A Case Study involving Nursing Processes

Nursing Process Paper

Mr. Black is a 67-year-old African-American man who is married with three children. His wife died about 15 years ago from a car accident, and he has been living alone since then with occasional checks from his daughter. Being a truck driver is in the middle-class income range; his highest qualification is a high school diploma. He has been his usual self until a month ago when he was admitted on February 15, 2020, to the emergency room when he noticed some swelling on his feet, shortness of breath, and fatigue. With his preexisting conditions on Hypertension, CVA, diabetes, asthma, and Hyperlipidemia, he was admitted, and a student was assigned on February 17, 2020.

Medications

Mr. Black had been given medication to deal with his preexisting conditions. For Hypertension, he was given losartan; for diabetes, he was prescribed metformin; he has prescribed albuterol for asthma. For Hyperlipidemia, his prescription was Simvastatin.

Optech LPN- ADN Flex Program Clinical Drug Information NUR 201X - 2020

Student Name: Khadijah Green, ADSN Pt. ’s Initials: M.B. Date of Care: 2/17/2020

Drug:

Trade name/Generic Name:

Losartan

Metformin

Albuterol

Simvastatin

Nexium

Classification:

Angiotensin II Receptor Blockers.

Biguanides

Bronchodilators

HMG-CoA Reductase inhibitors

Proton pump inhibitors

Frequency & Time/s Due:

one pill per day

One pill twice a day

Two puffs

One pill a day

One pill a day

Dose and Form: (pill capsule, ml, units, etc.)

100mg

500mg

180mg

10mg

20mg

Route:

Oral

Oral

Inhaled drug

Oral

Oral

Pt. diagnosis for this drug:

Hypertension

Diabetes

Asthma

Hyperlipidemia

Gastro-esophageal

reflux

disease

Indication Uses:

Once a week for five days

Once a week for five days

4-6 hours with

12inhalations/

24hrs

Used once a day for five days

Used twice a day for

Four weeks.

Common side effects:

Diarrhea

Stomach pain

Dizziness

Headache

Tiredness

Diarrhea ,nausea ,flatulence,

Indigestion

and abdominal pain.

Wheezing

Leg cramps

Extreme thirst

Blurred vision

Diarrhea

Abdominal bloating

Muscle cramping

Flatulence

constipation

Headache

Nausea

Flatulence

Adverse life-threatening effects :

Vasodilation

It decreased Blood pressure.

Allergic reaction

Kidney damage

Lactic acidosis

Nausea

Chest pains

Convulsions

Tremors

Cause muscle myopathies

Decrease liver function

Inhibits the gastric

Proton pump and

Prevent the formation of

Hydrochloric acid.

Action:

Block the binding of angiotensin II to receptor cells.

Lower blood glucose levels by decreasing liver glucose production

Prevent bronchospasm

Lowering LDL-C levels

It controls acidic reflux and its symptoms.

Nursing Implications:

Assessment:

What do you need to assess before giving?

Monitor the blood pressure

Do not give drugs without checking with the health care provider if systolic Blood pressure is below 100.

The patient does not receive the drug after the procedure requiring IV contrast material.

To teach patient to monitor heart rate

The patient should not have active liver disease or pregnant.

Nexium should not be

given with other IV

drugs

Implementation:

What do you need to know about this medication regarding food, other medications, crushing, route, etc.?

Avoid foods high in potassium because they can cause hyperkalemia.

Patients should not take alcoholic beverages when taking this drug

To use the drug five minutes before the other inhaled drugs.

To avoid grapefruit and grape juice in their diet.

To reduce alcohol or

caffeine consumption

Smoking and fasting.

Toxicity and Overdose:

If applicable:

Therapeutic Serum Level and Antidote:

It can lead to death due to the blocking of adrenaline

Visit the nearest hospital

Lactic acidosis.

Treatment include; sodium bicarbonate infusion and hemodialysis

Chest pain, irregular heartbeat to control the use of a ventilator.

If inactivated, it remains in patients’ bloodstream leading to kidney failure, heart failure, G.I. bleeding. Visit the nearest hospital

Dizziness, fast heartbeat, and increased fractures of the hip, wrist.

Visit the nearest hospital for treatment

Source/Page:

(Ignatavicus et al., 2018),

(Ignatavicus et al., 2018),

(Ignatavicus et al., 2018),

(Ignatavicus et al., 2018),

(Ignatavicus et al., 2018),

Laboratory Studies

Laboratory tests were done to determine the cause of his shortness of breath, fatigue, and swelling of his feet. Tests were done to determine his blood sugar level, his sodium and potassium concentration levels. Arterial blood gas tests, estimated glomerular filtrate rate, NT-proBNP test, creatinine are also done. Hematology tests are done as hemoglobin transports oxygen to tissues. Red blood cell count provides data about oxygen transport. A deficiency of hemoglobin leads to hypoxemia. The normal male has a 6.1×1012/L(Ignatavicus et al., 2018). Mr. Black has a red blood count of 4.5×1012/ L, which is lower due to the production of excessive production of erythropoietin. Hemoglobin levels range from 14-18g/dL in males, with hematocrit levels ranging from 42-52% in males. Mr. Black had a 14.5g/dl hemoglobin level and a hematocrit level of 43% (Ignatavicus et al., 2018). The white blood cells’ normal count in healthy living is between 5-10×109/L. His white blood cells count within the normal range of 9.8×109/L; however, elevation to the more remarkable range will indicate a possible acute infection. Arterial blood gas tests assess gaseous exchange and perfusion as the partial pressure of end-tidal carbon dioxide—the PaCO2 level in a healthy adult between 20-40mmHg(Ignatavicus et al., 2018). The patient had a lower partial pressure of end-tidal carbon dioxide of 10mmHg, indicating he has breathing effectiveness and gas exchange changes.

Diabetes mellitus is diagnosed by the blood glucose value and oral glucose tolerance level. The glycosylated hemoglobin value indicates the average blood glucose level with a fasting blood glucose level >100ml/dL. The patient had a high glucose level of about 199ml/dl, which is higher than the required one showing higher mortality levels and higher infection. A sodium range of 128mEq/24hr within the normal range of 40-250mEq/24hr(Ignatavicus et al., 2018). Increased sodium can lead to excessive salt intake, while low sodium intake leads to bleeding, shock, and prerenal kidney injury. Potassium levels in an average range person are between 3.5-5.0mEq/L (Ignatavicus et al., 2018), lower than the patient’s potassium content of 6mEq/L showing kidney disease.

Creatinine abnormal findings when low creatinine is found leads to deterioration of the kidney with increased amounts leads to infections and diabetes mellitus. The creatinine range for healthy adults is 1-2g/24hr, with it being slightly lower in older adults. A 0.2’ range with a previous of 0.5’ is seen in the patient. Creatinine clearance is a measure of the glomerular filtrate rate(eGFR). When a creatinine test is done, an estimated eGFR is done based on the modified diet in the renal diseases(MDRD)study equation. The estimated eGFR for the MDRD is >60mL/min/1.73m2.The patient’s eGFR was’ 58mL/min/1.73m2(Ignatavicus et al., 2018), which was lower than the previous ‘60Ml/min/1.73m2. BNP levels on the blood plasma are done to determine the rate of heart failure. A BNP of <100ng/ml shows a low heart failure rate, a level of >100ng/ml indicates heart failure with the highest rate reached 5000ng/ml (Ignatavicus et al., 2018), which Mr. Black has. The lower the BNP value shows the highest the survival level, and as age increases, the mortality rate increases.

Chest X-ray is used for patients with pulmonary problems to evaluate chest status. It uses Standard imaging uses the post anterior and lateral views, or in portables examinations, it uses the anteroposterior view(Ignatavicus et al., 2018). Chest X-ray determines the size of the heart, lungs, and blood vessels.

Diagnostic

Mr. Black had no head deformities, with clear ears and no deviation of the nasal septum. His eyes had pupils that were round, equal, and reactive to light. His throat had no edema with aortic murmurs being noted; Mr. Black has lungs filled with fluid causing crackles and any air movement in the sacs like breathing. Mild wheezing is seen when exhaling. There is noted shortness of breath when he lies flat and on exertion. There is noted swelling of feet and ankles.

The intermediary features manifest in the x-ray as peribronchial cuffing, indistinct vessels, and septal lines show the presence of pulmonary edema. The features X-ray shows determine the extent of pulmonary problems. The widened vascular pedicle, enlarged upper lobe vessels, and enlarged heart found in the early stages are considered pre-edema features(Assaad et al.,2017). The x-rays show increased chest pressures and fluid transudation as septal lines, peribronchial cuffing, and alveolar edema show negative pressure in the chest. Pulmonary edema has three severity stages: pulmonary vascular congestion, interstitial pulmonary edema, and alveolar edema. The features from the X-ray show acute cardiogenic pulmonary edema that is the same as for pulmonary capillary wedge pressures. Chest x-rays may not provide pulmonary edema’s required progress: therefore, Lung CT scans are recommended.

Medical Diagnosis

Samples were taken to the laboratory, and the results were analyzed. The patient was found to have high levels of potassium, creatinine, high glucose levels, low red blood cells count, low partial end-tidal carbon dioxide and low estimated glomerular filtrate, and high levels of BNP. The high levels can lead to chronic kidney disease, heart failure, and pulmonary edema from the x-rays taken.

Chronic kidney diseases lead to subdual declining of the kidney’s function, leading to disturbances of fluid and electrolyte balance, disturbance in the acid-base balance, the build-up of nitrogen-based wastes, and kidney loss function. Chronic kidney takes place in three stages. Mr. Black having an estimated glomerular filtrate rate of 58ml/min has stage three chronic kidney disease. The damage to the nephron is more significant, and low waste removal is present. Treatments that cause nephron damage, especially diabetes and Hypertension, should continue(Ignatavicus et al., 2018). As the disease progresses, kidney function decreases as the urine output decreases, making the patient at risk of fluid overload with edema, pulmonary crackles, shortness of breath, and decreased heart sounds. Decreases in kidney function lead to the build-up of serum creatinine. An increase in potassium levels leads to changes in heart rate and rhythm due to irregular repolarization. Sodium is lost in urine during the early stages of the disease because fewer healthy nephrons reabsorb it. Chronic kidney disease leads to the production of uremia, which affects the entire gastrointestinal system. The enzyme urease in the mouth breaks down urea into ammonia, which is retained in the mouth (Ignatavicus et al., 2018), leading to peptic ulcers. Due to his existing gastro-esophageal reflux disease, which was diagnosed in 2010, the peptic ulcer worsens, leading to internal bleeding.

Mr. Black has been suffering from Hypertension, which he was diagnosed in 2020, year 2009 he was diagnosed with asthma and Hyperlipidemia, and in 2011 he was diagnosed with type 2 diabetes. His preexisting Hypertension from causes such as atherosclerosis leads to pressure damages to the glomerular capillaries (Shimamoto et al., 2014). Hypertension damages kidney arterioles reducing the circulation of blood through tissues.

Fluid overload or blood vessel injury leads to pulmonary edema. The heart cannot remove blood from the left ventricle leading to increased pressure in the right atrium and blood vessels, leading to fluid crossing from the capillaries into the pulmonary tissue leading to edema. The patient had shortness of breath and crackles that had begun from the base of the lung. As the fluid level increases, the lungs’ level of fluid increases (Assaad et al., 2017). Heart failure is likely to occur because of the increased load due to fluid overload and Hypertension. The accumulation of uremia may lead to a uremic toxic effect on the myocardium. Patients with chronic kidney disease, pulmonary edema, and other cardiac and gastric diseases are less likely to respond to treatment.

Nursing Care Plan

Nursing of patients suffering from chronic kidney disease, pulmonary edema, and heart failure needs continuous evaluation, diagnosis, and accelerating treatment, avoiding the patient’s death by appropriately detecting the event and providing treatment to stabilize the patient. Patients with Pulmonary edema have impaired gas exchange due to excess fluid in the lungs and anxiety related to the sensation of suffocation and fear. Nursing management supplies the patient’s supplementary oxygen masks, raising the head to a sitting position, monitoring vital signs, using intravenous therapy and catheterization that allows urine to drain from the bladder. Pulse oximetry is monitored. Nurses help the patients relax to promote oxygenation and place them in a high Fowler position to enhance lung expansion and administer oxygen. The nurse records the morphine is administered and the amount administered, with persistent patient condition. Emergency pieces of equipment should be kept ready and vital signs checked for about 15-30 minutes, and record daily weight and report when weight gain is steady. Frequent mouth care to reduce the mucous membrane’s dryness and signs for increasing respiratory distress and edema should be assessed. Kidney chronic disease patients should be taught about carefully managing fluid volume, blood pressure, electrolytes, and other kidney-damaging diseases by following the defined drugs and nutrition therapies (Shimamoto et al., 2014). The drugs administered to patients should be adjusted correctly, and in case of any questions, the pharmacist should be consulted. Counseling to the patients should be done to reduce depression. Any abnormal finding in a patient’s urine undergoing a screening exam should be reported to the primary health care provider.

Conclusion

The patient was suffering from pulmonary edema. It is a condition in which the lungs fill with fluid, and the fluid collects in the air sacs making it difficult to breathe. The patient had been experiencing crackles, mild wheezing on exhalation, and shortness of breath when he laid down. Mr. Black had heart failure and chronic kidney disease, which lead to increased fluid in the lungs.

References

Assaad, S., Kratzert, W. B., Shelley, B., Friedman, M. B., & Perrino Jr, A. (2018). Assessment of pulmonary edema: principles and practice. Journal of cardiothoracic and vascular anesthesia, 32(2), 901-914.