Scenario: K.B. is a 32-year-old woman being admitted to the medical floor for complaints of fatigue and dehydration. Wle taking her story, you discover that she has diabetes mellitus (DM) and has been insulin dependent since the age of 8. She has undergone hemodialysis (HD) for the past 2 years because of endstage renal disease (ESRD). Your initial assessment of K.B. reveals a pale, tn, slightly drowsy woman. Her skin is warm and dry to the touch with poor skin turgor, and her mucous membranes are dry. Her vital signs are 140/88, 116, 18, 99.9° F (37.7° C). She tells you she has been nauseated for 2 days so she has not been eating or drinking. She reports severe diarrhea. The following blood chemistry results are back. Chart View Laboratory Test Results Sodium 145mEq/L Potassium 6.0mEq/L Chloride 93mEq/L Bicarbonate 27mEq/L BUN 48mg/dL Creatinine 5.0mg/dL Glucose 238mg/dL 1. What aspects of your assessment support her admitting diagnosis of dehydration? 2. Explain any laboratory results that might be of concern 3. Identify two possible causes for K.B.’s low-grade fever. The rest of K.B.’s physical assessment is witn normal limits. You note that she has an arteriovenous (AV) fistula in her left arm. 4. What is an AV fistula? Why does K.B. have one? 5. What steps do you take to assess K.B.’s AV fistula, and what physical findings are expected? Explain 6. As you continue the assessment, you notice that a nursing assistive personnel (NAP) comes in to take K.B.’s blood pressure (BP). The NAP places the BP cuff on K.B.’s left arm. What, if anytng, do you do? K.B.’s admission CBC yields the following results: Chart View Laboratory Test Result WBC 7600/mm3 RBC 3.2 million/mm3 Hgb 8.1g/dL Hct 24.3% Platelets 333,000/mm3 7. Are these values normal? If not, what are the abnormalities? 8. K.B.’s physician notes that she is anemic, wch most likely is the cause of her increasing fatigue. Why is K.B. anemic? K.B. is sent for an HD treatment. Over the next 24 hours, K.B.’s nausea subsides, and she is able to eat normally. Wle you are helping her with her morning care, she confides in you that she doesn’t understand her diet. “I just get blood drawn every week and meet with the dialysis dietitian every month—I just eat what she tells me to eat. It’s so hard!” 9. Because K.B. is on HD and has DM, what are her special nutritional needs? Name at least four specific components of the diet recommended for K.B. 10. Patients in renal failure have the potential to develop comorbid conditions. Identify five potential problems, determine how you would assess the problem, then delineate nursing interventions and patient education strategies for each. The following day, K.B. is discharged feeling much better and with a good understanding of her dietary restrictions. Her iron stores have been evaluated and found to be low. Her physician has instructed her to resume her preadmission medications, with the addition of ferrous fumarate oral suspension 100mg PO tid between meals with water, if tolerated (or with meals if GI distress occurs) and epoetin (Epogen) to be given three times a week intravenously with dialysis. She is also given a prescription for Nephrocaps vitamin supplements to be taken daily. 11. Explain the purpose of the new medications for K. B 12. You spend some time with K.B. to explain the new medications. Wch statement by K.B. reflects need for further teacng? a. “I won’t need to take the iron supplements as long as I get the Epogen during dialysis.” b. “The liquid iron will cause my bowel movements to turn black or dark green.” c. “Hopefully I will feel less tired all the time when these medicines start building up my red blood cells.” d. “I should dilute the liquid iron and drink it with a straw so that it won’t stain my teeth. 13. K.B. asks, “Why do I need a prescription for vitamins? I can just take sometng on sale at the drugstore, right?” How do you respond? 14. The ferrous fumarate suspension comes in a bottle that is labeled 100mg/5mL. Indicate on the measuring cup how much medication will be used for each dose. 15. In monitoring K.B.’s response to the epoetin, what adverse effect would you expect? a. Arthralgia b. Tachycardia c. Drowsiness d. Diarrhea 17. Wch vital sign will you monitor carefully wle K.B. is on epoetin therapy? Explain your answer 18. During the following weeks, wch laboratory result is most important to monitor wle K.B. is on the epoetin? Explain. K.B. is discharged to home and goes to the local dialysis center three times a week. She also keeps appointments with the registered dietitian and reports that she is feeling much better.