The patient in this ihuman case study has been diagnosed with Chronic Kidney Disease. He is considered to be in the guarded condition, hence not critical. Below is the Ihuman report and diagnosis.
Primary Diagnosis: Chronic kidney disease Status/Condition: (Critical, Guarded, Stable, etc.) guarded Code Status:full code
Allergies: nkda
Admit to Unit: monitored Activity Level: BRP Diet: renal and cardiac
IVF (ifordered, include type and rate ): none
Critical DripsNitroglycerin 5mcq IV drip and titrateto keep SBP<140
Respiratory: 5 liter NC prn to keep SPO2 >92% and titrate appropriately
Medications:
Lisinopril 2.5 mg PO daily Simvastatin 40mg PO daily Hydrochlorothiazide 12.5mg PO daily Ferroussulfate 60mg PO daily
Lasix 40mg IVP X1
50meq Sodium Bicarbonate 1 gm Ca gluconate IVPB
Nursing Orders:
Vital signs every 15 minutes until SBP returns to normal then q 1hr Bathroom privilege as tolerated
Keep SPO2 >92% Keep SBP<140
Monitor hourly urine output
Follow Up Lab tests :
BMP, CBC, ABG
Diagnostic testing (CXR, US, 2D Echo, etc…)
Chest xray to evaluate pulmonary edema
US of kidneys for size measurements and rule out obstruction
Consults
Nephrologist for kidney disease management and possible dialysis Cardiology for hypertension management
Nutritional consult for dietary modification
Patient Education and Health Promotion
smoking cessation Sodium restriction Keep SBP < 140
Fluid restriction Discuss diagnosis
Explain positive findings
Educate on medications given including signs and symptoms Importance of physical activity as tolerated
Importance of following treatment plan as prescribed Importance of Outpatient follow up appointments diet compliance with a renal and cardiac diet recommend annual influenza vaccination
Discharge planning and required follow-up care:
Follow up with PCP, cardiologist and nephrologist in 2 weeks
References
Ferri, F. F.(2019). Ferris clinicaladvisor 2020.(1st ed.). Amsterdam: Elsevier.
Lewis, R. (2012). Understanding chronic kidney disease. [electronic resource] : a guide for the non-specialist. M&K Pub. Retrieved from https://search-ebscohost- com.ezp.waldenulibrary.org/login.aspx?direct=true&db=cat06423a&AN=wal.EBC10513 49&site=eds-live&scope=site
Obialo, C. I., Ofili,E. O., & Norris, K. C. (2018).Statins and Cardiovascular Disease Outcomes in Chronic KidneyDisease: Reaffirmation vs. Repudiation. International Journal Of
Environmental ResearchAnd Public Health, 15(12).
Papadakis, M.A., & McPhee,S.J., & Rabow,M.W. (2018). Current medicaldiagnosis & treatment (57th ed.). New York, NY: McGraw Hill.
Get your Homework, Class, Exam and Essays handled b our professional tutors 24/7. Place your order today at acemyhomework.com/order-now. We guarantee quality and timely work.
