Quality of Care for Acute Kidney Disease Essay Assignment

Case Study Response

Your post has presented a well-developed and thought approach to managing the target patient condition of acute kidney injury (AKI), focusing On asking questions about the use of NSAID; it is key to implementing patient-tailored care as naproxen can exacerbate renal impairment, especially in the setting of chronic kidney disease. The choice to factor in other differentials, i.e., obstruction uropathy and pyelonephritis, plays a key role in understanding and developing the best-suiting medication and care plan for the patient given the patient’s urinary symptoms and flank pain (Liu et al., 2020). Quality of Care for Acute Kidney Disease Essay Assignment

On the other hand, the choice to stop or discontinue the use of NSAIDs and instead adopt acetaminophen for managing pain is appropriate, considering the risk associated with nephrotoxic and the patients’ osteoarthritis. Regarding the selected diagnostic testing, the labs’ work, including the CMP, urinalysis, and renal ultrasound, can be regarded as key steps in developing the patient’s right medication and care plan. For example, given the foul odor and dark-colored urine color, performing a urine culture can be the best bet or precaution to eliminate different or any underlying infection. It is equally important to check on the patients creatinine  clearance as it helps monitor ongoing renal function.

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According to Gameiro et al. (2020), implementing patient-tailored education helps improve self-care actions and choices, improving care outcomes. Regarding the focused patient, patient education on avoiding NSAIDs, chronic condition management, i.e., diabetes and hypertension, and maintaining body hydration are key practices for preventing further renal damage. On the other hand, including family members and caregivers in patient-related discussions helps improve patient adherence to tailored care plans. Lastly, referral to a nephrologist for additional CKD understanding and management, together with dietician input, would help use a friendly diet informing patients of detailed and comprehensive care. However, your work is well out and detailed regarding addressing complexities of AKI, such as in the case provided.

***RESPOND TO MARCELETE THOMPSON POST***
Original Post:
73-year-old Caucasian male with history of Hypertension, Diabetes Mellitus type 2 (managed with oral medications) Osteoarthritis in both knees and back, and Hyperlipidemia presented to your primary clinic for follow-up after being hospitalized for acute kidney injury in a local hospital about a week ago. He reports that he has been doing better but was told by the hospitalists to follow-up with his primary care provider. Today in the clinic he continues to report dark colored urine with foul smelling odor even after drinking at least eight gallons daily. He reports nocturia at least 3-4 times at night and urinary frequency. He also reports right sided flank pain that began about a week ago, but he thinks that this might be related to his Osteoarthritis. He denies any fever, chills, abdominal pain, or nausea with vomiting episode. His vital signs during the office visit are: Quality of Care for Acute Kidney Disease Essay Assignment

Temperature 98.4, Pulse 78, BP 121/78, O2 saturations 99%

He also presented with his list of medications which included:

Naproxen 500mg BID take with food for Osteoarthritis
Amlodipine 10 mg take daily for high blood pressure
Jardiance 25mg take every morning for diabetes Mellitus
He also presented to the clinic with the last lab results taken while he was admitted in the local hospital. CBC, Urinalysis, Lactic acid results were all normal at the time of discharge. The following lab results were noted to be abnormal

CMP

BUN – 45
Creatinine- 2.14
Sodium -131
24-hour urine collection showed 200mg of protein in the urine. On the spot urinalysis was normal at the time of discharge.
Questions

As the Primary care NP seeing this patient, what other questions would you ask to elicit a good history and narrow down your differentials?
What other differentials would you consider with this patient? What is your actual diagnosis? Include subjective and objective data that made you decide that is your actual diagnosis.
What diagnostic imaging or laboratory tests would you consider with this patient?
What medications would you treat this patient with and state the reason for your choice of medications with reference? Also write out the prescription with the appropriate dosage, timing, and number of days you are prescribing the medication for?
What patient education or referral would you consider for this patient.

Marcelete Thompson Response:
Case Discussion: 73-Year-Old Male with Acute Kidney Injury

History and Differential Diagnosis Quality of Care for Acute Kidney Disease Essay Assignment

To gain a comprehensive understanding of this patient’s condition, additional questions should be asked. They include inquiries about recent changes in medication, specifically the use of NSAIDs, and adjustments in diabetes or hypertension medications. It is also important to ask about recent infections, such as urinary tract infections (UTIs), or other systemic infections to identify possible causes of acute kidney injury (AKI) (Davis & Molnar, 2021). Questions about episodes of hypotension, dehydration, or cardiac symptoms should be asked to consider potential cardiovascular contributions to reduced renal perfusion. Additionally, it is crucial to assess the patient’s social situation by asking about family support and who assists him at home, because this can impact his ability to adhere to a treatment plan and make lifestyle adjustments. This scenario reminded me of a hospital follow up patient that was seen during my clinical rotation this summer. For me the scenario seemed complicated and I remember Dr. Martinez (my preceptor) emphasizing the importance of thorough history-taking and considering potential causes of AKI, such as medication use and underlying chronic kidney disease (CKD).

Based on the patient’s history and current presentation, several differential diagnoses should be considered, including acute interstitial nephritis, diabetic nephropathy, chronic kidney disease (CKD) exacerbation, and obstructive uropathy. The dark urine with foul-smelling odor, urinary frequency, and flank pain suggest a possible UTI or pyelonephritis, although the absence of fever or chills makes this less likely. The most likely diagnosis is acute kidney injury superimposed on chronic kidney disease, potentially exacerbated by NSAID use (naproxen) and inadequate fluid management (Davis & Molnar, 2021). Elevated blood urea nitrogen (BUN), creatinine, low sodium levels, and proteinuria support this diagnosis.

Diagnostic Imaging and Laboratory Tests

Additional diagnostic imaging and laboratory tests are necessary to confirm the diagnosis and assess the extent of renal impairment. A renal ultrasound should be performed to evaluate kidney size, structure, and check for any obstructive processes (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2022). Repeating the complete metabolic panel (CMP) and urinalysis is needed to assess current renal function and detect any changes since hospital discharge. A urine culture may also be warranted to rule out infection, given the symptoms of dark urine and foul odor, even though a UTI is less likely. Additionally, measuring urine sodium and creatinine clearance can provide insight into the extent of renal dysfunction. Quality of Care for Acute Kidney Disease Essay Assignment

Medications and Treatment

Medication adjustments and careful management are crucial for this patient. Discontinuation of NSAIDs like naproxen is recommended due to their nephrotoxic potential, especially in patients with existing renal impairment (Morgado et al., 2020). Instead, acetaminophen may be used for pain management, considering the patient’s osteoarthritis:

Acetaminophen 500 mg orally every 6 hours as needed for pain, not to exceed 3,000 mg per day (NIDDK, 2022).
Fluid management is critical, given the patient’s history of AKI. Monitoring and adjusting diabetes and hypertension medications, particularly Jardiance and amlodipine, might be necessary based on ongoing renal function assessments (Davis & Molnar, 2021).

Patient Education and Referral

Patient education should focus on avoiding NSAIDs, maintaining adequate hydration, and closely monitoring blood glucose and blood pressure levels. It is essential to ensure that the patient understands the diagnosis of acute kidney injury and the treatment plan, including the importance of medication compliance and lifestyle changes to prevent further renal damage. This understanding can be supported by involving family members or caregivers in discussions to provide additional support and ensure adherence to the treatment plan. Patients should be informed about the signs and symptoms of worsening renal function, such as decreased urine output, swelling, or weight gain, and advised to seek medical attention if these occur. Referral to a nephrologist for further evaluation and management of chronic kidney disease is recommended (NIDDK, 2022). Additionally, referral to a dietitian may be beneficial to discuss renal-friendly dietary modifications. Quality of Care for Acute Kidney Disease Essay Assignment

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References

Davis, J. A., & Molnar, A. O. (2021). Acute kidney injury: Risk factors, diagnostic evaluation, and management. StatPearls Publishing. https://www.statpearls.com/ArticleLibrary/viewarticle/121

Morgado, D., Dantas, J., & Almeida, J. (2020). Acute interstitial nephritis due to nonsteroidal anti-inflammatory drugs. StatPearls Publishing. https://www.statpearls.com/ArticleLibrary/viewarticle/118

National Institute of Diabetes and Digestive and Kidney Diseases. (2022). Kidney disease: Improving global outcomes (KDIGO) clinical practice guideline for the management of blood pressure in chronic kidney disease. https://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/professionals/chronic-kidney-disease-minimize-your-patients-risk/Documents/Professional-Education-Webinars/kdigo-clinical-practice-guideline-blood-pressure-in-chronic-kidney-disease.pdfLinks to an external site. Quality of Care for Acute Kidney Disease Essay Assignment