Mrs F 80 year old Muslim woman admitted to ward

Consider the following case study:

An ethical dilemma

Mrs F is an 80 year old Muslim woman admitted to your ward. She has limited English and is accompanied by her husband (also with little English) and their 2 sons who speak English fluently.

Mrs F has advanced bladder cancer with urinary retention and pain score of 6/10. She requires an Indwelling Catheter (IDC) to be inserted to relieve her pain and urinary retention. She has no other medical conditions. From handover you know that she has no EPOA or ACHD and has Capacity.

Her doctor comes in and speaks to the sons who say that their culture means that there is no need to talk to their mother about the procedure and they can make the decision for her. The doctor agrees with them and orders an IDC on free drainage to be inserted.

When you come in to do her vital signs prior to the IDC being inserted and while her family are outside she tries to ask you what is happening, grabbing her lower abdomen and crying.

Q4 What would you do in this situation?

In answering the question you need to make an Ethical Decision using the following as they relate to the case study:

·      Code of Ethics (ICN 2012)

·      Informed decision making and Consent.

·      Cultural Competency

·      Ethical concepts and principles in nursing

–  Autonomy – “Self-determination” – consider Mrs F’s rights.

–  Beneficence – “above all, do good” – what is best in Mrs F’s interests?

–  Non-maleficence – “above all, do no harm” – what is in Mrs F’s interests?

–  Confidentially – who should have Mrs F’s information?

–  Justice – “fairness” – what is fair for Mrs F?

–  Rights – what are Mrs F’s rights?

–  Veracity – “telling the truth” – what does this mean for Mrs F?

SOLUTION: Mrs F 80 year old Muslim woman admitted to ward

In this situation, several ethical principles and considerations come into play:

  1. Autonomy: Mrs. F has the right to make decisions about her own medical care, provided she has capacity. Despite the cultural beliefs of her sons, it is imperative to respect Mrs. F’s autonomy and involve her in the decision-making process to the extent possible.Beneficence: The primary goal of healthcare professionals is to do good for the patient. In Mrs. F’s case, relieving her pain and discomfort through the insertion of the indwelling catheter (IDC) is in her best interest from a medical perspective.Non-maleficence: Healthcare providers must strive to do no harm to their patients. In this context, withholding necessary medical treatment, such as the IDC insertion, could potentially harm Mrs. F by allowing her pain and urinary retention to persist.Confidentiality: Mrs. F’s medical information should be kept confidential and shared only with those involved in her care or with her explicit consent. While her sons may be involved in her care, Mrs. F should be given the opportunity to share her concerns and preferences privately with healthcare providers.Justice: Fairness requires that Mrs. F’s cultural background and beliefs be respected while also ensuring that she receives appropriate medical care that aligns with her best interests and preferences.Rights: Mrs. F has the right to receive adequate information about her medical condition and proposed treatments, to make decisions about her care, and to have her autonomy respected.Veracity: Healthcare providers have an ethical obligation to be truthful with their patients. Mrs. F should be provided with clear and honest information about her medical condition, the proposed IDC insertion, and the potential benefits and risks associated with the procedure.

Given these ethical considerations, the appropriate course of action would be to:

  • Respect Mrs. F’s autonomy by involving her in the decision-making process to the extent possible, ensuring that she understands the proposed procedure and its implications.Provide Mrs. F with culturally sensitive and linguistically appropriate information about the IDC insertion, addressing any concerns or questions she may have.Advocate for Mrs. F’s rights to receive appropriate medical care while also respecting her cultural beliefs and preferences.Ensure that Mrs. F’s medical information is kept confidential and shared only with those directly involved in her care, including her sons if she consents to their involvement.If Mrs. F is unable to provide informed consent due to language barriers or other factors, efforts should be made to facilitate communication through interpretation services or other means to ensure that her preferences and wishes are understood and respected. If necessary, involving an ethics committee or seeking legal guidance may be appropriate to resolve any conflicts between Mrs. F’s autonomy and her family’s cultural beliefs.

Mr George 65‐year‐old widowed father of Giovanni and Maria

Mr George is a 65‐year‐old widowed father of Giovanni and Maria. He was admitted to your ward for elective lumbar surgery after several years of back pain resulting from a workplace injury. His ability to mobilise has been significantly reduced and he uses a walking aid. Mr George does not speak English and relies on his son to translate for him. Mr George’s admission paperwork was completed with Giovanni’s assistance. Mr George is allergic to morphine. Giovanni thinks it caused an itchy rash, but Mr George cannot recall. RN Sriya has written this in the paperwork but forgot to put on a red allergy wrist band. His neurological limb assessment shows a left foot drop with full feet numbness and his vital signs are unremarkable. Mr George has a past history of atrial fibrillation. He is on digoxin (0.25 mg/day) and aspirin (100 mg/day). He is noted to be on the organ donor register and Giovanni is the documented medical treatment decision maker. Giovanni has advised that his father does not wish to be resuscitated in an emergency, but Giovanni is not supportive of this and would like all measures taken. Giovanni has also advised that Mr George is quite anxious about his brother, Steven who is also in the hospital, having been admitted for surgery after falling in the garden. Professor Charcot, the surgeon, visited Mr George and Giovanni on the ward to see that Mr George is settling in well and reminded Mr George and Giovanni that he would perform an L2/3 laminectomy the following morning. RN Kate looked after Mr George on night shift but had difficulty communicating with him. As she thought he might have had a stroke, she placed an electronic order for an emergency CT Brain. In her hand over to the AM nurse (RN Chan), she advised that the CT results were not back but did not documented this. When RN Chan took Mr George to theatre, they noted that a consent form signed by the patient and the surgeon was not in the file and inserted a blank form into the file for completion. RN Chan alerted Professor Charcot to this. Professor Charcot responded by yelling at RN Chan in front of other nurses and surgeons “You’re so incompetent. Who do you think you are? If you dare speak to me like that again I will have you fired! Of course, I have already consented the patient! He wouldn’t be here if he didn’t know what was happening. Are you the idiot who ordered a CT Brain on my patient?”. RN Chan returned to the ward, upset. They told their manager what had occurred and that they felt bullied and harassed by Professor Charcot. After surgery when Mr George returned to the ward, RN Chan noticed that the hospital consent form had still not been signed and when listening to the Registrars talking to each other about the case, overheard one say, “Prof didn’t use x‐ray and did the L4/5 by mistake”. RN Chan did not say anything to their manager as they thought that the doctors would advise the patient and his son. They were also too scared to say anything because they didn’t want to be yelled at further and lose their job. RN Chan went home very upset at the day’s events and wrote on their Facebook status update that “some surgeons are so arrogant! At least I am not the incompetent surgeon who operated on the wrong spinal level!” During the next shift and about 8 hours after surgery, it was noted by the PM nurse, RN Sriya, that Mr George had not passed urine. The protocol of the hospital requires a urinary catheter be inserted if the patient has not passed urine 8 hours after spinal surgery. RN Sriya contacted the Registrar who advised she could not arrive to insert the catheter for 2 hours as she was in surgery with another surgeon and that RN Sriya would have to do it herself. RN Sriya had not inserted a catheter into a male patient before and, assuming it couldn’t be much different to inserting female catheters, undertook the procedure. As a result, frank haematuria occurred with a large amount of blood loss. A MET (Medical Emergency Team) was called, and the patient assessed. Mr George was in a lot of pain and the attending MET doctor, Dr. Pratt orders 5mg of morphine intravenously stat. Mr George was rushed to emergency theatre and a Urologist, Miss O’Donnell, called to surgically repair the damaged urethra. During the operation Mr George went into cardiac arrest and died. When Giovanni and Maria arrived at the hospital to see their father, RN Sriya asked “Didn’t they call you? He died in the operation”. Maria was understandably angry and upset and stated “No one called me! I am going to sue the hospital and Professor Charcot for negligence, and I am going to the coroner, media, and escalating this as far as I can take it!”. 

Assessment title: Legal Case Analysis

Alignment with unit learning outcome(s):

2Describe the Australian healthcare system and how nurses practice in these settings
3Discuss common and statute laws relevant to professional practice
4Evaluate the legal concepts and mechanisms that underpin the practice of nursing
5Utilise legal and professional standards in the various practice related scenarios
6Analyse the legal implications of actions taken in nursing practice
9Explore ethical and legal aspects of end of life decision making

Preamble:  As citizens, we are obligated to uphold the law.  As nurses, we are also obligated to follow and adhere to the Nursing Standards of Practice.   This assessment will allow you to understand Standard 1: Thinks critically and analyses nursing practice; Standard 2: Engages in therapeutic and professional relationships and Standard 6: Provides safe, appropriate and responsive quality nursing practice

SOLUTION – Mr George 65‐year‐old widowed father of Giovanni and Maria


Based on the scenario provided, let’s analyze the legal and professional implications of the actions taken by the healthcare team:

  1. Informed Consent: It’s concerning that the consent form for Mr. George’s surgery was not signed by him or the surgeon. Informed consent is a fundamental ethical and legal principle, and procedures should not proceed without it. Professor Charcot’s reaction to RN Chan’s concern was inappropriate and unprofessional.
  2. Patient Advocacy: Nurses have a duty to advocate for their patients’ rights and preferences. RN Chan should have escalated concerns about the incomplete consent form and the overheard conversation regarding the wrong spinal level to appropriate authorities, regardless of fear of retribution.
  3. Medical Errors: Operating on the wrong spinal level is a serious medical error that can have significant consequences for the patient. This should be disclosed to the patient and their family promptly and transparently, and appropriate actions should be taken to address the error and prevent recurrence.
  4. Bullying and Harassment: Professor Charcot’s behavior towards RN Chan constitutes workplace bullying and harassment, which is unacceptable and unlawful. RN Chan should report this behavior to their manager or HR department for investigation and intervention.
  5. Urethral Catheterization: RN Sriya’s decision to proceed with urethral catheterization without proper training and experience led to a serious adverse event for the patient. Nurses must only perform procedures within their scope of practice and competence to ensure patient safety.
  6. Communication and Notification: Failure to communicate effectively with the patient’s family about his deteriorating condition and eventual death is a breach of professional and ethical standards. Open and honest communication is essential in healthcare, especially during difficult situations like end-of-life care.
  7. Documentation: Proper documentation of patient care, including assessments, interventions, and communication with other healthcare providers, is essential for continuity of care, legal accountability, and quality improvement.

In summary, the healthcare team in this scenario failed to uphold ethical and legal standards in various aspects of patient care, including informed consent, patient advocacy, medical error management, workplace behavior, procedural competence, communication, and documentation. These failures led to adverse outcomes for the patient and his family and could result in legal and professional consequences for the individuals involved and the healthcare institution.

Employer ABC international company new occupational health policy

Employer ABC an international company has a new occupational health policy. All employees must have genetic testing for cardiac disease , dementia and cancers that are transferred genetically. The information will be known by occupational health, employers and the private insurance company that provides health benefits to the company employees. Employees can refuse and if, so they will lose their medical benefits. The company says this information is needed to maintain a healthy work force. Employees will not be denied medical benefits when the results are known.What legal protections do Canadian have when they seek genetic testing? Explain whether and why you approve of this policy or not ,as an employer, medical insurance company president, employee and relative of an employee.

SOLUTION – Employer ABC international company new occupational health policy

In Canada, genetic testing is governed by various legal protections to ensure individuals’ privacy, autonomy, and protection against discrimination. Here are some key considerations:

  1. Canadian Charter of Rights and Freedoms: Section 7 of the Canadian Charter of Rights and Freedoms protects individuals’ rights to life, liberty, and security of the person. This includes the right to privacy and autonomy regarding medical decisions, which could extend to genetic testing.
  2. Genetic Non-Discrimination Act (GNA): Enacted in 2017, the GNA prohibits discrimination based on genetic testing results in areas such as employment and provision of goods and services. This means that employers cannot make decisions about hiring, firing, or providing benefits based on genetic information.
  3. Provincial Human Rights Legislation: Each Canadian province and territory has its own human rights legislation, which often includes protections against discrimination based on disability or genetic characteristics.
  4. Personal Information Protection Legislation: Canada has federal and provincial laws that regulate the collection, use, and disclosure of personal information, including genetic information. Employers and insurance companies must adhere to these laws to protect individuals’ privacy.
  5. Labor Laws: Labor laws may also come into play, particularly regarding the conditions of employment and any collective agreements in place.

As for the proposed policy by Employer ABC, there are several ethical and legal concerns:

  1. Invasion of Privacy: Requiring genetic testing without explicit consent could be seen as an invasion of employees’ privacy rights, particularly considering the sensitive nature of genetic information.
  2. Potential for Discrimination: Despite assurances that medical benefits won’t be denied based on test results, there’s a risk that employees could face discrimination in other ways based on their genetic predispositions.
  3. Coercion: Making medical benefits contingent on genetic testing could be perceived as coercive, as employees may feel pressured to undergo testing even if they have concerns about privacy or discrimination.

As an Employer: I do not approve of this policy as it could lead to legal challenges and damage to the company’s reputation. It’s essential to prioritize employee privacy and autonomy while promoting a healthy workforce through voluntary wellness programs.

As a Medical Insurance Company President: I would have concerns about the ethical implications of using genetic information to assess risk and set premiums. It’s important to uphold principles of non-discrimination and fairness in insurance practices.

As an Employee: I would be deeply concerned about the invasion of privacy and potential for discrimination inherent in this policy. I would advocate for my rights and consider seeking legal advice or support from advocacy groups.

As a Relative of an Employee: I would be worried about the potential harm to my relative’s privacy and well-being. I would support them in making informed decisions about whether to undergo genetic testing and advocate for policies that respect their rights and dignity.

CASE STUDY FOR ACUTE KIDNEY INJURY

Jose Garcia, a 65-year-old Hispanic male, was admitted to the hospital for an open cholecystectomy. He is married and has two sons and two daughters and four grandchildren. He is a retired investment banker. He speaks English as a second language. Source of income is his pension. He has health benefits through his previous place of employment. Mr. Garcia reports that he has had abdominal pain that radiates to the right shoulder following some of his meals. He also reports nausea and sometimes vomiting when this occurs. This has been occurring for at least six months. He also reports that nothing has helped to relieve the pain nor the nausea and vomiting. He reports his health as good otherwise. Mr. Garcia reports no major illnesses, no past surgeries, nor any previous hospitalizations. His parents are still alive and in fair health, having hypertension, heart disease, and diabetes. Recent lab work includes the following: TEST WBC RBC Hgb Hct Platelets Sodium Potassium Chloride Total CO2 Glucose BUN Creatinine NORMAL VALUES 5000-10,000/mm3 4.7-6.1 million/mm3 14-18 g/dl 42-52% 150,000-400,000/mm3 135-145 mEq/L 3.5-5.0 mEq/L 90-110 mEq/L 23-30 mEq/L 70-105 mg/dl 10-20 mg/dl 0.6-1.2 mg/dl PRIOR TO SURGERY 8.4 5.1 16.2 49.8% 235,000 142 4.7 103 24 99 15 0.8 Current medications at home are MVI 1 tablet daily, Tylenol ES 1000 mg prn for pain. Mr. Garcia has NKA. VS are temp 37 C, pulse 78, resp 18, BP 134/74. Mr. Garcia is alert and oriented x 3, communicates appropriately, has full cognitive ability. Color of skin, mucus membranes, nail beds are pink. Has +2 pedal and radial pulses. No edema present in lower extremities. Capillary refill is less than 3 seconds. Homan’s sign is negative. Apical pulse is 78 and regular. S1 and S2 are clearly noted. Chest is symmetrical with downward sloping of ribs, spine is straight, and scapulae are placed symmetrical. AP diameter of chest is less than transverse diameter and ration is 1:2. No use of accessory muscles. Respirations are 18 of moderate depth and regular rhythm. PERRLA. Sclera icteric. Acuity is 20/20 with corrective lenses. Last visual exam was 3 months ago. Has adequate hearing. Reports no alterations in taste or touch. Denies any pain. States usually awakens at 7 a.m. and goes to sleep at 12 MN. States feels rested when he awakens. Takes no sleep medications. Has no scars. Abdomen is round and soft. Bowel sounds active x 4 quadrants. Reports having a BM qd and had a soft, brown stool this AM. Voids clear amber urine several times a day. Is able to participate in all activities of daily living. Moves all extremities equally, has full ROM to all extremities. Ambulates without assistance. Has no history of falls. Height is 5’10”. Weight is 192 lbs. Reports appetite is usual. Teeth are intact, no sores noted in mouth. Denies difficulty in swallowing. Drinks no caffeinated beverages. Has been eating a diet as tolerated. Is sexually active with his spouse. No history of STD’s. Last prostate exam and PSE was 9 months ago with no abnormal findings. Overall appearance is appropriate. Patient denies any other problem in his life. He has maintained a positive attitude about his current health condition. He believes that surgery will correct the problem. Has some anxiety in regards to the surgery, anesthesia, and pain afterwards. He states he is Catholic and in times of stress he turns to God and prayer and that provides him with comfort. He states he is satisfied with his life. He was born in Cuba and moved to the US in the 1960’s. Major life focus at this time is “enjoy life with his wife who is also of Cuba descent and children and grandchildren”. He reports having friends at On Top of the World, the retirement community where he lives, who will help out as needed. He reports enjoy eating typical Cuban foods. Mr. Garcia had unexpected complications immediately following his surgery. He had an excessive amount of blood loss and went into shock, which has resolved. Two days later your initial assessment includes: He is asleep, slow to arouse and nods off easily and frequently during the assessment. He is able to state he is in the hospital, but does not remember the name of the hospital. His older daughter spent the night with Mr. Garcia and is pacing the room. She states, “He’s getting worse, isn’t he”? Vital signs are temp 38 C, pulse 112 and irregular, resp 32, deep and labored, BP 196/100. PERRLA. Crackles are auscultated throughout the lung fields. There is a murmur present. Abdomen is distended, and bowel sounds are present. Abdominal dressing is clean and dry. No urine output is noted for the past several hours. Urine output for the last 24 hours is 270 mL’s. He has 3+ pitting edema of both feet and lower legs. Pedal pulses are not palpable. Orders include: BRP only I&O VS q4j 500 mg Na+, 30 g protein, 2500 cal diet Total fluid PO intake not to exceed output of previous 24 h plus 400 mL’s Saline lock, change site q72h Vasotec 1.25 mg IV q6h prn Systolic greater than 140 or diastolic greater than 100 Furosemide 40 mg IV bid MOM 30 mL PRN constipation Ativan 0.5 mg PO HS PRN, may repeat x 1 Consent for Tessio catheter insertion Oxycodone 2 tablets PO every 4 hrs. PRN for moderate to severe post-op pain Lab data are as follows: LAB: TEST WBC RBC Hgb Hct Platelets Na+ K+ CL- Total CO2 DATES: 2nd day postop 12.4 3.1 9.4 28.1% 168,000 130 5.4 94 1st day postop 9.0 3.2 9.7 29.0% 167,000 135 5.0 104 16 85 63 3.1 287 15 Glucose 76 BUN 81 Creatinine 4.2 Serum Osmolality TEST Urine Specific Gravity ABG’s pH PaCO2 HCO3 pO2 O2 Sat Base Excess mOsm/kg 285 NORMAL 1.010-1.025 7.35 – 7.45 35 – 45 mmHg 21 – 28 mEq/L 80 – 100 mm Hg 95 – 100% +/-3mEq/L 2nd day postop 1.010 7.30 30 14 88 93% -1 1st day postop 1.010 7.39 32 20 92 95% +1 1. Explain the changes in the lab data. 2. At this time, what is Mr. Garcia’s major stressor? 3. What precipitated the problem? (How would this be classified?) 4. What are other causes for acute renal failure? 5. Explain hypoperfusion and its relationship to the development of acute renal failure. 6. What psychological, sociocultural, spiritual, and development problems relate to Mr. Garcia? 7. What nursing actions would you employ related to Mr. Garcia’s daughter? 8. After analyzing the medical plan for Mr. Garcia, identify the TOP priority nursing diagnoses and actions for him. 9. Mr. Garcia’s latest K+ is now 6.4. The physician has prescribed a Kayexalate enema. What is the rationale for a Kayexalate enema? 10. What would be the EXPECTED outcomes of treatment? 3rd day postop 0700. On initial rounds, while assessing Mr. Garcia, you note his last 8 hr urine output was 1200 mL’s urine. Two hours after emptying the foley bag, it contains 300 mL’s. Mr. Garcia tells you he is very thirsty. His eyes and mucous membranes look dull; little saliva is present in his mouth. His underarms and groin are warm and dry. Skin turgo is poor. VS – T 38C, P 120 IRREG, R 34, B/P 102/54 TEST WBC RBC Hb HCT Platelets Na+ K+ CL- BUN Creatinine OSMOLALITY UPDATED MEDICAL PLAN 3rd day postop 18.4 6.1 15.4 46.2 143 131 2.8 105 54 3.2 293 2,500 calorie, 50 gm protein diet Progressive ambulation IV fluid D5 1⁄2 NS with KCI 20 mEq/L at 200 mL’s/hr. Potassium extend tabs 10mEq PO every 0900 and 2100 Colace 100 mg every AM D/C furosemide 11. What phase of the disease process has Mr. Garcia entered? 12. What are the characteristics of this stage? 13. What is his most urgent nursing diagnosis now? 14. For which electrolyte imbalance(s) must Mr. Garcia be observed at this time? 15. Analyze Mr. Garcia’s new medical plan. What is the rationale for the changes? 4th day postop 0700. The night nurse reports Mr. Garcia has been restless during the early morning hours. He has also been a bit confused. You find Mr. Garcia turning and moving restlessly about in bed. He says, “Something is wrong. I can’t get right”. He is confused. His skin is warm and dry. VS – B/P 80/40, P 162, R 36, T 39.1 No urine has appeared in the foley bag since 6 a.m. 16. Based on analysis of this data, what is your conclusion regarding Mr. Garcia’s condition? 17. What sequence of nursing actions would you prescribe in PRIORITY order? The M.D. came in to see Mr. Garcia and remained at his bedside until he stabilized. The medical plan included: remove vascular cath and culture establish a new IV line, then remove present angiocath and culture culture blood, culture urine stat ceftriaxone 1 g BID IVPB begin stat after cultures vancomycin 1 g IVPB one dose after cultures By the next morning it became clear, based on lack of urine output and changes in lab values, this most recent insult has wiped out Mr. Garcia’s renal function. Mr. Garcia and his wife live in a rural area and it would be difficult for him to travel for hemodialysis. During grand rounds, the physician asks your assessment of Mr. Garcia’s ability to be successful with peritoneal dialysis. You relate the Garcia’s are highly motivated, flexible, conscientious people with excellent learning ability. After a thorough explanation of peritoneal dialysis, the Garcia’s agree it is their best option. 18. What is the function of the peritoneal catheter? 19. What serves as the membrane across which dialysis occurs? 20. What principles of fluid and electrolyte movement apply in peritoneal dialysis (what makes it work)? 21. What does the term “dwell time” mean? 22. What does the term “exchange” mean? 23. What is the composition of “typical” dialysis solution and what is the purpose of each component? 24. What is the temperature of dialysate at the time of infusion? Mr. Garcia has his catheter in place and is ready to begin dialysis. Preparation for dialysis procedure: Mr. Garcia’s assessment remains unchanged. VS – T 37.4 C, P 109 REG, R 28, B/P 190/96, WT 195 lbs. You secure the prescribed dialysate. Infusion of 1500 mL’s of dialysate is completed. You unclamp the catheter to begin drainage. One thousand mL’s drains and drainage stops. 25. What is the next nursing action? 26. If the remainder of the fluid does not drain, what would be the best nursing action? Your nursing actions are successful and the fluid begins to return. The fluid is blood tinged. 27. What does this mean and what nursing action is appropriate? 28. What might it mean if, during fluid return, the nurse notes brown or yellow fluid? 29. What would you do if Mr. Garcia’s pulse suddenly became rapid and irregular? Post-dialysis assessment: VS – T 38.3 C, P 112 reg, R 24, B/P 176/86, WT 191 Lab – NA+ 136, K+ 4.9, CO2 20, BUN 34, creatinine 3. 30. Based on this assessment, how has Mr. Garcia improved after dialysis? 31. What can you identify as possible additional problems? Mr. Garcia is stabilized and maintained on peritoneal dialysis. He continues to improve and is ready to go home. Mr. Garcia tells you he loves traditional Cuban food. 32. How would the nurse counsel him regarding his diet? 33. What discharge planning should occur related to Mr. Garcia’s family? 34. What are the most important elements to include in discharge planning for Mr. Garcia, including community resources?

Solution: CASE STUDY FOR ACUTE KIDNEY INJURY

  1. Changes in Lab Data:
    • WBC: Increased from 9.0 to 12.4 (indicative of infection or inflammation post-op).
    • RBC, Hgb, Hct, Platelets: Decreased from pre-op values (indicative of blood loss).
    • Sodium, Potassium, Chloride, Total CO2: Within normal range initially but may be affected by fluid and electrolyte imbalances post-op.
    • Glucose: Decreased from pre-op values (indicative of stress response).
    • BUN, Creatinine: Elevated from pre-op values (indicative of acute kidney injury).
    • Urine Specific Gravity: Normal, but low output suggests inadequate renal function.
    • ABG’s: Acidosis evident, possibly due to respiratory and metabolic factors.
  2. Major Stressor:
    • Mr. Garcia’s major stressor is likely the acute kidney injury following excessive blood loss post-cholecystectomy, leading to acute renal failure.
  3. Precipitating Problem:
    • Excessive blood loss during surgery precipitated the acute renal failure, which can be classified as prerenal due to inadequate renal perfusion.
  4. Other Causes for Acute Renal Failure:
    • Intrinsic renal injury (e.g., nephrotoxic drugs, acute tubular necrosis), obstructive causes (e.g., kidney stones, tumor), and postrenal causes (e.g., urinary tract obstruction) can also lead to acute renal failure.
  5. Hypoperfusion and Acute Renal Failure:
    • Hypoperfusion refers to inadequate blood flow to tissues, including the kidneys, which can lead to ischemia and acute renal failure due to decreased glomerular filtration rate (GFR) and subsequent impairment of kidney function.
  6. Psychological, Sociocultural, Spiritual, and Development Problems:
    • Mr. Garcia may experience anxiety and fear related to his deteriorating condition, language barriers, and cultural preferences for traditional Cuban foods. His spiritual beliefs may provide comfort during stressful times.
  7. Nursing Actions for Mr. Garcia’s Daughter:
    • Provide emotional support, clarify medical information, involve her in care decisions, and offer reassurance regarding her father’s condition and prognosis.
  8. Top Priority Nursing Diagnoses and Actions:
    • Acute Pain related to post-operative complications: Administer prescribed analgesics and monitor pain levels.
    • Risk for Fluid Volume Excess: Monitor intake and output, assess for signs of fluid overload, and adjust IV fluids accordingly.
    • Risk for Imbalanced Nutrition: Monitor dietary intake, provide education on renal diet restrictions, and refer to dietitian if necessary.
  9. Rationale for Kayexalate Enema:
    • Kayexalate helps lower serum potassium levels by exchanging sodium ions for potassium ions in the colon, facilitating potassium excretion through the stool.
  10. Expected Outcomes of Treatment:
    • Stabilization of vital signs, improvement in renal function, resolution of acidosis, and relief of symptoms associated with acute kidney injury which can lead to ischemia and damage to renal tubules, resulting in acute renal failure. In Mr. Garcia’s case, the hypoperfusion caused by excessive blood loss during surgery likely contributed to his acute renal failure.
  11. Psychological, Sociocultural, Spiritual, and Developmental Problems:
    • Psychological: Mr. Garcia may experience anxiety, confusion, and fear related to his deteriorating health status and the need for additional medical interventions.
    • Sociocultural: Cultural beliefs, language barriers, and access to healthcare resources may impact Mr. Garcia’s understanding of his condition and treatment options.
    • Spiritual: Mr. Garcia finds comfort in prayer and spirituality, which may help him cope with his illness and recovery process.
    • Developmental: As a retired individual with grandchildren, Mr. Garcia may have concerns about his ability to maintain his role within the family and community.
  12. Nursing Actions for Mr. Garcia’s Daughter:
    • Provide emotional support and reassurance to Mr. Garcia’s daughter about her father’s condition and prognosis.
    • Encourage open communication and address any concerns or questions she may have regarding her father’s care.
    • Offer information about support services available for family members of hospitalized patients, such as counseling or support groups.
  13. Top Priority Nursing Diagnoses and Actions:
    • Priority Nursing Diagnoses: Acute Pain related to surgical procedure and complications, Impaired Gas Exchange related to respiratory distress, Risk for Decreased Cardiac Output related to fluid volume excess.
    • Actions: Monitor vital signs and oxygen saturation closely, administer oxygen therapy as prescribed, assess pain levels and administer pain medication as needed, monitor fluid intake and output, assess for signs of fluid overload or electrolyte imbalances.
  14. Rationale for Kayexalate Enema:
    • Kayexalate is a medication used to treat hyperkalemia by binding to potassium in the gastrointestinal tract and promoting its excretion through feces.
  15. Expected Outcomes of Treatment:
    • Resolution of hyperkalemia and electrolyte imbalances.
    • Improvement in renal function and urine output.
    • Reduction in symptoms such as confusion, fatigue, and edema.
    • Prevention of further complications such as metabolic acidosis or cardiac arrhythmias.
  16. Phase of Disease Process:
    • Mr. Garcia has entered the oliguric phase of acute renal failure.
  17. Characteristics of Oliguric Phase:
    • Decreased urine output (<400 mL/day), electrolyte imbalances, fluid overload, metabolic acidosis, uremia, and retention of nitrogenous waste products.
  18. Most Urgent Nursing Diagnosis:
    • Risk for Fluid Volume Excess related to oliguria and fluid overload.
  19. Electrolyte Imbalances to Observe:
    • Hyperkalemia, hypernatremia, metabolic acidosis.
  20. Analysis of New Medical Plan:
    • Focuses on correcting fluid and electrolyte imbalances, preventing complications, and promoting renal function recovery. Introduction of IV fluids, diuretics, and antibiotic therapy reflects management of acute kidney injury and infection.
  21. Conclusion Regarding Mr. Garcia’s Condition:
    • Mr. Garcia is experiencing worsening renal function and hemodynamic instability, likely due to complications of acute renal failure and fluid overload.
  22. Priority Nursing Actions:
    • Ensure patent IV access, administer prescribed medications, monitor vital signs and urine output closely, notify the healthcare provider of changes in condition, provide emotional support to Mr. Garcia and his family.
  23. Function of Peritoneal Catheter:
    • The peritoneal catheter is inserted into the abdominal cavity to allow for the infusion and drainage of dialysis fluid during peritoneal dialysis.
  24. Membrane for Dialysis:
    • The peritoneal membrane serves as the semipermeable membrane across which dialysis occurs during peritoneal dialysis.
  25. Principles of Fluid and Electrolyte Movement:
    • Dialysate solution is infused into the peritoneal cavity, where solutes and excess fluid move across the peritoneal membrane into the dialysate by diffusion and osmosis.
  26. Meaning of “Dwell Time”:
    • Dwell time refers to the duration that the dialysate remains in the peritoneal cavity before drainage, allowing for adequate exchange of solutes and fluid.
  27. Meaning of “Exchange”:
    • Exchange refers to the process of infusing fresh dialysate into the peritoneal cavity and draining used dialysate after a dwell period.
  28. Composition of Dialysis Solution:
    • Typically contains electrolytes (sodium, potassium, calcium, magnesium), glucose or icodextrin as osmotic agents, and buffer solutions to maintain pH balance.
  29. Temperature of Dialysate:
    • Dialysate is typically warmed to body temperature (37°C) before infusion to minimize discomfort and enhance solute transport.

G.C. 78-year-old widow relies on late husband’s Social Security income

G.C. is a 78-year-old widow who relies on her late husband’s Social Security income for all of her expenses.

Over the past few years, G.C. has eaten less and less meat because of her financial situation and the trouble of preparing a meal “just for me.” She struggles financially to buy medicines for the treatment of hypertension and arthritis. She goes to the outpatient clinic complaining that over the past 2 to 3 months she has felt increasingly tired, despite sleeping well at night. Her vital signs (VS) are 136/76, 16, 80. She denies any dyspnea or palpitations. The nurse practitioner orders blood work. G.C.’s chemistry panel findings are all within normal limits and a stool guaiac test result is negative. Her other results are shown in the chart.

Laboratory Test Results

White blood cell (WBC) count                             7600/mm3

Hematocrit (Hct)                                                  27.3 %

Hemoglobin (Hgb)                                               8.3 mg/dL

Platelets                                                                151,000/mm3

Red Blood Cell (RBC) Indices

Mean corpuscular volume (MCV)                                                            65 mm3                               

Mean corpuscular hemoglobin (MCH)                                                    31.6 pg                                                        

MCH concentration (MCHC)                                                                    35.1 %

Red cell distribution width (RDW)                                                            15.6 %

Iron (Fe)                                                                                                    30 mcg/dL

Total iron-binding capacity (TIBC)                                                          422 mcg/dL

Ferritin                                                                                                      8 mg/dL

Vitamin B12                                                                                               414 pg/mL

Folate                                                                                                        188 ng/mL

1.   Which laboratory values are normal, and which are abnormal?

2.   Explain the significance of each abnormal result.

3.   Based on these results and her history, what condition does G.C. have? 4. What individuals are at risk for this condition?

4.   What individuals are at risk for this condition?

5.   What other signs and symptoms of this condition do you assess for in G.C.?

6.   Which question would best help you determine the impact of fatigue on her activities of daily living?

a.     “Are you upset about feeling more tired?”

b.    “Do you sleep more now than you used to?

c.     “How far can you walk until you get short of breath?”

d.    “Have you been able to do what you would like to do?”

7.   Discuss the treatment options for her condition.

8.   The physician starts G.C. on ferrous sulfate (Feosol) 325 mg orally once per day. What teaching needs to be done regarding this medication?

MCH concentration (MCHC As you are evaluating your teaching about ferrous sulfate, you determine that additional instruction is needed if G.C. says:

a.  “My stools will likely turn a tarry, black color soon.”

b. “I can take the iron and my calcium supplements at the same time.”

c.  “I will increase my fluid and fiber intake as long as I am on the iron.”

d. “Taking the tablets when I eat my meals will help my stomach not be upset.”

10.  Discuss some ideas that might help her with her meal planning.

11.  You teach G.C. about foods she should include in her diet. You determine that she understands your teaching if she states she will increase her intake of which of the following foods?

a.  Whole-wheat pastas and skim milk

b. Lean cuts of poultry, pork, and fish

c.  Beans and dark green, leafy vegetables

d. Cooked cereals, such as oats, and bananas

12.  What evaluative parameters could you use to determine whether G.C.’s condition is improving?

SOLUTION – G.C. 78-year-old widow relies on late husband’s Social Security income

  1. Normal and Abnormal Laboratory Values:
    • Normal Values: White blood cell (WBC) count, Hematocrit (Hct), Platelets, Mean corpuscular volume (MCV), Mean corpuscular hemoglobin (MCH), Mean corpuscular hemoglobin concentration (MCHC), Red cell distribution width (RDW), Vitamin B12, Folate.
    • Abnormal Values: Hemoglobin (Hgb), Iron (Fe), Total iron-binding capacity (TIBC), Ferritin.
  2. Significance of Abnormal Results:
    • Low Hemoglobin (Hgb), Hematocrit (Hct), and Ferritin indicate iron-deficiency anemia, which can lead to fatigue and weakness.
    • Low Iron (Fe) and Total iron-binding capacity (TIBC) confirm iron deficiency.
  3. Diagnosis and Risk Factors:
    • G.C. likely has iron-deficiency anemia due to her low hemoglobin, hematocrit, ferritin, and iron levels, as well as her symptoms of fatigue and weakness.
    • Risk factors for iron-deficiency anemia include poor dietary intake of iron-rich foods, chronic blood loss (e.g., gastrointestinal bleeding), and conditions that impair iron absorption (e.g., celiac disease).
  4. Other Signs and Symptoms:
    • Pallor, shortness of breath, dizziness, brittle nails, and headache are additional signs and symptoms of iron-deficiency anemia.
  5. Impact of Fatigue on Activities of Daily Living:
    • Option c. “How far can you walk until you get short of breath?” would best help determine the impact of fatigue on her activities of daily living, as it directly assesses her functional capacity.
  6. Treatment Options:
    • Treatment for iron-deficiency anemia typically includes oral iron supplementation, dietary modifications to increase iron intake, and addressing underlying causes of iron loss or malabsorption.
  7. Teaching about Ferrous Sulfate:
    • Advise G.C. to take ferrous sulfate on an empty stomach to enhance absorption, but if gastrointestinal upset occurs, she can take it with food.
    • Instruct her to avoid taking iron supplements with calcium supplements, as calcium can impair iron absorption.
    • Encourage increased fluid and fiber intake to prevent constipation, a common side effect of iron supplementation.
  8. Additional Instruction Needed for Ferrous Sulfate:
    • Option a. “My stools will likely turn a tarry, black color soon.” If G.C. believes this, she needs additional teaching, as black, tarry stools are associated with gastrointestinal bleeding, not iron supplementation.
  9. Meal Planning Ideas:
    • Encourage G.C. to include more iron-rich foods in her diet, such as lean meats, poultry, fish, beans, lentils, fortified cereals, spinach, and dried fruits.
  10. Dietary Foods to Increase Iron Intake:
    • Option c. Beans and dark green, leafy vegetables are good sources of non-heme iron, which is important for individuals with iron-deficiency anemia.
  11. Evaluative Parameters for Improvement:
    • Improvement in symptoms such as fatigue and weakness.
    • Increase in hemoglobin, hematocrit, and ferritin levels on repeat laboratory tests.
    • Resolution of signs of iron deficiency, such as pallor and brittle nails.
    • Increase in energy levels and ability to perform activities of daily living without excessive fatigue.