Case Study: Renal Nursing Care and Management for Mrs. A's Condition

This case study focuses on Mrs. A, a 53-year-old patient with a 17-year history of type 2 diabetes, hypertension, hyperlipidemia, and a 35-year history of smoking, who presents with shortness of breath, pruritus, and pitting edema. Diagnosed with stage 3 chronic kidney disease (CKD), the assignment explores the relevant nursing care and management strategies to maximize Mrs. A's health and delay the progression to end-stage renal disease (ESRD). It details the patient's conditions, risk factors, and complications of diabetes, hypertension, and hyperlipidemia, along with nursing interventions such as lifestyle changes, medication management, and symptom relief. The study also addresses the management of specific symptoms like dyspnea, pruritus, and pitting edema, emphasizing the importance of a holistic approach to patient care, including dietary adjustments, exercise, and regular monitoring of blood sugar and blood pressure levels. The case study aims to provide a comprehensive understanding of nursing care for patients with complex medical histories and renal conditions.

NURSING
(Case study)

Table of Contents
INTRODUCTION ..........................................................................................................................1
PATIENT SCENARIO ...................................................................................................................1
NURSING CARE............................................................................................................................1
Type 2 Diabetes-.........................................................................................................................1
Hypertension- .............................................................................................................................2
Hyperlipidaemia- ........................................................................................................................3
Shortness of breathe- .................................................................................................................4
Pruritus........................................................................................................................................4
Pitting edema of bilateral extremities ........................................................................................5
MANAGEMENTS OF DESEASES...............................................................................................6
Type 2 diabetes ..........................................................................................................................6
Management................................................................................................................................7
Hypertension...............................................................................................................................8
Hyperlipidaemia..........................................................................................................................9
Managements...................................................................................................................................9
Dyspnea (shortness of breath).....................................................................................................9
Pruritus......................................................................................................................................10
Pitting Edema............................................................................................................................10
CONCLUSION..............................................................................................................................11
REFERENCES..............................................................................................................................12

INTRODUCTION
Nursing is process of care, with collaborative behaviour with respect of all age. Nursing
encompasses a saturated behaviour with all ages of people, families, and a group of
communities sick or well, and in all settings. Nursing include a good promotion of health, in the
prevention of illness and with a warm of mother caring is called nursing.
As per the above case study, Mrs A who really in a case of pure illness the mentioned
detailed harsh the index of health. Mrs A fight with diabetes and at a same time hypertension,
hyperlipidaemia and other disease and condition are observed. Which create a critical condition
for the Mrs A in the living situation (Holmgren and Kraft, 2018). There are some way which
retaliate the condition and situation from worst to normal by some nursing care and management
which mention below.
PATIENT SCENARIO
As we observed from the above case study of Mrs A the stage of diabetes is their for 17
years which a long time. At the same time there is hypertension and hyperlipidaemia which
make critical situation. Mrs A need a good care and bed rest to being normal from the critical
situation. With a short analysis type 2 diabetes with hypertension. Where type 2 diabetes occurs
when body becomes resistant to insulin, and sugar builds up in your blood. Hyperlipidaemia
state that blood has too many lipids (or fats), such as cholesterol and triglycerides are increased
due to regular diet. The diet is full of cholesterol and fat which accumulated. Hypertension due to
the high blood pressure where the management is easy. In simple the change in the form of diet
the hypertension is controlled.
NURSING CARE
Type 2 Diabetes-
As per the case study of Mrs A their was 17 year of history of diabetes type 2 ( also
called diabetes mellitus ). The complication which arrives due to diabetes are :
 Heart and blood vessel disease- Diabetes increases the risk of heart disease, stroke, high
blood pressure and narrowing of blood vessels ( called atherosclerosis).
 Kidney damage- Diabetes can sometimes create a chance of kidney failure or irreversible
end-stage kidney disease, which may require dialysis or a kidney transplant.
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 Slow healing- Left untreated, cuts and blisters will become serious infections, which
may heal slowly (Cortez-Navarrete and et. al., 2018).
 Hearing impairment- Hearing problems are more common in people with diabetes
because of loss of ear drum.
 Skin conditions- Diabetes leave more susceptible to skin problems, including bacterial
and fungal infections.
These are the risk factor which will be observed in the case of type 2 diabetes. Mrs A
must need a care and medication on the regular basis to proper treatment.
Hypertension-
As per the case study of Mrs A, she also deal with hypertension. The risk factor with
hypertension are:
 Diet low in vitamin D- It's happens due to little vitamin D in diet that lead to high blood
pressure.(Grandner and et. al., 2018.)
 chronic conditions- Certain chronic conditions, including diabetes, kidney disease and
sleep apnea, also may increase your risk of high blood pressure.
 Stress- High levels of stress can lead to a temporary, but for long time increase in blood
pressure. Mrs A need to relax and happy.
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Illustration 1: Type 2 diabetes

 Too much salt (sodium) in diet- Too much sodium in diet can cause body to retain fluid,
and also causes the arteries in your body to constrict. Both factors increase blood
pressure. Mrs A followed the non salty food which provide by nurses.
Hyperlipidaemia-
The risk factor with hyperlipidaemia are:
 plague- High cholesterol can cause a dangerous accumulation of cholesterol and other
deposits on the walls of your arteries (atherosclerosis). These deposits (plaques) can
reduce blood flow through your arteries Mrs A feels shorting in breathe due to the plague
deposition.
 Heart attack- plaques tear or rupture, a blood clot can form at the plaque-rupture site —
blocking the flow of blood and plugging an artery downstream. Blood flow to part of
heart stops, the chance of heart attack appears.
 Stroke- Similar to a heart attack, a stroke occurs when a blood clot blocks blood flow to
part of your brain. Mrs A had habit to smoke so as per the above observation the chance
of stroke is much. She needs to quit smoke.
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Illustration 2: Hypertension

Shortness of breathe-
As per the case study of Mrs A, the observation is clear, due to the hyperlipidaemia the
flow property of blood is affected. The deposition of fat is much in the vessel of blood. The
blood not in the form of free flow due the plaque and heart receive lesser amount of
blood(Devasahayam and et. al., 2018).. So the shortening in breathe has observed. If it will
continue for a long time then the chance of heart attack and strokes are applied ( as mentioned
above ).
Pruritus
Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to
scratch. It is a characteristic feature of many skin diseases and an sign of some systemic diseases.
e.g dermatitis (Koech, 2019). As per the case study of Mrs A due to the diabetes and smoking
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Illustration 3: Hyperlipidaemia
Illustration 4: shortening of breathe

formulate the chance of pruritus. The drug therapy of hypertension or other which follow the
drug of opioid class get interacted. Which create a chemical side effect and cause pruritus.
Managing as practice is art; organized knowledge about management is science. The
development of management theory involves the development of concepts, principles, and
techniques. ... The operational, or management process, approach draws on each “school” and
systematically integrates them.
Pitting edema of bilateral extremities
Edema is swelling in the body caused by excess fluid. It affects the lower body, such as
the legs, feet, and ankles, but it can occur anywhere. In the pressing on a swollen area and an
indentation or pit remains, it’s called pitting edema. If there’s enough fluid, and the swelling is
from fluid and not something else, then most edema will pit. Pitting edema is either caused by a
localized problem with veins in the affected area, or a systemic problem with your heart,
kidneys, or liver function. Edema without pitting is more likely to be caused by issues with
thyroid or lymphatic system.
◦ Risk factor - eating too much salt ,a sedentary lifestyle, immobility when
an extremity is in a dependent location, emphysema or other severe lung
disease.
◦ Complication- skin around the swelling may change and develop a
“woody” appearance due to scarring. If the edema is from varicose veins,
those may worsen. Prolonged edema increases risk of developing an
infection in the tissues that are swollen, especially if there is skin cracking.
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Illustration 5: pruritus

So, Mrs A need a proper care in term of bathing, eating, a proper hygiene
to diminished the complication.
Managing as practice is art; organized knowledge about management is science. The
development of management theory involves the development of concepts, principles, and
techniques. ... The operational, or management process, approach draws on each “school” and
systematically integrates them.
MANAGEMENTS OF DESEASES
Type 2 diabetes
People with type 2 diabetes are said to having insulin resistance which clearly means that
there is no sign of effect of insulin on their body due to their high age we can say she have adult-
onset diabetes. Type 2 diabetes are so mild that they don't even noticed.
Some symptoms are always being thirsty, Peeing on small interval of time, Fatigue, Wound that
don't heal for long, hunger, weight loss can be seen and getting infection easily.
According to the ADA, A1C level below 5.7 percent is considered normal. An A1C
between 5.7 and 6.4 percent signals pre-diabetes, according to the ADA. Type 2 diabetes s
diagnosed when the A1C is at or over 6.5 percent. For many people with type 2 diabetes, the
goal is to lower A1C is at or over 6.5 percent. For many people with type 2 diabetes, the goal is
to lower A1C levels to a healthier percentage. People with diabetes who have well-controlled
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Illustration 6: pitting edema

glucose levels with medication have a different target glucose range. Range from 80-130 mg/dL.
According to American Diabetes Association normal blood sugar levels before and after eating
should be 80-130 mg/dL before eating should be 80-130 mg/dL, before eating meal or fasting
and less than 180 mg/dL about 1-2 hours after eating a meal.
Management
 Lifestyle changes- With the help of diet and exercise you need to reach your target blood
sugar levels(Pratuangtham, S.R. and Jerawatana, R., 2019)
 HealtManaging as practice is art; organized knowledge about management is science.
The development of management theory involves the development of concepts,
principles, and techniques. ... The operational, or management process, approach draws
on each “school” and systematically integrates them.hy eating- There is no specific diet
for type 2 diabetes till now. With the help of professional dietitian you can make a meal
plan for you and need to stick with that plan on regular basis which should be focusing on
Eating fewer calories, avoid the refined food specially sweets, having more fibre on
regular basis and need veggies and fruits to add-on on your diet.
 Exercise- Having exercise on regular basis at least half-an-hour to about 1 hour. Which
can include walking, cycling, swimming or any thing which make your heart rate little bit
up. But due to shortness of breath and others complication with the lady she need to walk
around 50-100 meters on regular basis and try to walk on the grass without any footwear
so it can help in controlling the breath.
 Weight loss- Loosing extra weight can help in controlling blood sugar level which should
not loose 5 to 10%. Loosing about 7% seems to be ideal. Weight loss can seem
overwhelming, but portion control and eating healthy foods are good to start.
 Monitor your blood sugar levels- If you are depending on the Insulin then depending on
your treatment and management you should need to test blood sugar levels and how
often to do it.She need to quit her smoking activity for gaining weight after quitting.
As per given scenario Miss A is not able to manage her medical conditions only with the
given managements so she must need some medication for better effect on health.
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Some mManaging as practice is art; organized knowledge about management is science.
The development of management theory involves the development of concepts, principles, and
techniques. ... The operational, or management process, approach draws on each “school” and
systematically integrates them.edications are Metformin, Sulfonyl ureas, Megalitinides,
Thiazolidinediones, DPP-4 inhibitors GLP-1 receptor agonist and insulin can help her in
controlling her blood sugar.
Hypertension
The latest European guidelines retain the previous definition of hypertension ie,
BP>140/90 mm Hg, whereas the American guidelines lowered the threshold to define
hypertension to <130/80 mm Hg (Allaire and et. al., 2020).
Lady having the BP 165/92 mm Hg which discloses the presence of hypertension
Blood pressure measurement into four general categories:
 Normal blood pressure
 Elevated blood pressure
 Stage 1 hypertension
 Stage 2 hypertension
Management of Hypertension
 Changing in Lifestyle can help more toward controlling high blood pressure.
 Some recommendations are having healthy diet with less salt, Getting regular
physical activity but not need to more due to other decreases and complications,
maintaining the weight if overweight then loose, if underweight then gain as per
ideal, need to avoid the alcohol consumption.
As per given scenario Miss A is not able enough for maintaining the hypertension with just by
management she needs to take some medication for her better health.
Some medicines are preferred e.g.
 Thiazide diuretics- which acts on kidney to help in elimination of sodium and
water and reducing blood volume.
 ACE Inhibitors- such as captopril, benzepril and others they help relax blood
vessels by blocking the formation of a natural chemical that narrows blood
vessels.
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 Angiotensin II receptor blockers- help in relax blood vessels by blocking the
action\, not the formation.
 Calcium channel blockers- like Tiazac, cardizem and others help relax the
muscles of you blood vessels.
Additional medications sometimes used to treat high blood pressure Alpha blockers ,
Alpha-beta blockers, Beta blockers, Aldosterone antagonists, Renin inhibitors, Vasodilators,
Central-acting agents etc.
Hyperlipidaemia
Hyperlipidaemia involves an imbalance of cholesterol levels, including low0density
lipoprotein cholesterol and high-density lipoprotein cholesterol in the blood. LDL-C and HDL-C
regulate the amount of cholesterol in the body so imbalance can increase the risk of
cardiovascular events, myocardial infraction and stroke.
Managements
The same heart-healthy lifestyle changes that can lower the cholesterol can help prevent
you from having high cholesterol. To help prevent high cholesterol, you can:
 Eat a low-salt diet that emphasizes fruits, vegetables and whole grains
 Limit the amount of animal fats and use good fats in moderation
 Lose extra pounds and maintain a healthy weight
 Quit smoking
 Exercise on most days of the week for at least 30 minutes
 Moderate use of alcohol..
Management is not the only measures you need to have some medications. which is
Statins. It reduce cholesterol and LDL-C via inhibition HMG-CoA. It may give some adverse
effect like muscle pain, weakness and inflammation, which chance is less than 10%.
Dyspnea (shortness of breath)
Short of breathless is known as Dyspnea, It it an uncomfortable condition in which it
makes difficult to fully get air into lungs, problems with lungs and heart can harm your
breathing. Range of human breath is normally 12-16 breath per minute and here Miss A having
26 breath per minutes.
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Here., Miss A having 26 breath per minutes and said that there is shortness in breath
which means due to regular smoking shortness of breath is there which means there is persistent
tightness in your chest due to smoking. Miss A need to Quit her smoking habit so she can get
the normal breath rate. Management as some home treatment
 Pursed-lip breathing
 Sitting Forward
 Standing with supported background
 Sleeping in a relaxed position
Changing in lifestyle can help in shortness of breath
 need to quit smoking
 avoid the exposure in pollutions
 losing weight if you have more weight
Pruritus
It is time taking response which can cause either by due to medication history which
involves some physical exams according to this you may get the treatment(Koech, P.K., 2019.)
Management
 Avoiding such items and situations which can cause you to itch.
 Moisturise your skin on daily basis.
 Use lotions, gels, creams that can cool and helps to smoothing the skin.
 Take bath or shower on regular basis.
 Reduce stress.
 Wearing light weight clothing can help you.
Pitting Edema
Pitting Edema is most probable cause of bilateral edema in older person, It may be due to
Heart failure or renal disease or liver disease which can be seen in Miss A.
Management
Here are some self-care techniques which should be choose according to your doctor's advice-
 Movement – movement of body parts, specially your legs may help to pump the
access of fluid back to the heart.
 Hold the swollen body part to upper the level of your heart for several times a
day.
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 Massage - A normal massage can help in move the excess fluid out of that area,
but it should not be painful(van der Bijl and et. al., 2018)
 Compression – due to one limbs affected by the edema, as per doctor advice you
may have to wear compression stockings, sleeves or gloves etc.
 Protection- keep the affected are clean and moisturised and free from injury.
 Reduce salt intake- salt can increase fluid retention and worsen edema.
Delay in the progression of end-stage renal disease (ESRD):
In end stage renal disease, the delay can cause kidney failure. In this stage, dialysis is the
only treatment which keeps the body balance. This will help in removing waste from the body
and prevent it from developing the waste. It also helps in controlling the blood pressure and keep
a safe level of some chemicals in blood. In end stage kidney failure or chronic kidney disease,
the kidney does not get better and the patient will need dialysis for rest of the life.
ARBs and Angiotensin-converting enzyme inhibitors are the antihypertensive agents in
Chronic Kidney Disease, targeting both blood pressure and kidney function through inhibition of
RAAS (renin-angiotensin-aldosterone system), which decreases proteinuria and decelerates
progression of chronic kidney disease. Additional classes of antihypertensive agents are also
generally utilized to further ameliorate the risk of CVD and delay Chronic Kidney Disease
progression. Diabetes is associated with Chronic Kidney Disease as well as poor control of
glycaemic levels contributes further to the progression of CKD. Procedures recommend a level
of glycosylated hemoglobin (HbA1c) not exceeding 6.5–7.0% in order to delay the progression of
CKD.
CONCLUSION
As per the above case study, Mrs A had diabetes, hypertension and hyperlipidaemia
which formulate a critical and severe situation that leads to may fatal if the condition persist for
long time. As per the observation of cavan der Bijl and et. al., 2018se the blood pressure is
165/92 mm Hg which show a hypertension condition. If hypertension persist in long range that
leads some severity which mention above. Overall primarily control the current situation by
proper caring, medication and management. The major cause to start the condition was obesity
and smoking which make the condition more worse.
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REFERENCES
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