My name is AAI, I`m charge in MM1, would like to present a case of a patient with ESKDs.
1. First let to me present patient`s admission data:
–ThePt name: KHMA, he is 50, y.o, he was admitted in 16 of March 2020. He was brought by his son to ER, with wheel chair. The pt was admitted to male medical word 1 bed # 220. His file # is 123P
2. Presenting/ chief Complaint (CC);
According to patient; he seeking a medical help because he has, fatigue, weakness, can`t sleep well. In addition to these he has nausea, vomiting, also he feels muscles twitches and cramps.
3. History of Presenting Complaint (HPC) :
According the patient, these symptoms and signs are extending since four weeks ago. He feels fatigue and weakness even without activities, so he can`t able to perform his ADL well. He vomited 3 times a day, about 150ml in each time. His muscle cramps increase with movement. In additional to these he said he sleep disturbance which affects his condition and made him more tension along the day.
4. Medical history
– This pt is known case of DM ,type 2 for 15years. And hypertension for 11 years
– Surgical history; this pt hasn’t significant surgical history
5. Drug history:
– For DM he using glipizde 2.5mg /day taken by oral. For hypertension he using amlodipine 10mg once a day.
– The pt not known to be allergic to any medication
6. Family history(FH):
This pt has FH of DM &HNT first degree (parent).
7. Social History (SH):
– This patient is married has 2 daughters and 3 sons, now he lives with his family
– He has low income
– He has history of smoking 2 packages/day for ten years. Now the stop smoking
– There is no history of alcohol or other bad habits
8. Physical assessment
– On examination; the patient is generally oriented to time , persons and places , he looks ill & not comfortable
– He is able to Communicate Verbally
– He require assistant to perform ADL
His morning vital signs by automatic machine (dinamap) were as follow;
– Radial pulse Rate ;115b/m regular with normal strength
– RR; 22 regular and slightly deep breathing
– Tympanic temperature ; 37.1C
– BP reading (RA) ;165/100 mmHg
– His pain score is 2 on 0 t0 10 scale
– Capillary Refill is normal on both fingers and toes.
Medico legal issue:
This patient is unable to understand Arabic language, so he medical interpreter
Systematic overview:
o CVS:
– He has tachycardia (115), lower limbs pitting edema grate 3, there is normal heart sounds.
o Respiratory:
– He is dyspnic, he has whitish cough product, and there is fine crackles on both lungs.
– There is not air flow limitation
o GIT
– His Abdomen is soft not distended
– There is nausea and vomiting as I mentioned in PIH
– In regards to eating and food requirement; he has loss of appetite , there is no heart burn
– His bowel sounds are auditable in all abdominal quadrants.
o Genitourinary and kidney:
– There is few urine output around 100/ml/24h
– Both kidneys are impalpable
o Integumentary Status
– The patient skin is dry with pallor seen in hands , eyes and oral mucous membranes
– He has itching aggravating by warm weather
– His skin is warm
– There is mild skin breakdown due to itching
o Patient`s concerns and questions:
– The patient is asking, is his condition treatable?
– He express fears about chronicity of disease
– Also his inquiries about the findings of lab results.
o The patient` Lab results were as following:
– Creatinine 4mg/dL
– BUN 125mg/dL
– K+ 6mEg/L
– Ca++ 8mEg/L
– HB 10g/dL
– Chest X-Ray – lung fluid
– RBS 340mg/dl
1. Case study
Based on this scenario answer the following questions
1. What are the other clinical manifestations of ESKDs not mention by Mr. K? 0.5mark
2. Why Mr. K has skin itching? 0.5mark
3. Is there any life-threating complications can occur to Mr.K ?1mark
4. Can you interpret Mr. K lab results? 1mark
5. Explain why Mr. K requires hemodialysis? 1mark
6. Until preparation of permanent dialysis access, a double-lumen, cuffed hemodialysis catheter was inserted into Mr.K`s jugular vein, explain how to provide care for this type of temporary dialysis access? 1mark
2. Application of nursing care plan to Mr. K
1. Based on this scenario design nursing care plan for Mr. K
A. Outline health problems encountered to Mr. K
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B. Actual Nursing Diagnosis
First actual nursing diagnose according to priority [1.25 Mark]
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Intervention: [1.5 Mark] three interventions
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Second actual nursing diagnosis [1Mark]
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