NURBN2016 Assignment 2: Analysis of Melanie Johnson's Renal Failure

This report presents a comprehensive analysis of a case study involving Melanie Johnson, a 55-year-old patient diagnosed with chronic renal failure. The report begins with an overview of kidney anatomy and physiology, followed by a detailed discussion of the pathophysiology of Melanie's condition, including her high blood pressure, anemia, and uremic symptoms. The report explores the risk factors contributing to her condition, such as age, and provides a clear differentiation between acute and chronic renal failure. It then delves into renal replacement therapy, specifically hemodialysis, and discusses the medications prescribed to Melanie, including Valsartan and Eprex, detailing their mechanisms of action, side effects, and nursing considerations. The report also analyzes Melanie's Glomerular Filtration Rate (GFR) and Hemoglobin (Hb) levels, providing insights into her kidney function and anemia. Finally, the report discusses the importance of the teach-back approach for patient education and provides recommendations for dietary management to prevent the progression of her condition, emphasizing the importance of fluid and electrolyte balance.

Running head: HEALTHCARE 1
Healthcare
Student’s Name
Institutional Affiliation

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Part 1
Question 1.1
Kidneys are retroperitoneal organs which are bean-shaped and the center of each kidney
there is an indentation which fits to the hilum of the kidney. They are enclosed by a thin layer of
a thick connective tissue called kidney fascia which clinches the kidney to its surrounding. Also,
a thin layer of fibrous connective tissue, the adipose capsule, is a fatty layer that safeguards the
kidney from injury and the adipose capsule contains a soft, dense, vascular renal cortex. Every
kidney has around one million nephrons and the nephron contains two major parts which are
kidney tubule along with kidney corpuscle (Chalmers, 2019).
Kidneys’ chief function is to excrete waste materials originating from protein metabolism
along with muscle contraction and the glomerulus filters them out of the blood, excreting them
out of the body in urine. The concentrated blood left in the glomerulus capillaries occupies the
efferent arterioles and the peritubular capillaries enclosing the proximal convoluted tubule
(Chalmers, 2019). From the proximal convoluted tubule, the tubular fluid infiltrates the Henle
loop where ion plus water are resorbed. The filtrate passes via the ascending Henle loop limb
while exiting the medulla and the tubular fluid exiting, passes via the distal convoluted tubule
and the collecting nephron duct.
Question 1.2
The renal blood flow rate of relatively 400 ml/100g of tissue per minute is much higher
compared to that observed in the brain, heart, and liver. Subsequently, renal tissue may be
susceptible to a consequential quantity of likely dangerous circulating agents. Even under
physiologic conditions, glomerular filtration is dependent on high intra-glomerular and trans-
glomerular pressure hence the glomerular capillaries become prone to hemodynamic damage (De

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Rosa, Prowle, Samoni, Villa & Ronco, 2019). On that note, glomerular hypertension along with
hyperfiltration is the chief contributor to the advancement of persistent kidney disorder.
Glomerular filtration membrane has negatively charged particles that act as an impediment
controlling anionic macromolecules. With the interference in the electrostatic barrier, plasma
protein gains access to the glomerular filtrate.
The regular arrangement of nephron’s microvasculature along with the tubuli
downstream position concerning glomeruli control the glomerulo-tubular balance and enhances
the glomerular damage spreading to a tubulointerstitial compartment in disorder, revealing
tubular epithelial cells to anomalous ultrafiltration (De Rosa et al., 2019). Furthermore, a decline
in glomerular or preglomerular perfusion results in a decline in peritubular blood flow which
contingent upon the hypoxia level consists of tubulointerstitial damage and tissue reconstruction.
Therefore, the hypothesis of the nephron as a functional unit implores to kidney physiology as
well as to pathophysiology of kidney disease.
Although Melanie was not diagnosed with hypertension, during her examination her
blood pressure was high at 190/110mm Hg. This could be a risk factor for the progression of
Melanie’s condition. Systemic high blood pressure is spread to intraglomerular capillary pressure
resulting in glomerulosclerosis along with loss of renal function, hence variable peril of kidney
function impairment is normally found among hypertensive people (Kazancioğlu, 2013).
Furthermore, age is a risk factor for Melanie as she is now 55 years old. Kidney function
declines with age both in males and females thus the elderly people are more prone to develop
chronic renal failure after several kidney insults.
Anemia is a complication of chronic renal disorder (Bello et al., 2017). It is described as
a decline in one or several of the main red blood cell measurements, that is, the concentration of

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hematocrit, red blood cell count, or hemoglobin. As per Melanie’s blood test results, her
hemoglobin was 95g/L which is lower than normal. Moreover, uremic symptoms which include
fatigue, nausea and pruritus are complications of chronic renal disorder (Bello et al., 2017). This
is evident in Melanie since she got concerned with her feeling of escalated tiredness, general
pruritus, and nausea and then decided to visit her GP.
Chronic kidney disease has no cure but treatment can aid in relieving the symptoms and
stopping its progression. Hemodialysis is a treatment option for Melanie whereby tubes connect
the patient to a machine that filters the blood. It is performed around thrice per week and the
more frequent the sessions the better the quality of life for the patient. Another treatment option
is kidney transplantation (Aimaretti & Arze, 2016). The donated kidney is surgically placed in
the lower abdominal region and replaces the operation of the natural kidneys.
Question 1.3
Acute renal failure (ARF) is an abrupt hike in serum creatinine while Chronic Renal
Failure (CRF) is the gradual loss of kidney performance (Chawla, Eggers, Star & Kimmel,
2014). With ARF, no symptoms at first but with CRF, there are early symptoms like
hypertension. CRF is as a result of long-term disorder while ARF is as a result of an event.
Furthermore, ARF is largely reversible while CRF is often irreversible. ARF develops rapidly
but CRF develops slowly. Lastly, patients with ARF are put on temporary dialysis while those
with CRF are put on permanent dialysis (Chawla et al., 2014).
Question 1.4
Renal replacement therapy replaces nonendocrine renal function in persons with kidney
damage. The objectives of renal replacement therapy (RRT) include correction of electrolyte
abnormalities, solute and water removal along with acid-base disturbances normalization. It is

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achieved through convection or diffusion which is respectively referred to as hemofiltration or
hemodialysis (Gemmell, Docking & Black, 2017). Solute clearance in hemodialysis is attained
by diffusion through the membrane.
The space outside the blood-containing fibers in the filter is loaded with dialysate which
is forced in a reverse-flow manner to the blood flow. The dialysate is overhauled to involve a
buffer and important electrolytes dissolved in ultrapure water concluded deficient of impurities
and toxins (Gemmell et al., 2017). Moreover, diffusion happens on down concentration gradients
enabling swift balance of solutes over the membrane.
Melanie is advised to undergo hemodialysis after creating an arteriovenous fistula (AV
fistula). An AV fistula is an artery to a vein link which is proposed because it gives a good blood
flow for dialysis, it’s long lasting, and is less probable to be affected (Viecelli & Lok, 2019).
This vascular access enables blood to flow through soft tubes to the dialysis machine where it is
cleaned as it passes through a dialyzer.
Part 2
Question 2.1
Valsartan is a nonpeptide, orally active and peculiar angiotensin II receptor blocker
acting upon the AT1 receptor subtype. It is suggested to treat high blood pressure in adult
patients. Administration of several doses of this drug results in an increase in plasma cyclic
guanosine monophosphate, angiotensin II along with renin concentration and activity (Cada,
Baker & Leonard, 2015). Valsartan functions by obstructing the vasoconstrictor and aldosterone-
generating effects of angiotensin II at receptor sites and the adrenal glands along with the
vascular smooth muscle. As seen in the case study, Melanie’s blood pressure is very high at 190/

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110 mmHg which needs to be lowered to minimize the peril of fatal along with nonfatal
cardiovascular events, mainly myocardial infarctions and strokes.
The major adverse reactions identified with valsartan are low blood pressure,
hyperkalemia, cough and dizziness (Cada et al., 2015). When nurses are administering the drug,
they should consider its allergy to the patient. If the patient is allergic to valsartan or has had a
severe allergic reaction to a blood pressure drug like an ACE inhibitor or ARB, the nurse should
not administer it within 36 hours before or after taking the ACE inhibitor drug. Moreover, nurses
should observe the blood pressure, kidney performance along with electrolyte levels before
giving the drug to the patient. Health professionals should consider not administering valsartan to
a patient who has kidney disease. Lastly, the administration time of valsartan should be put into
consideration because it results in dizziness (Versmissen, Danser & van den Meiracker, 2015).
On the contrary, Eprex is utilized in escalating the generation of red blood cells and
decline the need for red blood cell transfusion. The rationale for this medication is for the
treatment of symptomatic anemia affiliated with chronic renal failure (Sinha et al., 2019). It is
used for people with chronic renal failure since their kidneys are not able to generate sufficient
natural erythropoietin on their own. According to Melanie’s blood test results, her hemoglobin
concentration is indicating to be lower than normal which means that she has anemia which is
linked to her condition and the drug will be useful for her condition.
Side effects of eprex can be mild or severe, temporary or permanent. However, the major
adverse reactions of this medication include a general feeling of tiredness or weakness and flu-
like symptoms such as dizziness, muscle and joint pain along with headache (Sinha et al., 2019).
Other adverse reactions are the clotting of the vascular access site and hypertension or
hypotension.

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Before initiating eprex administration, nurses should consider the patient’s blood pressure
to make sure it is adequately regulated. If the blood pressure cannot be controlled, the medication
should be discontinued. Moreover, they should consider individualizing the doses to make sure
that hemoglobin is controlled at an appropriate level for patients. Nurses should consider not
administering eprex to patients who have an allergy to eprex or any of the ingredients. Finally,
they should consider iron supplementation and treat their deficiency before administering the
drug (Barni et al., 2016).
Question 2.2
Glomerular Filtration Rate (GFR) constitutes plasma flow from the glomerulus into
Bowman’s space across a defined duration and is the primary standard of renal performance. The
changes in GFR are utilized to define and diagnose much pathology. Melanie’s GFR is
10ml/min/1.73m2 and a GFR of less than 15ml/min shows a stage 5 kidney failure (Kaufman,
Basit & Knohl, 2019). This shows that it is incompatible with life without hemodialysis or
kidney transplantation and is also the end-stage renal disorder.
Hemoglobin (Hb) is a protein molecule in red blood cells that carries oxygen from the
lungs to the body tissues and retreats carbon dioxide from the tissues to the lungs. Melanie’s
result was 95g/L which is lower than the normal concentration of greater than 130g/L. The low
concentration is a result of anemia and results from the destruction of erythrocytes or decline of
their production (Otto et al., 2017).
Part 3
Question 3.1
The teach-back approach confirms that the professional educator has construed to the
patient what is vital and in such a way that the patient comprehends (Farris, 2015). The approach

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is not about testing the patient’s knowledge but instead how well the concept was explained and
it goes beyond utilizing questions like “have you understood?” and “is that clear?” The
understanding of the patient is affirmed when the patient explains the content back in their words
to the professional educator. This technique helps the health professional to identify
communication strategies and explanations that are most commonly understood by the patient
(Farris, 2015).
Question 3.2
Healthy eating protects the kidneys from further injuries and limiting some foods and
fluids ensures that certain minerals do not build up in the body. Also, it ensures that a person gets
the right balance of vitamins, proteins, and minerals. To control the quantities of fluids taken by
a patient with chronic renal failure, the patient should practice using small sips instead of big
gulps and use small cups or filling cups only half-full. Moreover, since using a lot of salt makes a
person thirsty making it hard for her to stick to the fluid allowance, the salt intake can be cut by
utilizing pepper to add flavor rather than salt (Van IJzendoorn, Buter, Kingma, Navis & Boerma,
2016).
To maintain a healthy diet, the person should limit phosphorus and calcium intake by
eating more veggies and fresh fruits, limiting dairy foods and selecting corn and rice cereals
(Kelly, Rossi, Johnson & Campbell, 2017). Furthermore, a reduction in potassium intake
declines the progression of chronic kidney failure. Foods with low potassium recommended for
these patients include cabbage, plums, apples, pineapples, along with cranberries and cranberry
juice.
After explaining to the patient what she needs to do to prevent the progression of her
condition, the patient is requested to explain it back to the professional educator using her own

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words. In reliance on the patient’s response, the nurse can ascertain how well and how much the
patient understands and remembers what is taught. In case the patient has difficulty in clarifying
or remembering the material, the nurse has to repeat, explain it and then reexamines the recall
and apprehension of the patient.

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References
Aimaretti, L. A., & Arze, S. (2016, March). Preemptive Renal Transplantation—The Best
Treatment Option for Terminal Chronic Renal Failure. In Transplantation
proceedings (Vol. 48, No. 2, pp. 609-611). Elsevier.
Barni, S., Glahn RP, Lee, Srai SK, Bomford, Shyla B, Bhaskar, Bai, J. C., Fried, M., & Catassi,
C. (2016). Understanding the anemia of chronic disease.
Bello, A. K., Alrukhaimi, M., Ashuntantang, G. E., Basnet, S., Rotter, R. C., Douthat, W. G., &
White, S. L. (2017). Complications of chronic kidney disease: current state, knowledge
gaps, and strategy for action. Kidney international supplements, 7(2), 122-129.
Cada, D. J., Baker, D. E., & Leonard, J. (2015). Sacubitril/valsartan. Hospital pharmacy, 50(11),
1025-1036.
Chalmers, C. (2019). Applied anatomy and physiology and the renal disease process. Renal
Nursing: Care and Management of People with Kidney Disease, 21-58.
Chawla, L. S., Eggers, P. W., Star, R. A., & Kimmel, P. L. (2014). Acute kidney injury and
chronic kidney disease as interconnected syndromes. New England Journal of
Medicine, 371(1), 58-66.
De Rosa, S., Prowle, J. R., Samoni, S., Villa, G., & Ronco, C. (2019). Acute Kidney Injury in
Patients with Chronic Kidney Disease. In Critical Care Nephrology (pp. 85-89). Content
Repository Only!
Farris, C. (2015). The teach-back method. Home healthcare now, 33(6), 344-345.

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Gemmell, L., Docking, R., & Black, E. (2017). Renal replacement therapy in critical care. BJA
Education, 17(3), 88-93.
Kaufman, D. P., Basit, H., & Knohl, S. J. (2019). Physiology, Glomerular Filtration Rate (GFR).
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Kazancioğlu, R. (2013). Risk factors for chronic kidney disease: an update. Kidney international
supplements, 3(4), 368-371.
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phosphate, and potassium: potential dietary interventions in kidney disease. In Seminars
in dialysis (Vol. 30, No. 3, pp. 197-202).
Otto, J. M., Plumb, J. O., Clissold, E., Kumar, S. B., Wakeham, D. J., Schmidt, W., ... &
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Sinha, S. D., Bandi, V. K., Bheemareddy, B. R., Thakur, P., Chary, S., Mehta, K., ... &
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handling. Critical care research and practice, 2016.

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Versmissen, J., Danser, A. J., & van den Meiracker, A. H. (2015). Comment on ‘Time of
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