Patient Profile:
R.J. is a 19-year-old male who was diagnosed at age 5 with ESRD from oligomeganephronia or renal hypoplasia. He briefly underwent hemodialysis and then received a cadaver transplant, which functioned for about 5 years. After that kidney failed, R.J. started peritoneal dialysis (PD). Since he was in school, this seemed to be the best option at the time. After about 2 years on PD, it was determined that R.J.’s physical condition might improve on hemodialysis (HD). He has been on HD since July 2002 and is now in his senior year of high school. R.J. lives in rural New England with his mother, who works evenings. R.J. has a driver bring him from school to dialysis and back, which is about 1.5 hours each way.

1. The patient will be free of disability related to renal osteodystrophy.
2. The patient will demonstrate knowledge of chronic kidney disease and systemic effects.
   
3. The patient will participate in the development of a treatment plan and demonstrate ability to follow it.

Discussion:
The biggest problems for R.J. have been hyperphosphotemia, secondary hyperparathyroidism, and hypertension, all directly related to noncompliance.

The Standards of Nephrology Nursing Practice (ANNA, 1999) note the importance of knowledge regarding the proper use of binders and how they affect PTH secretion and the bones. The standards also recommend patient education to help patients understand how to take their medications and why they are important. Related to this outcome is compliance to the medication regime for both phosphate binders and antihypertensives.

When R.J. came to HD from PD, his average blood pressures were 204/120 mmHg pre-dialysis, down to 180/98 after 3 hours of dialysis. He dialyzed after school Monday, Wednesday, and Friday from 4-7 pm. R.J.’s interdialytic weight gains were between 1.5-2.5 kilograms, and he received calcitriol intravenously each treatment. R.J. completed each HD treatment and tolerated ultrafiltration of up to 3-4 kilograms as needed. Consistent with Orem’s Self-Care framework (Fawcett, 2000), ongoing education was presented to R.J. and his mother, although R.J. came alone most of the time. He was able to verbalize the names of his medications, when to take them and why, but he openly admitted that he found it difficult to be consistent in taking them. He was encouraged to keep his phosphate binders near where he ate his meals, frequently in front of the TV, to help him to remember to take them. His blood pressure medications were prescribed once and twice a day. After much discussion with R.J. and with his school nurse, it was decided to have him take a supply of both phosphate binders and blood pressure medications to school as well as to the dialysis center. This would enable R.J. to request them from the school nurse and the dialysis nurse when he was at those places.

When the program began, R.J.’s phosphorus was between 9.0-11.0 mg/dL, his BI-PTH was as high as 1124 pg/ml, and his blood pressures were often more than 200/120 mmHg pre-dialysis. After the new regimen was instituted there was a dramatic improvement in R.J.’s phosphate control, PTH levels and BP. His phosphorus has consistently been around 6.0-6.5 mg/dL, his BI-PTH is down to 207 pg/ml, and his blood pressure is around 140/80 mmHg most of the time. The added support from the staff in the dialysis unit as well as at school has increased R.J.’s awareness of the importance of these meds and made them more available to him. Ultimately, because he needs to ask for the meds, it enhances his sense of responsibility and he has been able to achieve the desired outcomes more consistently.

Summary
By involving R.J. in a multidisciplinary team effort, his outcomes have largely been met. Compliance has been better with a heightened awareness of the medications he needs to take in order to meet his goals. Although his blood pressure and lab values have improved, it is important to continue support and encouragement for R.J. The methods used in this case study have provided great benefits for this adolescent with renal osteodystrophy and may be helpful for other patients.

References

American Nephrology Nurses’ Association (ANNA). (1999). Standards and guidelines of  clinical practice for nephrology nursing. (Rev. ed., pp. 39, 49-50). Pitman, NJ: Anthony J. Jannetti, Inc.

Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge: Nursing models and theories. Philadelphia: F.A. Davis Company.