Running Head: PLAN OF CARE 1

Plan of Care Assignment

Delaware Technical Community College

NUR 320 Health Assessment

Alexis Leskovac

December 6, 2020
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During the health history assessment, the patient identified that he was born with

posterior urethral valves (PUV). These obstructive membranes develop in the urethra and block

the outflow of urine, resulting in progressive dilation and damage to the bladder, ureters, and

kidneys (Children’s Hospital of Philadelphia [CHOP], 2011). PUV are thought to occur in the

early stages of fetal development. They only affect male infants, and they occur in approximately

one in 8,000 births (CHOP, 2011). As the patient revealed, having PUV lead to his diagnosis of

stage three chronic kidney disease (CKD) and ultimately, a kidney transplant in 2013.

Due to the patient’s kidney disease and transplant, a risk for acute kidney injury has been

identified as a potential problem. During the health history assessment, the patient reported

taking Rapamune (Sirolimus) and Mychophenolic Acid (Cellcept), two immunosuppressive

agents, for his kidney transplant. The patient is also taking Vitamin D because, as he reported, he

is Vitamin D deficient. This is because the kidneys are responsible for converting Vitamin D

from food, supplements, and the sun into its active form to be used by our body (National

Kidney Foundation, 2020a). Having injured kidneys means they are less able to convert Vitamin

D into its active form (National Kidney Foundation, 2020a). The patient is taking Oxybutynin

(Ditropan) for his neurogenic bladder, Olmesartan (Benicar) for his high blood pressure, and

Amoxicillin as urinary tract infection prophylaxis secondary to frequent straight catherization.

As part of the patient’s plan of care, it is recommended that he remain compliant with all his

medications. An intervention to maintain medication compliance would be face-to-face

education with a pharmacist for chronic disease co-management (Kini & Ho, 2018). Evaluations

of this intervention would occur at the patient’s follow-up appointments with his primary care

physician (PCP) and nephrologist. A review of his blood studies would ensure his laboratory

values are in range and no infections have occurred. The patient should continue his annual
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follow-ups with the transplant team at Johns Hopkins, where he had his kidney transplant in

2013. The patient’s current nephrologist is in Delaware at Nephrology Associates of Delaware,

but the patient now lives in Reston, Virginia. Nephrology Associates of Northern Virginia has

been referred to the patient in his plan of care.

The patient reported exercising with a physical trainer but having to stop due to abnormal

lab values. High-intensity interval training (HIIT) has been shown to cause significant elevations

in creatinine kinase, myoglobin, serum creatinine, microalbuminuria, and urinary biomarkers

indicative of muscle and kidney damage (Spada et al., 2018). Exercise is beneficial for many

reasons including, blood pressure control and lowered levels of blood cholesterol and

triglycerides (National Kidney Federation [NKF], 2020). Individuals with kidney disease should

exercise for a minimum of three non-consecutive days a week for thirty minutes at a time (NKF,

2020). Suggested forms of exercise include walking, swimming, and bicycling where large-

muscle groups are being used (NKF, 2020). Low-level strengthening exercises with low weights

and high repetitions is also suggested (NKF, 2020). Evaluation of these interventions and

outcomes will be monitored by laboratory results of creatinine kinase, myoglobin, serum

creatinine, microalbuminuria, and urinary biomarkers during routine laboratory work.

The patient should follow a renal diet by monitoring his consumption of protein,

potassium, sodium, phosphorous, and fluids (National Institute of Diabetes and Digestive and

Kidney Diseases [NIDDK], 2014). Several studies show that proteinuria increases the

progression of kidney disease to end-stage renal disease (ESRD) (Office of Disease Prevention

and Health Promotion [ODPHP], 2020). Increased consumption of protein can make the kidneys

work harder, causing more damage. Therefore, doctors may recommend limiting protein intake

or changing the source of protein (The Kidney Foundation of Central Pennsylvania [KFCP],
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2020). The purpose of a renal diet is to avoid buildup of waste products in the body (KFCP,

2020). It is recommended that the patient maintain his routine of getting blood studies performed

every three months. Some dialysis units have renal dietitians that can review the patient’s blood

studies and provide a recommended dietary plan in accordance with their laboratory values

(KFCP, 2020). A local registered dietitian who specializes in renal diet has been listed as a

resource in the patient’s plan of care.

Kidney disease may cause high blood pressure, which the patient reported having.

Progression of kidney disease can be significantly slowed by managing blood pressure with

angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), or

diuretics (NIDDK, 2014). ACE inhibitors and ARBs also reduce proteinuria, thereby slowing the

progression of kidney disease (ODPHP, 2020). The patient is currently taking Olmesartan

(Benicar) which is an ARB. The patient also reported having a blood pressure cuff at home but

that he is non-compliant with using it. Suggested interventions for this health problem are to

remain compliant with taking his Olmesartan and to regularly monitor his blood pressure. The

American Heart Association recommends at-home monitoring of blood pressure to anyone with

hypertension (Mayo Clinic, 2020). Monitoring blood pressure at home and keeping a log of

readings allows the patient to keep track of their blood pressure, ensure their medications are

effective, and alert their provider when needed (Mayo Clinic, 2020). The patient’s recordings of

blood pressure should be reviewed during doctor visits to ensure that medications, diet, and

exercise routines are effective in managing blood pressure. The patient’s current primary care

physician is located in Delaware, but the patient now lives in Reston, Virginia. A primary care

physician who accepts the patient’s insurance has been referred.

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A risk for chronic urinary tract infections (UTI) has been identified as a problem because

the patient reported having a neurogenic bladder, requiring him to frequently use a straight

catheter to empty his bladder. The patient is already prescribed Oxybutynin (Ditropan) to relax

his bladder, and Amoxicillin as prophylaxis for UTIs. Interventions to prevent this problem

include medication compliance, proper sterile technique when catheterizing, and maintaining a

consistent schedule for emptying his bladder (National Library of Medicine, 2019). The

outcomes of these interventions can be evaluated with a urinalysis when he receives his routine

laboratory work every three months. Having the patient describe his process of catheterizing to

ensure he is following sterile technique and assessing for presence of UTI symptoms during his

PCP visits would help evaluate his outcomes as well. For this reason, a local PCP near his new

apartment in Virginia has been referred in his plan of care.

The patient must take Rapamune (Sirolimus) and Mychophenolic Acid (Cellcept), two

immunosuppressive agents, because he has a kidney transplant. Therefore, immunosuppression

has been identified as another problem within the patient’s plan of care. It is recommended that

the patient stay up to date on his vaccinations and continue taking his immunosuppressants as

prescribed. Using a pill box and setting and alarm to ensure his medications are taken every day

at the same time will promote medication compliance (National Kidney Foundation, 2020b). The

patient should be educated on what medications, foods, or supplements to avoid. Grapefruit

juice, St. John’s Wort, erythromycin, tuberculosis medications, anti-seizure medications, and

certain blood pressure medications (Cardizem and Verapamil) can cause the levels of

immunosuppressive agents to go above or below their threshold (National Kidney Foundation,

2020b). The patient should strictly adhere to the Center for Disease Control’s COVID-19

precautions. He should continue to wear a mask, practice social distancing, work from home,
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wash his hands with soap and water, and clean frequently used surfaces (Centers for Disease

Control and Prevention, 2020). The patient should be informed to monitor for signs and

symptoms of infection or rejection of his transplant. These may include a drop in urine output,

fever, tenderness near the transplant site, hematuria, flu-like symptoms, or weight gain of more

than three pounds in two days (National Kidney Foundation, 2020b). Referrals for this health

problem include the closest CVS pharmacy located to the patient’s apartment. This is so the

patient can obtain his prescriptions and always have a minimum of a 30-day supply on hand in

case he needs to quarantine. This is also because this pharmacy offers COVID-19 testing in case

he needs to get tested.

This patient has extensive health issues that have been present since birth. Since they are

all he has ever known, he thankfully has them well-managed and under control with a consistent

routine of care. This assignment taught me that I should allow the patient to better explain in

their own words and to demonstrate how they follow their plan of care at home. During his

health assessment, the patient demonstrated that he was well-informed on the names, doses, and

purpose of each of his medications. This is beneficial to his medication compliance. He pointed

out that he is not as compliant with monitoring his blood pressure as he should be. Next time, I

would like to ask the patient to show me his blood pressure cuff and demonstrate how he takes

his own blood pressure. He was also aware that he had to reduce his level of exercise due to his

laboratory work, but he was not sure which laboratory value was out of range. If possible, I

would have liked to review those laboratory values with the patient to educate him on their

importance and significance. He stated that he is following precautions to protect himself against

COVID-19 as well. The referrals were specifically made for locations closer to his new

apartment in Virginia so that he does not have to travel to Delaware for every appointment. This
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sense of convenience is also intended to promote compliance with his therapeutic regimen. This

plan of care will serve to better educate the client on the rationale behind health interventions,

and to encourage compliance towards all his health problems.

References
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Centers for Disease Control and Prevention. (2020). If you are immunocompromised, protect

yourself from COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-

precautions/immunocompromised.html

Children’s Hospital of Philadelphia. (2011). Posterior urethral valves (PUV).

https://www.chop.edu/conditions-diseases/posterior-urethral-valves-

puv#:~:text=Posterior%20urethral%20valves%20(PUV)%20are,of%20urine%20through

%20the%20urethra

The Kidney Foundation of Central Pennsylvania. (2020). Kidney disease diet

https://www.kfcp.org/learn/treatment/nutrition/

Kini, V., & Ho, P. M. (2018). Interventions to improve medication adherence: A review.

National Library of Medicine, 320(23), 2461-2473.

https://doi.org/10.1001/jama.2018.19271

Mayo Clinic. (2020). Get the most out of home blood pressure monitoring.

https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-

blood-pressure/art-20047889

National Institute of Diabetes and Digestive and Kidney Diseases. (2014). Kidney disease in

children. National Institutes of Health. https://www.niddk.nih.gov/health-

information/kidney-disease/children#eating

National Kidney Federation. (2020). Living with kidney disease: Exercise.

https://www.kidney.org.uk/exercise

National Kidney Foundation. (2020a). Immunosuppressants.

https://www.kidney.org/atoz/content/immuno

National Kidney Foundation. (2020b). Vitamin d: The kidney vitamin?

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https://www.kidney.org/news/kidneyCare/spring10/VitaminD#:~:text=The%20kidneys

%20convert%20vitamin%20D,D%20into%20its%20active%20form

National Library of Medicine. (2019). Self catheterization – male. MedlinePlus.

https://medlineplus.gov/ency/patientinstructions/000143.htm#:~:text=Ask%20how

%20often%20you%20should,had%20more%20fluids%20to%20drink

Office of Disease Prevention and Health Promotion. (2020). Chronic kidney disease. Healthy

People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-

kidney-disease

Spada, T. C., Silva, J., Francisco, L. S., Marçal, L. J., Antonangelo, L., Zanetta, D., Yu, L., &

Burdmann, E. A. (2018). High intensity resistance training causes muscle damage and

increases biomarkers of acute kidney injury in healthy individuals. PloS one, 13(11).

https://doi.org/10.1371/journal.pone.0205791