Question

I'm doing a case study for clinical. I need the following information: Subjective data, Nursing diagnosis, expected outcomes, implementation, rationale. objective data, risk for / potential, nursing DX. R/T, AEB.

CASE STUDY 1

Patient H is a white woman, 89 years of age, who resides in a skilled nursing facility. She is being

evaluated due to an Hgb level of 8.1 g/dL. She is ambulatory with a rolling walker, generally alert, and

oriented with some mild cognitive impairment. She is compliant with medical treatments and takes

medications as prescribed. Her medical history is positive for congestive heart failure, chronic

obstructive pulmonary disease (COPD), chronic kidney disease, and osteoarthritis. She is oxygen

dependent on 2 L/minute per nasal cannula. She is bright and outgoing and verbalizes multiple vague

physical complaints.

During her last hospitalization, one year ago for pneumonia, the nephrologist and pulmonologist told

Patient H there was not much else that could be done for her. Despite the poor prognosis, her multiple

medical conditions stabilized, and she completed a rehabilitation program. She enjoys participating in

activities and has developed friendships with some other residents. Over the past year, she has been

treated for multiple infections, including bronchitis and multiple urinary tract infections.

Patient H's chief complaint is of feeling tired and short of breath at times. She also complains of arthritic

pains in her neck and hands. Review of systems is notable for hearing loss, dentures, glasses, and

dyspnea, mostly with exertion. She has occasional palpitations of the heart and orthopnea at times. Her

bowel movements are regular, and she has not noticed any blood in the stool. She has 1+ chronic edema

of the legs, which is about usual for her. She has not had a mammogram for five years, and she has not

had a dual energy x-ray absorptiometry scan, colonoscopy, or other preventive care recently.

Patient H's record indicates an allergy to sulfa drugs and penicillin. She also has completed advance

directives (a do not resuscitate order and a living will). She is taking the following medications:

Amlodipine besylate (Norvasc): 5 mg/day

Calcium carbonate (OsCal) with vitamin D twice daily

Polyethylene glycol powder (Miralax): 17 g in 8 oz liquid daily

Furosemide (Lasix): 40 mg/day

Escitalopram (Lexapro): 20 mg/day

Prednisone: 10 mg/day

Omeprazole (Prilosec): 20 mg/day

Cinacalcet (Sensipar): 30 mg/day

Simvastatin (Zocor): 20 mg at bedtime

Tiotropium oral inhalation (Spiriva): 1 cap per inhalation device daily

Vitamin B12: 1,000 mcg twice daily

Enteric-coated aspirin: 81 g/day

Upon physical examination, Patient H appears well-nourished and groomed. She is mildly short of

breath at rest but in no apparent pain or distress. She is 5 feet 6 inches tall and weighs 156 pounds. Her

vital signs indicate a blood pressure of 132/84 mm Hg; pulse 72 beats/minute; temperature 97.4

degrees F; respirations 20 breaths/minute; and oxygen saturation 94% on 2 L/minute. Her oropharynx

is clear, and her neck is supple. There is no lymphadenopathy. The patient is hard of hearing and wears

glasses for distance and reading.

Patient H's heart rate is slightly irregular, with a soft systolic ejection murmur. Evaluation of her lungs

indicates diminished breath sounds in the bases with no adventitious sounds. Abdomen palpation finds

it to be soft and non-tender, with active bowel sounds and no signs of hepatosplenomegaly. As noted,

Patient H has 1+ non-pitting chronic edema and vascular changes to lower extremities. There are no

active skin lesions. Neurologic assessment shows no focal deficit. Extremity strength is rated 4 out of 5.

ANEMIA Case Study NUR 112

A mini-mental status exam is administered, and the patient scores 22/30, indicating mild cognitive

impairment.

Blood is drawn and sent to the laboratory for CBC and a basic metabolic panel. The results are:

Leukocytes: 5,700 cells/mcL

RBC: 3.02 million cells/mcL

Hgb: 8.1 g/dL

HCT: 25.2%

MCV: 83 fL

MCH: 26.5 Hgb/cell

MCHC: 32%

RDW-CV: 15.8%

Platelets: 150,000 cells/mcL

Glucose: 82 mg/dL

Blood urea nitrogen (BUN): 34 mg/dL

Creatinine: 1.4 mg/dL

GFR: 38 mL/minute/1.73 m

2

Patient H is in no apparent distress at present, but she appears to have anemia, as evidenced by the low

Hgb. She has chronic kidney disease (stage 3), which may be contributing to the anemia. Further

laboratory evaluation is necessary to determine the etiology of the anemia and to determine if specialty

referral to gastroenterologist or hematologist is necessary. The clinician orders an iron profile, vitamin

B12 and folate levels, reticulocyte count, and stool for occult blood. The results of this testing are:

Vitamin B12: 1,996 pg/mL

Folate: 9.9 mcM

Ferritin: 20 ng/mL

Serum iron: 26 mcg/dL

Unsaturated iron binding capacity: 216 mcg/dL

Total iron binding capacity: 242 mcg/dL

Transferrin saturation: 11%

Reticulocyte count: 1%

Stool for occult blood: Negative (three samples)

Vitamin B12 is a water-soluble vitamin that is excreted in urine, so a high level is generally not

significant. The folate level is sufficient, while the ferritin level is considered low-to-normal. The iron

profile shows a low level of iron in the blood; this may be caused by gastrointestinal bleeding or by

inadequate absorption of iron by the body. Patient H has medical conditions that can cause elevated

cytokines, which would interfere with iron absorption. If her ferritin level was high, which it is not, it

would suggest AI/ACD. Therefore, the patient appears to have anemia secondary to chronic kidney

disease.

Prior to initiating treatment with an ESA, the patient is evaluated for a history of cancer, as these agents

may cause progression/recurrence of cancer. Before writing the prescription for darbepoetin alfa, the

clinician signs the ESA APPRISE Oncology Patient and Healthcare Professional Acknowledgement Form

to document discussing the risks associated with darbepoetin alfa with the patient. The lowest dose that

will prevent blood transfusion is prescribed.

The multidisciplinary team works with Patient H to develop a treatment plan. It is determined that

treating the anemia will improve the patient's quality of life. The patient is prescribed ferrous sulfate

ANEMIA Case Study NUR 112

325 mg twice daily. Because vitamin C facilitates iron absorption, the iron can be given with a glass of

orange juice or other citrus juice (not grapefruit). Iron must not be given with calcium, milk products,

and certain medications as they can interfere with absorption. The patient should be monitored for the

development of constipation and the need for stool softeners. In addition, darbepoetin alfa 40 mcg is

prescribed, to be administered subcutaneously every week. This requires significant monitoring. Hgb

and HCT should be measured on the day patient is to receive the injection, and the drug should be held if

the Hgb is greater than 11.5 g/dL. If a current Hgb level is unavailable, the drug should not be given.

Blood pressure should be measured twice daily after treatment with darbepoetin alfa is initiated. Staff

must also monitor for symptoms of a deep vein thrombosis and pulmonary embolus (e.g., unilateral

edema, cough, and/or hemoptysis). Daily exercise is encouraged to help reduce the risk of a blood clot.

After one month, Patient H has received darbepoetin alfa weekly for four weeks. She is also taking the

ferrous sulfate and a stool softener. The review of systems is unchanged from the previous evaluation.

The physical examination is also unchanged aside from a 1-pound weight loss. No new complaints or

problems are reported. A review of the patient's vital signs shows a blood pressure of 130/80 mm Hg;

pulse 78 beats/minute; temperature 97.8 degrees F; and oxygen saturation 97 on 2 L/minute. Her Hgb

levels over the last month have improved:

Week 1: 8.4 g/dL

Week 2: 9.2 g/dL

Week 3: 9.6 g/dL

Week 4: 10.1 g/dL

No side effects as a result of the darbepoetin alfa are observed. Patient H's blood pressure remains

stable, with no signs or symptoms of a blood clot.

The clinician orders the weekly monitoring of Hgb and HCT to continue with the darbepoetin alfa held if

the Hgb is greater than 11.5 g/dL. If the medication is held more than once, the clinician will re-evaluate

the dosage and frequency. The patient may only need the injection once or twice a month after the

anemia is stabilized. The clinician also reduces the patient's vitamin B12 supplement to daily (rather

than twice daily) and reduces her prednisone dose to 5 mg/day.

Answer 1

Assessment	Nursing Diagnoses	Goal/Expected outcome	Intervention	Rationale
Subjective data complaints of tiredness, breathing difficulty on exertion Objective data occasional palpitations and irregularites in heart beat edema-1+ Hb- decreased values usually less than 10g/dL	Risk for decreased cardiac output related to altered afterload, preload, heart rate and rhythm	client will maintain cardiac output as evidenced by BP and heart rate within client's normal range;peripheral pulses strong with prompt capillary refill tome	Auscultate heart and lung sounds. Evaluate presence of peripheral edema, vascular congestion and reports of dyspnea Monitor laboratory studies for serum electrolytes and chest X-ray Administer medications as prescribed. For e.g: ACE inhibitors,aldosterone receptor blockers Erythropoetin stimulating agents	S3 and S4 heart sounds with muffled tones , tachycardia, irregular heart rate, tachypnea, dypnea, crackles, wheezes,and edema, jugular venous distention suggest heart failure Imbalances can alter electrical conduction and cardiac function. Chest X-ray is useful in identifying cardiac failure and response to therapies These drugs may be prescribed not only to lower patient's BP but also to protect kidneys from further damge ESAs may be given to treat anemia associated with CRF especially when hemoglobin falls below 10g/dL to improve oxygen carrying capacity of circulating hemoglobin and reuce left ventricular strain
Subjective data Complaints of arhtritic pains in her neck and back	Acute pain related to pre-existing joint diseases as evidenced by verbalises/coded reports of pain distractions	Client will report pain relieved or controlled , appear relaxed, able to rest or sleep appropriately	Perform comprehensive assessment of pain, noting intensity(0-10), duration and location Encourage stress management techniques such as progressive relaxation, guided imagery, visualization nd meditation. provide therapeutic touch as appropriate Apply ice packs, as indicated	provides information on which to base and monitor effectiveness of intervention reudces muscle tension,refocusses attention, promotes sense of control, promote coping abilities in the management of discomfort or pain promotes vasoconstriciton and lessens perception of discomfort
Subjective data complaints of tiredness breathing difficulty on exertion Objective data SPO2 -94% maintained at 2L/min Oxygen Dyspnea on exertion Diminished breath sounds at the base of the lung	Impaired gas exchange related to ventillation-perfusion imbalance (retained secretions, bronchospasm, air trapping) as evidneced by diminshed breath sounds	Clent will demonstrate improved ventillation and adequte oxygenation of tissues and remains free from symptoms of respiratory distress	Monitor level of consciousness and mental status. Investigate changes Evaluate the level of activity tolerance. Provide calm, quiet environment. Limit client's activity or encourage bed rest or chair rest during acute phase. Have client resume activity gradually and increase as individually tolerated	Restlessness and anxiety are common manifestations of hypoxia During severe, acute or refracory respiratory distress, client may be totally unable to perform basic self care activities because of hypoxemia and dyspnea. An exercise program is aimed at improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea and enhance sense of well being
Subjective data	Ineffective self health management related to complexity of therapeutic regimen as evidenced by reports difficulty woth prescribed regimen	client will demonstrate and initiate necessary life style changes verbalizes understanding of condition, disease process and potential complications	Review dietary modifications or restrictions , fluid, potassium, sodium restricitons as indicated Discuss drug therapy including use of vitamin D, calcium supplments and phsphate binders Empazise importance of reading all product labels and not taking medications without prior approval of health care provider	Dietary restrictions to control phosphorus are usually associated with reduction in protein intake. If fluid retention is a problem, client may need to restrict intake of fluid prevents serious complications such as reducing phosphate absorption from the GI tract It is difficult to maintain electolyte balance when exogenous intake is not factored into dietary restrictions. For e.g: htpercalcemia can result from routine supplement use in combination with increased calcium intake of calcium-fortified foods and medications containing calcium