Rob Fran is a 57 year old male who has been admitted to hospital with acute kidney failure secondary to dehydration.
Patient – Rob Fran, 56-year-old male from Adelaide currently working in Darwin
Presenting problem – Oliguria, nausea, lethargy and confusion
Presenting diagnosis – Volume responsive Acute Kidney Injury secondary to dehydration
Background – Mr Fran had been concreting outside when he became ill with an increasing headache followed by dizzy spells and nausea. He self-administered Ibuprofen for symptoms with little effect. The following day he collapsed at work and an ambulance was called to take him to hospital. His work colleagues stated he had been irritable and confused at times during the day preceding his collapse but felt it was related to not coping with the Darwin heat and humidity. He also had not been eating or drinking due to nausea and feeling unwell.
Mr Fran was treated with IV fluids in the emergency department and transferred to ICU for 48 hours to monitor his renal function.
He has now been transferred to a medical ward.
Phx – Hypertension, Type II diabetes (diet controlled), mild osteoarthritis in back, knees and hands
Medications • Perindopril 2 mg mane
- Ibuprofen 400mg PRN (OTC, self-medicates)
Diet/fluid intake – Mainly diabetic, with occasional “treats”, drinks 5 – 8 cups of coffee daily and occasion fruit juice/diet soft drink if he is thirsty
Alcohol use – Social drinker, 2 to 3 beers, 2 to 3 times per week
Tobacco use – 5 – 10 cigarettes per week, usually when drinking alcohol
Drug use – Prescription medications only
Home/personal relationship – Married with 2 adult children, all living in Adelaide. Wife is arriving in Darwin today after hearing of her husband’s hospitalisation.
Career/work – Self-employed concreter
Education – Completed year 10 prior to working in the family concreting business
Economic background – Owns his own house and business, but states if he doesn’t work he doesn’t get paid. Wife is not employed and does home duties.
Ethnic background – AustralRob born to Greek immigrant parents
Language spoken – First language Greek, but educated in Australia with good understanding of English as a second language
Religion/spirituality – Catholic, attends church at Easter and Christmas and special occasions with a strong belief in God.
ADLs – Independent.
IADLs – Drives both car and truck. Independent with finances. Wife attends to cooking, all housework and bookkeeping for their business.
Sleep – States he sleeps well 5 – 7 hours per night
Health maintenance – Visits a GP in Adelaide every few months for diabetic and blood pressure review. He states he is very rarely ill.
After 2 days of oliguria Mr Fran urine output has increased and he has been transferred to a medical ward.
Below is the information you have been handed over as you commence your shift on the medical ward.
Temperature – 36 degrees Celsius
Heart rate – 95 beats per min
Respiratory rate – 22 resps per min
Blood pressure – 160/95mmHg
O2 saturations – 94% on room air
Pain score – 0-2 / 10
Specific gravity – 1.030
pH – 5.5
Leukocytes – Neg
Blood – Neg
Nitrite – Neg
Ketones – Neg
Bilirubin – Neg
Urobilinogen – Neg
Protein – ++
Glucose – +
CNS • Alert and orientated
- GCS 15/15
- Lethargic, fatigued, tired
- Sometimes slow to respond
CVS • Nil oedema noted
- Peripheries warm and well perfused
- Serum urea and creatinine levels slightly elevated
- Regular pulse rate and rhythm
- No abnormalities detected on auscultation of heart
Respiratory • Shallow regular respirations
- Chest expansion symmetrical
- No abnormal breath sounds on auscultation
Skin • Skin intact
- Slight pruritus to arms
Gastrointestinal • Loss of appetite and slight nausea
- Nil vomiting
- Regular bowel movements but slightly constipated
- Low potassium diabetic diet
- Protein restriction to 60g per day
Urinary • IDC insitu
- Output 40 – 80 mls per hour
- Strict hourly monitoring of input and output
- Fluid restriction 1 litre per day
- eGFR 59 mL/min/1.73m2
- Ramipril 5mg mane oral
- Frusemide 20mg bd oral
- Paracetamol 1g PRN oral
- Ibuprofen 400mg PRN oral
Based on the information above, address the following tasks.
Task 1. Nursing Assessments (500 words)
Mr Fran will require the following nursing assessments during your shift.
- Fluid assessment
- Cardiovascular assessment
Under each of the assessment sub headings below: –
- Identify the goal of the assessments
- Explain why they are important in relation to Mr Hayne’s renal function and
- Describe specifically how you will conduct undertake? these assessments.
Write answer here……..
Cardiovascular assessment (blood pressure and pulse)
Write answer here…….
Write answer here…..
Task 2. Plan and Implement Nursing care (1000 words)
You identify alterations in fluid volume related to acute kidney injury as a priority nursing problem for Mr Fran today.
Your care plan includes imbalanced fluid intake as the specific nursing problem.
- Identify the nursing actions/interventions you would implement to manage this problem today.
- Explain why each of your interventions are appropriate for this nursing problem today.
Actions and explanations must be evidence based
Write answer here………..
Task 3. Patient education (500 words)
If managed appropriately Mr Hayne’s renal function should improve rapidly during the recovery phase and then continue to improve for up to a year.
During hospitalisation, Mr Fran will have multiple learning needs in regard to acute kidney injury and maintenance of renal function on discharge.
- Identify specific education Mr Fran will require regarding acute kidney injury
- Identify any management strategies you will include in the information you give Mr Fran to assist him to maintain and improve his renal function after discharge
- Why Mr Fran requires the information you are providing.
Write answer here……………
Lemone, P., Burke, M. K., Levett-Jones, T., Dwyer, T., Moxham, L.,Reid-Searl,… Raymond,D.(2014). Medical-Surgical nursing: critical thinking for person-centred care. (2 nd ed.).French Forest, NSW: Pearson Australia.
Task 1 – Assessing
Consistently provides a succinct description of the purpose/goal of all assessments.
Clearly demonstrates the relevance of the assessment.
Clearly demonstrates how assessments are relevant to renal function.
Explains clearly, succinctly and specifically how to conduct the relevant assessments.
Task 2 – Assessing
Demonstrates high level ability and critical thinking to develop individualised, comprehensive nursing care relevant to the case study and nursing problem.
More than 15 actions/interventions identified.
All interventions are within the scope of the registered nurse.
All rationales are referenced and demonstrate high level ability to explain or justify each nursing action.
Task 3 – Assessing
Demonstrates a high level ability to provide relevant and comprehensive patient education including use of medications.
Education provided is based on current evidence and referenced.
Academic Integrity – referencing
Demonstrates high level ability to acknowledge the work of others. All ideas supported with appropriate and accurate in-text citations and there is a complete and accurate reference list.
Minimal direct quotes (<3)
No errors detected in APA 6th format. Academic integrity standards met at a high level.
Evidence for practice – Assessing
Minimum of 10 peer reviewed journals.
No more than 2 current text books cited.
Journal articles and textbooks (Must use – Lemone, P., Burke, M. K., Levett-Jones, T., Dwyer, T., Moxham, L.,Reid-Searl,… Raymond,D.(2014). Medical-Surgical nursing: critical thinking for person-centred care. (2 nd ed.) ) are no more than 5 years old.
No inappropriate resources in reference list.
Academic Writing – assessing
Meets written communication standards for nursing practice and academic literacy at a high level.
Content is well organised with a coherent flow.
Assignment is free from spelling and /or grammatical errors.
No lists, abbreviations, diagrams, acronyms and/or nursing jargon.
Rob Fran Case Study
One of the primary responsibilities of registered nurses in the hospital settings is the delivery of hands-on care to patients via the assessment of the patient’s conditions, planning, and implementation of care, and the provision of patient education. Additionally, according to LeMone et al. (2014), registered nurses are tasked with the management of intravenous lines and the observation and monitoring of patients’ conditions. In the case of Rob Fran, dehydration has resulted in acute kidney injury. Although he has been transferred to the medical ward because of increased urine output, a need arises for the registered nurse to measure and maintain fluid balance. This paper provides a discussion of the nursing assessments that a registered nurse can do on Fran, how nursing care can be planned and implemented and the nature of patient education which should be offered to the patient.
Fluid assessment on Mr. Fran will entail the evaluation of his hydration status and the measurement of fluid balance which will result in actions being taken to ensure optimal hydration. The fluid assessment will aim to measure the balance of the input and output of fluids in his body which will allow for the proper functioning the metabolic processes. Notably, one of the issues that Mr. Fran faced when he was being admitted in the hospital was acute kidney injury resulting from dehydration. As such, the fluid assessment will be vital in evaluating the fluid balance as the presence of inadequate fluid or excessive fluid can adversely affect the renal function and cardiac functions (Prowle, Kirwan, & Bellomo, 2014). In the case of Mr. Fran, I would conduct the fluid assessment via capillary refill time and renal output and input. In specific, I will hold Mr. Fran’s hand at heart level and press on the pad of his middle finger for five seconds. I will then release the pressure and measure the time in seconds until the return of the normal body color. In the renal output and input, I will assess the volume of water he takes against the urine including its color and odor.
A cardiovascular examination will be vital for Mr. Fran is ensuring a healthy heart. Although the cardiovascular examination did show any abnormal pulse rates and rhythms nor were there any abnormalities detected in heart auscultation, his hypertensive condition will require a regular review of the heart. The primary goal of cardiovascular assessment will be to measure the heart sounds (auscultation) and pulse rate. Notably, according to Ostermann and Joannidis (2016), chronic kidney disease is one of the markers of cardiovascular risks. As such, there is a probability that Mr. Fran’s heart health is affected. Assessing his cardiovascular will seek to establish whether it has been affected by acute kidney injury. The assessment will be done via listening to the heart sound with a stethoscope. Additionally, the basic heart sound auscultation will be performed in the chest rates of the aortic, pulmonic, tricuspid, and mitral (Jin et al., 2017). Afterward, I will conduct a patient interview for any pain the chest which could be a manifestation of ischemia.
Conducting urinalysis on Mr. Fran will have the primary goal of screening for diabetes especially the insulin levels as well as any kidney disorders and injuries, liver problems, and urinary tract infections. Notably, Mr. Fran’s specific gravity is 1.030 which means that he is experiencing mild dehydration. According to Schley et al. (2015), dehydration of more than 1.010 can lead to the formation of kidney stones and urinary tract infections which can result in renal damage. As such, a urinalysis will be vital to examine kidney health. Moreover, a urinalysis will be used to measure the electrolyte balance (Ostermann & Joannidis, 2016). I will collect of Mr. Fran’s urine, observe the urine color and odor, and then use the test stripes to establish any revealing findings from the urinalysis test.
Plan and Implement Nursing Care
In the nursing problem of imbalanced fluid intake, the following are the nursing actions/interventions which I would implement to manage the problem in Mr. Fran:
Regularly Offer of Fluids
To ensure that Mr. Fran does not continue to suffer from hydration, the regular provision of fluids such as water will be vital. Proper fluid intake today makes patients stay hydrated and thus avoid some of the issues/concerns such as renal failure, and imbalances in the potassium and sodium electrolytes (Ostermann et al., 2015).
Regularly Replenish and Refresh of Fluid Supplies
One of the probable causes of Mr. Fran failing to have a proper fluid balance is the absence of fluid supplies such as fruits juices, sports drinks, and even milk. As such, regularly replenishing him with fluid supplies will provide him with an opportunity to choose from among the many provided depending on his taste and preference (Vanmassenhove et al., 2017).
Use of Beverage Carts
The use of a beverage cart will provide Mr. Fran with a wide variety of fluid choices from which he can choose which one he will favor. Studies have demonstrated that the use of beverage carts results in a significant increase in fluid in each of the body compartments as well as the increased urine output (Ostermann et al., 2015).
It will be vital to identify any instances of anorexia as it can lead to the patient limiting the amount of food and fluid that he takes. Anorexia monitoring can prevent hydration and protect the heart through a balance of fluid intake in the body (Wilson, 2014).
Provide Ice-Blocks and Other Fluid-Rich Foods
Mr. Fran might not be comfortable with taking water because he is feeling nauseated. As such, providing ice blocks which are fluid rich can ensure that he has an alternative source of fluid (Carrero et al., 2016). Ice blocks have been found to result in increased hydration and thus better renal health.
Use Visual Reminders
The fact that Mr. Fran may not be a fan of fluid intake can be cured via the use of reminders to drink such as posters. Today, according to Vanmassenhove et al. (2017), using posters reminds and convinces the patient about the importance of fluid intake and thus increases their consumption of fluids.
Assess Both Presence and Location of Edema
The dynamic interactions of blood hydrostatic and osmotic pressures, as well as interstitial fluid hydrostatic, may lead to a shift in body fluid from one compartment to the next. Prowle, Kirwan, and Bellomo (2014) state that assessing and finding edema will signify a need to minimize the fluid intake.
Monitor Fluid Intake and Output
I will monitor the amount of fluid taken by Mr. Fran (in millimeters) and the urine output to establish whether vast amounts of fluid are being retained in the body. Fluid intake and output monitoring will prevent the absorption of excess fluids and thus attain a balance in fluids and electrolytes (Wilson, 2014).
Weigh Mr. Fran Daily
I will have to weight Mr. Fran daily and compare the weight with the 24-hour intake and of fluids and renal output. Comparing the weight against the input and output will provide a reflection of intravascular volume and thus lead to a decrease or increase in fluid intake (Clark et al., 2016).
Monitor Vital Signs and Central Venous Pressure
Some of the vitals signs such as temperature elevation of orthostatic hypotension will be monitored every day as they will tell the degree of fluid deficit. Wilson (2014) argues that any presence of fever will increase metabolism and thus exacerbate the loss of fluids and increase dehydration.
Monitor Blood Pressure
Any sudden or marked elevation of blood pressure, restlessness, frothy sputum, and basilar crackles will be monitored especially because other fluid supplements will be used in general fluid replacement. Low blood pressure could be a demonstration of the presence of dehydration which would then call for increased fluid intake (Prowle, Kirwan, & Bellomo, 2014).
Ascertain Mr. Fran’s Beverage Preferences
After establishing the beverage that Mr. Fran prefers, a 24-hour schedule for fluid intake will be set up, and the client will be required to take foods with high fluid concentration. Such an action will not only relive thirst but also augment any parental replacement (Wilson, 2014).
Evaluate Mr. Fran’s Ability to Manage Own Hydration
Some of the impediments which might hinder the ability of Mr. Fran to hydrate include impaired gag and swallow reflexes, oral discomfort, and nausea. As such, establishing these factors can lead to appropriate actions being taken to increase or replace the fluids orally (Ostermann et al., 2015).
Provide Safety Precautions
The dehydration of Mr. Fran and the fact that he collapsed at work requires safety precautions such as the use of side rails, positioning the bed in a low situation, frequent observations, and any soft restraints. According to Greer et al. (2016), safety precautions will be protective measures against any injury to the client due to any altered thought processes arising from decreased cerebral perfusion.
Administer IV Solutions
I would give Mr. Fran colloids or isotonic solutions depending on whether he requires increased fluid or decreased one in the body. Notably, Prowle, Kirwan, & Bellomo (2014) argue that colloids such as Hespan and Dextran will correct any deficit in plasma protein concentration. However, isotonic solutions will be used if a need will be found for circulatory improvement. However, it may also result in increased renal clearance.
Monitor Mr. Fran for Complications
One of the issues which will arise during the nursing care is that Mr. Fran will be a risk of the relapse of some symptoms such as confusion and even fainting. As such, according to Murugan et al. (2016), monitoring any complications will be vital for the nurse. In specific, close surveillance of the patient will prevent any complications being an unnoticed and reduce the likelihood of adverse events.
Task 3: Patient Education
Mr. Fran will require education on acute kidney injury as well as maintenance of renal function and discharge. I will ensure that he learns about the definition of severe kidney injury, causes of the injury, symptoms, and when to call a doctor or a nurse. In this case, will educate Mr. Fran that the signs that he has such as vomiting, acting confused, and seizures are some of the symptoms of kidney failure (Ostermann et al., 2015). Additionally, I will endeavor to explain to him the actions that he should take to ensure that his renal function improves. One of those will be taking a lot of water and ensuring that he is hydrated in most of the times. Additionally, I will make him understand the need for change in diet as well as the medications which will be provided to him.
To help Mr. Fran maintain and improve his renal function after discharge, I will include management strategies such as drinking fluids as necessary and keeping a record of everything that he eats and drinks. Additionally, I will educate him on the importance of measuring the amount of urine each day, weighing himself, and keeping a record of the daily weights (Greer et al., 2016). Moreover, I will ensure that Mr. Fran learns how to take her temperature every day as well as blood pressure and keep records of the same. Mr. Fran will also be informed about the importance of maintaining good personal hygiene, taking the medications as directed, and the need for frequent blood and urine tests to monitor the kidney function. I will educate him that he should call the doctor right away if he encounters signs of bladder infection such as frequent urination, burning, and pain, as well as bleeding.
The information I have provided in the paragraph above will be vital in ensuring that Mr. Fran understands the condition he is in and how he can improve his renal functions and thus ensure a quick recovery. Educating him on the activities and actions that he should take will ensure that he does not exacerbate the situation by worsening the acute kidney injury (Sawhney, Marks, & Black, 2016). Additionally, the management strategies will be vital in making sure that he continues to monitor the condition even after discharge (LeMone et al., 2014). Moreover, educating him about the vital signs that should make him call a doctor will be critical so that an alarm will be raised in advance and any issues addressed. Patient education will be a fundamental aspect in this case for the patient to continue with the care actions and interventions after discharge.
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