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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