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Chronic Kidney Disease (CKD) - Coggle Diagram
Chronic Kidney Disease (CKD)
Listing of the subjective and objective information that indicates the presence of ESRD and complications of ESRD
Subjective information
Uremic symptoms
fatigue & weakness
nausea
constipation
dry, scaly arms and legs
leg swelling
anemia
Objective information
High BP: 175/88 mm Hg (Predialysis)
High BUN level: 59 mg/dL
High Scr level: 8.9 mg/dL
GFR value: 9.99 mL/min/1.73m
Low Hgb & RBC level: 9.3 g/dL & 2.84 x 10^6 /mm3.
High alkaline phosphatase & phosphate level: 175 IU/L & 6.7 mg/dL
Complication
mineral & bone disorder
cardiovascular disease
dyslipidemia
malnutrition
hyperparathyroidism
Additional information to fully access this patient's ESRD
Physical examination
Urine test
Check Albumin level in urine.
Amount of urine produced.
Assessment of laboratory values
High iPTH level: 855 pg/mL
Do kidney biopsy to asses the type of kidney disease and its severity.
percutaneous biopsy (renal needle biopsy)
open biopsy (surgical biopsy)
Assessment of the severity of ESRD based on the subjective and objective information available
Assessment based on the subjective information
Anuria
Fatigue and weakness
Nausea
Swelling of feet and legs
Assessment based on the objective information
BUN level = 59 mg/dL
SCr level = 8.9 mg/dL
Phosphate level = 6.77 mg/dL
TSat = 12%
iPTH = high
List of patient's drug therapy problems and prioritize them.
Patient's drug therapy problems
Lisinopril + Furosemide problem
Metoprolol + calcium acetate
Ferrous sulphate therapy
Lisinopril dose
Goals of pharmacotherapy in this case
To prevent the mortality and morbidity of the patient
To control the blood pressure level
To improve the signs and symptoms of ESRD
To improve the quality of life
To control the Intact Parathyroid Hormone (iPTH) level
To control the phosphate ions level
To control the anemia condition of the patient
Non-drug therapies that might be useful for this patient
Lower the intake of salts in diet
Control fluid intake (maximum 500ml)
Limit the protein intake in diet
Avoid all processed and canned foods
Smoking cessation
Increase physical activities such as light exercise
Lower the potassium foods intake e.g banana
Stop/Avoid drinking alcohol
Eat foods rich in iron such as red meat
Feasible pharmacotherapeutic alternatives available for treating this patient's ESRD related problems
Alternatives Medications
Replacing iron sucrose if no longer successfull
Ferric pyrophosphate citrate via hemodialysis session (iv)
Ferric Gluconate via hemodialysis session (iv)
Replacing the hypertensive drug
Add on ACE Inhibitors (Double)
Double ACE Inhibitors ?????????
Change CCB
Lisonopril & Atenolol
Replacing medicines to high phosphate
Ferric citrate
Sucroferric oxyhydroxide
If this hypertensive dialysis patients noncompliant with their medications
Transdermal clonidine therapy once a week.
Individualised, patient-centred, team-based care plan in optimising the medication therapy for this patient's ESRD and other drug-related problems. And the Implement Care Plan.
Care Plan to the patient
Patient Centred Goals
Reduction of the blood pressure of the patient
Strategies
Optimise the doses of antidiuretic & hypertensive medicines
Outlining Task & Schedule
Increase the dose of: Lisinopril - 40 mg per oral daily
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Maintain the dose of: Metoprolol - 50 mg per oral BID
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Maintain the dose of: Furosemide - 80 mg per oral Daily
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Prevention of mortality and morbidity of the patient
Strategies
Preventing the other organ dysfunction; and drug toxicity
Outlining Task & Schedule
Monitor the respond of the patient towards the recommended therapeutic plan with follow up
Controlling the phosphate level of the patient
Strategies
Optimise the doses of the medicines to control the phosphate level
Outlining Task & Schedule
Maintain the dose of: Calcium Acetate - 667mg three caps per oral TID with meals
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Improving the quality of life of the patient
Strategies
Provide the best advice for the benefit of the patient
Help in improving the sign and symptoms of ESRD
Nephro- vite
Time suggestion
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Omeprazole - 20 mg daily
Time suggestion
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Ducosate - 100mg per oral
PRN
Calcium Carbonate per oral
PRN
Controlling iPTH level of the patient
Strategies
Optimise the doses of the medicines to control the iPTH level
Outining Task & Schedule
Maintain the dose of: Calcitriol - 0.5 mcg IV TID with dialysis
Improving Anemia condition of the patient
Strategies
Optimise the iron intake for the patient
Outlining Task & Schedule
Maintain the dose of: Epoetin alfa- 10,000 units IV TID with dialysis
Increase dose of: iron sucrose to 100 mg IV once weekly at dialysis
Information that should be provided to the patient to improve medication use patterns, ensure of the successfull therapy, and minimising adverse effects
Information to the patient
Don’t take all drugs in one time
Take the medication at the same time on daily basis
Don’t double up the doses on missed doses (and take the missed dose immediately if almost time for your next schedule dose.
Inform the side effects of the drugs to the patient
Advise the patient on how to take the patient on appropriate time and frequency
Description on how the care should be coordinated with other health care providers.
Follow up: Monitor & Evaluation
Monitor blood glucose
Monitor all the drugs prescribed
Monitor the dialysis (Practice Good Hygiene when using catheter)
Monitor phosphate level
Monitor electrolyte balance
Monitor blood pressure
Monitor thyroid function
Monitor blood urea nitrogen
Monitor hemoglobin, glucose, creatinine, calcium, potassium
Clinical and laboratory parameters that should be used in evaluating the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects.
Clinical and laboratory parameters
Clinical parameters
skin condition
physical appearnce
clinical presentation
facial expression
laboratory parameters
Serum creatinine level, a normal serum creatinine reference concentration range is 0.59-1.04mg/dL
A blood test for creatinine, a waste product from muscle breakdown. This should be used to calculate your glomerular filtration rate, or GFR. Your GFR is a measure of your level of kidney function.
Blood pressure, within normal range is blood pressure to less than 130/80
Systolic pressure less than 130mmHg , diastolic pressure less than 80 mmHg
Urine output, a normal urine output reference concentration range is 1-2 ml/kg/hr
High levels of phosphorus in your blood may lead to bone disease.
High level phosphorus is indicated a sign of kidney damage.
Lead to cardiovascular calcification, metabolic bone disease (renal osteodystrophy) and the development of secondary hyperparathyroidism (SHPT)
Red blood cells and white blood cells. a normal red blood cell reference concentration range is4.3-5.4x 106/mm3. a normal white blood cell reference concentration range is 4,5-11 x103/mm3
Phosphate level, a normal phosphate reference concentration range is 2.5-4.5 mg/dL
If your GFR is too low, it may mean your kidneys are not able to remove enough wastes and extra fluid from your blood.
Development of a plan for follow-up that includes appropriate time frames in accessing the progress toward the achievement of goals of the therapy.
Follow-up plan
Urine output
800 to 2,000 ml daily
Once in a week
For 2 months
Serum phosphorus level
>
3.5 mg/dL, <5.5 mg/dL
Once in 2 days
For 2 months
Serum creatinine
0.59 to 1.04 mg/dL
Once in 2 days, after reaching the target range: once in a week
Lifetime
Glomerular filtration rate
Maintain current level
Once in a week
Lifetime
Corrected total calcium serum level
8.4 to 9.5 mg/dL
Once in 3 months
Until 20 years after menopause
BUN
7 to 27 mg/dL
Once in 2 days, after reaching the target range: once in a week
For 1 year
Blood pressure
Systolic: <130 mmHg
Once daily
Lifetime
Diastolic: <80 mmHg
Blood potassium level
3.5–5.5 mEq/L
Once in a week
For 3 months
Hemoglobin A1C
<7% (<7 gm/dl)
Twice in a year
Lifetime
RBC count
3.92-5.13 million cells/mcL
Once in a week
Lifetime
WBC count
3,400 to 9,600 cells/mcL
Once in a week
Lifetime
Haemoglobin
12 to 18 g/dL
Once in a week
Lifetime
Hematocrit
33-36%
Once in a week
Lifetime
iPTH (intact parathyroid hormone)
150-300 pg/ml
Once in 2 weeks
For 3 months
Urea reduction ratio
>
65% :
Once in a month
Lifetime
Kt/V
>
1.2
Once in a month
Lifetime
Alkaline phosphatase level
44 to 147 IU/L
Once in 6 months
Lifetime