Nursing Assessment Problem Identification Case Study Mr Lim

Nursing Assessment Problem identification Case Study Mr LimThe medical record likewise shows that Mr. Lim has Type 2 diabetes (DM). His demarcation glucose level is 6.5mmol//L which according to Changi General Hospital (2009), is well-controlled for a diabetic long-suffering. DM whitethorn be the major cause of Mr. Lims breeding of degenerative nephritic failure (CRF) as suggested by Daniels and Hostetter (1992). Diabetes results in kidney wrong by accelerating atherosclerosis and inducing spunkyschool declivity pressure (Rachmani, Ravid, 2003). A recent investigate links diabetes with atherosclerosis by the large amount of advanced glycation shutdown products produced in diabetic patients that suppress the enzymes capable of dilating derivation vessels and inhibiting inflammation of blood vessels (University of Rochester Medical Center, 2008, March 17). Inflammation of the glomerulus send away result in exercise set with scar formation, inducing tubulointerstitial injury in diabetic nephropathy cause it to progress into CRF (Brosius et al, 2008).The medical record shows that he has history of hypertension. On assessment, he exhibits high blood pressure (B/P) of atomic number 53 hundred sixty-five/105, jugular venous distension (JVD), bilateral lower limb edema and change in genuflect turgor. Hypertensive nephrosclerosis is the second approximately common cause of CRF subsequently DM. It causes CRF by increasing pressure in the arterial wall leading(p) to stiffening and thickening of the afferent arteriolar and subsequently damages the glomerulus (Hill, 2008). However, hypertension as the only cause of CRF only go ons in those who ar genetically predisposed (Freeman, Sedor, 2008). The other way round, Mr. Lims elevated B/P could be callable to change magnitude cardiac siding associated with sodium and fluid keeping as a complication of CRF (Hortom-Szar, 2007). Hypertension is exacerbated in CRF because damaged kidney is no longe r able to hold electrolyte balance and excreting of sodium is impair collectable to damaged nephrons, leading to more amount of water reabsorbed, and therefore hypertension and edema (Moorthy, 2009).As a result of fluid retention, Mr. Lim whitethorn report experiencing breath littleness and paroxysmal nocturnal dyspnea. On assessment, he exhibits tachypnea with amplificationd respiration rate of 22/min, may be accompanied with crackles. This is associated to change magnituded oxygen saturation of 95% leading to an increased in respiratory rate as the body attempts to compensate by exhaling more light speed dioxide (Broscious, Castagnola, 2006). Left ventricular heart failure ignore also lead as a result of compensatory mechanism to reduced cardiac railroad siding in fluid constipate (Thomas, 2008).The blood test results show increase in both creatinine (Cr) to 1.7mg/dL more than normal shed of and blood urea nitrogen (BUN) to 28mg/dL, more than normal range of 0.6- 1.3mg/dL and 10-20mg/dL, indicating decrease in renal ability to pass by waste product of metamorphosis (Hattersley, Mahon, 2002). Estimation of glomerular filtration rate (eGFR) is a break off indicator of kidney persona than blood serum creatinine level as it also takes into consideration of singles body battalion according to race (Thomas, 2008). Mr. Lims eGFR of 41 indicates stage 3 kidney damage.Mr Lims hemoglobin level of 12g/dL falls in the normal range of 12-18g/dL only when in the lower end as anemia only starts to occur in state 3 CRF as suggested by Moorthy (2009). He is plausibly to become anemic if left uncontrolled as CRF progression results in fewer production of erythropoietin leading to a shortage of red blood stalls (Moorthy, 2009).2. SleepingMr. Lim reports insomnia. It could be due to twinge, itchy skin, breathlessness or judgments of powerless, fear and financial stress. Depression and apprehension are also hurdles to Mr. Lims shape to medical an d sustenanceetic management of CKF as suggested by Kopple and Massry (2004). He may find life meaningless when challenged with poor health leading to ghostlike deprivation and lack of impetus to improve his conditions.3. Maintaining a safe purlieuMr. Lim exhibits hyperthermia with temperature 37.8C, higher than normal temperature of 37.0C. Mr. Lim should be assessed for other signs of infection such(prenominal) as chills, aches, nausea, vomiting and cloudy pee caused by pus or bacteria. This is important because indwelling catheter and intravenous line provide entrance for stabbing microorganisms and infection is likely as his immune system is suppressed due to disease progression (Heinzelmann et al, 1999). Lower leg edema also increases Mr. Lims take chances for infection by ulcer development (Stalbow, 2004).Mr. Lim may complain of abrupt onset of itching skin. According to Brewster (1996), Mr. Lim has a high risk of getting severe uremic pruritus because of his gender and high BUN level. Pruritus is caused by voiding of atomic number 20, phosphorus and urea in the skin (Thomas, 2008). Assessment may attain scratch marks. Scratching backside cause blooding and bruising in Mr. Lim because of capillary tubing permeability and altered clotting functions due to disease progression (Thomas, 2008).A nurse should assess Mr. Lims risk for injury associated with uremia induced fundamental nervous system disorder. Mr. Lim may exhibit mental disabilities such as poor memory, way out of concentration and slower mental ability (Moorthy, 2007). Mr. Lim has high risk for fall if his mental status is altered.A nurse should also assess for signs of head injury associated with Mr. Lims fall.4. PainMr. Lim reports a trouble oneself build of 4. He may describe flank pain as dull, comprehend and steady pain at the posterior costal margin. He may also complain of leg pain due to edema. Joint pain could also occur due to renal bone disease resulted from let go o f calcium may be released from bone to compensate decreased serum calcium (Broscious, Castagnola, 2006). Serum calcium level decreased due to white loss in CRF because some calcium is bind to protein. CRF also reduces vitamin D synthesis, resulting in less calcium absorption in the gut. He exhibits healthy spasm and tetany due to hypocalcemia (Moorthy, 2007).5. Eating and drinkingMr. Lim may report loss of appetite due to metallic taste in mouth and prescribed unpalatable renal diet. Weight measurement may show rapid charge loss. Mr. Lim also requires a high-calcium diet to flip low serum calcium level.6. CommunicationEffective patient learning may be impeded by his lack of attention and scare off as preaching requires a lot of patient participation. Ineffective converse would also prevent patient from discussing his concerns with his sons, making him detect more baffled and powerless.7. Personal cleansing and dressingMr. Lim reports extreme fatigue, weakness resulting in obstruction performing the activities of workaday living. On assessment, Mr. Lim exhibits unkempt appearance and decreased range of motion especially of lower extremities.8. MobilisingMr. Lim may have difficulties ambulating due to pain from lower limbs swelling and renal bone disease. It could also be due to Wittmaack-Ekboms syndrome and paresthesia of feet associated with sensory neuropathy from uremia (Moorthy, 2008).9. EliminatingMr. Lim reports oliguria for last 24 hours and his body of water output is measured to be 20 to 25ml/hour, below than normal volume of 33 to 84ml/hour suggested by Dugdale (2009). As a result, his urine colour appears Cimmerian due to decrease urine excretion. Urine output decreases because kidney is unable to excrete water due to damaged nephrons with decreased GFR (Broscious, Castagnola, 2006). Weight measurement may show rapid weight gain. However, fluctuation of weight may non occur due to mal diet.Mr. Lim may exhibit hematemesis and tarry j ackpot associated with gastrointestinal haemorrhage due to irritation by ammonia which is released in the gut by the breakdown of urea (Thomas, 2008).Mr. Lim may report clog in passing motion. Constipation occurs in patients with CRF as fluid use is restrict and patient is inactive due to fatigue (Thomas, 2008).Nursing diagnosing1. Fluid overload related to inability of the kidneys to produce and eliminate urine as evidenced by high B/P of 165/105, edema and decreased urine output to 20 to 25mL/hour2. impotence related to lack of understanding of diagnosis and treatment plan and feeling of loss of control as evidenced by patient verbalisation of financial concerns and appearing anxious and worried.3. Risk for imbalanced nutrition less than body requirements, related to decreased calcium absorption and decreased spoken intake associated with loss of appetite and prescribed unpalatable diet as evidenced by low serum calcium of 2.0mg/dL, weight loss and patient verbalizes lack of energy.4. Pain5. Activity intolerance6. Knowledge shortfall7. Risk for impaired skin integrity8. Risk for prolonged bleeding9. Risk for infection10. Risk for fallC) Nursing Interventions1. Fluid overloadA nurse should monitor circulating volume by evaluating Mr. Lims daily weight, fluid intake and output records, JVD and circumference of edematous parts and bouncy signs, particularly blood pressure and pulse. Nursing care should also complicate assessing for crackle and S3 heart sound. Close monitoring allows the nurse to consult a physician if signs and symptoms of fluid overload worsen so interventions can be taken to prevent complications such as pulmonary edema or cardiac failure (Martchev, D).Medications such as diuretics which increase excretion of urine and arterial vasodilators to increase renal perfusion should be administered. This is important as controlling of hypertension and primary diseases are the only interventions proven effective in preventing progression of C RF (Thomas, 2008). Since Mr. Lim is diabetic, he requires B/P lower than 130/88mmHg to light upon same benefits as non-diabetic patients whose target B/P is 140/85mmHg (as cited in Thomas, 2008). However, Mr. Lim should not be intensely treated to become edema-free because of the danger of hypotension (Carpenito-Moyet, 2009).A nurse should collaborate with dietician in planning a renal diet with strict fluid restraints, low sodium and low protein with high biological protein and encourage Mr. Lim to adhere to the diet. The amount of fluid given to Mr. Lim is restricted to 24-hour urine output plus 500mL to replace insensible loss to curb fluid balance. Low-sodium diet is beneficial to prevent further fluid retention. heights biological proteins from meats, cheese and milk provide amino acids essential for cell growth and repair but release less BUN during metabolic process (Carpenito-Moyet, 2009).A nurse should assist Mr. Lim to sit in a semi-Fowler localization since not contr aindicated and elevate his feet when sitting up. Literature revue shows that this increases lung volume, allowing him to breathe better and reduces venous return to the heart and thus decreases blood pressure (Bixby, 2005). evaluate outcomes During treatment in hospital, Mr. Lim does not develop complications of CRF. Before discharge, Mr. Lims B/P returns to his baseline prior to onset of renal failure, his edema is decreased and his electrolytes are normal or at baseline.2. PowerlessnessSince Mr. Lim expresses financial concerns, the nurse can inform Mr. Lim and his family that he is included in the Medisave for Chronic Disease care Programme as he suffers from DM and hypertension which are cover in the programme, as such, he can activate Medisave to pay most of the bill when he visits general practitioner which can total up to $150 per visit (Health Professionals Portal, 2008).A nurse should encourage Mr. Lim to verbalize his concerns closely potential changes in body image, li fe style and express feelings and frustrations. Patients with CRF feel inferior due to a restricted life style and colony on others (as cited in Carpenito-Moyet, 2009). Effective communication between the nurse and the patient is necessary for a successful discharge planning including reduced anxiety and better quality of life (Carroll, Dowling, 2007).A nurse should and tell him not to see himself as a victim of disease as he has the capability to control the disease progression by complying with diet, fluid restriction and follow-up care. The nurse should provide adequate information about the double facets of the illness and therapy options encourage him to make decisions with the new knowledge. Self-worth and dignity can be enhanced when patient actively participates in decision making. Literature review shows that increasing patients self-worth is an effective treatment for depression in elderly (Ku et al, 2008).A nurse should explore the effects of the disease on Mr. Lims fa mily as chronic illness has negative impact for the whole family, not just the individual with the disease. judge outcomes The nurse provides a holistic care to Mr. Lim and his family. Mr. Lim participates actively in decision-making for plan of care and identifies personal strengths and factors he can control and as a result is highly compliant to the treatment.3. Risk for imbalanced nutritionA nurse should explain to Mr. Lim and his family about the reasons for dietary and fluid restrictions. interaction between patient and nurse and family can enhance adherence to treatment by empowering them with knowledge (Kopple, Massry, 2004).The nurse should encourage good oral hygienics before and after meals and provide a pleasant environment during mealtimes to fix appetite. The nurse should be aware that individuals cultural background influences his food choices and alliance between diet and health (Kopple, Massry, 2004). He/she may discuss with Mr. Lim dietary options rather than restrictions as he might become discouraged if the diet is too restrictive and unpalatable (as cited in Kopple, Massry, 2004).A nurse can provide methods for Mr. Lim to relieve dry mouth with metallic taste and maintain fluid restriction as required by his condition. He/she can suggest Mr. Lim to take ice chips instead of water as one cup of ice equals only half cup of water and he can attain more satisfaction from ice as it cincture in the mouth longer. He may also keep hard-fought candy with him as it can alleviate dry mouth by stimulating saliva secretion. Frequent rinsing is also useful.Administer vitamin D or calcium supplements as ordered. Calcium supplements can replace calcium and decrease risk of tetany. Vitamin D facilitates calcium reabsorption in the gut.Expected outcomes Mr. Lim understands the importance of adequate nutritional intake and complies with the prescribed dietary regime within 2 days. His calcium level increases after 1 hebdomad and he reports no muscul ar spasm and tetany. He maintains ideal weight and adequate nutrition during the hospital stay and after he is discharged.