CASE STUDY

Medical History

Nessa Tuazon is a 67-year-old woman and is diagnosed with End Stage Renal Failure during
her dialysis treatment. Her ESRD is presumed to be secondary to diabetic nephropathy. She
has also a known case with Type 2 diabetes mellitus. Mrs. Tuazon has an arteriovenous (AV)
fistula in her left arm as her vascular access for hemodialysis. She was also an ex-smoker.

Scenario 1: Emergency Department

Narrator: Patient Nessa is on regular hemodialysis, three times per week as her renal
replacement therapy and is currently on the waiting list of a kidney transplant. She was
admitted to the hospital because of missed dialysis and with a diabetic foot ulcer. On arrival
to the hospital she was very unwell and is reluctant to speak about her situation as she is
scared and depressed.

Nurse: Good morning. My name is Michelle. I am one of the registered nurses working in
this ward. Today, I will be your attending nurse. For the confirmation may I know your name
please.

Patient: I am Nessa Tuazon.

Nurse: Mrs. Tuazon, how are you feeling now?

Patient: I don’t feel really good today.

Nurse: Why what happened? Would you like to tell me more?

Patient: I have been thinking about my condition and I don’t find anything to look forward
to.

Nurse: I definitely understand Mrs. Tuazon, but I think if you could open up a little more
about what your feeling I could help you to probably feel better. Would you like to talk to me
about that?

Patient: To be honest, I really think that this dialysis is not going to work for me, and to be
frank I get really irritated to be undergoing dialysis thrice in a week, it is too much for me. I
also don’t think I would end up getting a kidney donor and I am scared that this is all going to
be a wasted time.

Nurse: Oh Mrs. Tuazon don’t say that. You have been doing great and you have been brave
for the past couple of months that you have been here.

Patient: Thank you Nurse Michelle, I really appreciate that.

Nurse: You could feel that you are wasting time but undergoing dialysis is really important
and if you continue to miss your dialysis sessions it could end up in multiple issues or
problems and could be harder to treat, this is why you need to undergo dialysis to lessen your
complications.

Patient: To be honest that gives me a bit of relief and hope. Thank you very much.

Narrator: Mrs. Tuazon is now being addressed to the ward and Nurse Michelle is starting
with the assessment of Mrs. Tuazon. After the assessment, Mrs. Tuazon’s blood results
showed hyperkalemia, uremia and definite signs of infection by an elevated CRP.

(INSERT ECG VIDEO)

Nurse: (In the emergency department Mrs. Tuazon was given Calcium Resonium prior to
emergency dialysis to treat her hyperkalaemia. (as her serum potassium was 6.8mmol/l.
Hyperkalaemia is actually a life threatening condition in which serum potassium exceeds
5.5mmol/l, Lehnhardt & Kemper, 2011). To help remove the excessive amounts of potassium
from the blood.)

Narrator: She was given emergency dialysis to stabilize her urea, creatinine and electrolytes.
As she has missed dialysis sessions together, she underwent missed dialysis protocol as per
hospital guidelines.

(hours later)

Scenario 2:

Narrator: Mrs. Tuazon was then referred to the Diabetic Rosales Foot clinic for further
review for her foot ulcer. 

Nurse: Hello. I am Nurse Gel. I will be performing your foot exam for today. Can you please
say your name for the record?

Patient: My name is Nessa Tuazon.

Nurse: May I please know your candidate number?

Patient: My candidate number is 0001.

Nurse: Mrs. Tuazon I would like you to relax while I inspect your foot. (Nurse starts
inspecting right foot).
Nurse: Mrs. Tuazon, you have a debridement on your right foot. We will administer
antibiotics and please take the medication as prescribed.

Patient: Okay nurse.

(Nurse starts cleaning the wound and puts bandage)

Nurse: All done Mrs. Tuazon. You will also be coming twice a day for injection of
piperacillin or tazobactum to help treat your foot ulcer.

Patient: I understand Nurse Gel. Thank you.

Narrator: Tuazon received tazocin post dialysis in dialysis days because haemodialysis
removes 31 – 39% of piperacillin and tazobactam from the body (Cervelli, M J. 2008).

Scenario 3: Renal medicine department

Narrator: Mrs. Tuazon was then admitted in the renal unit for further dialysis. Nurse
Michelle has started with the daily assessment and had noticed that Mrs. Tuazon is
experiencing shortness of breath, is hypertensive and has edema on her right leg which is due
to fluid excess related to the missed dialysis of Mrs. Tuazon.

Initial assessment:

Pre dialysis assessment of the patient done by the Nurse which included vital signs, the
assessment for peripheral edema, measuring jugular venous pressure and auscultation of
chest and lungs. After conducting pre-dialysis assessment, a hemodialysis plan was made as
per missed dialysis protocol and Kathy had two hours of dialysis aiming for 1.5litres of fluid
removal including isolated ultrafiltration (ISO UF)

Scenario 4: Weeks in the hospital

Narrator:

This complex case study illustrates the history of the Mrs. Tuazon experiencing End Stage
Renal Failure and was presented in Emergency Department with missed Dialysis,
hyperkalemia, fluid overload. She received an effective dialysis treatment over two weeks.
She had her missed dialysis protocol bur Mrs. Tuazon underwent hemodialysis for
consecutive days to complete her missed dialysis protocol. Through the missed dialysis
protocol more fluid was removed and Mrs. Tuazon has more stabilized serum electrolyte
levels. Mrs. Tuazon received a complete dose of tazocin which helped her with the foot ulcer.