Case Study: Mr. D.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mr. D., presented below.
Health History and Medical Information
Mr. D. is a 65-year-old male nonadherence diabetic with end-stage renal disease receiving dialysis. He is a retired certified public accountant in the last 5 years and practices the Muslim faith. He reports that he avoids all pork products. His complaints included decreased balance, loss of sensation, fear of falling, and decreased endurance during activities of daily living due to the effects of dialysis treatment. Patient’s previous medical evaluation includes end stage renal disease (ESRD) on dialysis and referral for recommendations for initiating exercise program. Patient comorbidities include obesity with a body mass index (BMI) of 45, type II diabetes mellitus with long-term insulin use, hypertension, sleep apnea, depression with lack of family support and understanding, and diabetic neuropathy. Patient denies suicidal ideation but does report feelings of loneliness and helplessness. Mr. D. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months.
Objective Data:
- Height: 68 inches; weight 134.5 kg
- BP: 140/94, HR 84, RR 22
- 2+ pitting edema bilateral feet and ankles
- Fasting blood glucose: 146 mg/dL
- Total cholesterol: 250 mg/dL
- Triglycerides: 312 mg/dL
- HDL: 30 mg/dL
- Serum creatinine 1.8 mg/dL
- BUN 32 mg/dl
- GRF (glomerular filtration rate)-13mL/min
Clinical Manifestations
Describe the clinical manifestations present in Mr. D., focusing on the normal and abnormal findings and how this relates to his current condition.
Subjective
Objective
Potential Health Risks for Diabetes With End-Stage Renal Disease
Identify the potential health risks for a diabetic with ESRD and the impacts of nonadherence.
Identify the potential health risks for a diabetic with end-stage renal disease (ESRD) that are of concern for Mr. D.
How does Mr. D.'s nonadherence to his diabetes self-management plan for DM Type II contribute to ESRD?
Describe the common considerations with insulin use for practicing Muslims.
Pathophysiology of Renal Dialysis
Explain the pathophysiology of renal dialysis.
Explain the pathophysiology of renal dialysis. Compare peritoneal dialysis and hemodialysis.
Describe in detail the pathophysiological explanation and stages of renal disease that leads to ESRD.
Explain the potential factors that contributed to Mr. D.'s ESRD.
Full Answer Section
How it applies to Mr. D.'s practice situation:
- Access to Dialysis: Mr. D. is 65 years old and already receiving dialysis. The Medicare ESRD program is the foundational policy that guarantees his access to this life-sustaining treatment. Without it, the cost of dialysis (which is extremely high, often tens of thousands of dollars annually) would likely be prohibitive, regardless of his prior profession as a CPA. This policy ensures that the financial barrier to essential care for ESRD is removed.
- Comprehensive Coverage: Medicare ESRD covers a broad range of services related to ESRD, including:
- Dialysis treatments (both hemodialysis and peritoneal dialysis).
- Dialysis-related equipment and supplies.
- Prescription drugs related to ESRD (e.g., erythropoiesis-stimulating agents, phosphate binders).
- Kidney transplant services.
- Physician services. This comprehensive coverage directly supports Mr. D.'s ongoing medical needs.
- Impact on Care Planning: For Mr. D., who has multiple comorbidities (obesity, type II diabetes, hypertension, sleep apnea, depression, diabetic neuropathy), the existence of this policy means that his care team (including the RN-BSN nurse) can focus on managing his complex health needs without the immediate and overwhelming concern of how he will pay for his primary life-sustaining treatment. It allows for the referral to exercise programs, management of his blood glucose and lipids, and addressing his depression, knowing that his fundamental ESRD treatment is secured.
- Addressing Non-Adherence (Indirectly): While the policy doesn't directly solve non-adherence, it creates the opportunity to address it. Because Mr. D. has guaranteed access to dialysis, healthcare providers can then focus on the psychosocial factors contributing to his non-adherence (like his depression, loneliness, and lack of family support) and work on strategies to improve his self-management, rather than fighting for basic treatment access.
Citation:
- The Social Security Act, Title XVIII, Section 226A.
- This is typically cited as the legal basis for the Medicare ESRD program. You can find information about it on official U.S. government websites like the Social Security Administration (SSA) or the Centers for Medicare & Medicaid Services (CMS). For instance, a common reference point is the 1972 amendments to the Social Security Act, Public Law 92-603, which specifically extended Medicare coverage to individuals with ESRD.
Clinical Manifestations
Describe the clinical manifestations present in Mr. D., focusing on the normal and abnormal findings and how this relates to his current condition.
Subjective Findings:
Sample Answer
Policy Selected: Medicare End-Stage Renal Disease (ESRD) Program
1. Overview of the Policy and How it Applies to Mr. D.'s Practice Situation:
The Medicare End-Stage Renal Disease (ESRD) Program is a specific federal entitlement program under Title XVIII of the Social Security Act. It was established in 1972 (Public Law 92-603) and ensures that virtually all Americans diagnosed with ESRD, regardless of age, can qualify for Medicare coverage for dialysis and kidney transplant services. Prior to this legislation, individuals with ESRD often faced catastrophic financial burdens for life-sustaining treatment,