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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. A primary nursing diagnosis will be formulated with related SMART goals and interventions. Finally, a teaching care plan using seven different teaching strategies will be provided. Keywords: atherosclerosis of renal arteries, nursing process paper, nursing care plan

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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, diagnostic testing results, psychosocial information, past and family medical history, medications and allergies; is collected about the patient and analyzed. Once the data is analyzed, the nurse will form nursing diagnoses. These are problems, as defined by NANDA, facing the patient related to his or her health status, which the nurse can address within the scope of their practice. The nurse can then use the AHA critical thinking pathways to prioritize these nursing diagnoses and plan the patient care. This plan contains the patient goals that improve quality of life for the patient. Planning also includes the necessary interventions that are needed 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 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.

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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 for diabetes, Plavix 75mg daily for clot prevention, Norvasc 10mg daily for hypertension, Apresoline 50mg every six hours by hypertension, Catapres 0.2mg every eight hours for hypertension and has an IV of normal saline running at 50 mL/hr for hydration. 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 (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.

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Atherosclerosis is a chronic and progressive disease with a long asymptomatic period and high prevalence. 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) Many risk factors can contribute to developing atherosclerosis. Age alone is a contributing risk factor with men over 45 and women over 55 being susceptible. Family history of heart disease also increases risk. Lifestyle choices such as smoking, alcohol use, poor diet and lack of physical activity increase the risk. Physical conditions such as stress, obesity, insulin resistance and poor cholesterol levels are also contributing risk factors. Patients with disease processes such as diabetes, peripheral vascular disease, and hypertension are also at risk. Finally, an emerging factor currently being researched is high levels of C-reactive protein in the blood. My patient had many risk factors for atherosclerosis of renal arteries. The biggest factor is that she already has a prior medical diagnosis of atherosclerosis of the native arteries. The patient is a geriatric with hypertension and type 2 diabetes. Mrs. SA admits to a sedentary lifestyle and poor diet which contributes to her risk. She has a family history with contributing factors as well. 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 signs and symptoms may include: 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

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Sudden worsening of controlled blood pressure in patients over 60 years old (Swierzewski, III, M.D., 2011)

Headache, nausea, fatigue and swelling of the abdomen and legs which are signs of a condition known as uremia ("Renal artery stenosis," 2007)

While doing the patient assessment, the clinician should look for these possible signs and symptoms as well: 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 workup should include glomerular filtration rate and a comprehensive metabolic panel. The glomerular filtration rate is an indicator of how much kidney function exists by cross-referencing creatinine levels with patient demographic information. The comprehensive metabolic panel will provide these creatinine levels and also show electrolyte balance issues (if present) that stem from kidney failure. Imaging test used to detect renal issues include ultrasound and a CT scan. ("Glomerular filtration rate," 2007) When Mrs. SA came to the hospital, she had recently developed uncontrollable hypertension and mild pulmonary edema. A renal sonogram showed increased renal cortical 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.

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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

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

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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. 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. I would recommend her for further diagnostics 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).

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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 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

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decreased slightly at 3.2, which is common in geriatric patients. All other lab values were within normal limits. A renal sonogram showed increased renal cortical echogenicity with bilateral renal cysts, which is indicative of renal insufficiency. It is my conclusion that all blood work and imaging tests are supportive of early stage renal insufficiency in a geriatric patient. (Leeuwen, Poelhuis-Leth & Vroomen-Durning, 2010) VINursing Care Plan 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. The rationale for this priority nursing diagnosis follows the AHA critical care pathways ABC assessment, in that tissue perfusion is a circulatory issue. Furthermore, renal tissue perfusion can also affect breathing if conditions worsen and the body cannot maintain fluid and electrolyte balances. Capillaries are an integral part of the kidneys filtration system. As renal perfusion falls, the kidneys are less able to remove waste from the blood and maintain fluid and electrolyte balance. Waste buildup in the blood, known as uremia, further complicates the function of every other organ and system in the body. This can lead to a very large number of additional complications and ultimately be fatal. (LeMone & Burke, 2008) The first goal is to improve urinary output to an average of 30 mL per hour within the next 24 hours. This will be accomplished by enforcing her renal diet and monitoring and recording her fluid intake and output. Physician ordered diuretics will be administered accordingly. Mrs. SA will also be encouraged to ambulate and void regularly. The second goal is to for all electrolyte lab values to be within normal limits, within the next 48 hours. Blood for a metabolic panel will be drawn daily per physician orders. Abnormalities will be reported to the physician. Medications and supplements to improve electrolyte levels will be administered according to physicians orders. The third goal is the patient will show a weight loss of one pound of fluid per day within 72 hours. Patient weight will be measured at the same time daily. Fluid intake and output ratio will be calculated every four hours and converted into weight loss or gain.

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Most of the patient goals and interventions are reliant on physicians orders. Unfortunately, with ineffective renal tissue perfusion this is going to be the case. Other interventions that may help improve cardiac output, which in turn improves tissue perfusion, would be; ambulation, encouraging use of incentive spirometer, coughing and deep breathing, wearing sequentials and TED stockings, and range of motion exercises. 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. I will use YouTube videos, handouts, demonstration, a physician consult for education, a diabetes educator, a medication profile from Lexi-Comp, and a home health care agency to assist in teaching Mrs. SA. 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 Mrs. SA has expressed concerns as to why her procedure has been delayed. I will ask the physician to inform the patient and her family of her diagnoses, how they are affecting her body and why her procedure has been delayed. I intend to witness this exchange, so I am aware of what the physician tells Mrs. SA and her family, in case I need to reiterate any of the information. I will explain that her restricted diet and strict input and output measurements are important in stabilizing her condition. Then I will demonstrate how to properly measure her intake and output values using the graduated water pitcher, labels on prepackaged drinks, the hat in the toilet, and the graduated cylinder in the

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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. Uncontrolled diabetes may be adversely affecting her current condition. To assist Mrs. SA and her family in understanding the importance of controlling diabetes with other methods besides insulin, I will set up a consult with a diabetes educator. 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 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. Finally, Mrs. SA should make it a goal to improve her overall wellness. I will consult with the care coordinator to get a home health agency out to see Mrs. SA and her family within 48 hours after discharge. The home health nurse can assist in the transition home with medications, reinforcing teaching from the hospital and developing a plan for wellness. The home health nurse will have diabetes, dietary, and physical therapy resources available to her that she can put into a single plan with the family in pursuit of wellness improvement. The teaching 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

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health was being discussed. Hopefully, using a home health care agency to reinforce what was learned in the hospital can help Mrs. SA and her family achieve better wellness.

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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 National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. (2007). Renal artery stenosis (07-6020). Retrieved from http://kidney.niddk.nih.gov/kudiseases/pubs/RenalArteryStenosis/ National Kidney Foundation. (2007). Glomerular filtration rate (gfr). Retrieved from http://www.kidney.org/kidneydisease/ckd/knowgfr.cfm 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 LeMone, R., & Burke, K. M. (2008). Medical-surgical nursing, critical thinking in client care. (Fourth ed., pp. 899-923). Upper Saddle River, NJ: Prentice Hall. 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.