This case study is an example of how the nurse collects, analyses, identifies and individualizes a plan of care for the elderly patient on hemodialysis. The importance of the nurse as the coordinator of care, initiator of interventions needed, and holder of knowledge about resources available are discussed.

Patient Profile
G.B. is a pleasant 81-year-old white male who has been on dialysis for 6 months. He transferred to the outpatient unit from a major metropolitan hospital where dialysis was initiated using an arteriovenous fistula. Ongoing cannulation problems were encountered there and continued at the outpatient facility.

G.B.’s past medical history includes Type 2 diabetes for 20 years and uncontrolled hypertension. Medications were labetolol, norvasc, minoxidil, furosemide, clonidine and valsartan, which were all at maximum dosages prior to the start of dialysis.

1. Patient will maintain adequacy of dialysis through improved access function.
2. Patient’s blood pressure will be controlled.
   
3. Patient will regain an independent lifestyle while adhering to dialysis schedule and routine. 
   

Discussion
Maintaining adequacy of dialysis in the elderly patient presents a special challenge for the nurse (National Kidney Foundation [NKF], 2001). Early recognition of cannulation difficulties, monitoring patient adherence and promoting patient comfort require ongoing evaluation and intervention. G.B.’s assessment included reviewing lab data and blood drawing techniques, assessing blood flow rate of dialyzer, placement of needles, and ongoing monitoring of time and weight loss during treatments.

Cannulation problems were immediately addressed in the new setting. Plans were made to evaluate the fistula and a referral to the vascular surgeon was arranged. In the interim, a staff member who had successfully cannulated his fistula was assigned as much as possible. This allayed some of the fear associated with repeated sticks and subsequent infiltrations. Self-management and involvement of the patient and family encouraged the use of simple strategies to strengthen and protect his access site. These included exercising his arm by squeezing a stress ball, and the use of ice to decrease the swelling after an infiltrate.

Reassuring the patient about the need to have the fistula evaluated in order to improve access was well received when the information was explained and reinforced by the nurses. The terms percutaneous transluminal angioplasty and surgical revision were introduced but not yet fully understood by the patient. Though G.B.’s urea reduction rates were explained, he was unable, or perhaps unwilling, to process the fact that his treatments were not consistently meeting the KDOQI recommended parameter which is greater than 65%. (NKF, 2001). At this time, the family became involved and the KDOQI guidelines were used to assist the family in understanding the need for adequate dialysis, as well as control of his blood pressure.

The goals of the KDOQI guidelines (NKF, 2001) are to maximize patient adherence, improve quality of life, and improve patient outcomes. On days that runs were cut short because of infiltration or poor venous pressures, a decision was made not to restart the dialysis but to work with G.B. to decrease his fluid intake for the next day. In this situation the decision was made that patient comfort was most important for the short term in order to prepare him for long-term adherence to his hemodialysis prescription. Because comfort is an ongoing issue for the patient on hemodialysis, it was important to minimize the amount of discomfort. This was seen as a preventative measure with G.B. in order to gain trust and cooperation in working on establishing his routine.

It was anticipated that declotting or fistula revision would result in improved access. Patient adherence is a major barrier to providing adequate hemodialysis and this was difficult for G.B. Anxiety and an inability to hear well contributed to his inability to comprehend instructions given during treatments. Reassurance and reestablishing the family connection helped. Because of his decreased hearing, he depended on the nurse to speak clearly through all the noises and distractions in the unit. The connection with the nurse was crucial for the provision of care and patient satisfaction.

Blood pressure control was a challenge for G.B. because of fluctuations he experienced at home and during treatments. Though his blood pressures were high at the beginning of treatments, he experienced many intradialytic hypotensive events. Interventions included frequent medication adjustments, increasing the sodium content of the dialysate, and post treatment chicken soup. In addition, monitoring parameters were reinforced with G.B. and his family members. Attention to and reporting of blood pressure readings led to a weaning of clonidine and minoxidil and eventually a decrease in G.B.’s labetolol. The importance of weaning labetolol gradually was emphasized because of associated cardiac events with abrupt discontinuance. Frequent reminders to monitor blood pressure at home helped G.B. because he tended to comply for short periods and then began to revert to previous behaviors.

The difficulty of knowing dialysis is a lifelong commitment is a hard reality to face day to day, particularly for those older persons who are not transplant candidates. In order to maintain adherence to his dialysis regimen, issues around the importance of having adequate dialysis needed constant reiteration.

G.B. remained independent with family support as he underwent his dialysis treatments. His overall health stabilized during these 6 months. Viewing his treatment sessions as a part-time job helped with adherence to his schedule. Treatments were scheduled early in the morning and G.B. was able to drive himself, which was an advantage of transferring to a freestanding clinic close to home.

Summary
Elderly patients on dialysis present a special challenge because they are often unsure of taking their health into their own hands and may be more resistant to self-management. When G.B. started on dialysis, he had little knowledge of what this entailed and self-management was not a concept that he could accept. Assertive communication with caregivers and protective self-management strategies were stressed as he transitioned to the unit. He did not complain to his providers when cannulation became more difficult, perhaps because of what he perceived as negative repercussions (Curtin, Sitter, Schatell, & Chewning, 2004). Reassurance, presence, and explanations were helpful in alleviating G.B.’s fears of speaking up. Communication was critical and required an ongoing effort by the staff.

End of life issues common to the elderly patient include establishing an advance directive. G.B. chose a do not resuscitate status. He discussed his wishes with the social worker and though he did not want heroic efforts if he was at his home, he wanted reasonable measures done while at the dialysis center. Therefore, he decided that full resuscitative measures should be instituted. He was not a candidate for transplantation.

G.B. presents with many issues familiar to dialysis nurses. On going and ever-changing planning is needed for the patient undergoing any extracorporeal treatment. As the primary contact with the patient the nurse is also the primary communicator with the physician who rounds in the dialysis unit. In addition, problem identification and initiation of referrals makes the nurse the most important connection for the patient on dialysis.

This case uses the recently revised standards of care for nephrology nursing and the KDOQI guidelines. The standards support the creativity and decision making needed for individual patients in planning of care (Amato, 2006; Burrows-Hudson & Prowant, 2005) and the KDOQI guidelines substantiate interventions used in caring for G.B. Interpretation of the guidelines for individual patients and families is an important step. Problems for the elderly as they undergo hemodialysis require ongoing assessment and evaluation in order to bridge care from dialysis to end of life. Each of the guidelines offers just that, a guideline for the stages and experiences of the patient on dialysis.

References

Amato, R.L. (2006). Changes to the nephrology nursing standards of practice and guidelines for care, 2005. Hemodialysis Horizons, 76-79. Retrieved August 1, 2006, from http://www.aami.org/publications/HH/Nephrology. Nursing.Amato.pdf

Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing standards and guidelines for care. Pitman, NJ: American Nephrology Nurses’ Association.

Curtin, R.B., Sitter, D.C.B., Schatell, D., & Chewning, B.A. (2004). Self-management, knowledge, functioning and well being of patients on hemodialysis. Nephrology Nursing Journal, 31(4), 378-388.

National Kidney Foundation (NKF). (2001). KDOQI clinical practice guidelines. American Journal of Kidney Diseases, 37, S1-S182.