NR 507 Recorded Disease Process Presentation Peer Review
NR 507 Recorded Disease Process Presentation Peer Review
I really enjoyed your presentation and felt like I learned more about Addison’s disease. I was interested in this subject matter due to someone I know having this disease and wanting to understand more about her condition.
Discuss the risk factors and the connection to the etiology of the initial injury to the cell/tissue/organ
One of the things I found most interesting about Addison’s that I did not remember from nursing school was the most common cause of Addison’s being tuberculosis worldwide. Upon further research, I found that this is not common in further developed countries such as the United States, but in those underdeveloped countries (Burton, Cottrell, & Edwards, 2015, p. 488). Most often in established countries the cause is an autoimmune disease as you mentioned. Example of the autoimmune diseases would be type 1 diabetes, or Graves’ disease. Other risk factors include other chronic infections, removal of part of the adrenal gland, or polyendocrine deficiency syndrome. These autoimmune disorders cause breakdown of the adrenal cortex most often causing Addison’s disease.
Provide a brief diagnosis of how the disease is diagnosed
In your presentation you mentioned that diagnosis is made based on laboratory values to determine either primary or secondary adrenal insufficiency with high ACTH being primary and low ACTH being secondary. It is important to understand that the cortisol levels must be drawn in the morning to give a more accurate result. In my research, I found that patients are often misdiagnosed until they progress into Addisonian crisis due to providers focusing on other differential diagnoses based on the patient’s sign and symptoms (Burton, et. al, 2015, p.489). Once patients have become this ill, they usually present to the emergency department and the diagnosis is made based on presentation, laboratory values of hyperkalemia and hyponatremia, and then can be confirmed by morning cortisol levels. The delay in diagnosis was the most interesting.
Burton, C., Cottrell, E., & Edwards, J. (2015). Addison’s disease: identification and management in primary care. The British Jounral of General Practice, 65(638), 488-490. http://doi.org/10.3399/bjgp15X686713Links to an external site.
Thank you for your response and all of your kind words in regard to my presentation. I hope that my presentation allowed for a better understanding of renal disease and how as nurse practitioners we can provide the best care possible for these patients. I am so pleased with the questions you asked and was able to do some further research into this disease and gain some helpful knowledge because of them. Both questions you asked are addressed below.
Regarding this question, if a patient is told they will need dialysis, but they refuse, they have an approximate survival time of six months. What would you do to change the patient’s mind about dialysis?
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For patients who are instructed to use dialysis for a treatment method, this can be scary and life changing. For patients that refuse at the initial instruction of dialysis it is essential to educate and ensure that he or she has an understanding of the outcome if refusal continues. One initial response, as was mentioned in the case you presented to me, the amount of time per week that the patient must set aside for the treatments. One important factor to mention to the patient is the possibility of performing the hemodialysis at home. In all cases it is not necessary to go to an outpatient setting to have dialysis performed. This option is often more acceptable to patients and allows them more independence than having to attend scheduled appointments. Another important fact that I did not mention in the presentation is the choice to do either hemodialysis or peritoneal dialysis. If the choice of peritoneal dialysis is made the patient will need to be aware a surgical procedure to place a abdominal catheter will be needed in order for treatments to take place. “During PD, sterile dialysate fluid is introduced in the patient’s peritoneal cavity and remains there for 6–8 hours while excess body fluid and toxins are filtered across the peritoneal membrane; at the completion of treatment, the dialysate fluid is drained from the peritoneal cavity” (Schub, Mennella, 2018, p. 1). This type of dialysis differs from hemodialysis because typically a catheter is placed in the chest until a graft can be established in the arm and then the blood is filtered rather than the peritoneal fluid. Again, it is important to educate the patient that both can be performed at home independently as long as compliance is achieved. After explaining all options of dialysis to the patient, inform the patient of the complications of not having dialysis such as electrolyte imbalances, fluid overload, toxin build up, and ultimately death. Healthcare is patient driven and ultimately it will be the patient’s decision whether or not he or she wants to have dialysis or not. The job of the healthcare provider is to educate and supply patients with the appropriate options and tools the live the best life possible living with this chronic disease.
If a patient does receive a kidney transplant, is there a lifetime medication regimen?
For patients with renal disease a kidney transplant is life changing and unless complications occur, will allow for a
life without the disease. Patients who received a kidney transplant will be required to take medications for immunosuppression. The reasoning behind this is to prevent the body from rejecting the transplanted kidney. In the event of rejection, the patient will begin so show symptoms similar to that of infection and ultimately if not treated the patient can lose the transplanted kidney, enter into a state of shock, or even death. Drugs that are often times used in the immunosuppressive therapy are as follows: Rituxan, Rapamune, Prograf, Astagraf XL, Prednisone, CellCept, Nulojix, Cytoxan, Cyclosporine, Campath, Thymoglobulin, Imuran, and Simulect (Colaneri, 2014). These drugs are often times used in combination and it is imperative the patient does not miss a dose. Patients will also need to see the primary care provider to have blood drawn regularly in order to monitor levels such as with the medication Prograf. “immunosuppression should modify the immune system enough to prevent rejection, but not allow infection, malignancies, and other side effects” (Colaneri, 2014, p. 550). It is imperative to monitor transplant patients to ensure proper kidney health and the optimal life post-surgery.
Colaneri, J. (2014). An Overview of Transplant Immunosuppression – History, Principles, and Current Practices in Kidney Transplantation. Nephrology Nursing Journal, 41(6), 549-561.
Schub, T. B., & Mennella, H. A. (2018). Hemodialysis vs Peritoneal Dialysis. CINAHL Nursing Guide.
I agree with you that congenital malformations, pre-existing kidney, genetics, and infections are some of the risk factors for chronic renal disease.
Obesity, low birth weight, nephrotoxins, age, and ethnicity, are also risk factors associated with the disease (Kazancioğlu, 2013). According to Chang & Kramer, 2013, Glomerular hypertrophy and hyperfiltration increase capillary wall tension of the glomeruli and decreasing podocyte density. Obesity can also contribute to the pathogenesis of kidney damage through hypervolemia, adipokine disorders, inflammation, oxidative stress and endothelial dysfunction. Intrauterine growth restriction can also cause low nephron number that leads to intraglomerular hypertension and hyperfiltration in the available nephrons (Vikse, Irgens, Leivestad, Hallan, & Iversen, 2018). According to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI), the elderly population is more prone to develop chronic kidney disease (CKD) after several renal insults. Exposure to heavy metals, alcohol, and other drugs has linked to constant kidney disease progression (Falodia & Singla, 2013).
Treatment and prevention
You haven’t included nephrectomy anywhere in the treatment of chronic kidney disease. Nephrectomy is the surgical removal of the kidney to treat kidney cancer and other related kidney diseases. Partial and radical nephrectomy can be done to treat chronic renal disease. According to Charytoniuk et al., 2018, partial Nephrectomy is done on the diseased or injured portion of the kidney, and radical nephrectomy includes removing the entire organ together with a section of the tube leading to the bladder. Retroperitoneal robotic partial nephrectomy is, however, more effective in the treatment of chronic kidney disease due to reduced operative time and a shorter Length of stay as compared to trans peritoneal nephrectomy (Paulucci et al., 2018). Good job on your presentation.
Chang, A., & Kramer, H. (2013). CKD progression: a risky business. Nephrology Dialysis Transplantation, 27(7), 2607-2609. doi:10.1093/ndt/gfs095
Charytoniuk, T., Małyszko, M., Bączek, J., Fiedorczyk, P., Siedlaczek, K., & Małyszko, J. (2018). Progression to chronic kidney disease in patients undergoing nephrectomy for small renal masses: a price to pay for a therapeutic success? Postgraduate Medicine. doi:10.1080/00325481.2018.1511211
Falodia, J., & Singla, M. K. (2013). CKD epidemiology and risk factors. Clinical Queries: Nephrology, 1(4), 249-252. doi:10.1016/j.cqn.2012.09.004
Kazancioğlu, R. (2013). Risk factors for chronic kidney disease: an update. Kidney International Supplements, 3(4), 368-371. doi:10.1038/kisup.2013.79
Paulucci, D. J., Beksac, A. T., Porter, J., Abaza, R., Eun, D. D., Bhandari, A., … Badani, K. K. (2018). A Multi-institutional Propensity Score Matched Comparison of Transperitoneal and Retroperitoneal Partial Nephrectomy for cT1 Posterior Tumors. Journal of Laparoendoscopic & Advanced Surgical Techniques. doi:10.1089/lap.2018.0313