Week 6: Recorded Disease Process Presentation Peer Review

Please upload your recorded Disease Process PowerPoint presentations to this area by Tuesday, 11:59 p.m. MT. See the Disease Process Presentation Peer Review Guidelines and Rubric located in the Course Resource section for specific information. 

Students are to review at least one peer’s recorded presentation and respond to it by Thursday, 11:59 p.m. MT using the Disease Process Peer Review Guidelines. 

Presenters are also required to monitor comments and questions from peers and faculty about their presentations and respond appropriately. Make sure to respond to all faculty questions. All responses are due by Sunday 11:59 p.m. MT. 

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Collapse SubdiscussionJulie Beery 

Julie Beery 

Aug 13, 2018Aug 13 at 3:23pm 

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Rachel Bennefield 

Rachel Bennefield 

Aug 16, 2018Aug 16 at 7:23pm 

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Julie, 

I really enjoyed your presentation and felt like I learned more about Addison’s disease. I was interested in this subject matter due to someone I know having this disease and wanting to understand more about her condition. 

  1. Discuss the risk factors and the connection to the etiology of the initial injury to the cell/tissue/organ 

One of the things I found most interesting about Addison’s that I did not remember from nursing school was the most common cause of Addison’s being tuberculosis worldwide. Upon further research, I found that this is not common in further developed countries such as the United States, but in those underdeveloped countries (Burton, Cottrell, & Edwards, 2015, p. 488). Most often in established countries the cause is an autoimmune disease as you mentioned. Example of the autoimmune diseases would be type 1 diabetes, or Graves’ disease. Other risk factors include other chronic infections, removal of part of the adrenal gland, or polyendocrine deficiency syndrome. These autoimmune disorders cause breakdown of the adrenal cortex most often causing Addison’s disease. 

  1. Provide a brief diagnosis of how the disease is diagnosed 

In your presentation you mentioned that diagnosis is made based on laboratory values to determine either primary or secondary adrenal insufficiency with high ACTH being primary and low ACTH being secondary. It is important to understand that the cortisol levels must be drawn in the morning to give a more accurate result. In my research, I found that patients are often misdiagnosed until they progress into Addisonian crisis due to providers focusing on other differential diagnoses based on the patient’s sign and symptoms (Burton, et. al, 2015, p.489). Once patients have become this ill, they usually present to the emergency department and the diagnosis is made based on presentation, laboratory values of hyperkalemia and hyponatremia, and then can be confirmed by morning cortisol levels. The delay in diagnosis was the most interesting.   

Burton, C., Cottrell, E., & Edwards, J. (2015). Addison’s disease: identification and management in primary care. The British Jounral of General Practice, 65(638), 488-490. http://doi.org/10.3399/bjgp15X686713Links to an external site. 

 

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Joanne Brown 

Joanne Brown 

Aug 18, 2018Aug 18 at 10:42pm 

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Hi Julie, 

  1. Analyze pathophysiologic mechanism associated with Addison’s Diseas: 

Mediated destruction 

Sanne van Haren, Hannah, Alex & Gijs (2018) indicated as did you that Addison’s Disease Caused by Tuberculosis.  Just like Aspergillus Pneumonia, Addison’s disease is difficult to diagnose and treat.  Fichna, Żurawek, Bratland, Husebye, Kasperlik-Załuska, Czarnocka & … Nowak. (2015) stated that Interleukin-2 subunit alpha (soluble receptor) reveals and confirms a direct connect between 21OH=directed reactivity and AAD, and 11.2 SNP.  Fichna, Żurawek, Bratland, Husebye, Kasperlik-Załuska, Czarnocka & … Nowak. (2015) continued that Addison’s disease (AAD) has a direct connect to T-cell destruction of the adrenal cortex.  

So there is lyphocytic infiltration of the adrenal gland, autoantibodies, 21 hydroxylase (21OH).  It is also indicated that he etiology remains obscure but genetic and environmental factors can be significant.  Your PowerPoint presentation was excellent.  I read about genes influencing T-cell fate.  Is this true about transcription factors STAT4, GATA3, interleukin-23 (IL23A:  activates STAT4) and interferon-Gamma production aides in the production of interferon-Gamma by the memory CD4+ cells.  

  1. Relate research findings to the management of patients with complex pathophysiologic dysfunction of the adrenal cortex and how the hormones are all related. I can see the difficulty with the treatment in that rifampicin and steroids is part of the treatment, but low dose of steroids can be a problem with any long disorder, especially those who are immunocompromised. In addition, Aspergillus Pneumonia which is a rare opportunistic fungal infection would have a field day and be invasive to this type of individual.  Any type of compromised disease would contribute to a host of problems later down the line.  As with the disease that I had chosen, systemic considerations should be taken when it comes to signs and symptoms.  For example, similarities exist with both diseases in that weight loss and gastrointestinal symptoms are common signs and symptoms for both.  Clara, Joana, Marina, Fábio, Sara, Alexandre & … Teresa (2018) also agree that it is difficult to diagnose Addison’s disease in that this disease is rare and even gave a case about a teenager having multiple visits to the emergency room to which the teenager was treated with hydro cortisone and fludrocortisone and added that Addison’s disease has unspecific symptomatology.  

References: 

Clara, P., Joana, C., Marina, P., Fábio, B., Sara, L., Alexandre, F., & … Teresa, B. (2018). 

        Addison’s disease – the difficulty of diagnosis. Nascer E Crasser , Vol 27, Iss 1, Pp 

        39-42 (2018), (1), 39. 

Fichna, M., Żurawek, M., Bratland, E., Husebye, E. S., Kasperlik-Załuska, A., Czarnocka, 

        B., & … Nowak, J. (2015). Interleukin-2 and subunit alpha of its soluble receptor in 

       autoimmune Addison’s disease–an association study and expression analysis. 

       Autoimmunity, 48, 2, 100-107. doi:10.3109/08916934.2014.976628 

Sanne van Haren, N., Hannah, V., Alex, M., & Gijs, L. (2018). Addison’s Disease 

       Caused by Tuberculosis: Diagnostic and Therapeutic Difficulties. European 

      Journal of Case Reports In Internal Medicine (2018), doi:10.12890/2018_000911 

 

 

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Collapse SubdiscussionPaige Schnittker 

Paige Schnittker 

Aug 13, 2018Aug 13 at 10:10pm 

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Collapse SubdiscussionJulie Beery 

Julie Beery 

Aug 15, 2018Aug 15 at 4:46pm 

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Week 6 Disease Process Peer Review for Paige Schnittker (Chronic Renal Disease) 

Paige, 

I thought your presentation was outstanding. Great job! You presented the material in a very clear and concise manner with no distractions. Your slides are easy to read and well organized. I see that you covered all the required information, so it is difficult to disagree or come up with any negative feedback. Therefore, I will ask some questions related to your presentation that I am interested in hearing more about that I did not see in the presentation. 

 

#5 Link changes in tissue, organ, and system functioning to the initial presenting signs and symptoms seen in primary care of the disease. 

Regarding this question, if a patient is told they will need dialysis, but they refuse, they have an approximate survival time of six months. What would you do to change the patient’s mind about dialysis? 

Shafi, Saleem, Anjum, Abdullar, and Shafi (2018) give the results of a six-month study on patients hospitalized with chronic kidney disease. The study included 125 patients, in Pakistan, who were patients in a hospital within a 6-month’s time-frame.  The mean patient age was 47.9±12.1 years. Of all patients, 72 agreed to dialysis and 53 refused.  The study showed that those in middle to higher income groups agreed more frequently to dialysis than those in lower income groups. Trust in the primary care provider (86%) was the most common reason to accept dialysis.  The most common reasons for refusing were frequency of dialysis during the week (52.8%), permanent nature of dialysis (50.9%), and perception of poor quality of life (35.8%).  In this study the median survival after withholding dialysis was 6 months. 

 

#7 Provide a brief description of the pharmacological and non-pharmacological interventions used to treat and manage the disease. 

If a patient does receive a kidney transplant, is there a lifetime medication regimen? 

Spivey, Burns, Garrett, Duke (2014) explain how immunosuppressant therapy (IST) plays a very important role in maintaining graft function in kidney transplantation.  In a meta-analysis, 22.6% of low-income and minority groups are vulnerable to an increased risk of non-compliance.  There may be severe consequences to this non-adherence such as, rejection or failure of the transplanted organ.  The complexity of medication regimens can be overwhelming to some recipients as well as the high cost of the multiple medications that are needed to prevent graft rejection. 

 

Any information about these two topics that you could add would be great. Again, GREAT JOB!! 

 

Regards, 

Julie Beery 

References 

Shafi, S., Saleem, M., Anjum, R., Abdullah, W., & Shafi, T. (2018). Refusal of hemodialysis by hospitalized chronic kidney disease patients in Pakistan. Saudi Journal of Kidney Diseases and Transplantation, 29(2), 401-408. 

Spivey, C., Chisholm-Burns, M., Garrett, C., & Duke, K. (2014). Serving underserved transplant recipients: Experience of the medication access program. Patient Preference and Adherence, 8, 613-619. 

 

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Paige Schnittker 

Paige Schnittker 

Aug 17, 2018Aug 17 at 12:12am 

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Julie, 

            Thank you for your response and all of your kind words in regard to my presentation. I hope that my presentation allowed for a better understanding of renal disease and how as nurse practitioners we can provide the best care possible for these patients. I am so pleased with the questions you asked and was able to do some further research into this disease and gain some helpful knowledge because of them. Both questions you asked are addressed below. 

  1. Regarding this question, if a patient is told they will need dialysis, but they refuse, they have an approximate survival time of six months. What would you do to change the patient’s mind about dialysis? 

 

For patients who are instructed to use dialysis for a treatment method, this can be scary and life changing. For patients that refuse at the initial instruction of dialysis it is essential to educate and ensure that he or she has an understanding of the outcome if refusal continues. One initial response, as was mentioned in the case you presented to me, the amount of time per week that the patient must set aside for the treatments. One important factor to mention to the patient is the possibility of performing the hemodialysis at home. In all cases it is not necessary to go to an outpatient setting to have dialysis performed. This option is often more acceptable to patients and allows them more independence than having to attend scheduled appointments. Another important fact that I did not mention in the presentation is the choice to do either hemodialysis or peritoneal dialysis. If the choice of peritoneal dialysis is made the patient will need to be aware a surgical procedure to place a abdominal catheter will be needed in order for treatments to take place. “During PD, sterile dialysate fluid is introduced in the patient’s peritoneal cavity and remains there for 6–8 hours while excess body fluid and toxins are filtered across the peritoneal membrane; at the completion of treatment, the dialysate fluid is drained from the peritoneal cavity” (Schub, Mennella, 2018, p. 1). This type of dialysis differs from hemodialysis because typically a catheter is placed in the chest until a graft can be established in the arm and then the blood is filtered rather than the peritoneal fluid. Again, it is important to educate the patient that both can be performed at home independently as long as compliance is achieved. After explaining all options of dialysis to the patient, inform the patient of the complications of not having dialysis such as electrolyte imbalances, fluid overload, toxin build up, and ultimately death. Healthcare is patient driven and ultimately it will be the patient’s decision whether or not he or she wants to have dialysis or not. The job of the healthcare provider is to educate and supply patients with the appropriate options and tools the live the best life possible living with this chronic disease. 

 

  1. If a patient does receive a kidney transplant, is there a lifetime medication regimen? 

 

For patients with renal disease a kidney transplant is life changing and unless complications occur, will allow for a life without the disease. Patients who received a kidney transplant will be required to take medications for immunosuppression. The reasoning behind this is to prevent the body from rejecting the transplanted kidney. In the event of rejection, the patient will begin so show symptoms similar to that of infection and ultimately if not treated the patient can lose the transplanted kidney, enter into a state of shock, or even death. Drugs that are often times used in the immunosuppressive therapy are as follows: Rituxan, Rapamune, Prograf, Astagraf XL, Prednisone, CellCept, Nulojix, Cytoxan, Cyclosporine, Campath, Thymoglobulin, Imuran, and Simulect (Colaneri, 2014). These drugs are often times used in combination and it is imperative the patient does not miss a dose. Patients will also need to see the primary care provider to have blood drawn regularly in order to monitor levels such as with the medication Prograf. “immunosuppression should modify the immune system enough to prevent rejection, but not allow infection, malignancies, and other side effects” (Colaneri, 2014, p. 550). It is imperative to monitor transplant patients to ensure proper kidney health and the optimal life post-surgery. 

 

References 

Colaneri, J. (2014). An Overview of Transplant Immunosuppression – History, Principles, and Current Practices in Kidney Transplantation. Nephrology Nursing Journal, 41(6), 549-561. 

Schub, T. B., & Mennella, H. A. (2018). Hemodialysis vs Peritoneal Dialysis. CINAHL Nursing Guide. 

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Collapse SubdiscussionIngrid Spence 

Ingrid Spence 

Aug 16, 2018Aug 16 at 7:55pm 

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Hello Paige, 

Risk factors 

I agree with you that congenital malformations, pre-existing kidney, genetics, and infections are some of the risk factors for chronic renal disease. 

 Obesity, low birth weight, nephrotoxins, age, and ethnicity, are also risk factors associated with the disease (Kazancioğlu, 2013). According to Chang & Kramer, 2013, Glomerular hypertrophy and hyperfiltration increase capillary wall tension of the glomeruli and decreasing podocyte density. Obesity can also contribute to the pathogenesis of kidney damage through hypervolemia, adipokine disorders, inflammation, oxidative stress and endothelial dysfunction. Intrauterine growth restriction can also cause low nephron number that leads to intraglomerular hypertension and hyperfiltration in the available nephrons (Vikse, Irgens, Leivestad, Hallan, & Iversen, 2018). According to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI), the elderly population is more prone to develop chronic kidney disease (CKD) after several renal insults. Exposure to heavy metals, alcohol, and other drugs has linked to constant kidney disease progression (Falodia & Singla, 2013). 

Treatment and prevention 

You haven’t included nephrectomy anywhere in the treatment of chronic kidney disease. Nephrectomy is the surgical removal of the kidney to treat kidney cancer and other related kidney diseases. Partial and radical nephrectomy can be done to treat chronic renal disease. According to Charytoniuk et al., 2018, partial Nephrectomy is done on the diseased or injured portion of the kidney, and radical nephrectomy includes removing the entire organ together with a section of the tube leading to the bladder. Retroperitoneal robotic partial nephrectomy is, however, more effective in the treatment of chronic kidney disease due to reduced operative time and a shorter Length of stay as compared to trans peritoneal nephrectomy (Paulucci et al., 2018). Good job on your presentation. 

Ingrid 

 

References 

Chang, A., & Kramer, H. (2013). CKD progression: a risky business. Nephrology Dialysis Transplantation, 27(7), 2607-2609. doi:10.1093/ndt/gfs095 

Charytoniuk, T., Małyszko, M., Bączek, J., Fiedorczyk, P., Siedlaczek, K., & Małyszko, J. (2018). Progression to chronic kidney disease in patients undergoing nephrectomy for small renal masses: a price to pay for a therapeutic success? Postgraduate Medicine. doi:10.1080/00325481.2018.1511211 

Falodia, J., & Singla, M. K. (2013). CKD epidemiology and risk factors. Clinical Queries: Nephrology, 1(4), 249-252. doi:10.1016/j.cqn.2012.09.004 

Kazancioğlu, R. (2013). Risk factors for chronic kidney disease: an update. Kidney International Supplements, 3(4), 368-371. doi:10.1038/kisup.2013.79 

Paulucci, D. J., Beksac, A. T., Porter, J., Abaza, R., Eun, D. D., Bhandari, A., … Badani, K. K. (2018). A Multi-institutional Propensity Score Matched Comparison of Transperitoneal and Retroperitoneal Partial Nephrectomy for cT1 Posterior Tumors. Journal of Laparoendoscopic & Advanced Surgical Techniques. doi:10.1089/lap.2018.0313 

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Victoria O’Babatunde 

Victoria O’Babatunde 

Aug 17, 2018Aug 17 at 11:55am 

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Hi Ingrid, 

Please allow me to humbly disagree with one of your comments in response to Paige’s presentation. In the post; Nephrectomy was mentioned as a treatment for chronic renal disease and further stated that “Retroperitoneal robotic partial nephrectomy is, however, more effective in the treatment of chronic kidney disease” (Spence, 2018). 

In a recent article published in ‘The World Journal of Clinical Urology’; Nephrectomy was identified as the treatment of choice for renal cancers. The authors further explained the association of nephrectomy with new-onset of chronic renal disease (Yong, & Kareeann, 2017). This seems very logical to me because the removal of one or more kidneys either put an extra burden on the leftover kidney hence increasing the risk of its functions getting decreased or if radical nephrectomy was performed, then there are no kidneys at all for the job; which means patient had to be on dialysis. 

Moreover, it was deduced that the aim of the cited study in the comment was to examine the effects of kidney tumor’s location (anterior versus posterior), the chosen surgical approach in performing the needed nephrectomy, and their subsequent outcomes on the patients’ prognosis (Paulucci et al., 2018). 

The following was a direct quote of the conclusion statement from the cited article. 

“The transperitoneal approach to partial nephrectomy for posterior tumors resulted in no difference in operative time, WIT, EBL, LOS, positive surgical margins, reduction in eGFR, or postoperative complications. The TPRPN approach to treat a posterior tumor is reasonable and is the preferred technique at our institution” (Paulucci et al., 2018). 

Thank you 

Victoria 

                                 References 

Spence, I. (2018). Re: Chronic Renal Disease: Treatment and                    prevention [web log comment]. Retrieved from                                https://chamberlain.instructure.com/courses 

           discussion_topics/633364?module_item_id=3471579 

Paulucci, D. J., Beksac, A. T., Porter, J., Abaza, R., Eun, D. D.,                Bhandari, A., . . . Badani, K. K. (2018). A Multi-institutional              propensity score-Matched comparison of transperitoneal                and retroperitoneal partial nephrectomy for cT1 posterior                tumors. Journal of Laparoendoscopic & Advanced                          SurgicalTechniques. doi:10.1089/lap.2018.0313 

Yong, T. Y., & Khow, K. S. (2017). Chronic kidney disease after               radical nephrectomy for suspected renal cancers. World                Journal of Clinical Urology,6(1), 10. doi:10.5410/wjcu.v6.i1.10