Interdisciplinary Care of a Patient

Interdisciplinary Care of a Patient with Acute Glomerulonephritis with Acute Kidney Injury and Pulmonary Hypertension

Background Summary

Demographics

John is a 35-year-old American male who resides in Washington with his family. Together with his wife, he has an 8-year-old daughter. John works as a kindergarten teacher, while his wife is an entrepreneur who works at a cosmetic shop while their daughter is in the second grade. After work, John usually assists the wife at her shop. He was admitted on July 28, 2017, to the Washington Hospital for possible hemodialysis.

History of the Presenting Illness

John was presented to the hospital with complaints of fatigue, puffiness of his face as well as legs. He mentioned lack of appetite, shortness of breath, and headache. John had experienced fatigue for about three weeks, but he did not visit a hospital. He thought the fatigue had been caused by his overworking since lately, there had been an increased workload at the workplace. The fatigue was alleviated with adequate rest after work. A week after the onset of fatigue, John started passing little amounts of tea-colored urine even after taking adequate fluids, and a few days later, he noticed that his face and legs were swollen. The swelling on the legs was aggravated by standing for a long time and relieved while resting on a sofa, with the legs placed on a stool. Shortly after these symptoms manifested themselves, he started experiencing a severe headache, shortness of breath, and loss of appetite. Thus, John decided to seek medical attention at the Washington Hospital.

The Relevant Past Medical and Surgical History

The past medical history revealed that on December 10, 2016, John was admitted to the hospital with rheumatic fever that was managed with penicillin V benzathine. He recovered without developing any complications or allergies to the medication. On June 1, 2017, John has treated at the outpatient department with amoxicillin and acetaminophen for a streptococcal sore throat after a positive throat culture for group A beta-hemolytic streptococcus. He is not allergic to any food or drug. The surgical history revealed that John had been admitted to the surgical ward on January 4, 2009, with a fractured femur after a motor vehicle accident. He was transfused with one pint of blood during hospitalization, and he did not develop any transfusion reaction.

Admitting Diagnoses

Acute glomerulonephritis with acute kidney injury and pulmonary hypertension.

The Course of the Current Hospitalization to Date

Since John was admitted on July 28, 2017, hemodialysis was performed to treat his hyperkalemia and uremia. He was also put on antidiuretics and antibiotics. Thus, the prognosis of his condition is as follows. Oliguria reduced as the urine amount increased and the color of the urine changed to amber. The renal clearance has reduced and the concentration of blood urea returns to normal. The edema has subsided, and experienced hypertension has lessened. Some little proteinuria and hematuria are still present.

Significant Assessment Findings (Vitals, Focused Assessments, Data from Monitoring Values)

On inspection, John appeared to be fatigued, with a puffy face and swollen lower extremities. He was dyspneic, while the neck vein was engorged. On chest auscultation, he had basal crackles and the presence of S3 heart sound, while a dull sound was heard on percussion. The vital signs are BP 180/100 mmHg, a temperature of 400 C, a pulse of 108 b/m, respirations of 26 b/m, and oxygen saturation of 98%.

Laboratory and Diagnostic Tests

• The Tests and the Findings

The performed laboratory and diagnostic tests included urinalysis, serum creatinine, creatinine clearance, throat culture, serum electrolytes, serum blood urea nitrogen, complete blood count, need a biopsy of the kidney, and chest x-ray. Below are the findings of the tests and procedures

Table 1: Tests and procedures

The tests and procedures	The findings
Urinalysis	Proteinuria and hematuria, red blood cells
Serum creatinine	Increased
Creatinine clearance	Reduced
Throat culture	Positive for group A beta-hemolytic streptococcus
Serum electrolytes	Increased potassium, sodium, phosphorus Reduced calcium
Serum blood urea nitrogen	Increased
Complete blood count (CBC)	Reduced red blood cells, increased white blood cells, reduced hemoglobin levels
Need biopsy of the kidney	Obstruction of the capillaries of the glomeruli
Chest x-ray	Pulmonary arteries and the right ventricles are enlarged

• The Rationale

Urinalysis was ordered to establish the presence of proteinuria, hematuria, and red blood cells that were common clinical findings in glomerulonephritis. The serum creatinine, creatinine clearance, and serum blood urea nitrogen were ordered to establish the functioning of the kidneys since glomerulonephritis affected the regulatory and excretory functions of the nephrons (Timby & Smith, 2013). Furthermore, CBC was ordered to evaluate the prognosis of the disease. The rationale for a needle biopsy was to confirm the diagnosis of glomerulonephritis, and the chest x-ray was to confirm the presence of pulmonary hypertension.

Analysis of the Findings of the Disease

The urinalysis revealed proteinuria and red blood cells. In acute glomerulonephritis, glomeruli are destroyed by the antigen-antibody reaction allowing the passage of protein and red blood cells since the filtering surface is lost (Timby & Smith, 2013). As the disease progresses, there occur vascular injuries to the blood vessels of the nephrons and the presence of hematuria is observed. The loss of blood in urine is associated with the reduced number of red blood cells and hemoglobin levels in the blood as demonstrated in the complete blood count (DeWit, Stromberg, & Dallred, 2016). The injured glomeruli basement membrane will eventually be replaced with scar tissue. The patient will present with decreased glomerular filtration rate, leading to reduced creatinine clearance and a subsequent increase in serum creatinine (Ignatavicius & Workman, 2015). The damaged nephrons cannot perform their function, and as a result, there is an accumulation of blood urea nitrogen, potassium, sodium, and phosphorus while the calcium level reduces (Timby & Smith, 2013). The retention of sodium is associated with water retention, thus leading to fluid overload in the pulmonary circulation, which is why the x-ray showed the enlargement of the pulmonary arteries and the right ventricles (DeWit et al., 2016). A biopsy demonstrated obstruction of the capillaries of the glomeruli due to the proliferation of the endothelial cells as caused by the antigen-antibody inflammatory reaction. The fact that the throat culture is positive for group A beta-hemolytic streptococcus is an indication that the aforementioned organism is behind the initiation of the antigen-antibody reaction. The latter led to the deposition of the immune complex at the glomeruli of acute glomerulonephritis, which was further evidenced by an increase in the number of white blood cells in the complete blood count findings (Timby & Smith, 2013). White blood cells usually increase in number in an attempt to engulf pathogenic microorganisms.

Medications and Rationale for Prescription

John was given the following medications: hydralazine, furosemide, lanthanum, ceftriaxone, and insulin. Hydralazine is an antihypertensive (Ignatavicius & Workman, 2015). Thus, it was given because John had been admitted with a high blood pressure of 180/100 mmHg. Furosemide is a loop diuretic (Ignatavicius & Workman, 2015). This medication was given to alleviate the edema of the face and the extremities as well as pulmonary hypertension, which was the result of fluid overload. Lanthanum is a phosphate binder (Ignatavicius & Workman, 2015). It reduces the level of phosphate in the blood and increases the level of calcium. Ceftriaxone is an antibiotic (Ignatavicius & Workman, 2015) to combat the infection since John has been presented with a positive throat culture for group A beta-hemolytic streptococcus. Insulin, as a hypoglycemic agent, is used with glucose to alleviate hyperkalemia (Ignatavicius & Workman, 2015). The movement of glucose into the cells is always accompanied by potassium, and that is why small amounts of insulin are beneficial in this condition.

Table 2: Overview of the prescribed drugs

Drugs	Classification	Therapeutic use	Adverse effects	Nursing implications
Generic name	Trade name
Hydralazine 10 mg oral	Apresoline	Antihypertensive	To lower the blood pressure	Headache, diarrhea, anorexia,	Monitor blood pressure Assess complete blood count and electrolytes
Furosemide 40 mg intravenous	Lasix	Diuretic	To reduce the number of body fluids	Tinnitus, anorexia	Monitoring input and output
Lanthanum 500 mg oral	Fosrenol	Phosphate binding agent	To reduce the level of phosphorus and increase the level of calcium	Hypophosphatemia	Assessing the electrolyte levels
Ceftriaxone 2 gm intravenous	Rocephin	Antibiotics	To alleviate infection	Nausea and vomiting Anaphylactic reaction	Assessing the white blood cells count
Insulin 5 I.U subcutaneous	Novolog	Hypoglycemic agent	To treat hyperkalemia by enhancing the uptake of potassium and glucose by the cells	Reaction at the injection site, hypoglycemia	Assessing the electrolyte levels Monitoring the blood glucose levels

Nursing Diagnoses

I. Ineffective perfusion of the tissue (renal parenchyma) is related to the damage to the glomeruli as evidenced by increased blood pressure of 180/100 mmHg, fatigue, and edema.

Nursing outcome	Nursing interventions	Collaborative interventions
1. The patient’s blood pressure will reduce to 160/80 mmHg in the next 24 hours. 2. The patient will not experience fatigue throughout the hospitalization period 3. The patient’s edema will reduce in the next 24 hours as indicated by decreased swelling of the face and the lower extremities.	1. Monitor the patient’s blood pressure after every four hours to note the progress in response to the treatment regimen. 2. Encourage the patient to rest until the blood pressure is back to normal because resting enhances the functioning of the renal tissues by increasing diuresis and reducing the incidences of fatigue. 3. Monitoring the input and output of the patient to determine his fluid balance will help detect if the edema subsides or not.	1. Administer hydralazine as it is an antihypertensive, and it will help reduce blood pressure. 2. Developing a resting exercise program with the help of a physiotherapist. 3. Administering furosemide, which is a diuretic that will help the patient lose fluids; hence, his edema will reduce.

II. Fluid volume excess is related to the compromised function of the renal system as evidenced by the edema of the face, extremities, pulmonary hypertension, and weight gain.

Nursing outcome	Nursing interventions	Collaborative interventions
1. The patient’s weight will decrease during the period of hospitalization. 2. The patient’s respiration rates will reduce from 26 breaths per minute to 20 breaths per minute in the next 24 hours. 3. The patient will have a balanced fluid volume at the end of hospitalization.	1. Monitoring the weight of the patient daily to help determine whether the patient loses the excess fluid. 2. Monitor the patient’s respirations every four hours to ascertain whether pulmonary hypertension subsides, 3. Monitor the fluid balance of the patient to help assess if the patient retains fluid.	1. Replacement of fluids as per the findings of the blood electrolyte results. 2. Assessing the CVP to determine the extent of pulmonary hypertension. 3. Administering ceftriaxone to help combat infection as it is the cause of glomerulonephritis and the subsequent accumulation of fluids.

III. The patient is at risk of impaired breathing patterns related to pulmonary hypertension

Nursing outcome	Nursing interventions	Collaborative interventions
1. The patient’s breathing patterns will remain normal during his stay in the hospital and afterward. 2. The patient will not develop a cough throughout hospitalization. 3. The pulmonary edema will reduce in the next 24 hours.	1. Positioning the patient in semi-fowler’s position to enhance breathing and allow the easier movement of air in and out of the respiratory system. 2. Deep breathing exercises help improve the use of muscles for respirations, hence alleviating coughing. 3. Inspection of the neck for jugular vein distention.	1. Performing chest physiotherapy to help improve breathing. 2. Relaxation techniques with the aid of an occupational therapist will prevent straining and reduce the incidences of coughing. 3. Dietary restrictions of sodium and fluids will help alleviate fluid overload, which predisposes the patient to pulmonary hypertension.

Independent Nursing Interventions

The focus of the independent nursing interventions is to increase the comfort of the patient, reduce the incidences of complications, and provide health education to the patient to increase awareness of the prognosis of the disease. The patient’s comfort improved after he had had adequate rest, which helped alleviate his fatigue (Timby & Smith, 2013). The patient was always placed in the positions that enhanced his breathing, such as the fowler’s and the cardiac positions; consequently, they helped the easier expansion of the lung tissues, thus alleviating straining while breathing (DeWit et al., 2016). Hygiene was promoted through assisted bed bath as it helped increase the patient’s comfort by removing sweat and dirt as well as some of the uremic deposits on the skin (Ignatavicius & Workman, 2015). To avoid skin irritation caused by the uremic deposits, a mild soap was used for bathing and a mild lotion was applied afterward. The patient’s bedding was always dry and wrinkle-free to prevent the development of pressure sores, which was achieved by giving the patient a urinal and a bed pan during the time that he was having bed rest (Ignatavicius & Workman, 2015). Passive exercises were done to allow the supply of blood to different parts of the body since the patient presented with a low hemoglobin level. The patient should be given food with little proteins to avoid the accumulation of uremic waste products that usually cause skin irritations, headaches, and vomiting. The patient was given a vomitus bowl to always use in the event of vomiting and a nurse was not nearby; thereafter, he had to call a nurse for the disposal of the vomitus.

The nurse needs to adhere to the standards of preventing infection. To prevent complications, a head-to-toe examination was done to exclude any skin breakdown. Thus, a broken skin could create a portal of entry for the pathogenic microorganisms and the patient might develop an infection of the wound that could proceed to sepsis (Timby & Smith, 2013). To improve the hemoglobin level and prevent anemia, the patient was given a diet rich in iron; he was also advised to always report in case the color of urine turned dark brown and he manifested any increased signs of fatigue. During the initial period of management, the patient’s position was changed every two hours to prevent the development of pressure sores (Ignatavicius & Workman, 2015). Moreover, pressure area care was performed every four hours to improve blood circulation, which helped prevent the development of decubitus ulcers. The vital signs were monitored every four hours as well, including temperature, pulse, respiration, blood pressure, and oxygen saturation to exclude the occurrence of cardiac arrhythmias, endocarditis, and heart failure. These complications are commonly associated with acute glomerulonephritis (Ignatavicius & Workman, 2015). To improve the coping mechanism of the patient and prevent incidences of stress and depression, the family member, his wife, was involved in the treatment regimen, and she was encouraged to visit the patient as often as possible.

The patient was given health education, which empowered him with knowledge of the disease process. As a result, the disease will not occur again. The patient was informed to treat any infections of the throat immediately as this will help prevent future incidences of glomerulonephritis post-streptococcal sore throat infection (Timby & Smith, 2013). The need for follow-up at the surgical outpatient clinic was emphasized so that the prognosis of the disease was evaluated and any interventions were performed before the condition deteriorated. The patient was informed to report back to the healthcare facility in the case of signs of decreased functioning of the renal system, such as oliguria since this was an indication of poor prognosis and a sign of possible complications (DeWit et al., 2016). Visiting the healthcare facility promptly would allow taking appropriate measures, which would lead to a good prognosis for the patient.

Interdisciplinary Care: The Team

The interdisciplinary team that was involved in the care of John include the doctor, the urologist, the cardiologist, the dietician, the physical therapist, the occupational therapist, the pharmacist, the nurses, the radiologist, and the surgeon. The doctor had the initial contact with the patient at the outpatient department; he took the patient’s history, performed a complete physical examination, ordered the different tests and examinations as well as developed a diagnosis for the patient (Ignatavicius & Workman, 2015). The doctor made the initial prescription of drugs for John and assessed him on the daily basis during the rounds to know the patient’s progress in response to the treatment regimen. The urologist was called to review the patient due to the specialization in urinary system disorders (DeWit et al., 2016); after a focused review, the urologist ordered a needle biopsy of the kidney to confirm the diagnosis of glomerulonephritis. Since the patient had azotemia, dialysis was prescribed to alleviate its disturbing symptoms such as pruritic, severe headache, and fatigue. The urologist continued evaluating the laboratory investigations to ascertain whether the function of the renal system showed any signs of improvement.

The cardiologist assessed the patient’s heart to determine its functioning. Since the patient with glomerulonephritis is at risk of cardiac dysrhythmias due to the high levels of potassium in the blood, such an assessment is required. The cardiologist also monitored the heart sounds of the patient frequently to exclude any cardiac anomaly (Timby & Smith, 2013). The dietitian advised John on the diet that should be rich in carbohydrates, moderate protein, limited salt, fluid, and phosphorus. The dietitian also educated the patient on the most affordable sources of food with different nutrients. The physical therapist helped John perform a different range of motions and developed an activity rest program based on the course of the disease. The occupational therapist helped the patient to be able to perform the various activities of the daily routine such as feeding and bathing themself so that John did not become completely dependent on any person.

The pharmacist helped in dispensing the prescribed medications and ensuring that the ordered medications and fluids were always available. The radiologist took the patient’s chest x-ray to be able to confirm the existence of pulmonary hypertension (Ignatavicius & Workman, 2015). The surgeon performed a biopsy of the kidney tissues. The nurses played a critical role in providing nursing care such as administering prescribed medications, monitoring vital signs, taking the patients for x-ray, and assisting the cardiologist during electrocardiography. They also helped in serving meals and feeding the patient, turning him, participating in ward rounds, and ensuring that he took the right diet and did all prescribed exercises. Finally, nurses educated John regarding the disease process.

Interdisciplinary Care: Therapeutic Modalities

The two therapeutic modalities for the patient were kidney biopsy and hemodialysis. The rationale for the kidney biopsy was to determine the extent of the damage to the kidney to confirm the diagnosis of acute glomerulonephritis and to establish whether further surgery was needed to improve renal function (Ignatavicius & Workman, 2015). The biopsy of the kidney tissues was performed by the surgeon with the assistance of the nurse. The latter played a great role in nursing the patient before and after the procedure. Before the kidney biopsy, the role of the nurse involved ensuring that the needed investigations, such as urinalysis, serum creatinine, and coagulation studies were done, keeping the patient nil per oral, administering intravenous fluids, and explaining the procedure to him as well as his role during the procedure. After the needle biopsy, the nurse’s role was in positioning John in the prone position for about 24 hours to minimize bleeding, monitor vital signs, assess pain and administer analgesics, assess for bleeding, and limit the fluid intake to 3 liters in a day. The doctor evaluated the condition of the patient to assess the progress post-biopsy. The physical therapist educated John on the activities to undertake and to avoid strenuous activities.

Another therapeutic modality was hemodialysis. This procedure was indicated to remove the accumulated waste product from the patient’s blood (DeWit et al., 2016). The urologist performed hemodialysis by creating an arteriovenous fistula and connecting the patient to the dialysis machine. The nurse was supposed to monitor the status of the patient during the procedure by taking the vital signs. The nurse also assessed John’s electrolyte and acid-base balance to establish the effectiveness of dialysis. Furthermore, the nurse maintained sterility and a closed system to prevent the patient from developing infections. After hemodialysis, a continuous review of the patient was performed by the doctor. The dietitian educated John on limiting the intake of protein so that the uremic waste products could not accumulate in the body. Since one of the greatest complications of hemodialysis is heart failure, the cardiologist assessed the electrical activity of the patient’s heart by the use of an electrocardiogram.

Nursing Role Reflection

Regarding communication, the interdisciplinary team worked collaboratively with the patient and his family member during the treatment regimen. Each member of the team was always available when called to review the patient, and this aspect ensured a smooth running of various procedures. All members of the team always documented the performed activity on the patient’s file, which helped in the continuity of care even in the absence of a team member. The patient was always informed about the procedure that would be performed or any activity, and this helped in getting cooperation from him. During the visiting hours, the patient’s wife was always informed by the nurse about the progress of her husband, which gave her hope that he would have a good prognosis.

My communication style had a positive impact on the interdisciplinary team, the patient, and the family member. To the interdisciplinary team, I always ensured that whenever a patient required a review, I called the needed person in advance and explained the rationale of the review. This factor greatly helped the team work in harmony. Moreover, after every procedure, I always reminded the team member to document any actions since anything that had not been documented was considered not done. I also managed to create a rapport with John, which assisted me in gaining his cooperation. In addition, I always acquired informed consent before performing any procedures; this assured me that the patient fully understood the need for the procedure. During my communication with John’s wife, I always reassured her that all would be well, thus keeping her strong and enabling her to remain positive that the husband would recover.

One of the system barriers is the fact that interdisciplinary team members, who are called to review the patient, also work in other healthcare facilities, and it takes longer for them to report upon being called. A delay in response to a change in the patients’ condition has been linked with incidences of morbidity and mortality (Timby & Smith, 2013). The other system barrier is that some of the members of the team are not familiar with the hospital policy on documentation after an intervention. Thus, if not reminded, they are likely not to document their actions.

One of the recommendations is that the facility should employ an adequate amount of health care personnel. To provide quality care and prevent the development of complications for the patient, there is a need for a sufficient number of healthcare providers (Ignatavicius & Workman, 2015). The final recommendation is that the interdisciplinary team needs to be empowered with the information on the need for documenting the care administered to the patient. Documentation help in the continuity of care, which will present evidence that the patient is given the required care (Timby & Smith, 2013). This means that the patient’s documents can be used to evaluate the progress of treatment.

To develop professionally, I plan to work together with the members of the interdisciplinary team to be informed on what they do to the patient. In case I am asked by the patient about what has been done, I can confidently inform them. Collaborative management has been liked with quality care and a good prognosis of the disease (DeWit et al., 2016). I have realized that most nurses do not like assisting other members of interdisciplinary teams, saying that it is beyond the nursing scope. For instance, most nurses do not participate in the doctor’s ward rounds; yet, I find such participation important as I learn about the patient. I also plan to read more about the patient’s condition and its management as this will help me contribute to the discussion during an interdisciplinary team meeting.

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