Adult Health 2
Learning Objective #1: Explain the function of the kidneys in regulating fluids, electrolyte balance, acid–base balance, blood pressure, RBC production, and Vitamin D synthesis.
a. What are the main functions of the kidneys?
b. During urine formation, which two substances should be reabsorbed and not excreted in the urine?
c. What two major electrolytes do the kidneys help regulate?
d. What is the role of the kidneys in maintaining serum pH through bicarbonate?
e. Explain the renin-angiotensin system in regulating blood pressure, including the roles of anti-diuretic hormone and aldosterone in this system.
f. How do the kidneys contribute to RBC production?
g. How do the kidneys contribute to Vitamin D synthesis?
Learning Objective #2: Explain the renal system changes and nursing implications for older people.
Learning Objective #3: Initiate education, preparation, and monitoring for patients undergoing diagnostic studies, including labs, 24-hour urine collection, any that use contrast media, and kidney biopsy.
a. What are the normal ranges for urine specific gravity, creatinine clearance, serum creatinine, serum BUN, and GFR?
b. What is the significance of abnormal values of urine specific gravity, creatinine clearance, serum creatinine, BUN, and GFR in kidney disorders?
c. What is the purpose and proper collection steps for a 24-hour urine collection?
d. What are the pre-, intra-, and post-procedure interventions and rationales for a patient who will receive intravenous contrast media during a diagnostic test?
Brunner and Suddarth Chapter 54
· Chronic Kidney Disease, pp 1569-1570
· Acute Kidney Injury, pp 1576-1581
· ESKD, pp 1581-1589
· Renal Replacement Therapies, pp 1589-1602
· Chart 54-1, Stages of Chronic Kidney Disease
· Figure 54-4, Causes of Acute Kidney Injury
· Chart 54-6, Assessing for ESKD
· Chart 54-7, Nursing Care for ESKD
Learning Objective #1: Differentiate between chronic kidney disease (CKD) and acute kidney injury (AKI).
a. What is the definition and diagnostic criteria of AKI?
b. What are the categories and causes associated with each category for AKI?
c. What is the definition of CKD?
d. What are the risk factors and causes of CKD?
Learning Objective #2: Explain the pathophysiology, clinical manifestations, medical management, and nursing management for patients with acute kidney injury.
a. Identify and describe the phases of AKI and estimated timeline for each.
b. What are the clinical manifestations (signs/symptoms) for each phase of AKI? How are these s/s for each phase of AKI related to the patho of the condition?
c. Explain the changes to the following labs in the oliguric phase of AKI: BUN, creatinine, GFR, creatinine clearance, potassium, magnesium, phosphorus, calcium, sodium, pH.
d. Explain why the following nursing management is necessary in AKI, what assessments for each should be completed, and what are the expected nursing and collaborative interventions for each?
ii. Fluids and electrolytes
iii. Metabolic rate
iv. Pulmonary function
v. Infection prevention
vi. Skin care
Learning Objective #3: Explain the pathophysiology, clinical manifestations, medical management, and nursing management for patients with chronic kidney disease.
a. What are the stages of CKD?
b. What are the main treatments in early stage CKD? Why?
c. Why does ESKD affect all body systems?
d. Explain the changes to the following labs in the ESKD: BUN, creatinine, GFR, creatinine clearance, potassium, magnesium, phosphorus, calcium, sodium, pH.
e. What are the signs/symptoms and nursing/collaborative interventions for the following pathologic changes in ESKD?
i. Activation of the RAAS system
ii. Reduced urea excretion and decreased bicarb reabsorption
iii. Inadequate erythropoietin excretion
iv. Hyperphosphatemia, hypocalcemia, and decreased Vit D synthesis
v. Hyperkalemia and hypermagnesemia
Learning Objective #4: Compare and contrast the renal replacement therapies, including hemodialysis, peritoneal dialysis, continuous renal replacement therapies.
a. What is the purpose of dialysis, regardless of type?
b. What acts as the semi-permeable membrane in hemodialysis vs. peritoneal dialysis?
c. What is a continuous renal replacement therapy, and when is it a preferred dialysis treatment?
d. Differentiate between temporary and permanent dialysis access. When is a temporary access used?
e. What is the difference between a hemodialysis fistula vs graft?
f. Differentiate the permanent dialysis access of hemodialysis vs. peritoneal dialysis.
Learning Objective #5: Identify the nursing management of the patient on hemodialysis.
a. What are the nursing considerations for a temporary dialysis access?
b. What are the nursing assessments and interventions for a hemodialysis fistula and graft?
c. What are the side effects of hemodialysis, and why do these occur?
d. What is the nursing/collaborative assessments and interventions for the following HD complications:
iv. disequilibrium syndrome
Learning Objective #6: Identify the nursing management of the patient on peritoneal dialysis.
a. What are the nursing assessments and interventions for a peritoneal dialysis catheter?
b. Explain the phases of a peritoneal dialysis exchange, including the differences between AIPD, CAPD, and CCPD.
c. Explain the pre-, intra-, and post-PD (including patient education) nursing assessments/interventions and rationales for each.
d. Identify the signs/symptoms and management of the following PD complications
ii. Exit site infections
iii. Catheter leakage
Learning Objective #7: Develop a perioperative plan of nursing care for the patient undergoing kidney transplantation.
Get An Oder Like The One Below From Our Nursing Writers
Leadership consists of
various qualities, skills and aspects relating to the action of leading an
organization or a group of individuals (Ennis et al, 2013). The focal point of
the NHS is to enable cultures that provide safe, compassionate and high-quality
care (West et al, 2015). Furthermore, leadership has an impact on a number of
different aspects such as mortality levels, patient satisfaction, staff
well-being, financial performance and generally, the quality of care (West et
al, 2015). The Francis report discussed the importance of distributed
leadership, whereby all healthcare professionals are enabled to think freely,
make decisions and take control themselves. It leads to the provision of
high-quality care (Francis, 2013). This piece of work will assess effective
leadership and why it is a necessity within nursing practice.
Ennis et al (2013) implemented
a study in order to assess the communication characteristics needed for good
leadership within nursing. Interviews were carried out, outlining how effective
communication is key in order to provide high quality care, develop as a
professional and to harbor working relationships (Ennis et al, 2013). The study
produced the following themes: choice of language, listening skills, relevance,
non-verbal communication and relationships. Participants outlined that good
leaders have the knowledge to choose the type of language used and can adapt it
to any scenario that they are faced with. In addition, they suggest that an
effective leader considers the outcome and consequence of each conversation
(for example, whether further support was needed) (Ennis et al, 2013). When
leadership is successful, it enables excellence and ethical and
patient-centered care (Ennis et al, 2013).
Furthermore, it was
noted that good leaders needed to be able to listen, be affable and have
patience (Ennis et al, 2013). One participant outlined that listening should be
first and foremost, valuing its importance and showing great interest in what
the patient has to say (Ennis et al, 2013). Respondents noted the need for
effective communication across all aspects of nursing; with junior staff,
between healthcare professions and when directly caring (Ennis et al, 2013).
Good clinical leaders need to be able to communicate to a high level, adapting
to enable all patients to understand, noting body language, non-verbal cues and
avoiding medically complex terms as much as possible (Ennis et al, 2013). The
study notes the link between effective communication and the amount of
influence that leader has, the team’s performance and their development of
staff member relations (Ennis et al, 2013). Guidelines by NICE also emphasize
the importance of effective communication to enable high quality care (NICE,
2016). Non-verbal communication is also key; effective leaders need to note
their body language and level of eye contact, assessing not only their own
non-verbal cues, but also those of the patient or fellow professional (Ennis et
al, 2013). This will enable them to judge the scenario and to foresee any
issues that may arise (Ennis et al, 2013). Within the study by Ennis et al,
(2013) respondents outlined that good leaders had excellent people skills,
building a good rapport with everyone. To do so, respect and treating each
person as an individual is key (Ennis et al, 2013). It is also vital to ensure
that no judgements are made and that support is offered when needed (Ennis et
al, 2013). Effective leaderships can only be implemented when these areas are
adhered to, building work relationships and providing high quality,
patient-centered care (Ennis et al, 2013).
Emotional intellect is
a key aspect to adhere to when managing situations and caring for patients
(Powell et al, 2015). Controlling emotions and self-awareness are both vital
components of emotional intellect (Powell et al, 2015). Doing so decreases the
risk of burnout and ensures that patients are receiving high quality care
(Powell et al, 2015). In addition, being aware of one’s emotions enables a
collaboration that is needed to meet the needs of individuals within the
complex and increasingly technical NHS system (Powell et al, 2015).
The qualities of a leader
The main traits of a
good leader were assessed by Yukl (2013). They consist of a high level of
energy, stress coping mechanisms, confidence, control, maturity, integrity, as
well as being a high achiever, with low needs for affiliation. Nursing leaders
need to be empowering, promote independence, encourage a critical and effective
work environment and remain positive (Jukes, 2013). They should enable fellow
healthcare professionals to build resilience, enabling them to make their own
decisions yet providing protection when needed (Jukes, 2013). In order to
achieve structural change for the provision of high-quality care, the following
should be adhered to: promoting inclusive team work, maintaining trust, seeking
contribution, using personal authenticity, valuing relationships, enabling
learning and challenging any issues that arise (Cleary et al, 2011). Patients
need support and care which cannot be carried out without effective leadership
(Cleary et al, 2011). If a nurse does not show effective leadership skills,
they often retreat towards more traditional methods of behavior (more
documentation and relying on medicine), instead of promoting patient-centered
care (Jukes, 2013). Furthermore, leaders need to support any professionals that
they are responsible for in following the nursing and midwifery code at all
times (Nursing and Midwifery Code, 2015: 18).
The qualities of a manager
Managers oversee a
certain area, supervising fellow staff and ensuring that patient care is
upheld, in addition to administrative aspects (Jukes, 2013). Concerns are
addressed through their specialized nursing experience, good communication and
the ability to take the lead (Jukes, 2013). Good communication is key when
assessing any risks, managing plans, delegating work and ensuring the effective
and safe provision of resources (Jukes, 2013). Delegating work is an integral
part of effectively leading, encouraging active learning, whilst freeing up
more time for aspects that cannot be delegated (Weir-Hughes, 2011). Delegation
is a necessity, especially when staff numbers reduce and pressures rise
(Griffin, 2016). Managers also demonstrate excellent leadership skills by
improving nurse confidence and upholding morale (Timmins, 2011). They need to
ensure that staff are communicating effectively, in order to provide high
quality, safe care (Timmins, 2011). This can be carried out by implementing an
open leadership style, listening to the nurses and involving the team when
making decision (Timmins, 2011). Gilmartin and D’Aunno (2007) outline how nurses prefer managers who are
emotionally intelligent, facilitate change and who actively participate.
Further stating that this leads to cohesion, a sense of empowerment and reduces
stress and burnout (Gilmartin and D’Aunno,
2007). Management and leadership can only be improved by adhering to the
following: ensuring a good set of qualities and knowledge, a supportive environment,
an adequate number of managers and ensuring rewards or acknowledgement for good
practice (World Health Organization, 2007).
can lead to the unsafe provision of care (Nicolson et al, 2011). This was portrayed
during the 1990s, in which nurse Beverly Allitt
murdered children by injecting them with insulin. She was not supervised and
the deaths were not challenged by management (Nicolson et al, 2011). More
recently, the investigation into the Airedale NHS trust found nurse Anne
Grigg-Booth to be providing dangerous care. Many patients died under her care,
which was noted as an abundance of failures in which dangerous actions were not
acknowledged by management (Nicolson et al, 2011). Within the Mid Staffordshire
Foundation Trust, a lack of leadership and supervision detrimentally impacted
upon the lives of many, with high mortality rates (Nicolson et al, 2011). The
Francis Report identified various issues such as, call bells not being
answered, patients lying in their own urine and left without water or food
(Francis, 2013). Saving money was a priority and management preferred to meet
targets than deal with individual needs and thus leadership was poor (Nicolson
et al, 2011). Ineffective management has not only led to unsafe care but cost
more than £16m in legal fees and implementation costs (Calkin, 2013).
leadership encourages nurses to provide a high level of care by making
influential changes (Cleary et al, 2011). It involves the following actions:
building trust with fellow healthcare professionals, showing integrity,
inspiring team members, offering intellectual inspiration, adhering to the
needs of each individual and providing support (Malloy and Penprase,
2010). With this leadership style, professionals provide clear aims and a
pathway for their work, prioritising mutual respect,
working together, gaining nurse autonomy and upholding staff morale (Cleary et
al, 2011). Doing so prevents burnout, improves job satisfaction and a sense of
commitment (Cleary et al, 2011). Transformational leadership can be contrasted
with the transactional style in which leaders focus upon meeting targets (it is
not creative, reflective and prevents emotional connection) (Cleary et al,
Support for the transformational leadership
A study was
implemented by Malloy and Penprase (2010) on 122
nurses in order to assess their supervisor’s leadership style. The following
leadership styles were analysed: transactional,
transformational, exceptional-active, exceptional-passive and laissez-faire
(Molloy and Penprase, 2010). The study concluded that
aspects of transformational leadership were connected with 17 out of 37 areas
within the working environment, as calculated by the Copenhagen Psychosocial
questionnaire (Molly and Penprase, 2010). Leaders
implementing the transactional style also made positive contributions, but
fewer than that of a transformational style (Molly and Penprase,
2010). In addition, the laissez-faire, exceptional-passive and
exceptional-active styles all negatively impacted the nursing environment
(Molly and Penprase, 2010). Corrigan et al (2002)
carried out a mental health study, consisting of 236 leaders who had
responsibility for 620 staff members. Leaders who noted themselves as high on
the transactional style, had staff outlining low transformational scores. In
comparison, leaders who noted high levels of inspirational and stimulatory
aspects were likely to have staff who felt that their style was transformative
(Corrigan et al, 2002). Lastly, staff members who stated that their leader has
a transformational style experienced less burnout, a better working environment
and support, adhering to conclusions by Malloy and Penprase
(2010). In a time of uncertainty, healthcare budget cuts, policy changes and
financial strain, transformational leadership is key (Cleary et al, 2011). It
encourages staff to treat patients with respect and dignity, promoting patient-centred care and upholding values (Cleary et al, 2011).
Many argue however, that there needs to be more evidence into whether
transformational leaderships enable better care, improved quality of life and
patient satisfaction (Holm and Severinsson, 2010).
NHS leadership review
published findings in order to analyze leadership within the NHS (Department of
Health, 2015). It noted three main areas of concern: a lack of vision, poor
management and leadership and the need for clear pathways in regards to NHS
management careers (Department of Health, 2015). The key recommendations
include: refreshing the NHS graduate scheme, the transfer of NHS leadership
Academy to Health Education England as those responsible for training and
introducing a minimum term on some senior management contracts. In addition,
managers should be supported and have their knowledge updated regularly in
order to prevent ‘skill fade’ (Department of Health, 2015: 53). The report
concluded that, ‘the NHS as a whole, lacks a clear, consistent, view of what
‘good’ or ‘best’ leadership looks like’ (Department of Health, 2015: 20). The
recommendations focus upon training, management, support, performance
management and bureaucracy (Department of Health, 2015).
To conclude, effective
leadership is necessary in order to provide a high level of safe care. It leads
to patient-centered care, excellent communication skills and high quality care.
Leaders need to communication well, have emotional intelligence, distribute
work and implement a transformational style. Whereas poor leadership can lead
to death or severe harm, as took place in the independent investigation into
the Airedale NHS trust. Ineffective leadership was also a main aspect of why
the detrimental acts of Anne Grigg-Booth went undetected by managers (Nicolson
et al, 2011). To emphasise, leadership is a key area
of the NHS and so it is vitally important to ensure that behaviours,
communication skills, qualities, skills, leadership styles and strategies are
focused upon to improve (West et al, 2015). Without doing so, the lives of many
will be affected.