Description
● Overview of the Case:
➣ Patient Profile: 63-year-old woman with stage 5 chronic kidney disease (CKD), type 2 diabetes mellitus, and hypertension.
➣ Haematemesis, or blood vomiting, is the main complaint.
➣ Related symptoms include:
• Dysphagia, which is the inability to swallow, especially solid food.
• For a month, there will be occasional melena (black, tarry stools).
• For a month, there was weight loss and sporadic low-grade fever.
➣ No prior history of headache, haemoptysis, dyspnoea, or cough.
● Clinical Assessment:
➣ General Examination:
• Appearance of moderate anaemia.
• Lymphadenopathy in the left anterior cervical and supraclavicular regions.
• Both legs have erythema nodosum.
• There was no evidence of postural hypotension.
➣Systemic Examination:
• Within normal ranges, with the exception of lymphadenopathy and CKD-related abnormalities.
● Screening and radiological investigations:
➣A normal chest X-ray shows no signs of pulmonary tuberculosis.
➣ Acid-Fast Bacilli (AFB) in Sputum: Negative. Instead of pulmonary involvement, it suggests extrapulmonary tuberculosis.
● Findings from the endoscopy:
➣ Upper Gastrointestinal Endoscopy: • Excavated ulcers 20–24 cm from the incisors showed linear mucosal growth (Figure 3).
• Indicates esophageal disease instead than cancer or reflux.
● Microbiological and Histopathological Results:
➣ The esophageal lesion biopsy revealed well-formed granulomas with Langhans large cells, but no signs of cancer.
➣ The tissue sample tested positive for Mycobacterium tuberculosis DNA using the Xpert MTB/RIF assay.
• No rifampicin resistance was found.
➣ Lymph Node Biopsy:
• Confirmed tubercular lymphadenitis by revealing many caseating granulomas.
★ The final diagnosis in a patient with chronic kidney disease (Stage 5) was disseminated tuberculosis affecting the cervical lymph nodes and oesophagus.
Protocol
● Treatment and Management:
➣ Antitubercular Therapy (ATT):
• Started with dose modifications for CKD.
• Standard 4-drug regimen: Pyrazinamide (changed dose schedule), Ethambutol, Rifampicin, and Isoniazid.
➣ Supportive Management:
• Electrolyte imbalances and anaemia correction.
• Nutritional assistance for gaining weight.
• Fluid restriction and routine nephrology follow-up are two CKD-specific treatment strategies.
➣ Relieving symptoms:
• Haematinic supplements and antiemetics;
• Proton pump inhibitors to lower the risk of more bleeding.
● Nursing Management Techniques and Interventions :
→ These issues are addressed by evidence-based nursing interventions:
➣Personalized Patient Education: Nurses offer patients individualised instruction to help them manage chronic conditions like diabetes and heart failure on their own, which improves treatment compliance and clinical results.
➣Medication Management: Nurses increase adherence and decrease medication errors through reconciliation and routine reviews, which lowers adverse events and readmissions to the hospital.
➣Infection Control: Strict isolation and hand hygiene guidelines are used to prevent the transmission of illnesses and drastically lower the number of infections linked to healthcare.
➣Pain Management: To reduce pain intensity and enhance patient satisfaction, non-pharmacological methods (such as music therapy) and patient-controlled analgesia are employed.
➣Continuing Nursing and Follow-Up: Platforms for managing chronic diseases and frequent reminders (like SMS follow-ups) guarantee that patients keep their appointments and care plans, providing continuous support and direction.
➣Psychological Support: To improve patients' mental health and promote resilience and a positive attitude towards treatment, regular counselling and emotional support are offered.
➣Team-Based Care: Nurses play a key role in coordination, and regular interdisciplinary team meetings assist coordinate treatment plans and promote consistency in care.
Notes
For more details visit https://doi.org/10.1016/j.clinpr.2024.100383