11/2/2016Care Case Study (1)Pain Flashcards | Quizlethttps://quizlet.com/99242449/carecasestudy1painflashcards/1/5Care Case Study (1)-Pain29 terms by sarrahthompsonLike this study set? Create a free account to save it.Create a free accountDuring RN's intiial interview, Wrenda sharesinformation about her home, career, and family.The RN evaluates the info to determinepsychosocial factors that may impact painmanagement. Which info obtained by RN ismost likely to influence Wrenda's perception ofher pain?Wrenda's younger child is an infant who feedsevery 3 hoursfeeding infant every 3 hrsinterrupts sleep and results in fatigue. Fatigueoften heightens perception of pain and impairscoping skills.To assess the quality of Wrenda's pain, the RNasks which question?"What word best describes the pain are youexperiencing?" The quality of painexperienced is typically a descriptive term,such as burning, crushing, aching or stabbingWhich behavior that Wrenda exhibits supportsher subjective report of acute pain?Frequent guardingGuarding or protectingpainful area is common behavioral response topainAfter completing the pain assessment, the RNdevelops of care. RN identifies pain andanxiety as the priority problems. To determinethe etiology of Wrenda's anxiety, what is thepriority nursing intervention?Continue interview with clientfurtherassessment by RN is needed to determine causeof client's anxietyWhat is the best goal for the RN to include inthe plan of care related to the problemstatement "Acute pain related to strain onmuscles with movement?"Client reports pain 1 on a 010 scalegoal is abroad statemetn that reflects a positive directionfor the client's problem, in this case, acute pain
Posted on 2/01/08
This case represents an actual case that the author participated in. The names and certain details regarding the patient were changed to protect privacy.
Mr. TP is a 79 year old male with moderately severe Alzheimer’s dementia presently residing in a long-term care facility. He was sent to the Emergency Department by nursing staff who noted he was less responsive than usual. Specifically, while he normally did not verbalize on a regular basis, he did sometimes utter one word answers, and he did communicate through the use of affirmative or negative nods of the head. At the time of presentation, the patient was minimally responsive. His blood pressure was 96/50 and his pulse rate was 112. His respiratory rate was 22 and his temperature was 100.5 degrees Fahrenheit. Initial physical examination showed an unresponsive white male in no obvious distress. Skin turgor was poor with obvious tenting. Cardiorespiratory and abdominal examinations were within normal limits. Initial laboratory studies showed:
Hemoglobin 18.5 g/dL
Sodium 176 meq/L
Potassium 6.9 meq/L
Chloride 145 meq/L
Bicarbonate 10 meq/L
BUN 212 g/dL
Creatinine 14.4 mg/dL
Hepatic transaminases, calcium, and cardiac enzymes, including troponin were within normal limits.
Urinalysis revealed 2+ protein, 2+ blood, positive leukocyte esterase, and positive nitrite. Microscopic exam of the urine revealed too numerous to count white blood cells, 50-100 red blood cells, and 4+ bacteria. Gram stain of the urine revealed numerous gram negative rods.
ECG revealed minimally peaked T waves in the precordial leads.
Chest x-ray revealed no active disease.
Review of records from the long term care facility revealed that the patient had had decreased oral intake for the past 4 days. No advanced directive was recorded in the paperwork provided.
The patient was admitted to the intensive care unit and started on intravenous hydration with normal saline at 200 cc per hour. Renal consultation was called and renal ultrasound revealed no hydronephrosis or other abnormality. The patient was also started empirically on levofloxacin, 500 mg every 24 hours, until the urine culture returned >100,000 E. coli, at which time he was switched to ceftriaxone, 1 gram every 24 hours.
Over the initial 24 hours, the patient’s BUN improved to 110 and his creatinine improved to 9.6. Continued hydration over the next 4 days resulted in complete normalization of his renal function and he gradually became more responsive. By hospital day #6, he was awake and alert, non-verbal but responsive to verbal cues, and was tolerating a chopped diet with pureed liquids.
Discussions were initially had with the patient’s wife and sons regarding his condition, and his poor prognosis upon initial presentation. As time passed, however, the patient improved so much that the family was informed that the patient did have a significant probability of returning to his pre-morbid state. A DNR order was entered into the patient’s medical record after discussions with the family.
The patient was discharged back to the long term care facility on hospital day #8.
Case Presentation Part 2
Three weeks later, the patient again was sent to the Emergency Department with lethargy. Initial evaluation revealed the patient to have BUN of 99 g/dL and a creatinine of 7.8 mg/dL. He was again unresponsive. On this occasion, there was no evidence of a urinary tract infection or pneumonia.
Treatment again consisted of intravenous fluids and supportive care. Over the next 3 days, his renal function again returned to normal and his level of alertness improved. DNR status was affirmed by his family. On hospital day #4, a percutaneous gastrostomy tube was placed by the gastroenterology consultant. Tube feedings and free water flushes were started and the patient was discharged to the long term care facility on hospital day #5.
This case brings up several very interesting and important questions and observations.
1. What factors were involved in the patient’s development of acute renal failure?
2. Was it reasonable at the outset to expect that this patient’s renal function would improve with conservative measures?
3. What actions were available to the treatment team to prevent the development of acute renal failure once again?
4. What safeguards could have been put in place in the long term care setting to protect this patient?
5. Was the use of the feeding tube appropriate in this patient?
Question #1: What factors were involved in the patient’s development of acute renal failure?
This patient’s acute renal failure was most likely related to volume depletion as a result of inadequate oral intake. He likely had an age-associated reduction in renal function, and may have had other co-existing renal disease. His decrease in oral intake may have been precipitated by the development of the urinary tract infection acutely, and by the ongoing decline in mental status from his dementia.
Question #2: Was it reasonable at the outset to expect that this patient’s renal function would improve with conservative measures?
Based upon the degree of renal insufficiency at the outset, combined with the patient’s age, completely recovery of renal function was not expected. However, identifying the precipitating causes above made it more likely that he would recover. In light of the patient’s age and co-existing dementia, the recovery that the patient experienced was frankly quite astonishing.
Question #3: What actions were available to the treatment team to prevent the development of acute renal failure once again?
Identification of the above causes of renal insufficiency and exclusion of other causes was important in this patient. Once this was done, and it was determined that the patient’s acute renal failure was due largely to volume depletion, a discussion with the patient’s family and the staff of the long term care facility was appropriate to ascertain how well the patient was eating prior to the hospitalization and what his level of intake was at baseline. Additionally, identifying any evidence of dysphagia was appropriate in this patient as well.
Discussions with the patient’s family regarding the patient’s ability to eat and drink, and thereby sustain appropriate amounts of intake, were important. Discussions about alternate methods of feeding should have been carried out (and was), and attitudes of the family regarding the appropriateness of the feeding tube should have been sought out (and they were).
Explanation to the family that this event was likely to occur again was appropriate to have and to reinforce throughout the patient’s hospitalization. Open levels of communication with the staff of the long term care facility was paramount to prevent the recurrence of the patient’s acute renal failure.
Question #4: What safeguards could have been put in place in the long term care setting to protect this patient?
In addition to careful communication between the hospital staff and the staff of the long term care facility, other safeguards which could be put in place include frequent physician evaluation to assess for adequate intake and the development of volume depletion, frequent laboratory monitoring to assess renal function, and a comprehensive feeding plan which includes all staff caring for this patient.
Regarding the latter of these, it would be important for nursing staff to note how much the patient consumes, and if he does not appear to be able to feed himself in an efficient manner, then feeding schedules should be set up. Additionally, consultation with a dietician would be helpful to conduct a calorie count and to assess the patient’s caloric needs.
If it is determined that the patient is still unable to meet intake needs, then it would be appropriate for the physician at the long term care facility to address the potential use of a feeding tube to prevent further development of acute renal failure.
Question #5: Was the use of the feeding tube appropriate in this patient?
This is as much a philosophical or ethical question as it is a medical one. Clearly, this patient was unable to maintain adequate food and fluid intake to prevent the development of renal failure, so an alternate method of feeding was required. While studies have shown that the use of feeding tubes do not necessarily prevent mortality in patients with advanced dementia, in this case, the patient may have received an additional benefit, especially in light of his significant response to hydration. In other words, while a feeding tube in most demented patients might just “delay the inevitable”, in this patient’s case, the ability to carefully provide adequate fluid and calories may have prevented acute renal failure, which was responsible for 2 hospitalizations, and could have very well resulted in the patient’s death.
The use of the feeding tube in this case, however, in no way changed the natural history of this patient’s overall medical condition, though, so some would argue that while there were certain tangible benefits, its use was not appropriate. In fact, detailed discussions were had with the patient’s family regarding the use of a feeding tube versus close monitoring of the patient at the long term care facility and consideration of hospice and comfort care, with no further treatment of volume depletion and acute renal failure should it occur. While the family did understand that the feeding tube would not reverse the patient’s underlying condition, they believed that the patient had significant quality of life to warrant the insertion of the feeding tube to prevent a recurrence of acute renal failure. They also believed that use of the feeding tube would provide the patient with comfort, since the patient would not suffer the effects that acute renal failure might cause in this patient. It was explained to the family that the patient likely did not experience any significant symptomatology from the acute renal failure, but they nevertheless believed that visually he did, and accordingly were quite emphatic in their beliefs in this instance.
At the time of this case study, the patient has returned to the long term care facility. Communications with nursing staff and the physician caring for the patient there were initiated. No further evidence of acute renal failure has been demonstrated and the patient remains generally awake and alert, with minimal communication as noted above.
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