What home health interventions are appropriate for a 74-year-old female with hypertension, hyperlipidemia, end-stage renal disease (ESRD) on dialysis, anxiety disorder, insomnia, gastroesophageal reflux disease (GERD), generalized muscle weakness, and urinary incontinence, taking medications including quetiapine (Seroquel) 25mg, alprazolam 0.5mg, cetirizine (Zyrtec) 10mg, amlodipine 10mg, esomeprazole (Nexium) 40mg, labetalol 200mg, losartan 100mg, furosemide 40mg, zolpidem 12.5mg, sevelamer 800mg, and albuterol sulfate, with normal vitals and hypotension, and an allergy to codeine?

From the Guidelines

Home health interventions for this 74-year-old female with ESRD should prioritize comprehensive management of her multiple conditions, focusing on symptom burden reduction, and supporting her dialysis regimen, as emphasized by the KDIGO controversies conference 1. The nurse should monitor vital signs, particularly blood pressure, as her current reading of 115/45 shows a wide pulse pressure which may need evaluation. Medication reconciliation is essential, noting potential interactions between her multiple antihypertensives (amlodipine, labetalol, losartan) and ensuring proper timing around dialysis sessions, considering the importance of managing symptoms and medication interactions in ESRD patients 1. The nurse should assess the left AV fistula site for proper function, signs of infection, or complications at each visit. Physical therapy should focus on improving generalized muscle weakness through progressive strengthening exercises and fall prevention strategies. Education should include proper fluid management between dialysis sessions, dietary restrictions (low sodium, potassium, and phosphorus), and recognition of uremic symptoms requiring immediate attention. The nurse should also monitor for signs of anxiety and insomnia, as these conditions may worsen with chronic illness, and consider the high prevalence of anxiety in ESRD patients 1. A bathroom safety assessment and continence management plan should address her urinary incontinence. Coordination with the dialysis center is crucial to ensure continuity of care, particularly regarding medication adjustments and fluid status, and to address the potential discordance between symptoms experienced by patients and those identified by care providers 1. Regular assessment of medication effectiveness and side effects is important, especially with her complex regimen that includes psychotropic medications (Seroquel, alprazolam, zolpidem) that require careful monitoring in elderly patients with renal impairment. Additionally, considering assisted home dialysis models, as discussed in the KDIGO conference 2, may be beneficial in supporting her care, and addressing the challenges of home dialysis, such as care-partner burden and burnout 2. The importance of patient-centered care, education, and support, as well as the need for a multidisciplinary approach to address the complex needs of ESRD patients, is highlighted in the recent literature 3, 4. Overall, a comprehensive and patient-centered approach to home health care is essential to improve outcomes and quality of life for this patient.

From the Research

Home Health Interventions for the Patient

The patient has a complex medical history, including end-stage renal disease (ESRD), hypertension, hyperlipidemia, anxiety disorder, insomnia, primary hypertension, GERD, generalized muscle weakness, and urinary incontinence. Considering the patient's conditions, the following home health interventions can be implemented:

• Skilled nursing care to monitor the patient's condition, manage medications, and provide education on disease management 5
• Physical therapy to address generalized muscle weakness and improve mobility
• Pelvic floor muscle training (PFMT) to manage urinary incontinence, which has been shown to be effective in decreasing urine loss in women with stress urinary incontinence 6, 7
• PFMT protocol should last 6-12 weeks, with >3 sessions/week and a length of session <45 min for large effects 6
• The most effective training protocol consists of SEPFM by digital palpation combined with biofeedback monitoring and vaginal cones, including 12 week training parameters, and ten repetitions per series in different positions 7

Management of ESRD

For the patient's ESRD, the following interventions can be implemented:

• Monitoring of blood pressure and volume control through adequate dialysis and sodium restriction to optimize hypertension treatment 5
• Insulin therapy for diabetes management, if applicable
• Monitoring for signs of protein-energy wasting and malnutrition
• Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus, and Streptococcus pneumoniae 5

Considerations for Urinary Incontinence

Given the patient's urinary incontinence, it is essential to:

• Assess for bladder dysfunction, which is common in patients with ESRD 8
• Consider urodynamic assessment to evaluate lower urinary tract function, especially if the patient reports symptoms of dysfunctional voiding and/or bladder storage problems 8