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One of the leading causes of chronic kidney disease (CKD) is hypertension (HTN). HTN is the pressure of the blood pushing up against the arterial walls as blood is being pumped out by the heart (National Kidney Foundation). A gradual loss of kidney function over time will cause chronic kidney disease which can inversely leads to HTN, dialysis, strokes, heart attacks and ultimately death. This paper will discuss the facts about a case study of an African male patient who was admitted to the emergency room with a admitting diagnosis of poorly controlled HTN and transferred to a medical surgical unit ( National Kidney Foundation, 2018).
JR fifty-six year old Africain American male patient, admitted to the emergency room and later transferred to the medical surgical unit with a diagnoses of with elevated HTN secondary to CKD on 6/29/2018. Per JR medical records, he has no known drug allergies, English as the primary language, Baptist, divorced with four kids. JR worked as a Construction Labor for over 17 years, and his medical insurance is Anthem Blue Cross. JR physician is a Nephrologist, while in the hospital the port will be replaced for his peritoneal dialysis.Biological System
JR past medical history includes CKD and HTN in the year 2016 JR had chronic hypertension and was on three medications Norvasc 25, Hydrochlorothiazide 25 mg, and Losartan 50 mg daily. JR was not taking his medication and chose to abuse alcohol and eat foods that were outside of his diet. JR medical records revealed that he had in April 2016 he had a Nephrectomy and was placed on peritoneal dialysis in January 2018. JR went to the hospital and found that his blood pressure was not being control and computed tomography (CT) revealed that he had a cyst on his left kidney.
(Provide date of onset and/or diagnosis for each condition)1990, blood pressure increased and got a ct scan 2011 black dot on the kidney, April 2016
Recent Medical History/Reason for Admission/Course of Hospitalization:
JR is non compliant with his dialysis treatments and medication on 6/10/18 his son found him passed out on the floor with an empty liquor bottle next to him. The son call 911 and JR was taken to the emergency room. The son told the admitting doctor that his father in the past couple of weeks missed his dialysis treatment and had been drinking heavily. Check peer-review on non compliant for Pathophysiology
*Integrate all information including vital signs, lab data, diagnostic test & procedures, and medications. Write a paragraph. Make sure you site your pathophysiology book. See data form.
According to ( Huether & McCance, 2017), chronic kidney disease is the progressive loss of renal function . As the GFR declines the levels of plasma creatinine gradually become elevated; sodium is excreted in the urine; potassium is retained; acidosis develops, calcium and phosphate metabolism are altered; and erythropoietin production is diminished causing anemia. Due to CKD it affects all the bodies’ organs systems.
The basic need is treatment and hospitalization, for a patient on dialysis. The main focus is self-esteem, love and belonging is at the bottom. During nursing assessments the attention and focus should be on JR’s behavior because he felt abandon by his family and the community due to his illness, his wife abandon him and moved to her mother’s home leaving him with no access to his children. After the family and community abandon him, JR isolated himself in his home feeling as if he is a burden. Through long term counseling and accepting his illness JR will be able to live on his own and accept his illness. (site). Spiritual Subsystem
*Write a paragraph, based on your interview and observation of your patient. Make sure your site your reference, ex. (Author, year). See data form.
How does you patient view his disease? His spirituality? Your recommendations
JR says he feels the only thing in life he has is hope and his bible. JR is upset and depressed with the fact that he is ill, “no one calls he says”. JK stopped going to church and communicating with family and friends saying I just want to be alone. Feelings of being overwhelmed because of his daily routine has been altered due to doctors appointments, dietary restrictions, monitoring weight and blood pressure, multiple new medication are factors that may lead to depression (Shirazian et al., 2016). Recommendations for JR is outpatient group therapy, dietitian consult, and volunteering.
Evidenced Based Research
*Reminder: You may integrate your evidenced based research in any part of your paper. You must site your source (Author, year). Your source should be part of the reference in your last page. However, you still have to discuss it in this section.
*Discuss your overall experience when you took care of the patient and how you are able to understand and apply pathophysiology when you cared for the patient. You can write this as a first person or reflection of your experience.
Name: _______________ UNRS 367 Case Study Rubric
_____ 1. Identifying Data (5 pts)
_____ 2. Biological System (5 pts)
_____ 3. Pathophysiology (15 points)
_____ 4. Psychological Subsystem (5 pts)
_____ 5. Spiritual Subsystem (5 pts)
_____ 8. (2) Evidenced Based Research (5 pts)
_____ 9. (1) Ethnopharmacology& Precision Medicine (5 pts)
_____ 10. Introduction and Conclusion (5 points)
_____ 11. Reference List (5 pts)
_____ 12. APA Format (5 pts)
_____ 13. Organization (5 pts)
_____ 14. Data Form (10pts)