MR. SMITH CASE STUDY

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Mr. Smith Case study

Mr. Smith Case study
Mr. Smith Case study
Case of Mr. Smith
Mr. Smith arrived at the local clinic complaining of general malaise and loss of appetite. His doctor referred him to the lab for testing and the results indicated there is a concern with his liver function. Six months later he arrived at the Emergency Department with jaundice, complaints of itchiness and swelling in his legs and has a distended abdomen. Mr. Smith has been admitted to a general medical unit with a medical diagnosis of Ascites. Mr. Smith Case study. It is day three of his admission and you are the RN assigned to him. The following is information you have gathered on Mr. Smith prior to your care: Mr. Smith is 65-years-old, divorced and has no children. He was a factory worker and retired recently. He has lived in Canada his whole life.
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Past Medical History:
History of alcohol abuse x 20 years.
Previous diagnoses of cirrhosis,
Previous diagnosis of hepatitis C
Depression
He has periodic lower extremity swelling.
He has never smoked.
Family history is unremarkable
Mr. Smith Case study
Medications Taken at Home:
Spironolactone 100 mg PO QD,
Furosemide 40 mg PO QAM,
Loratadine 10 mg PO daily,
Folic Acid 0.2 mg PO daily,
Thiamine 5 mg PO daily,
Multivitamins 1 Tab PO daily,
Gabapentin 100 mg PO TID,
Paroxetine 40 mg PO daily,
Trazodone 50 mg PO QHS,
Lactulose 30 mls PO TID.
Mr. Smith Case study
Physical Exam:
BP 132/82
Pulse: 88
Resp: 24
Sat 90% RA
Temp: 37 C/98.6 F
Weight: 106kg/235lbs
BMI: 26.7
Alert, oriented to person, place, year and month but not to day. Neuro exam without motor or sensory deficits
Sclera is icteric
Pulmonary and Cardiovascular exam normal
Abdomen distended with fluid noted, mild tenderness to palpation. Complaints of loss of appetite x one week along with nausea and vomiting
3+ edema to mid-calf/pedal pulses barely palpable bilaterally
Integumentary exam with a few spider telangiectasia on face and upper chest and his palms are reddened
Patient stated that he has gained more than 5kg this month and has been lethargic
Spleen is enlarged
Patient mobilizes very slowly and is unsteady on his feet
Mr. Smith Case study
Lab Values on admission:
WBC: 4.0 x 109/L (4.0 x 103/ mm3) Normal
Platelets: 127 x 109/L (127 x 103/mm3) Low
Hct: 0.35 (35.5%) Low
INR: 1.9 High
Albumin: 33 g/L 3.3 g/dL) Low
BUN: 8.0 mmol/L (8 mg/dL) Normal
Creatinine: 100 umol/L (1.0 mg/dL) Normal
Sodium+: 125 mmol/L (132mEq/L) Low
Potassium+: 3.2 mmol/L (3.2 MEq/L) Low
Mg+: 0.73 mmol/L (1.7 mg/dL) Low
AST: 68 U/L High
ALT: 2 U/L Low
Alkaline phosphatase: 130 U/L High
Total bilirubin: 28umol/L (1.8 mg/dl) High
Protein:66 g/L (6.6 g/dL) Normal
Ammonia: 70 umol/L High
Mr. Smith Case study
Day One
Diagnostics Ordered:
Abdominal ultrasonography detected fluid
Diagnostic paracentesis with 5L of fluid removed
Ascitic fluid cultures showed an elevated polymorphonuclear cell count
Mr. Smith Case study
Lab Values post diagnostic tests:
Ascitic fluids results:
20,000 rbc/uL high
500 u/L Polymorph nuclear leukocytes High
SAAG 1.3 g/dL Low
Total protein, 66 g/L High
Cytology smear: indicates malignancy.
Mr. Smith Case study
Day Two
BP: 109/58
Pulse: 99
Resp: 20
Sat: 93% RA
Temp:8 C/100 F
Weight: 100 kg/220 lbs.
Smith has stage 4+ tense ascites and has now been diagnosed with Hepatocellular Carcinoma (HCC). He received three vials of IV albumin 25%. He has been referred to an oncologist and gastroenterologist.
Mr. Smith Case study
Day Three
Mr. Smith is verbalizing that he has taken the cancer news well. He is still a little confused as to what day of the week it is. His abdomen is not as distended since he had the paracentesis completed however his breathing hasn’t slowed down since the removal of abdominal fluid. His appetite has not changed and he doesn’t seem to eating or drinking very much. With the removal of 5L of fluid, Mr. Smith’s weight has now dropped by 6kg in this short time. His peripheral edema is still +4 and pedal pulses are present with the use of a Doppler and paresthesia is noted in feet bilaterally. His mobility is minimal as he finds it difficult to move around. He sometimes feels dizzy when he gets out-of-bed, and is worried that he doesn’t remember which day it is. He has voiced concerns about the amount of fluid that is seeping through his lower legs, as he has to have pads put under him to keep his bed dry and it wonders why they are still itchy Mr. Smith Case study. He has been embarrassed because he is experiencing uncontrolled diarrhea and has not made it to the toilet in time.
As the RN in charge of Mr. Smith’s care you want to develop a nursing care plan to provide direction on the type of nursing care Mr. Smith may need. You have gathered valuable data to assist with this. In order to come up with a priority direction of nursing care, you must first analyze (break down into parts) and synthesis (combine elements into a pattern) the gathered information in order to evaluate your priorities (Bloom’s Taxonomy). Mr. Smith Case study.
 

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