Nursing Process Paper: Chronic Kidney Disease and Pulmonary Edema
This nursing process paper presents a clinical case study of Mr. Black, a 67-year-old African-American male admitted to the emergency room with swelling of the feet, shortness of breath, and fatigue. The paper documents his medication regimen for multiple comorbidities including hypertension, diabetes, asthma, and hyperlipidemia, and analyzes his laboratory and diagnostic findings. Abnormal results — including elevated potassium, low eGFR, elevated BNP, and chest X-ray findings — support diagnoses of stage three chronic kidney disease, cardiogenic pulmonary edema, and heart failure. The paper concludes with a nursing care plan addressing impaired gas exchange, fluid overload, and patient education strategies.
- Patient Overview and Medical History: Introduces patient demographics, comorbidities, and admission
- Medication Regimen: Details five prescribed drugs and nursing implications
- Laboratory Studies and Diagnostic Findings: Analyzes abnormal lab values and chest X-ray results
- Medical Diagnosis: Links lab data to CKD, pulmonary edema, and heart failure
- Nursing Care Plan: Outlines nursing interventions for fluid overload and oxygenation
- Conclusion: Summarizes diagnoses and key clinical findings
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What makes this paper effective
- Integrates pharmacology, laboratory data, and physical assessment into a cohesive clinical narrative, demonstrating how each data source informs the final diagnoses.
- Systematically links abnormal lab values (e.g., low eGFR, elevated BNP, elevated potassium) to specific pathophysiological mechanisms, grounding the diagnoses in evidence.
- Provides a practical nursing care plan that maps directly to the diagnosed conditions, connecting assessment findings to interventions and patient education goals.
Key academic technique demonstrated
The paper demonstrates clinical reasoning through convergent evidence — gathering data from multiple sources (medication history, laboratory values, diagnostic imaging, and physical assessment) and synthesizing them into a unified diagnosis. This technique is foundational in nursing education and illustrates how students learn to move from isolated data points to a comprehensive clinical picture.
Structure breakdown
The paper follows the standard nursing process framework: it opens with a patient overview and comorbidity history, proceeds through a medication table, analyzes laboratory and diagnostic findings section by section, arrives at a medical diagnosis with pathophysiological rationale, and closes with a condition-specific nursing care plan and brief conclusion. This structure mirrors the ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) model used in clinical nursing education.
Patient Overview and Medical History
Mr. Black is a 67-year-old African-American man who was married with three children. His wife died approximately 15 years ago in a car accident, and he has been living alone since then, with occasional check-ins from his daughter. He works as a truck driver, placing him in the middle-class income range, and his highest level of education is a high school diploma. He had been his usual self until a month before admission, when he was brought to the emergency room on February 15, 2020, after noticing swelling of his feet, shortness of breath, and fatigue. Given his preexisting conditions — hypertension, cerebrovascular accident (CVA), diabetes, asthma, and hyperlipidemia — he was admitted, and a nursing student was assigned to his care on February 17, 2020.
Medication Regimen
Mr. Black had been prescribed medications to manage his preexisting conditions. For hypertension, he was given losartan; for diabetes, metformin; for asthma, albuterol; for hyperlipidemia, simvastatin; and for gastroesophageal reflux disease, Nexium (esomeprazole). The table below summarizes the key clinical information for each drug.
Classification: Angiotensin II Receptor Blocker. Dose/Route: 100 mg orally, once daily. Diagnosis: Hypertension. Common side effects: Diarrhea, stomach pain, dizziness, headache, tiredness. Adverse effects: Vasodilation, decreased blood pressure. Action: Blocks the binding of angiotensin II to receptor cells. Nursing assessment: Monitor blood pressure; do not administer if systolic blood pressure is below 100 mmHg without consulting the healthcare provider. Implementation: Instruct patient to avoid foods high in potassium, as they may cause hyperkalemia. Toxicity/Overdose: Can lead to death due to blocking of adrenaline; patient should visit the nearest hospital immediately.
Classification: Biguanide. Dose/Route: 500 mg orally, twice daily. Diagnosis: Diabetes mellitus. Common side effects: Diarrhea, nausea, flatulence, indigestion, abdominal pain. Adverse effects: Allergic reaction, kidney damage, lactic acidosis. Action: Lowers blood glucose levels by decreasing hepatic glucose production. Nursing assessment: Patient should not receive this drug after procedures requiring IV contrast material. Implementation: Patients should avoid alcoholic beverages while taking this medication. Toxicity/Overdose: Lactic acidosis; treatment includes sodium bicarbonate infusion and hemodialysis.
Classification: Bronchodilator. Dose/Route: 180 mg inhaled, two puffs every 4–6 hours (maximum 12 inhalations per 24 hours). Diagnosis: Asthma. Common side effects: Wheezing, leg cramps, extreme thirst, blurred vision. Adverse effects: Chest pain, convulsions, tremors. Action: Prevents bronchospasm. Nursing assessment: Teach the patient to monitor heart rate. Implementation: Administer albuterol five minutes before other inhaled medications. Toxicity/Overdose: Chest pain and irregular heartbeat; a ventilator may be required to manage the airway.
Classification: HMG-CoA Reductase Inhibitor. Dose/Route: 10 mg orally, once daily. Diagnosis: Hyperlipidemia. Common side effects: Diarrhea, abdominal bloating, muscle cramping, flatulence, constipation. Adverse effects: Muscle myopathies, decreased liver function. Action: Lowers LDL-C levels. Nursing assessment: Patient should not have active liver disease and should not be pregnant. Implementation: Patient should avoid grapefruit and grapefruit juice. Toxicity/Overdose: If drug is inactivated in the bloodstream, it can lead to kidney failure, heart failure, and gastrointestinal bleeding; visit the nearest hospital.
Classification: Proton Pump Inhibitor. Dose/Route: 20 mg orally, once daily. Diagnosis: Gastroesophageal reflux disease. Common side effects: Headache, nausea, flatulence. Adverse effects: Inhibits the gastric proton pump and prevents the formation of hydrochloric acid. Action: Controls acid reflux and its associated symptoms. Nursing assessment: Nexium should not be administered concurrently with other IV drugs. Implementation: Patient should reduce alcohol and caffeine consumption and avoid smoking and fasting. Toxicity/Overdose: Dizziness, fast heartbeat, and increased risk of hip and wrist fractures; visit the nearest hospital for treatment.
Source for all medications: Ignatavicius et al. (2018).
Laboratory Studies and Diagnostic Findings
Laboratory tests were performed to determine the cause of Mr. Black's shortness of breath, fatigue, and foot swelling. Tests included blood glucose, sodium and potassium concentration levels, arterial blood gas (ABG), estimated glomerular filtration rate (eGFR), NT-proBNP, creatinine, and hematology studies, as hemoglobin is responsible for transporting oxygen to tissues.
Red blood cell (RBC) count provides data about oxygen transport capacity; a hemoglobin deficiency leads to hypoxemia. The normal RBC count for adult males is 6.1 × 1012/L (Ignatavicius et al., 2018). Mr. Black's RBC count was 4.5 × 1012/L, lower than normal, likely due to the excessive production of erythropoietin. Hemoglobin levels in males normally range from 14–18 g/dL, and hematocrit from 42–52%. Mr. Black's hemoglobin was 14.5 g/dL and his hematocrit was 43% (Ignatavicius et al., 2018), both within acceptable ranges. The normal white blood cell (WBC) count is between 5–10 × 109/L; Mr. Black's WBC count was 9.8 × 109/L, which is within normal range, though elevation beyond this would indicate a possible acute infection.
Arterial blood gas (ABG) tests assess gaseous exchange and perfusion. The partial pressure of end-tidal carbon dioxide (PaCO₂) in a healthy adult ranges between 20–40 mmHg (Ignatavicius et al., 2018). Mr. Black's PaCO₂ was 10 mmHg, indicating altered breathing effectiveness and impaired gas exchange.
Diabetes mellitus is diagnosed by blood glucose value and oral glucose tolerance level. The glycosylated hemoglobin value reflects average blood glucose, with a fasting blood glucose level greater than 100 mg/dL considered abnormal. Mr. Black's blood glucose was approximately 199 mg/dL, indicating poor glycemic control, which is associated with higher mortality and increased infection risk. His sodium level was 128 mEq/24 hr, within the normal range of 40–250 mEq/24 hr (Ignatavicius et al., 2018). His potassium level was 6 mEq/L, above the normal range of 3.5–5.0 mEq/L (Ignatavicius et al., 2018), suggesting kidney disease.
Abnormal creatinine findings — particularly low creatinine — indicate kidney deterioration, while elevated creatinine can signal infection and diabetes mellitus. The normal creatinine range for healthy adults is 1–2 g/24 hr, slightly lower in older adults. Mr. Black's creatinine was 0.2 g/24 hr, compared to a previous value of 0.5 g/24 hr. Creatinine clearance is a measure of the glomerular filtration rate (eGFR), estimated using the Modified Diet in Renal Disease (MDRD) study equation, for which a normal value is greater than 60 mL/min/1.73 m². Mr. Black's eGFR was 58 mL/min/1.73 m² (Ignatavicius et al., 2018), down from a previous value of 60 mL/min/1.73 m², indicating stage three chronic kidney disease (CKD).
BNP (B-type natriuretic peptide) levels in blood plasma are used to assess the degree of heart failure. A BNP below 100 ng/mL indicates a low risk of heart failure; a level above 100 ng/mL indicates heart failure, with the highest levels reaching 5,000 ng/mL (Ignatavicius et al., 2018). Mr. Black's BNP was elevated. Lower BNP values are associated with improved survival, and as age increases, mortality risk rises.
Chest X-ray is used to evaluate pulmonary status. Standard imaging uses posteroanterior and lateral views; portable examinations use the anteroposterior view (Ignatavicius et al., 2018). Chest X-ray is used to assess the size of the heart, lungs, and blood vessels.
Mr. Black had no head deformities, clear ears, and no deviation of the nasal septum. His pupils were round, equal, and reactive to light. His throat showed no edema, but aortic murmurs were noted. His lungs were filled with fluid, producing crackles and impaired air movement through the alveolar sacs. Mild wheezing was noted on exhalation. Shortness of breath was present when lying flat (orthopnea) and on exertion. Swelling of the feet and ankles was also noted.
The chest X-ray demonstrated intermediary features including peribronchial cuffing, indistinct vessels, and septal lines, all indicating the presence of pulmonary edema. Early-stage features — including widened vascular pedicle, enlarged upper lobe vessels, and cardiomegaly — are considered pre-edema signs (Assaad et al., 2018). The X-rays also showed features of increased chest pressures and fluid transudation, including septal lines, peribronchial cuffing, and alveolar edema, reflecting negative pressure in the chest. Pulmonary edema has three severity stages: pulmonary vascular congestion, interstitial pulmonary edema, and alveolar edema. The X-ray findings were consistent with acute cardiogenic pulmonary edema, correlating with elevated pulmonary capillary wedge pressures. Because chest X-rays may not fully capture the progression of pulmonary edema, lung CT scans are recommended for more definitive assessment.
Conclusion
The patient was suffering from pulmonary edema — a condition in which the lungs fill with fluid that collects in the air sacs, making it difficult to breathe. Mr. Black had been experiencing crackles, mild wheezing on exhalation, and shortness of breath when lying flat. His diagnoses of heart failure and chronic kidney disease contributed to increased fluid accumulation in the lungs. Comprehensive nursing assessment, timely diagnostic evaluation, and an individualized care plan are essential components of managing this complex, multi-system presentation.
Assaad, S., Kratzert, W. B., Shelley, B., Friedman, M. B., & Perrino, A., Jr. (2018). Assessment of pulmonary edema: Principles and practice. Journal of Cardiothoracic and Vascular Anesthesia, 32(2), 901–914.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. Elsevier Health Sciences.
Shimamoto, K., Ando, K., Fujita, T., & Hasebe, N. (2014). The Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2014). Hypertension Research, 37(4), 253–253. https://doi.org/10.1038/hr.2014.20
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