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School of Health Professions, Science and Wellness

Department of Nursing

Clinical Care Plan

Adult Gerontology Health Nursing I

Fall,2020

Student: _Amie kah king Date: 6th , April, 2019

Instructor: ______Prof Ramsey________________________ Clinical Course: _NURS 364

Client’s Initials: ___J.B________ Age: __40 YRS _______ Sex: _____M___ Room#: 12B

Date of Admission: __8th March, 2020______________ Date of Care: 11th March, 2020

Present Medical Diagnoses: Acute renal failure as a result of malignant hypertension (Bisognano, 2017)

Present Surgery (if applicable): _None Date of Surgery: ___None

Allergies: NKA Height: __5’6 Weight: 129.5 kg.

Code Status: F0ull Code

Section I

General Data

(Points 5)

Chief Complaint: Dyspnea and cough.

History of Present Illness (Detailed): The patient is having dyspnea and coughs which has been worsening and productive respectively for the past one week. He is also having subjective fevers. For the past week, the patient has had progressively worsening dyspnea + cough productive of clear sputum + subjective fevers. Had full dialysis on 11th March, 2020; but missed it on Friday

Past Medical/Surgical History: the patient is having chronic kidney disease (CKD), stage V, HIV disease, Hypertension, Obesity, and ESD on HD.

Social History: He is not a frequent alcohol user and he takes 1 to 2 times per year. He is unemployed and he denies tobacco and other substance use. He is born outside the United States and is single and living an independent life.

Family History of Illness: The mother and father have hypertension.

Immunization History: the immunization is up to date.

Description of Procedures (Surgeries) Performed this Admission: None

Section II

Pathophysiology and Etiology

(Points 10)

In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan)

Based on the information, the patient might be having mild malignant hypertension which leads to renal failure. The development of malignant hypertension is characterized with vascular lesion which is fibrinoid necrosis of arterioles and the smaller intestine (Harty, 2014). This leads to the clinical manifestation of the end-organ damage, the red blood cells are damaged as they flow through vessels obstructed by the fibrin deposition leading to microangiopathic hemolytic anemia. The treatment involves the use of drugs like hydralazine, nicardipine, fenoldopam, nitroglycerin, and enalaprilat (Jelic, 2020).

Section III

Assessment

(Points 20)

Physical Assessment:

General Appearance

A 40 year old patient who feel comfortable with no general acute distress

Neurosensory

No headache, no paresthesia, no limb weakness, alert and oriented ×3

Psychosocial

No anxiety, no depression, no suicidal thoughts

Cardiovascular

No chest pain, no pressure, no palpitations, no syncope, no loss of consciousness

Respiratory

Per HPI

Gastrointestinal

No change in the bowel habits,bowel sounds were hear in all four quadrant , no nausea, no vomiting, no diarrhea, no constipation, no melena, no anorexia.

Genitourinary

No hematuria, no nocturia, no discharge, no Dysuria, no incontinence, no change in the urinary frequency, no urinary retention.

Musculoskeletal

No back pain, no neck pain, no joint pain, no muscle pain, no swelling, no change in the range of motion

Integumentary

No rash, no pruritus, no abrasions

Incisions: None

Drains

None

Diet/Nutrition

= regular diet

IVs

None

Vital Signs

T: 98.1 (Oral); ; HR: 76 (peripheral); RR: 20; BP: 146/78; SpO2: 100%; WT: 175

lb; Oxygen Delivery Device: Room Air (03/11/20, 23:19:00)

Intake and Output

Volume overload is 2/2

Pain assessment (2)

Primary:

Fall Risk Assessment (6)

Pressure Ulcer Risk Assessment (2)

Section IV

Diagnostic Data

(Points 10)

Diagnostic Tests	Patient’s value	Normal Range	Inference(why is this patients value abnormal)
WBC	7.6 k/uL	4-11 µL	Normal
Hgb	10.8 gm/dL Low	13-17 g/dL	Anemia caused by insufficient erythropoietin
Hct	34.9 % Low	45-52 %	Low. Anemic
Platelet	236 k/uL	150k/ul-450 k/uL	Normal
Sodium	138 mmol/L	135-145 mmol/L	Normal
Potassium	3.7 mmol/L	3.5-5 mmol/L	Normal
Chloride	105 mmol/L	98-107 mmol/L	Normal
CO2	18 mmol/L Low	35-45mmHg	Low’ Kidney disease
BUN	74 mg/dL High	2.5-7.1 mmol/L	High. Inability of the kidney to remove urea
Creatinine	17.5 mg/dL	0.8-1.3 mmol/dL	Impaired Kidney function which causes poor clearance of the creatinine
Glucose	89 mg/dL	70-130 mg/dL	Normal
Calcium	8.5 mg/dL	8.5-10.5 mg/dL	Normal
Total Protein	7.6 gm/dL	6-8.3 gm/dL	Normal
Albumin	3.2 gm/dL Low	34-5.4 gm/dL	Low. Inflammatory disease, liver disease, or malnutrition.
AST	62 units/ L HI	10-40 units/L	Chronic condition
ALT	112 units/L HI	5-30 units/L	Possibility of heart damage
Bill Total	0.5 mg/dL	0.1-1.2 mg/dL	Normal
Bill Direct	0.16 mg/dL	< 0.3 mg/dL	Normal
Alk Phos	51 units/L	20-140	20-140 units/L

Section V

Treatment and procedures

List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.

(Points 10)

Interventions	Rationale
Dialysis-Physician initiated.	Dialysis to help in the removal of toxins and excess fluids from the body
Managing the blood pressure (Nursing Initiated)	To help in healing the renal lesions
Teaching on healthy nutrition (Nursing initiated)	This helps in the reduction of risks of increasing in body weight which exposes the patient to risk of hypertension
Participation in the activities such as physical exercise	Help in lowering the blood pressure and cardiac load
Frequent assessment of the neurologic status and urine output (physician initiated)	Helps in the management of the hypertension
Intravenous antihypertensive medications and fluids (nursing initiated)	Helps in the management of the hypertension
Continuously monitor cardiac (Physician initiated)	Helps in the reduction of the symptoms associated with hypertension

Section VI

Teaching and Health Promotion

(Points 5)

List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.

1) The patient is taught on the suitable diet for the long-term management

2) When the patient is discharged, he is informed about the signs and symptoms that should prompt immediately and to notify the physician

3) The patient is taught on the proper dosing

4) The patient is taught on the adverse effects of the medications

5) The patient is taught on the importance of engaging in the activities that helps in the control of hypertension for example taking of low salt foods, taking of law cholesterol foods, low sugary foods, and take part in the exercise to manage healthy weight which is a risk factor for the disease.

Section VII

(Points 5)

List of Nursing Diagnoses Use your assessment, the client’s medications and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)

1) Malignant hypertension

2) Acute renal failure as a result of poorly managed hypertension

3) Dyspnea

4) CKD

5) Eclampsia

Section VIII

Medications

(Points 10)

Medication Sheet

Medication Dose

Brand/

Generic Name

Mechanism of Action/Indication for Use

Contraindication

Adverse Effects/Side Effects

Nursing Implications

Outcomes

Safe Dose

(yes or no)

Why is your client on the drug?

Abacavir

Brand Name: Ziagen

Aspirin

Brand name: acetylsalicylic acid

LamiVUDine

Trade Name Epivir

Other name: 3TC

Prezcobix

Sevelamer

Trade Name: Renagel

amLODIPine

Trade Name: Norvasc

This is a nucleoside reverse transcriptase inhibitor which inhibits the replication of the virus

Low dose and long term use leads to blockage of the formation of the thromboxane A2 in platelets leading to the production of inhibitory effect on the platelet aggregation

Inhibit type 1 and 2 of HIV reverse transcriptase and the reverse transcriptase of hepatitis B virus.

Selectively inhibiting the cleavage sites of HIV-1-encoded Gag-Pol plyproteins in the infected cells thus preventing the formation of the mature virus particles

Preventig the hyperphosphatemia by inhibiting the dietary phosphate in the gut, prevents its absorption, and reducing the serum parathyroid hormone level

Inhibits the movement of the calcium ions into the vascular smooth muscle cells and the cardiac muscle cells which further prevents the contraction of the cardiac muscles and the vascular smooth muscle cells.

Contraindicated for individuals with high triglyceride in the blood, increase in the blood acidity, coronary heart disease, liver problems, severe liver disease, and the pancreatitis

Not effective for the bleeding disorder like hemophilia and the recent history of stomach or intestinal bleeding.

Increased blood acidity due to high levels of lactic acid; acute and chronic inflammation of the pancreas; chronic disease stage 3A

Contraindicated for high blood sugar, increased thirst, increased urination, dry mouth, fruity breath odor, headache, blurred vision

Contraindicated for low vitamin D levels, stomach or intestinal function, constipation, and the stomach muscle paralysis.

Contraindicated for patients with hypersensitivity to dihydropridines

Dizziness, nausea, allergic reactions, builds up of acid in the blood, liver problems.

Confusion, hallucination, rapid breathing, seizure, severe nausea, vomiting, stomach pain, and coughing of the blood.

Cough, diarrhea, fatigues, headache, malaise, nausea, and the nasal symptoms

Nausea, vomiting, stomach pain, headache, rashes

Nausea, Vomiting, stomach pain, loss of apetite, upset of the stomach, diarrhea, constipation, tired feeling, itching, the joint pain.

Nausea, tiredness, stomach pain, swelling of the legs, dizziness, and feeling of hot or warm in the face.

Nurse monitors the S & S of the hypersensitivity, fever, skin rash, fatigue, and GI distress. Nurse advice the patient to take drug as instructed. The patient is advised to withhold the drug and inform the physician if there is hypersensitivity.

Assessing pain and pyrexia one hour before or after the medication

Discontinue therapy if severe or accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis.

Assessment of the urinary function

Order lab test to obtain the frequent serum phosphate levels; patient not to use capsules after printed expiry date, patient to take daily multivitamin supplement.

Advising the patient to notify healthcare worker if there is light-sightedness, is syncope occur, discontinue until healthcare worker is consulted

Helps in the reduction of the viral load

Helps in the reduction of fever

Reduction in the viral load

Helps in lowering the concentration of other drugs thus leading therapeutic effect and development resistance

Helping in the reduction of phosphorus in the patient with end-stage kidney disease

Helping in the reduction of the risks of the total cardiovascular event and mortality

Yes. The patient is HIV positive, therefore the drug helps in the prevention of the immune system and reduction in the development of the AIDS-related illness.

Yes. The patient is having fever, therefore the low dosage of Aspirin is important for the patient

It is safe for the patient and it is needed to help in the reduction of the viral load.

Helps in the improvement of the therapeutic effect

Helping in improving the condition of the patient in terms of his CKD

The patient is having hypertension, therefore the drug helps in reducing the risk of cardiac disease.

Section IX

Nursing Interventions

(Points 15)

CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES

Assessment

findings

Nursing Diagnosis

(Actual & Potential Deficits, Wellness Diagnoses)

Outcomes

Short and Long Term

Interventions/Nursing Systems

(Dependent & Independent)

Rationale

(Why are performing that intervention?)

Evaluation/Outcome

(What was the actual result?)

The patient is having low levels of hemoglobin

Low CO2, Hct

High levels of BUN and creatinine

Anemic

Kidney disease leading to inadequate EPO. This leads to the making of the low or fewer red blood cells thus causing anemia

Renal disease

Short term: To improve the level of the hemoglobin

Long term: to ensure that the patient is in good condition to help in fighting the disease, blood loss from hemodialysis

Short term goal: increase the production of production of the EPO leading to Long-term goal: increase in the manufacturing of the red blood cells by the bone marrow.

Short-term: to improve the flow of blood into the kidney.

Long-term: reduction in the level of the BUN and Creatinine

Advising the patient to eat iron-rich foods like egg, spinach, beans, and lean meats.

Taking of the meals rich in iron

Reduction in the level of protein intake, eating of more fiber foods, avoiding the use food supplements with creatinine, and reducing the

This helps in increasing the level of the hemoglobin

Increase in the level of the CO2 and Hct

Assisting in lowering the creatinine and BUN levels

The patient will be able to acquire the normal level of HB.

Increase in the level of the CO2 and Hct to normal

Reduction in the dyspnea

References

Bisognano, J. D. (2017, January 13). Malignant Hypertension Treatment & Management. Retrieved April 6, 2020, from Medscape: https://emedicine.medscape.com/article/241640-treatment

Harty, J. (2014). Prevention and Management of Acute Kidney Injury. Ulster Medical Journal, 83 (3), 149-157.

Jelic, S. (2020, March 19). How Chronic Obstructive Pulmonary Disease (COPD) Is Treated. Retrieved March 6, 2020, from Very Well Health: https://www.verywellhealth.com/copd-treatment-915040

Revised 8/12/2015