Question

Case Study The patient is a 41-year-old male who has a longstanding history of hypertension and...

Case Study

The patient is a 41-year-old male who has a longstanding history of hypertension and diabetes and presents with a complaint of pruritis, lethargy, lower extremity edema, nausea, and emesis. He denies any other medical illnesses.

On physical assessment, the patient is a well-developed, well-nourished male in moderate distress. Blood pressure 180/110, pulse 80, respirations 24 and he was afebrile. Bodyweight 76.5 kg. HEENT was remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with the hypertensive injury. The cardiac assessment had an S1, S2, and S4. The remainder of the assessment was remarkable for 2+ lower extremity edema and superficial excoriations of his skin from scratching.

Laboratory Data

Chemistry

Normal Values

Urinalysis

Sodium

133

136-146 mmol/L

pH 6.0
Specific gravity 1.010
Protein 1+
Glucose negative
Acetone negative
Occult blood negative
Bile negative
Waxy casts

Potassium

6.2

3.5-5.3 mmol/L

Chloride

100

98-108 mmol/L

Total CO2

15

23-27 mmol/L

BUN

170

7-22 mg/dl

Creatinine

16.0

0.7-1.5 mg/dl

Glucose

108

70-110 mg/dl

Calcium

7.2

8.9-10.3 mg/dl

Phosphorus

10.5

2.6-6.4 mg/dl

Alkaline Phosphatase

306

30-110 IU/L

Parathyroid Hormone

895

10-65 pg/ml

Hemoglobin

8.6

14-17 gm/dl

Hematocrit

27.4

40-54 %

Mean cell volume

88

85-95 FL

24-hour urine protein and creatinine - volume 850 ml, protein 600 mg/dl, and creatinine 180 mg/dl
Renal ultrasound- Right kidney 9 x 6.0 cm, Left kidney 9.2 x 5.8 cm
Both kidneys illustrate hyperechogenicity and no hydronephrosis.

  1. Create numerous nursing diagnosis
  2. Create a nursing assessment and intervention for this patient
  3. Create a treatment plan for this patient considering his laboratory values
  4. If this patient is to go on dialysis, what nutrition advice will you give the patient? What food can this patient avoid, and what are the food that he can eat?
  5. Create a discharge teaching plan for a hemodialysis patient
  6. Case management plan for this patient

Homework Answers

Answer #1

Hypertension related to increased blood urea nitrogen as evidenced by BP monitoring

ASSESSMENT DIGNOSIS GOAL INTERVENTION EVALUATION

Subjective data:-

Patient is complainted about lethargy and weakness

Objective data:-

  • The patient looks weak
  • BP is 180/110
Hypertension related to increased blood urea nitrogen level as evidenced by BP monitoring After 5 days of nursing interventions the patient will be back to the normal life
  1. Assess the baseline data
  2. Check the BP
  3. Check the BUN level
  4. Advice the patient to avoid salt rich foods
  5. Administer antihypertensives as per the doctor's order

Goal met

The patient BP has been back to normal as evidenced by the vital signs monitoring

Risk for kidney damage related to increased creatinine level as evidenced by lower extrimity edema

ASSESSMENT DIAGNOSIS GOAL INTERVENTIONS EVALUATION

Subjective data:-

The patient has verbalised that i feel heavyness in the lower extrimities

Objective data:-

  • Lower extrimity edema
Risk for kidney damage related to increased creatinine level as evidenced by lower extrimity edema After 5 days of the nursing interventions the edema will be reduced
  1. Assess the baseline data
  2. Avdice the patient to move the legs always
  3. Elevate the foot end of the bed
  4. Provide angular massage
  5. Advice the patient to reduce the salt intake

Goal met

The angular edema has reduced as evidenced by the close observation

Risk for impaired skin integrity related to pruritis

ASSESSMENT DIAGNOSIS GOAL INTERVENTION EVALUATION

Subjective data:-

Patient had told that he is having untolerable itching over the skin

Objective data:-

  • Redness
  • Itching
Risk for impaired skin integrity related to pruritis After 3 days of the nursing interventions the patient pruristis will be relived and he will be back to the normal stage
  1. Assess the general condition of the patient
  2. Inspect the skin for any injury
  3. Provide skin care
  4. Demonstrate a good skin hygineic practice
  5. Check the awareness about the sensation
  6. Apply anti pruritis ointment as per the doctors order

Goal met

The pruritis has been relieved as evidenced by the normal skin integrity

Treatment plan

Laboratory result Treatment
Increased pottassium level Administration of sodium polysyrene sulfonate
Increased BUN
  • Low protein inteke
  • Maintain the hydration by IV infusion and oral fluids
Increased Phosphorus
  • Decreased phosphate rich diets (milk,red meat,frozen meals)
  • Hemodialysis
  • Administration of medication which reduce the phospurus absorption in the intestine Eg: Lanthanum
Increased alkaline phosphate
  • Avoid the intake of NSAIDS,steroids and birth control pills
  • Increase the intake of dietry vitamin D
  • Get exposure to the sunlight
Increased parathyroid hormone
  • Administer Calcimimetics which decreases the PTH
  • Treat the kidney diseases immediately
  • Intake a plenty of oral fluids
Decreased Hb and Hematocrit
  • Fe supplimentation
  • Blood transfussion
  • Intake of green leafy vegitables
Increased creatinine level
  • Avoid creatinine supplimentation
  • Decrease the protein intake
  • Increase the intake of fiber rich diets( fruits and vegitables)
  • Avoid smoking
  • Drink plenty of water
  • Avoid the intake of any NSAIDS

Dialysis patient food to be avoided and can be taken

Can be eaten should be avoided
meat canned chilli
fish Processed meat
egg foods and beverage containing pottassium and sodium
poultry jung foods

Discharge teaching plan for hemodialysis patient

  1. Do the regular exercices
  2. Dont use any medications without doctors precription
  3. Always monitor the BP and cholestrol level
  4. Don't skip the dialysis
  5. Eat healthy diet
  6. Avoid alchoholand smoking
  7. Make the body fit and avoid obesity
  8. Drink plenty of water
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