nursing -Activity homework‎

Each piece of information tells you about the patient, their pathophysiology and the pharmacology used to manage this case. By using the signs and symptoms we begin a process of elimination and confirmation.

Case studies are mainly not straightforward ‘textbook’ answers. Sometimes we have to ask lots of questions and explore each fact before we really understand the case.

Understanding pathophysiology and pharmacology can be simple by using the following 10 steps:

1. Underline/identify key words.
2. Define the disease or condition. Do you understand these terms? If you don’t understand, begin reading around these terms. You may also need to look at or revise your old anatomy and physiology notes to really understand how ‘normal’ bodies work before you can explore your patient in the case study.
3. List the common signs and symptoms associated with the disease or condition. Again if you are unsure look them up in a text book. Can you explain why each of these signs and symptoms manifest?
4. List the signs and symptoms your patient in the case study has presented with. Ask yourself do these signs and symptoms match those listed in the text book?
5. Are there signs and symptoms that don’t match or don’t make sense? What are some possible reasons for this (we could call this an hypothesis)? Begin exploring and eliminating possible reasons based on further reading.
6. Now ask yourself: are there any reasons this case could be complicated? Is it the condition/disease, the patient’s management of the condition, are there investigations missing or does the patient have other co-morbidities?
7. How would you investigate this case study? What might a doctor order to better understand this case study, e.g. blood tests or x-rays?
8. How is this condition treated/managed?
9. What pharmacotherapy is used to manage the disease/signs/symptoms?
10. When looking at pharmacotherapy: look at mode of action, therapeutic use, pharmacokinetics, side effects, drug interactions and nursing considerations.

Often on clinical you see a more simplified example of this 10 step process called ISBAR. ISBAR (or introduction, situation, background, assessment and recommendations) is a tool or framework that can be used to assist health professionals to communicate critical information to each other. As you explore the case study ask yourself the following questions:

• What is the situation at the moment with this case study?
• What is the background to this condition(s)?
• What is your assessment of the situation or the patient?
• What action do you recommend now (to make a recommendation you need to have a hunch, a hypothesis or a nursing diagnosis).
• Use the 10 steps or ISBAR to assist unpacking the many aspects of each case study. The more you do this the quicker, easier and more detailed your analysis of the case study will be. This is good news for your assignment.

1. List the differences between acute and chronic renal failure.
2. List the signs and symptoms of diabetes type 2.
3. Outline focal points of connections of renal functions and the complexity of diabetes type 2.

Patient case study

Georgina Lawson is a 55 year old IT consultant for the Adelaide City Council and has been admitted to the ward for investigation of a suspected urinary tract infection and possible renal failure. She saw her GP 3 days ago who prescribed her Trimethoprim. She presented herself to ED at midnight.

She is married and has 3 children ranging in age from 17-22. She works long hours and rarely gets home before 8 o’clock. She lives in Greenwith, has a mortgage and her husband works night duty as a cleaner since being made redundant during the global financial crisis.

Georgina was first diagnosed with type 2 diabetes mellitus when she was 40 years of age. She initially managed to control her sugar levels with diet and exercise. However in the last 12 years, when she returned to work, she has found it increasingly hard to control her glucose levels. She admits that she loves food and has trouble saying no to treats or several glasses of alcohol. Her long hours at work and busy lifestyle mean that she finds very little time for exercise. She often buys take away food or eats out at restaurants.

Read the handover sheet. Observe the clinical notes, medication charts, and laboratory results.

Discuss the following areas.

1   Nursing assessment

What data will you collect as a basis for your nursing assessment of Georgina? What questions would you ask? Why? What types of information are you trying to elicit? What factors have put Georgina at risk of this disease? Why?

Explore the aspects below in relation to Georgina’s case and discuss in detail:

• Hypertension
• 600 ml fluid restriction
• Stat glucose and insulin prescription
• Deep breathing pattern O/A

2   Medication management

Pharmacodynamics: What, when, how, contraindications, special nursing considerations, interactions. Pharmacokinetics—absorption, distribution, metabolism and excretion, remembering her possible diagnoses.

Georgina is prescribed Metformin 100 mg BD and Trimethoprim 200 mg nocte. Discuss the implications of giving these medications to Georgina with reference to the pharmacodynamics and pharmacokinetics of each medication.

• How would Georgina’s Pharmacology be different if her BMI was 45?

3   Signs and symptoms in relation to diabetes and urinary tract infection

Are Georgina’s signs and symptoms consistent with a patient who has a urinary tract infection? List the signs and symptoms of a urinary tract infection; acute and chronic renal failure

Chart Georgina’s vital signs on a graphic chart—does this make you respond to her symptoms differently?

Please explain the pathophysiology in detail of one of the following as it applies to Georgina.

• Acute renal failure as related to her Type 2 Diabetes Mellitus (T2DM)

Explain why you believe that she has acute or acute on chronic renal failure and explain the pathophysiology of three (3) signs and symptoms that Georgina has presented with to support your belief.

OR

• Chronic renal failure as related to her Type 2 Diabetes Mellitus (T2DM)

Explain why you believe that she has chronic renal failure and explain the pathophysiology of three (3) signs and symptoms that Georgina has presented with to support your belief.

Note:the signs and symptoms must be relevant and specific to Georgina. Thus you will need to investigate how this disease/illness affects adults with type 2 diabetes mellitus, not type 1 diabetes mellitus.

• How would Georgina’s pathophysiology be different if her BMI was 45?

4   Observe Georgina’s lab results

Do the results support the diagnosis of a urinary tract infection? OR Do the results suggest a change in renal function? Do the results suggest something else? What other explanations are there? What about Georgina’s fluid and electrolyte balance? What about Georgina’s nutritional status?

• What other explanations are there?

Hint: use the Cockcroft and Gault Equation (found in Porth 2011) to predict her creatinine clearance. This can be used to predict glomerular filtration rate.

• Discuss the tests that were ordered for Georgina and explain why they were chosen in regards to your chosen element discussed in question 1.
• Discuss any results that were given and what they add to the diagnosis/element that you chose to discuss.
• Discuss any tests that you believe should have been ordered; explain why you think this and what the expected results may be.

Note: there are many clinical findings in Georgina’s case that may not make sense. The goal is not to find all the answers or make a medical diagnosis, but to take note of them and try to reason through.

5   Advocating for your patient

How would you present all the data you have collected to the medical team to support or negate their diagnosis, and ensure best outcomes and treatment for your patient?

Kidney Health Australia Health Professionals: http://www.kidney.org.au/HealthProfessionals/tabid/582/Default.aspx

Diabetes Australia, ‘Best practice guidelines for health professionals’, http://www.diabetesaustralia.com.au/For-Health-Professionals/Diabetes-National-Guidelines/

SA Pathology: http://www.imvs.sa.gov.au/wps/wcm/connect/SA+Pathology+Internet+Content/IMVS/Hom

Lehne, RA 2013, chapter 4 ‘Pharmacokinetics’, in Pharmacology for nursing care, Elsevier, Chatswood, Australia. (read especially about drug absorption, distribution, metabolism and excretion)

Porth, C 2011, chapter 24 ‘Structure and function of the kidney’, in C Porth (ed.), Essentials of pathophysiology, 3rd edn, Lippincott Williams & Wilkins, Philadelphia, USA.

Porth, C 2011, chapter 25 ‘Disorders of renal function’, in C Porth (ed), Essentials of pathophysiology, 3rd edn, Lippincott Williams & Wilkins, Philadelphia, USA.

Porth, C 2011, chapter 26 ‘Acute renal failure and chronic kidney disease’, in C Porth (ed), Essentials of pathophysiology, 3rd edn, Lippincott Williams & Wilkins, Philadelphia, USA.

Guven, S, Matfin, G &Kuenzi, J 2011, chapter 33 ‘Diabetes mellitus and the metabolic syndrome’, in C Porth (ed), Essentials of pathophysiology, 3rd edn, Lippincott Williams and Wilkins, Philadelphia, USA.

DeLange, J 2013, chapter 2 ‘Balancing electrolytes’, in Fluids and electrolytes made incredibly easy, 1st edn, Lippincott Williams and Wilkins, Sydney.

DeLange, J 2013, chapter 17 ‘Renal impairment’, in Fluids and electrolytes made incredibly easy, 1st edn, Lippincott Williams and Wilkins, Sydney.