Analysis of the patient history
Analysis and comparison of the physical examination findings help the nurse to diagnose the present problem. Patient history shows that Mathew had brown-colored urine for 2 days and voided once a day for 2 days which are abnormal findings. Normal urine color is straw. Brown colored urine is the indication of bilirubin in the urine (Kavouras et al. 2016). Other abnormal findings in the patient history are headache, unusual tiredness, puffy face, Periorbital edema noted around both eyes, Mildly tachypnea, diffused abdominal discomfort on palpation. All the abnormal findings are co-related and indicate fluid retention. The biggest concern in the case of Mathew is dark-colored urine and decreased urine output.
2. Patient report – SBAR format
Situation
Physical assessment for patients shows that the vital signs are normal (Heart rate: 85, Blood pressure 135/85, Respiratory rate is 28 and oxygen saturation is 97%). The concern is about the brown colored urine and decreased urine output (voiding once a day for past two days). Background
Respiratory: Mildly tachypnea,
GI: Abdomen soft, diffused abdominal discomfort upon palpation
Neuro: Had a headache yesterday, 7/10 pain, resolved with acetaminophen
Constitutional: Reports having a fever 10 days ago, Maximum temp 102F. Overall, feels more tired than usual.
CV: Mom says he looks – puffier in the face
Assessment
The physical assessment and the patient history show that clinical problem of the patient is related to liver because Brown colored urine is the indication of bilirubin in the urine (Kavouras et al. 2016). Other symptoms headache, unusual tiredness, puffy face, Periorbital edema noted around both eyes, Mildly tachypnea, diffused abdominal discomfort on palpation are also the indication of abnormality of liver function (Cornell et al. 2014).
Recommendation
The recommendation for this patient is investigation as multiple investigations confirm the patient’s diagnosis and aid the nurse to make a treatment plan.
3. Comparison of Urinanalysis findings
Primarily the normal color of the urine is straw, Brown colored urine indicates the excessive bilirubin excreted in the urine (Kavouras et al. 2016). Protein is 3+ which is abnormal and it indicates acute or chronic kidney disease. Creatinine is 3mg/dL which is abnormal. Increased creatinine value indicates impaired kidney function or acute kidney failure (Lewis et al. 2016).The Urinanalysis findings show that some of the values are abnormal. Increased bilirubin in urine indicates impaired liver function. The Urinanalysis findings show increased bilirubin levels (0.8 mg/dL). The normal bilirubin level is <0.2 mg/dL. The patient had discomfort during palpation indicates liver enlargement. Bilirubin is metabolized by liver and excreted in the form of bile. Bilirubin in urine indicates impaired liver function. Creatinine and protein are filtered by kidneys. Creatinine and protein in the urine indicate impaired kidney function.
4. Renal pathology
Analysis of the history, physical examination and Urinanalysis indicates that the patient is suffering from multiple conditions. A primary pathological condition of the patient is impaired liver function. Bilirubin in urine is the typical sign of liver disease. He is also presented with proteinuria and increased creatinine level in urine which is the indication of impaired kidney function (Ali et al. 2016). Overall analysis shows that the patient is suffering from acute kidney failure which needs immediate action.
5. Risk factors, Pathophysiology and treatment plan
Risk factors
Risk factors for Acute kidney failure in children are a family history of kidney failure, a history of kidney injury, liver disease, and obesity (Kaddourah et al. 2017).
Pathophysiology
Abrupt loss of the ability of the kidneys to excrete the waste leads to less urine output, fluid retention, and electrolyte imbalance. In most cases, the cause of Acute renal failure in children is unknown. Acute renal failure happens in a sequence which is also indicated by the signs and symptoms. The first stage is said to be pre-renal in which the symptoms are not significant. In the stage of intrinsic, patient experiences decreased urine output. Oliguria is the primary sign of acute kidney failure (Ali et al. 2016). The third stage is post-renal in which the oliguria is significant and the renal tubules are also damaged.
Treatment Plan
The primary interventions are applied to manage the condition and maintain the normal state of the patient. The patient is advised to take renal diet which includes less sodium intake. The strict fluid restriction also needs to be implemented. Diuretic has to be administered. The administration of calcium helps to maintain the potassium level. The patient may need Dialysis as it is the medical intervention that helps the patient to relieve the symptoms.
6. Piaget or Erikson’s developmental model
According to Piaget or Erikson’s developmental model of development, the patient is in the stage of pre-operational stage. In this stage, a child begins to use more vocabulary and symbols. In this stage, children like to role play and do the roles of their mom and dad. Children can understand the conversation and likes to imitate (Lourenço, 2016).
Nursing interventions
- The nurse has to communicate with the child and need to identify the area of interest in play and games
- Organize drama or role-play and include family members and the child to ensure patient centered and family-centered care.
7. Nursing process – Acute renal failure
Nursing diagnosis
Increased risk of fluid retention related to impaired renal function
Nursing goal
Exhibit normal urinary output, with normalized vital signs and reduction of puffiness around the eyes.
Nursing intervention
Assess the intake and output, generalized edema, puffiness around the eyes, headache, unusual tiredness, puffy face, Periorbital edema noted around both eyes, and Mild tachypnea. The assessment provides information on the internal functions and changes (Peeters et al. 2014).
Implementation and evaluation
Assess vital signs, urine output, edema and blood pressure every two hourly. Assessment is the primary and essential role of the nurse as it provides the generalized and localized information of the disease condition, progress or deterioration of the patient, and potential complications (Thomas, 2014). The assessment helps the nurse to plan for the appropriate nursing care and modify the intervention if it is not effective. Evaluation of the nursing intervention shows that the periodical assessment helped the health care team to make an appropriate treatment plan which reduced the symptoms and improved the patient’s condition.
References
Ali, Z. A., Karimi Galougahi, K., Nazif, T., Maehara, A., Hardy, M. A., Cohen, D. J., … & Stone, G. W. (2016). Imaging-and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study. European heart journal, 37(40), 3090-3095 https://academic.oup.com/eurheartj/article/37/40/3090/2420804
Cornell, P., Gervis, M. T., Yates, L., & Vardaman, J. M. (2014). Impact of SBAR on nurse shift reports and staff rounding. Medsurg nursing, 23(5), 334 https://search.proquest.com/openview/02db380355c0d56144091bec5c781618/1?pq-origsite=gscholar&cbl=30764
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences https://books.google.co.in/books?hl=en&lr=&id=f-MCDQAAQBAJ&oi=fnd&pg=PP1&dq=Lewis%E2%80%99s+Medical-Surgical+Nursing+textbook+&ots=KKWAv_MkFI&sig=uPNF1VnPW0n5HEdg7PEkrYHfchc&redir_esc=y#v=onepage&q=urinalysis&f=false
