Health and Fitness

Clinical case example

A clinical case is a detailed description of everything related to a person’s illness: symptoms, medical signs, diagnosis, treatment, and observations.

Many of the clinical cases are presented in magazines or newspapers in order to inform the population about the progress in research on the particular disease or anything else related to the specific case.

Normally in clinical cases the following aspects are reflected:

  • Chronological presentation of events
  • Comprehensive valuation
  • Diagnostics
  • Detailed description of the interventions of the professionals
  • Evolution of the patient’s clinical situation

The report of a clinical case may contain more information about the patient, such as a demographic profile and his sociocultural condition, since these elements can have a great influence on the disease he suffers.

Clinical case example

CLINICAL HISTORY SUMMARY

71-year-old patient admitted to the Nephrology Service of the Hospital Clínic referred from the Plato Clinic for presenting a cough of 10 days of evolution, blood creatinine levels of 14 mg / dl and oligoanuria without bladder balloon. After several weeks hospitalized, he was diagnosed with rapidly progressive acute renal failure (ARF), caused by Glomerulonephritis due to anti-GBM antibodies, which required the start of several sessions of Plasmapheresis (FP) alternated with Hemodialysis (HD). He is discharged requiring definitive replacement treatment for renal function with HD.

PERSONAL AND FAMILY HISTORY

Uninteresting family history.

Personal history:

  • Probable COPD (no reports or respiratory function tests available)
  • Transurethral resection of the prostate for benign hyperplasia in 2002
  • Hydrocele herniorrhaphy years ago

PHYSICAL EXPLORATION

Conscious and oriented. Normohydrated and normocoloured. PA: 130/80; FC: 84; Temperature: 36.3 ° C. You do not edema. Soft and depressible abdomen, not painful on palpation. No signs of bladder balloon.

CURRENT ILLNESS

The patient went to the Plato Clinic Emergency Service due to a 10-day history of cough accompanied by oligoanuria without bladder balloon. There, he underwent an analysis, showing creatinine of 14 mg / dl and a bladder catheter was placed by endoscopy, revealing urethral stricture that required dilation. After bladder catheterization, treatment with serum therapy and furosemide was started. Despite this, he continues to be oligoanuric, for which he is transferred to the Hospital Clínic for diagnosis and treatment.

Upon admission, the patient remains anuric (50 cc in 24 hours) and with rising creatinine levels. It was decided to place a central catheter in the jugular vein and start daily HD to correct the creatinine values.

An abdominal ultrasound is performed where dilation of the excretory tract is observed, which suggests that there is obstruction in the urinary tract and this causes oliguria. In principle, the initial diagnosis is directed towards a rapidly progressive ARF of obstructive cause, which is later ruled out with the performance of a magnetic resonance urography (where urinary tract obstruction is not observed) and etiological study, in which a high number of anti-GBM antibodies, gross hematuria, leukocyturia, and proteinuria.

Given these results, the diagnosis of rapidly progressive ARF due to glomerulonephritis due to anti-GBM antibodies was made, initiating immunosuppressive treatment with prednisone and cyclophosphamide. PF sessions alternated with HD are scheduled, being well tolerated by the patient.

Given the difficulties that the patient presented in carrying out the bladder catheterization and the manipulations of the urinary tract through endoscopic dilations, a control urine culture was performed, which was positive for resistant Staphylococcus aureus. A nasal smear is subsequently performed, verifying colonization by said germ, so topical treatment is started and the isolation protocol is carried out by MARSA.

During admission, a renal biopsy was performed, the results of which reported an unfavorable and difficultly reversible evolution of renal function, despite the FP sessions. After finishing the treatment with PF, a definitive assessment is carried out in which the patient is informed of the state of renal function and the possibility of definitive replacement treatment with HD. He is discharged due to his good general condition and good tolerance to treatment, and must continue in the HD program.

CARE PLANS

Made from data collection and assessment of the 14 basic needs according to Virginia Henderson.

Need to breathe

Former smoker of 10 cigarettes a day since probable COPD was diagnosed (no reports or respiratory function available). No current treatment. On admission, patent airways, rhythm and normal depth. Eupneic. Chest X-ray without alterations.

Need for nutrition and hydration

Upon admission, he weighs 69.4 kg and measures 170 cm. Good appearance of skin and mucous membranes. At home, he follows a balanced diet that includes all the food groups and takes adequate fluid intake. No food intolerances.

He says he is worried and confused about which foods he can and cannot eat, as the nurses have told him that from now on he has to follow a diet because his K + is high and his kidney cannot eliminate it. He refers to not having problems following a diet if that is going to help him with his disease, but he does not know if he will know how to do it well: “now that I am admitted they bring me the diet that I should eat, but when I go discharged I do not know if I will to do well ”.

Need for elimination

Normal bowel rhythm. Appearance and consistency of normal stool.

Urinary elimination: oligoanuria. The patient shows great concern in this regard and does not understand what is happening to him: “the doctors are not clear about it and this worries me, they say they do not know what has happened to my kidneys. I think they do, but they don’t want to tell me ”.

Need for movement

Autonomous. Correct body alignment. He engages in physical activities of moderate effort, working and cultivating his fields during the weekends. The rest of the week he usually takes long walks with his wife.

Since his admission, he has trouble falling asleep, sometimes he wakes up in anguish because he is afraid of how the disease is going to evolve. Going deeper into the subject, the patient refers to being afraid of a neoplastic process: “I hear the doctors speak and I don’t understand anything. I have stopped urinating, my kidney has stopped working and that worries me… and since I had prostate cancer, I am afraid that it has reproduced and has spread to the kidney ”.

Need to dress / undress

Independent. Wear comfortable clothes according to the activities you do.

Need for thermoregulation

Upon admission, he presented a slight low-grade fever (37.2ºC). Two days later he presented a fever of 38ºC, blood and urine cultures were performed. Fever subsides after administration of antipyretics.

Need for hygiene and skin protection

It has a clean and neat appearance, with good hydration of skin and mucous membranes. Shower once a day. Oral hygiene 2 times a day. Short and clean nails.

For a few days he has reported presenting a feeling of padding in his hands and feet. He also reports having itching all over his body that makes him very nervous and he feels the urgent need to scratch.

Short peripheral line carrier and jugular HD catheter. During admission, he had to be replaced several times due to insufficient flow problems during HD.

Need to avoid dangers

Conscious and oriented. Very helpful. He attends to everything that is explained to him and, despite being anguished with his state of health, he adopts a collaborative attitude towards treatment and, above all, towards extracorporeal purification techniques, since he refers to having a lot of respect for them.

Need to communicate

Proper functioning of the sense organs. He defines himself as an outgoing person, he communicates easily. His main support person is his wife: “she is also worried but she does not show it, it gives me encouragement and I know she needs it too, but I cannot give it to her and act as if nothing is wrong. All this is beyond me and I am already very old … “

Need to live by your beliefs and values

Non-practicing Catholic.

Need for work and accomplishment

Retired since age 65. He refers to having gotten used to his current situation very well: “Now I have all the time to do what I want …”

Almost every weekend he is dedicated to cultivating his lands that he has on the outskirts of Barcelona. This is very distracting and makes you feel useful. Now he is worried because he does not know if he will be able to continue doing it.

Need to play / participate in recreational activities

Since his retirement, his daily activity consists of helping his wife with household chores and, in her spare time, she likes to read the sports newspaper, watch TV and listen to the radio. He usually takes long walks with his wife and, almost every day, he goes to a club where he meets his friends to play dominoes, cards… and discuss football matches. From time to time he hunts with his family.

He says that since he entered, he misses everything he did and, although he is all day from one place to another, he gets bored. He comments that: “when I get most bored is when I go to do Hemodialysis, since I am 4 hours in the Unit without being able to do anything, there is no TV there and they do not allow my family to pass.” This feeling is accentuated by the isolation by MARSA, since until now he was taking walks around the unit, talking to the nurses, etc.

Learning need

He shows interest in everything that is happening to him and constantly asks about hemodialysis treatment.

DATA ANALYSIS AND SYNTHESIS

A 71-year-old patient, he is married, lives with his wife and has 3 children with whom he maintains good relationships. He has been retired since the age of 65 and says he has gotten used to his current situation very well.

Follow a balanced diet that includes all the food groups and takes adequate fluid intake. As a result of his illness, he is forced to follow a stricter diet, which he says he does not care if that will help him, although he refers to being confused about what foods he can eat and which not. You are worried about not knowing if you are going to do well when you go home.

At all times, he is very concerned and anguished about his current situation and the rapid evolution of his disease. He refers that since his admission he cannot fall asleep and wakes up several times a night thinking about everything that has come to him in such a short time. He verbally expresses fear of the evolution and outcome of his disease, since he relates this entire process to a complication of “prostate cancer” (according to the patient) for which he underwent surgery a year ago.

Since his retirement, his daily activity consisted of helping his wife with household chores and, in his free time, watching TV, listening to the radio and going for a walk with his wife. Almost every day he goes to a club where he meets with his friends to play cards, dominoes or discuss football matches. He spends his weekends working and cultivating his land, which distracts him and makes him feel useful.

Since his admission, he claims to be very bored and, although he is all day from one place to another due to the tests that are being done, the HD and the PF, his daily activity is limited to watching TV and walking around the Unit. The fact of doing HD in the ICU is what bores him the most since he is 4 hours without doing anything, he cannot watch TV or be with his family, a situation that is accentuated by the isolation by MARSA. He comments that “if I could distract myself in some way, I would not think so much about everything that is happening to him.”

He shows interest in everything that is happening to him and attends to all the explanations that are given him about his illness. Otherwise, he has all his needs met and he is an independent man who is supported by his wife and children.

IDENTIFICATION OF INTERDEPENDENT / DIAGNOSTIC PROBLEMS NURSES

INTERDEPENDENT PROBLEMS

Potentials

  1. Infection and phlebitis of the peripheral catheter insertion site.
  2. Infection of the insertion site of the jugular central catheter for HD.

goals

  • Prevention and / or early detection of phlebitis or infection

Activities

  • Control of the dressing every 8h and realization of the pertinent cures according to the protocol of the unit or when necessary.
  • Observe the characteristics of the catheter insertion site and record if there are signs of infection. If so, discuss it with the doctors and assess their withdrawal.
  • Control of the Tª (especially during HD, since if the patient has a fever peak during the sessions and remains afebrile the rest of the day, it would indicate colonization of the vascular access).
  1. Urinary infection secondary to bladder catheterization and manipulation of the urinary tract by endoscopic dilation for the placement of said catheter.

goals

  • Prevention and / or early detection of signs of infection.

Activities

  • Prophylactic treatment with antibiotics is started according to medical guidelines to prevent colonization after traumatic catheterization.
  • Genital hygiene every 24 hours or when necessary.
  • Observe the periurethral area and observe the characteristics of the urine.
  • Control of the Tª.
  1. Systemic infection secondary to the initiation of the immunosuppression protocol with cyclophosphamide and corticosteroids, hospitalization longer than 72 hours, and renal replacement therapies.

goals

  • Prevent and / or detect signs of infection early.

Activities

  • Use aseptic technique in the manipulation of the vascular access.
  • Control of vital signs.
  1. Internal / external hemorrhage secondary to the renal biopsy.

goals

  • The necessary measures will be carried out to prevent or, where appropriate, detect early signs and symptoms of active bleeding.

Activities

  • Observe the dressing of the puncture site upon arrival of the patient to the ward and on each shift.
  • Control vital signs according to the unit’s protocol, especially monitoring BP and HR.
  • Ensure that the patient complies with the absolute rest prescribed in medical orders by offering our services and leaving the doorbell at hand so that he does not get up.
  • Hematocrit control.

Royals

  1. Cough (this problem will probably improve with the elimination of fluid through HD).

Activities

  • Administer medication according to medical prescription.
  • Provide the patient with measures against throat irritation (small sips of water, candy …)
  1. Pruritus

Activities

  • Administer medical treatment if prescribed.
  • Physical measures to decrease its intensity.
  1. Nasal and urinary colonization by MARSA

Activities

  • Establish respiratory isolation protocol.
  • Put a mask on the patient when he moves around the hospital.

NURSING DIAGNOSTICS

  1. Fear related to ignorance of the evolution and outcome of his disease, manifested by difficulty in falling asleep and staying asleep and by verbal expressions of the patient himself.

goals

  • The patient will identify the most effective ways to deal with his fear.

Activities

  • Assess the level of fear that the patient presents and the knowledge they have about their disease.
  • Explain to the patient in words that he understands everything related to his disease and the replacement treatment with Hemodialysis. Clarify that it is not a neoplastic process.
  • Attend to the patient whenever required and provide the necessary information.
  • Show a calm and open attitude to facilitate the expression of your feelings and emotions.
  1. High risk of deterioration of skin integrity related to pruritus and manifested by verbal expressions of the patient of intense itching throughout the body and an urgent need to scratch.

goals

  • The patient will maintain skin integrity and participate in activities to prevent skin lesions.

Activities

  • Teach the patient some measures to soften and refresh the skin:

– Scrubs and massages with moisturizing cream.

– Showers with cold water.

  • Tell him to keep his nails short and clean to avoid injury and possible skin infection.
  1. High risk of ineffective management of the therapeutic regimen related to its complexity in terms of diet and medical treatment, and the difficulty of the necessary care to maintain the vascular access for HD in ideal conditions.

goals

  • It will demonstrate an adequate pattern of regulation in integration into the daily life of the prescribed treatment and diet.
  • You will acquire and increase the skills required for daily vascular access self-care.

Activities

  • Diet:

– Provide clearly and simply written information to follow a low K + diet and adequate fluid intake.

  • Medical treatment:

– Explain the treatment to the patient very carefully so that he can follow the descending regimen of cyclophosphamide and corticosteroids without difficulties.

– Discuss with the patient the possibility of going to their health center if they have a problem or require more information.

  • Vascular Access:

– Provide you with information about the care of the Hemodialysis catheter while a new definitive vascular access is being performed.

  1. Recreational activity deficit related to hospitalization, frequent treatment with HD and FP and respiratory isolation and manifested by verbal expressions of boredom.

goals

  • The patient will identify the resources available to combat their boredom.

Activities

  • Analyze the tastes and preferences of the patient. Identify the resources we have and plan the activities:

– Provide you with a radio while you are in the Unit doing HD.

– Try magazines, hobbies … or comment with your family that they bring you the newspaper you usually read.

  • Be flexible in visiting hours of the Unit while he is doing HD and, in his spare time, put a mask on him and make it easier for him to walk around the unit.

GENERAL EVALUATION

During his stay in the hospital, the patient did not show signs of infection of the HD vascular catheter despite having required several replacements due to not achieving optimal flows during HD. Nor has he presented signs of peripheral phlebitis. He required respiratory isolation due to nasal and urinary infection by MARSA, which has followed a favorable evolution, with negative cultures performed prior to discharge.

He has not presented complications after performing the kidney biopsy, keeping the hematocrit and vital signs within normality. He has preserved skin integrity during his admission, commenting that he has noticed much improvement after the advice we gave him for skin care and relief of itching.

During his admission, the patient has been given all the information regarding his illness, reducing (although not eliminating) his fear. He reports that it is difficult for him to fall asleep, but when he falls asleep he maintains it throughout the night. The idea that his disease was not a neoplastic process has relieved him and he accepts with resignation that he has to live “at the expense of a machine” (as he himself tells us). It has helped him a lot that the nursing staff explained everything the doctors told him in an understandable way, and he is grateful that we have always had a moment to be by his side, especially during the HD sessions.

He tells us that he is no longer so concerned about whether he will follow the diet correctly. He assures that he will know how to do it if he respects the basic aspects that we have taught him and he will learn “as he goes”.

Regarding the boredom during his hospitalization, he comments that having a radio has helped him to entertain himself and being able to take it to the HD and FP sessions, the visits of his family and the talks he has had with the nursing staff.

HIGH

Medical treatment at discharge

  • Chaosine 0-2-1
  • Mupirocin 2 applications / 24h
  • Prednisone 70mg / 24h in a descending pattern until total suppression.
  • Cyclophosphamide 100mg / 24h in a descending regimen until total suspension according to medical orders.

Nursing observations at discharge

The patient is discharged from the Nephrology Unit requiring replacement treatment with HD every other day in the morning. He left with the central HD catheter waiting for a new admission to perform a definitive vascular access.

An assessment is made of the knowledge that the patient has about diet, medical treatment and catheter care, expanding and adding all the necessary information. He is told that if any doubt arises, he can comment on it in his HD center, as well as if he detects any signs of infection of the catheter.

It is also explained that you can find out about the HD centers closest to your vacation spot if that worries you, and about the possibility of using medical transport to go to your usual center. Just because you are in an HD program does not mean that you cannot carry out the activities that you have been doing up to now. It is discussed with him that on the days that he is going to be dialysed, he can choose another time to attend the club or that he considers the possibility of going out in the afternoon for a walk with his wife. It is also explained to him that he can continue working on his land if he feels like it, since the HD program he has entered makes it easy for him to have the whole weekend off to himself.

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