP paper being a learning experience and not a statistic.

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Nursing Process Paper: Atherosclerosis of native arteries IOverview of Nursing Process The nursing process is based on a theory developed by Ida Jean Orlando in the late 1950s (Quan, 20079). As she watched nurses in action, she saw both good and bad nursing. From these observations she established three things: The patient must be the central character Nursing care needs to be directed at improving outcomes for the patient; not about nursing goals The nursing process is an essential part of the nursing care plan (Quan, 2007-9) There are five simple steps to the nursing process: assessment, diagnosis, planning, implementation and evaluation. Assessment is when data, such as physical exam, lab results, psychosocial information, past and family medical history, medications and allergies; is collected about the patient and analyzed. Assessment includes subjective and objective information not just PE and labs What about other tests? What about FHx, Social Hx, medications, allergies, etc. I think you missed the definition of Assessment. Once the data is analyzed, the nurse will form nursing diagnoses. These are problems facing the patient related to his or her health status. This is unclear.the NDx are listed in the NANDAs. Please look up the definition of NDx The nurse can then use these nursing diagnoses to prioritize and plan the patient care. No, acutally the AHA critical thinking pathways helps you prioritize into the NDx. This plan contains the patient goals that improve quality of life for the patient. Planning also includes what is needed to carry out the necessary intervention to achieve these goals. With a plan in place, the nurse implements according to the plan. This implementation includes communicating the care plan with the rest of the health care team so that they may assist and report findings related to the plan. Finally, the whole process needs to be evaluated for successes

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and failures so that adjustments may be made and quality of life can continue to improve. This in turn will lead us back to assessment where the nursing process is repeated until the patient is discharged. IIResearch Data Identifiers Mrs. SA was a 76 year old caucasian female who came to the hospital with a prior medical diagnosis of atherosclerosis of renal arteries. She was scheduled for an angiogram of renal arteries with possible angioplasty and stenting. Upon admission, she was further diagnosed with renal failure and uncontrolled hypertension, which delayed her scheduled procedure. I took care of the patient on hospital day #2-3 and post-op day #0-1. Past Medical/Surgical/Psychosocial History Mrs. SAs past medical history (PMHx) included the following: arthritis of the knees, gout, IDDM type 2, cataract in the left eye, hypertension, atherosclerosis of native arteries in the left leg with angioplasty and stenting. Her family medical history includes the following: mother was a diabetic amputee with hypertension, sister has arthritis; and father had arthritis, hypertension and a cerebral vascular accident. Mrs. SA is a retired factory worker that is married, has children, has a high school education, is Pentecostal, and is covered by Medicare and Humana insurances. She has no known drug allergies. Mrs. SA is currently on Lispro ACHS, Plavix 75mg daily, Norvasc 10mg daily, Apresoline 50mg every six hours, Catapres 0.2mg every eight hours and has an IV of normal saline running at 50 mL/hr . In summation, nursing care of this patient will require glucose monitoring, safety measures due to visual impairment, monitoring of blood pressures, and risk prevention for DVTs. Medical Diagnosis Her medical diagnosis was atherosclerosis of renal arteries. This is a buildup of fatty deposits, called plaques, on the interior walls of arteries. These plaques restrict blood flow and can eventually occlude the artery in the form of a clot. The clot starves the tissue of needed oxygen and nutrients causing necrosis

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(tissue death). A clot that breaks off can cause renal insufficiency, an aneurysm, pulmonary embolism or stroke. These complications all have a high instance of disability or death. Atherosclerosis is a chronic and progressive disease with a long asymptomatic period. The clinical manifestations of atherosclerosis in all forms will occur in 2 out of 3 men and 1 out of 2 women over the age of 40. Subclinical atherosclerosis is a precursor to cardiovascular disease, myocardial infarction and stroke; which are responsible for almost 60% of deaths. (Robinson, Fox, Bullano & Grandy, 2009) Unfortunately, the primary risk factor for developing atherosclerosis is aging I dont think so. It due to inflammation and plaque formation See http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis/ Women are slightly less susceptible than men are due to protections provided by hormones. However, after menopause, a womans risk increases greatly. (Robinson, Fox, Bullano & Grandy, 2009) The biggest secondary factor is smoking. False: see http://www.nhlbi.nih.gov/health/healthtopics/topics/atherosclerosis/atrisk.html Other compounding factors include obesity, diabetes, hypertension and hyperlipidemia. : Tobi, See http://www.ncbi.nlm.nih.gov/pubmed/19365285 for risk actors My patient already had risk factors for atherosclerosis of renal arteries. The biggest factor is that she already has atherosclerosis of the native arteries. Hypertension and type 2 diabetes mellitus are also contributing factors to her latest bout with atherosclerosis. Her family history was also against her. Her mother was hypertensive with diabetes and her father had hypertension resulting in a stroke. IIITextbook PE vs Patients PE Signs and Symptoms Atherosclerosis of the renal artery has very specific signs and symptoms. These include you read the website incorrectlythese are conditions that indicate the presence of renal stenosis but are not s/s of the condition. Also, your choice of websites to cite information is dismal. Peer-reviewed websites are NIH or PUBMED or MAYOCLINIC or MEDLINE Look at http://kidney.niddk.nih.gov/kudiseases/pubs/RenalArteryStenosis/ Asymmetrical kidneys viewed on an ultrasound ? Calf pain when walking indicating poor circulation to the legs ?

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Intolerance of ACE-I Inhibitors or Angiotensin Receptor Blockers with a sudden worsening of renal function

Hypertension that requires more than three different medications to control Presence of a bruit in abdomen, neck, groin or other area New onset of high blood pressure in patients over 55 years old Sudden worsening of controlled blood pressure in patients over 60 years old (Swierzewski, III, M.D., 2011)

The patient assessment should look for poor English as the assessment is does not have eyes and is not a clinician electrolyte disturbances, excess fluid volume, metabolic acidosis, uremia, GI upset, urinary tract infection, septicemia, pulmonary infections, peritonitis, crackles (rales), and hypertension. Also, the patient history check should specifically ask if patient has a history of hypertension, any vascular disease, diabetes, or renal problems. (Swearingen, 2008) Lab Values indicate an injured kidney like nephritis or nephrosis or HTN . Tests of Renal stenosis include ultrasound, CT scans, bruit on auscultation, When Mrs. SA came to the hospital, she had recently developed uncontrollable hypertension and mild pulmonary edema. A renal sonogram showed increased renal corticol echogenicity with bilateral renal cysts. She was not showing hydronephrosis however. Her past medical history revealed that she previously was diagnosed with atherosclerosis of the native arteries and diabetes. During my assessment, a murmur like sound was auscultated with heart sounds. Mrs. SA had mild non-pitting edema in her ankles with the left being slightly greater than the right. My patient does display many of the textbook signs and symptoms associated with her medical diagnosis. IVPhysical Assessment General Assessment Upon entry of the patients room, I observed the appearance of the patient and room for safety issues, and their initial cardiopulmonary status. For the general assessment, patient was lying awake in bed with

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shallow unlabored breathing on room air, no acute distress and no visible bleeding. Side rails were up, bed wheels locked and environment was safe and clean. There was O2 set up at the head of bed (not in use) and an IV hanging on a pole IV site was patent without s/s of infiltration. This initial
observation is done in mere seconds and should be done every time a member of the health team enters the patients room. Primary Assessment The next step is the primary assessment in which she had a patent airway, slightly shallow respirations, normal color, no visible disabilities, and she was sitting upright eating with the TV on and then proceeded to the restroom without assistance. This part of the assessment should take two to three minutes maximum. Secondary Assessment With the patients safety ensured and urgent needs met, the assessment focus gets deeper into finding out the patient specifics. During the secondary assessment, I did a complete head to toe assessment on Mrs. SA and addressed psychosocial at the same time. Psychosocial information is noted in the research data section above. Mrs. SA had a temperature of 36.4C, pulse of 81, respirations were 16 shallow but unlabored and her pulse ox was 96% on room air. Her blood pressure was 152/76 mmHg. She stated her pain was a 0 on a 0 to 10 scale. Bedside glucose check was 167. Her heart sounds were difficult to interpret as it sounded like a murmur in place of S1, with a normal S2. The rhythm was irregular. Capillary refill in both hands and feet were < 2 seconds. Pedal and radial pulses could be palpated and were within normal limits. Upon auscultation, all five lobes of her lungs were clear though her breathing was shallow. Mucous membranes were pink and moist. Bowel sounds were active in all four quadrants and abdomen was soft, non-tender and obese. Urine was clear with normal odor. She had active full range of motion with head and all extremities. Mrs. SA had a GCS of 15; her eyes were PERRLA both with 3 to 2 mm constriction with light accommodation. Her skin was dry and smooth. Small blisters were noted her left ankle along with a small abrasion on her left shin which had a band aid on it. Mild non-pitting edema was noted on the left ankle.

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Not many problems manifest themselves during Mrs. SAs physical assessment. Her bedside glucose of 167 is expected with her type 2 diabetes mellitus. The blood pressure of 152/76 mmHg is expected with the uncontrolled hypertension. The mild edema could be due to her renal insufficiency or her previously diagnosed atherosclerosis of native arteries. The shallow respirations could be an early sign of electrolyte imbalance due to renal insufficiency. The most notable finding was the murmur like sound heard with the heart sounds. It is possible that she has a cardiac valve issue. Further diagnostics are necessary to confirm the source of the sound. Geriatric Assessment As we age our bodies go through some interesting changes. When an individual starts aging their hair becomes thinner and typically loses its pigment. Our skin begins to thin, lose its elasticity, and starts to sag due to a decrease in collagen and elastin. Our organs begin to decrease in function. The gastrointestinal system starts to lose the ability to break down and absorb nutrients from food. We begin to lose are peripheral vision and we have a decrease in the ability to judge depth. As we age we also lose the ability to clarify colors. We begin to lose our hearing, and it becomes harder to distinguish sounds when in large crowds. Our taste buds lose sensitivity and saliva production decreases. With aging our arteries begin to stiffen and fatty deposits build up in the blood vessels, this is atherosclerosis. It becomes difficult to control our bowel movements. Most aging patients find that they are on several more medications then they have been in previous years. Our body has a difficult time with absorbing and metabolizing the medications we consume. As you can tell with age everything begins to slow down in our bodies and makes it harder to live the normal, carefree life we had when we were younger (Area agency of aging, 2011). My patient definitely displayed the normal findings in a geriatric patient. Her hair was thin and graying. Her skin has thinned and lost elasticity. Her abdomen was obese and breasts sagged. She is diabetic, has an abnormal heart sound and is having kidney issues, signs of organs not functioning normal. Her GI tract was functioning, though she did have some problems with defecation. She required glasses for nearsightedness but did not appear hard of hearing. Her mucous membranes appeared pink and moist, though her teeth

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showed some decay. She has a history of atherosclerosis, another clear sign of the bodies aging process. Mrs. SA is polypharmacy as are most geriatric patients. Her body is clearly slowing down and displaying signs of a geriatric patient. Tertiary Assessment Mrs. SAs blood test showed some abnormal results. Renal insufficiency or failure is notable with a BUN of 35 and creatinine of 2.75. Her serum CO was slightly low at 21, her chloride was at the high end of normal at 110 and all other electrolytes were within normal limits. While not hypercholeremic, her blood levels have moved in that direction which is sometimes notable with renal disease processes. She had decreased RBC at 3.73, hemoglobin at 10.9 and hematocrit at 31.7. These decreased levels associated with red blood cells are all expected with chronic kidney disease processes. Mrs. SAs serum albumin was decreased slightly at 3.2, which is common in geriatric patients. All other lab values were within normal limits. It is my conclusion that all blood work is supportive of early stage renal insufficiency in a geriatric patient. (Leeuwen, Poelhuis-Leth & Vroomen-Durning, 2010) VLaboratory & Evaluative Tests Mrs. SAs blood test showed some abnormal results. Renal insufficiency or failure is notable with a BUN of 35 and creatinine of 2.75. Her serum CO was slightly low at 21, her chloride was at the high end of normal at 110 and all other electrolytes were within normal limits. While not hypercholeremic, her blood levels have moved in that direction which is sometimes notable with renal disease processes. She had decreased RBC at 3.73, hemoglobin at 10.9 and hematocrit at 31.7. These decreased levels associated with red blood cells are all expected with chronic kidney disease processes. Mrs. SAs serum albumin was decreased slightly at 3.2, which is common in geriatric patients. All other lab values were within normal limits. It is my conclusion that all blood work is supportive of early stage renal insufficiency in a geriatric patient. (Leeuwen, Poelhuis-Leth & Vroomen-Durning, 2010) VINursing Care Plan

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The priority nursing diagnosis for my patient is: Ineffective tissue perfusion renal related to interrupted blood flow secondary to occluded arterial lumen as manifested by ultrasound displaying reduced renal blood flow. Rationale? The first goal is to ensure sufficient renal output throughout the hospital stay. The patient should be on a strict I&O measurement with abnormalities reported to the physician immediately. Time frame? The second goal is to monitor for fluid overload and prevent it indefinitely. This is checked every shift with urinary output, monitoring lung sounds for crackles, watch for shortness of breath and distended neck veins. Time frame? The third goal is to monitor for renal failure and ensure it never happens. Daily analysis of I&O measurements, daily blood work for BUN and creatinine and adequate cardiopulmonary assessment every shift will provide the information needed to foresee impending renal failure. Time frame? I did monitor the patients I&O throughout the shift, I monitored her breathing including auscultation several times and did my complete assessment including interpreting lab values each shift with her. Ineffective protection related to neurosensory, musculoskeletal, and cardiac changes secondary to uremia as manifested by blood urea nitrogen and creatinine levels. The first goal is to maintain adequate nutritional intake without exacerbating the patients condition. The patient should immediately be placed on a low protein, high carbohydrate diet to ensure adequate caloric intake while not producing metabolic acidosis. The second goal is to ensure patient safety. The patient will be assessed for fall risk and appropriate measures will be taken to prevent a fall. This assessment should be repeated at least every 24 hours or more as needed. The third goal is to reduce the patient anxiety. This is accomplished by continuously educating the patient as to what is happening to their body and how the medical treatments will help correct it. I did confirm my patient was on a renal diet, checked her safety often and assisted with ambulation as needed, and educated her on many aspects of her care during my interactions with her. Risk for infection related to risk factors associated with uremia as manifested by blood lab values and ultrasound confirming renal insufficiency. The first goal is to monitor for signs and symptoms of infection. This is done by taking temperatures and monitoring bodily secretions for trademark signs of

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infection every four hours. The second goal is to prevent naturally occurring infection. Frequent skin care and good oral hygiene with every shift and as needed will aide in infection prevention. The third goal is to prevent nosocomial infection. This can be done by using sterile technique whenever doing an invasive procedure or accessing an invasive line. The fourth goal is prevention of a urinary tract infection. Avoiding indwelling catheters is the best prevention of this, but if they are necessary, frequent cleaning and assessment will be needed. I took my patients temperature with vital signs every four hours, checked her urine for cloudiness when emptying the hat, and did not access any invasive lines on the patient. During the two days that I saw Mrs. SA, several of these interventions were implemented or already in place. Dietary did have her on a very specific renal diet. She was assessed regularly by myself and the RN for fall risk and proper preventions were in place. She was to have vital signs done every four hours, assessment done every shift, blood work done daily and I&O measurements done constantly. Mrs. SA handled her own ADLs in which she cared for her skin and teeth. She did not have an indwelling catheter. VIITeaching Care Plan Mrs. SA is a combination learner utilizing auditory, visual and tactile methods. She seems to do best with auditory information and reciting back or demonstrating based on instructions. Her first need is to understand what condition her body is in and what will be done to help it heal. This is a YouTube video that will help her understand the basics of atherosclerosis. http://www.youtube.com/watch?v=qRK7-DCDKEA This is a YouTube video that will demonstrate the angioplasty and stenting that she is scheduled for. http://www.youtube.com/watch?v=veP5R-pzJVk After watching the videos, I will have Mrs. SA summarize for me her condition and treatment regimen as she understands it. For her post-op care, I will give her and her family this sheet so they know what to expect. http://www.utmb.edu/erc/facts/Angioplasty.pdf At this point, I will explain to Mrs. SA that her procedure has been delayed that is out of your scope of practice; A physician needs to discuss her MDx due to renal insufficiency and uncontrolled hypertension

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that stems from her atherosclerosis. I will assure her that once stability is reached, her procedure will proceed as planned. How do you know that since you are not licensed to make medical dx If she has difficulty understanding it as spoken, I will provide her with an entry level Med/Surg textbook for her to read about it. Having the reference material may make all this easier to understand. Well, depends on her education level and comprehension level. This could create much and unnecessary misunderstanding I will explain that her restricted diet and strict I&O measurements are important in stabilizing her condition. I will offer to let her do internet research on fluid overload and metabolic acidosis so that she can understand why we cant proceed with those conditions looming ahead ?Why are you stating this? . Once she has completed her research unreasonable statement I will ask her to summarize her understanding of her current treatments. Then I will demonstrate how to properly measure her intake and output values using the graduated water picture, labels on prepackaged drinks, the hat in the toilet and the graduated cylinder in the restroom. I will then ask her to demonstrate back how this is done so that she may assist with monitoring these values for her benefit. Mrs. SA noted that she does not attempt to control her diabetes via diet. This factor does not help her current condition. To assist her family in understanding the importance of controlling diabetes with other methods besides insulin, I will direct them to http://www.diabetes.org/ so they can learn dietary tricks and lifestyle adjustments that may help Mrs. SA improve her health overall. So the family understands how diabetes has played a role in her current condition, I will show them this video. http://www.youtube.com/watch?v=fwlLddvcBsc If they are a family that prefers natural remedies to assist in improving wellness, this YouTube video will be shown. It lists foods that natural help a diabetic patient. http://www.youtube.com/watch?v=_glTapm8kCk Mrs. SA will need to understand the medications she is put on for discharge. She will need to know their dosage schedule, side effects, when to discontinue, what not to take them with, and their overall action on her body. She will be provided with medication profiles printed from Lexi-Comp which she can review in the

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hospital and ask questions as needed. These reference materials will be for her to take home as well so she has something to look back on, should she forget. It should be noted that at this time I am unable to determine which medications she will be prescribed upon discharge as my last interaction with her was about one hour post-op. The assessment shows that she has a husband and children that will assist in her transition home. One of her main concerns upon discharge will be infection prevention. The family as well as Mrs. SA will be instructed on the basic signs and symptoms of infection and when to call the doctor. A hospital standard reference sheet on infection should be included in the discharge packet. They will also be shown repeatedly how to care for Mrs. SAs surgical wounds and what to expect from them. If time prior to discharge permits, Mrs. SA and her family should be afforded the opportunity to demonstrate back to the nurse proper wound care. Finally, Mrs. SA should make it a goal to improve her overall wellness. She will be encouraged by the staff to follow up with her family physician for another complete assessment and goal setting session where the doctor can properly advise her on lifestyle changes that should improve her health and wellness. The care plan for Mrs. SA provides numerous materials that are very straight forward and easy to understand for the average layperson. If she truly wants to better her health, she will take the information presented to her and her family and put it to use in the best of their capacity. She seems motivated to get better and was attentive for all teachings, but admits to being noncompliant with her diabetes control which sets the tone that once she is home the old ways will prevail. Nonetheless, she was able to demonstrate back and summarize when I taught her about the importance of I&O measurements and dietary control. Her family however, seemed very disconnected from the medical staff when anything concerning Mrs. SAs health was being discussed. Tobi, your Teaching Plan is unrealistic for a sick patient of her age

Summation of Hospitalization In the abstract, you promised summation of her hospitalization but you failed to follow through.

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Reference Quan, K. (2007-9). The nursing process. Retrieved from http://www.thenursingsite.com/Articles/the%20nursing%20process.htm Swierzewski, III, M.D., S. J. (2011, May 25). Renal artery stenosis (ras) & renal vascular hypertension (rvh). Retrieved from http://www.healthcommunities.com/renal-artery-stenosis/overview-renal-vascularhypertension.shtml I googled the author and found the site at http://www.healthcommunities.com/renal-artery-stenosis/overviewrenal-vascular-hypertension.shtml

Robinson, J. G., Fox, K. M., Bullano, M. F., & Grandy, S. (2009). Atherosclerosis profile and incidence of cardiovascular events: a population-based survey. BioMed Central, DOI: 10.1186/1471-2261-9-46 Swearingen, A. L. (2008). All-in-one care planning resource, medical-surgical, pediatric, maternity, & psychiatric nursing care plans. (2nd ed.). St. Louis: Mosby. Leeuwen, N. M. V., Poelhuis-Leth, D. J., & Vroomen-Durning, M. (2010). Davis's comprehensive handbook of laboratory and diagnostic tests, with nursing implications. (3rd ed.). Philadelphia: F A Davis Co.

Source

de Mast & Q, Beutler JJ. (2009) The prevalence of atherosclerotic renal artery stenosis in risk groups: a systematic literature review. J Hypertens. 2009 Jul;27(7):1333-40.

Abstract
OBJECTIVE:
We performed a literature review and analysis to improve the insight in the prevalence of renal artery stenosis (RAS) in risk groups.

METHODS:
Relevant studies were identified by a MEDLINE and EMBASE database search (1966 to December 2007), complemented by hand searching of reference lists. Review was restricted to English language studies, using any form of angiography as diagnostic method. Studies were grouped in risk group categories sharing similar clinical characteristics, and pooled prevalence rates were calculated for each category.

RESULTS:
Forty studies, involving a total number of 15 879 patients, were identified. The following pooled prevalence rates (95% confidence interval; sample size risk group) of RAS were found: suspected renovascular hypertension, 14.1% (12.7-15.8%; n = 1931); hypertension and diabetes mellitus, 20% (14.9-25.1%; n = 240); coronary angiography (CAG) in

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consecutive patients, 10.5% (9.8-11.2%; n = 8011); CAG in hypertensive patients, 17.8% (15.4-20.6%; n = 836); CAG and suspected renovascular disease, 16.6% (14.8-18.5%; n = 1576); congestive heart failure, 54.1% (45.7-62.3%; n = 135); peripheral vascular disease, 25.3% (23.6-27.0%; n = 2632); abdominal aortic aneurysm, 33.1% (27.4-39.2%; n = 239) and end-stage renal failure, 40.8% (27-55.8%; n = 49.) In patients with an incidentally discovered RAS, hypertension and renal failure were present in 65.5 and 27.5%, respectively.

CONCLUSION:
RAS has a high prevalence in risk groups, especially in those with extrarenal atherosclerosis, end-stage renal failure and heart failure. These findings are important when screening for RAS or prescription of an angiotensin converting enzyme inhibitor or angiotensin-II receptor blocker is considered.