Mr. Scottaline History of Presenting Illness (HPI) Mr. Scott

Mr. Scottaline History of Presenting Illness (HPI) Mr. Scottaline… Mr. ScottalineHistory of Presenting Illness (HPI)Mr. Scottaline is a 58-year-old male who was brought in to the emergency department by EMS. His neighbor called EMS on his behalf because he looked generally unwell, jaundiced, lethargic, and was behaving in a confused manner.Health HistoryAUD (alcohol use disorder)Non- smokerKnown Liver Cirrhosis with portal hypertensionDepressionFamily history is unremarkable  Home MedicationsCarvedilol 6.25mg PO dailyFolic Acid 5 mg PO dailyMultivitamins 1 Tab PO daily Paroxetine 40 mg PO daily Spironolactone 25 mg PO daily Thiamine 100 mg PO daily Physical Assessment on Admission Day 1General Appearance: disheveled, slow and unsteady gaitNeurological: lethargic, oriented to person, inconsistent with date and timeRespiratory:  clear air entry to all lung fields, no SOB, no cyanosis, respirations unlabouredCardiovascular: S1 S2 heard, no murmur, pulses moderate, regular and palpable, skin warm, dry. Cap refill <3 seconds, +2 edema to lower legs bilaterallyGastrointestinal: Abdomen large, softly distended, mild diffuse tenderness, BS x4, loose BM x2 today looseGenitourinary:  Voiding without difficulty, urine clear yellow. No bladder distention notedIntegumentary/ Musculoskeletal:  Skin intact, jaundiced skin & sclera, a few scattered bruises to arms and legs. Motor power moderate and equal x4.Psychosocial:  Lives alone, no kids, divorced. Retired factory worker. Poor management of cirrhosis and portal hypertension. Currently has ETOH consumption ~8beers/day. Vital Signs:  T.  37.8, HR 96 regular, RR 18, 96% RA, BP 94/60DiagnosticsCT scan demonstrates worsening liver cirrhosis Abdominal U/S demonstrates significant Ascites Ascites fluid diagnostics demonstrate spontaneous bacterial peritonitisEndoscopy demonstrates increased portal hypertension Blood Work on AdmissionCBC:  Hemoglobin 130 g/L (120-160), Platelets 90 (130-380), WBC 13.2  (3.5-10.5)Electrolytes:  Sodium 136 mEq/L (135-145), Potassium 3.8 mEq/L (3.5-5.0), Chloride 100 mEq/L (98-107), magnesium 0.82mmol/L (0.74-1.07) Renal panel:  Creatine 187 (53-106mcmol/L) , eGFR 26  ml/min (>60 ml/min)Liver panel:  AST 68 U/L (0-35), ALT 55  (4-36), ALP 225 (35-120 U/L),   Total Bilirubin 32  mcmol/L(5.1-17) Miscellaneous:  ammonia 77 mcmol/L (6-47 mcmol/L), albumin 22 g/L (35-50 g/L),  INR 1.9 (0.9-1.1) Working DiagnosisHepatic encephalopathySpontaneous bacterial peritonitis (SPB)Query onset of Hepatorenal syndrome Significant progression of liver cirrhosis and portal hypertensionAlcohol withdrawalIn-Hospital Treatment & Orders Paracentesis drained 3L fluid CIWA protocolDelirium and CAM (confused assessment method) monitoringMonitoring and replacement of electrolytes Monitoring of refeeding syndrome In-Hospital Medication Orders Albumin IV 25% x3 doses Baclofen 5mg TID (*new)Ceftriaxone 2g daily x5 days for SPB Carvedilol 6.25 mg PO daily   (discontinued)Diazepam 10mg IV/PO Q1H PRN for CIWA scores 10-19 until scores less than 10.Folic Acid 5 mg PO dailyKCL 10mmol IVPB x3 dosesLactulose 30ml QID- titrate to 3-4 BM’s /day (*New)Multivitamins 1 Tab PO daily Paroxetine 40 mg PO daily  Rifaximin 55mg PO BID (*new) Spironolactone 50 mg PO daily (*New dose) Thiamine 100 mg PO daily Day 2 Vitals and Blood WorkCBC:  Hemoglobin 126 g/L (120-160), Platelets 90 (130-380), WBC 12.4  (3.5-10.5)Electrolytes:  Sodium 132 mEq/L (135-145), Potassium 3.3 mEq/L (3.5-5.0), Chloride 100 mEq/L (98-107), magnesium 0.69mmol/L (0.74-1.07) Renal panel:  Creatine 190 (53-106mcmol/L) , eGFR 25  ml/min (>60 ml/min)Vital Signs:  T.  36.8, HR 92 regular, RR 18, 96% RA, BP 102/74Mr. Scottaline is having a complicated and likely an extended hospital stay for end-stage liver cirrhosis. His complications have included moderate alcohol withdrawal, electrolyte imbalances, refeeding syndrome, delirium, skin breakdown from edema and frequent diarrhea, hypotension, and deconditioned mobility. As his nurse on day 2, you need to prioritize his needs, create a plan of care, and demonstrate understanding of how all of these health concepts are related. Concept Map and Nursing Care PlanFor assignment 2 concept map and case analysis you are the RN in charge of Mr. Scottaline’s care and you want to develop a nursing care plan to provide direction for his acute priority needs. Use the assessment data and information in the case scenario to guide your development of the one-page only concept map visual diagram. Identify and outline 6-10 nursing care priorities related to this case scenario and number the care priorities in level of importance.  Include lines and arrows to visually display relationships and connections among concepts. Include linking words with the lines to indicate the nature of the connection or relationship (for example: leads to, influences, contributes to, results in, etc.) Include a full nursing care plan (nursing diagnosis, SMART goals, nursing interventions supported with credible and current sources of evidence, and evaluation statements) with the first nursing care priority you have identified. This can be completed as an appendix attached to the paper portion of the assignment. Refer to the Assignment 1 and 2 marking guide in the Assessment Overview for further direction of the requirements of the concept map as well as case analysis. You may also find it useful to go back to Unit 1 and review the content related to Concept Mapping. Keep in mind the concept map in Unit 1 is not as fully detailed as we expect your concept map to be. The concept map is worth 65% of your entire mark for this assignment, so spend your time constructing this. Choose three s from the case analysis list below that correlate to your learning needs. Ensure that you are adequately integrating the case of Mr. Scottaline into your discussion. Answers for eachare limited to 250 – 400 words (per ) and you are expected to use credible and current sources of evidence to support your discussion. Please refer to the Using Evidence in Scholarly Writing document in the References & Help section of the course homepage. The case analysis discussion must also be written in APA formatting and citation style, you do not need to include and intro or conclusion.  Describe one effect of late-stage cirrhosis on each of the following systems: central nervous system, hematologic, integumentary, hepatic, and renal. Explain the pharmacokinetics and pharmacodynamics of the medications rifamixin and baclofen. Why was Mr. Scottaline prescribed these? Discuss the pathophysiology of edema in Mr. Scottaline lower extremities and three nursing interventions.Why was Mr. Scottaline prescribed thiamine, folic acid, and multi vitamins? Describe the relationship between AUD, hepatic encephalopathy, ascites and SPB.What are three priority nursing interventions post abdominal paracentesis? Explain the use of albumin in this case scenario. Mr. Scottaline is experiencing frequent diarrhea. What lab values would you anticipate to be abnormal and why? Would you stop his lactulose? Why or why not? Explain the importance of monitoring alcohol withdrawal symptoms. Why are benzodiazepines used to treat withdrawal symptoms?Explain electrolyte imbalances and refeeding syndrome in this case study. You are planning to engage with Mr. Scottaline regarding health promotion strategies and addressing barriers to discharge. Discuss three health promotion teaching focuses for Mr. Scottaline.  Which allied members of the health care team you would consult in preparation for discharge? Health Science Science Nursing NURS 400

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