A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?
A.
Use a cushion when sitting.
B.
Perform range of motion exercises.
C.
Document abdominal girth.
D.
Weigh every morning.
The correct answer and Explanation is :
The correct answer is D. Weigh every morning.
Explanation:
In the context of a client with chronic kidney disease (CKD) who presents with elevated blood pressure and changes in mental status, daily weight monitoring is a crucial intervention. This is because fluctuations in weight can indicate changes in fluid status, which is particularly important in CKD patients who often struggle with fluid balance due to their compromised kidney function.
- Fluid Retention: CKD can lead to fluid overload as the kidneys become less effective in filtering waste and excess fluid from the body. This can manifest as edema, increased blood pressure, and changes in mental status due to fluid shifts in the brain. Daily weight checks help assess fluid retention; a rapid increase in weight can suggest fluid overload.
- Blood Pressure Management: Elevated blood pressure in CKD patients is often related to fluid overload. By monitoring weight daily, the practical nurse (PN) can provide critical information to the healthcare team about the client’s fluid status, allowing for timely interventions. For example, if a patient gains weight, adjustments to diuretics or fluid intake might be necessary.
- Mental Status Changes: Changes in mental status can result from several factors, including fluid imbalances, electrolyte disturbances, or toxins accumulating due to reduced kidney function. Regular weight monitoring helps track fluid shifts that could contribute to these neurological symptoms.
- Actionable Data: Weight changes provide actionable data for clinical decision-making. For instance, if a patient consistently gains weight, it may prompt the healthcare provider to reassess the treatment plan, including diet modifications or medication adjustments.
In contrast, while the other options—using a cushion, performing range of motion exercises, and documenting abdominal girth—are relevant in managing patient comfort and mobility, they do not directly address the critical issues of fluid status and its implications for the patient’s overall health and safety in the setting of CKD. Therefore, weighing the patient every morning is the most appropriate intervention in this scenario.