Question

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

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	Assess the baseline data Check the BP Check the BUN level Advice the patient to avoid salt rich foods 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	Assess the baseline data Avdice the patient to move the legs always Elevate the foot end of the bed Provide angular massage 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	Assess the general condition of the patient Inspect the skin for any injury Provide skin care Demonstrate a good skin hygineic practice Check the awareness about the sensation 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