Acute prerenal failure HCC (2023)

Clotrimazole
Betamethazone
(Lotrisone) Topical
BID, apply on armpits
and groin (pt refused)
Tinea Cruris (2013)

GIVEN TO PATIEN: Phytoplex

(Miconazole nitrate 2%) anti-
fungal powder applied on
affected areas (armpits and Mentally challenged (2023) surgical
groin) comlications Dementia Kidney failure

decreased
stress and unfamiliar Immobility due to Dehydration and Metabolic
hearing loss (2019) multi-morbidity HOH
depression environment Obesity (pt's malnutrition disturbances Patient Demographics:
weight is 255 lbs) KEY
Pt Initials: M.W
pt does not drink water Age: 69
unless reminded and he decrease in thirst Sun exposure Functional Advanced age Gender: Male are at Gender: Male Primary Medical
NANDA
Quetiapine/Seroquel Auditory drinks very little water when Renal disease Urinary or fecal retention Risk Factors
dependance (69yo) high risk
100mg PO at night hallucinations
Impaired mental alertness (2018) reminded Ethnicity: white Diagnosis Goal
Code status: Full Code
DOA: 09.09.23 Nursing intervention
340ml fluid intake in decrease in fluid dehydration Pathophysiology Mediactions
12 hours intake Polypharmacy AD: Yes (since 2012 but no new Rationale
Elevated LDL cholesterol level (2018) information was given after 2012)
decrease in waste Fall Risk: High Possible
Paitent's Data
UO is concentrated Labs and Diagnostics
removal from blood Allergies: NKA Complications
(dark yellow) dehydration
Tamsulosin (Flomax) Isolation: standard Evaluation/modification
0.4mg PO qd BPN associated with Nocturia (2016)
Increase in BUN (no Admitting diagnosis: Metabolic
(pt refused) evidence of increased encephalopathy secondary to Clinical Manifestation Patient Related=
BUN because patient dehydration Yellow highlight
chemical and electrolytes keep refusing drawing
imbalance in the blood his blood) Erickson's level: Integrity vs
HTN (2012)
Despair past medical History
Current surgery (NA)

Vitamin C 500mg PO
Mild cerebral atrophy (HCC - chronic) qd (pt refused)
Metabolic
Encephalopathy
(change in mental
status) Zinc sulfate 220mg
PO qd (pt refused) PRIORITY NANDA #1:Dehydration R/T advanced age and decreased fluid intake, history of present illness, non-
Hyperlipidemia type IV compliance AEB confusion, decrease in thirst sensation due to advanced age, fluid intake is 340ml (100ml water
and 240ml soup and coffee), UO is 350ml, urine color is dark yellow and concentrated, patient refuses to drink
water.
right sided frontal
right upper temporal left temporal occipital
Atherosclerosis of aorta (HCC - gyrus disruption
or
junction disruption
or basal ganglion Goal: at the end of the shift, the patient will be more hydrated. AEB patient will have clear yellow urine, output 40-
disruption
chronic) 50ml/hour, and finish around 700-1000ml of his water pitcher in 12 hours.

Nursing assessment/intervention:
cholinergic deficiency
Assessment/Monitoring:
Obesity with BMI of 36.6 with
comorbidity 1- I: Assess the patient's hydration by assessing skin turgor and mucosa, and monitor VS q 4 hours
Rationale: if skin tents and takes a few seconds to repel back to its position, it indicates dehydration. Decreases in
BP, increase in HR, increase in temperature, and dry mucosa can be an indicator of dehydration.
-Decrease in Ach PR: The skin wasn't tenting, probably because of obesity, but his mucosa and lips were dry; his blood pressure was
-Decrease in Melatonin
-Increase in Dopamine,
152/89, HR was average between (60-100bpm), and his temperature was normal < 99F.
Priority problem: Noncompliance/refusal R/T patient's altered mental status, LOC and confusion, hearing difficulty and complexity of health Norepinephren and Glutemate
2- I: Assess the patient's intake, output, and urine color.
regimen AEB, pt refuses to take his morning medication, pt refuses his blood to be drawn for lab results (last lab done was 09.11.23), patient
Rationale: Dehydration can result in acute confusion, delirium, and altered mental status; checking the output
refuse his Vital signs to be taken, patient unwilling to respond to nurses when doing their assessment and kick them out of the room, Labile mood, every time the patient voids and ensuring the patient has enough fluid intake of around 1000ml in 12 hours can
other alteration in Seratonin,
HOH, refuse to start an IV on him. prevent complications like confusion and delirium.
histamine and Y-aminobutyric acid
PR: The patient's output at 8:00 in the morning was 200ml - then he voided another time at 16:00, and the output
Goal: was 150ml; his urine characteristics were dark yellow, and he had a loss of ability to follow instructions, a decrease
inflammatory cytokines (C-reactive
By the end of the shift, the patient will be more compliant and implement a positive behavior AEB, VS will be taken q 4 hours (08:00-12:00-16:00), protein, interleukins, interferon and
in orientation, and confused behavior.
the patient will accept taking his medications prescribed for him, start an IV, Improve mood and behavior, and improve the ability to do his ADLs, TNF-alpha) affect the blood brain
barrier permeability Management/Intervention:
pt will allow the phlebotomist to draw his blood.
3- Encouraging fluid intake, at least 2L/day, unless contraindicated.
Rationale: our bodies are made of water. Water boosts physical and mental activity and allows us to flush waste
Nursing Interventions: impairment in products out. Keeping the body hydrated prevents constipation, headache, confusion, and other complications.
cerebral oxidative PR: The patient only had 100ml of water, and the rest of the fluid intake was taken from coffee and soup, 240ml.
metabolism
Assessment/intervention: 4- Check for alternatives; provide ice chips, soups, orange juice, and other fluids other than raw water or flavored
1- I: assess the patient's mental status: LOC (awake, alerted, tired, or lethargic); assess for concentration, clarity of speech, and memory; assess water if provided at the hospital.
mood (depressed, anxious, angry, euphoric); assess the patient's affect (flat, blunted, elated, labile, nervous), assess for hallucinations and Rationale: if someone struggles with drinking water, they can drink flavored water, soups, coffee, or any liquid that
oxidative stress can be counted in the patient's daily fluid intake.
illusions and assess the patient thought process (like see if their thought process is logical, or tangential), ask about their plans in the future and
PR: the patient had half of his soup, did not drink his juice, and had a full cup of coffee in the morning (240ml)
about awareness of their illness. Ask the patient about their family history, relationship with family and friends, and where he lived before, and try
to obtain more information about his life.
alterationin cerebral Patient Education:
Rationale: a brief MSE assessment is used for patients with an altered mental status and can help the nurse know the severity of the patient's
blood flow 5- I: Educate the patient to set an alarm to remind themselves and have the water in front of them so they can
mental condition and maybe identify the reason for the refusal. remind themselves about water and collaborate with the PCT to remind them to drink water.
PR: LOC (awake, alert), mood (angry and anxious, frustrated, agitated, low tolerance for others in the morning), affect (flat, labile). The patient Rationale: geriatric patients have decreased thirst receptors, and they only drink water if reminded because they
refused lab work and all medications in the morning and refused the 4:00 a.m. Vital signs to be taken. do not feel thirsty as younger adults do and are not moving as much, so they do not feel thirsty.
impairment of substance
2- I: Assess the causes of non-adherence and who is in charge of the patient's care delivery to the brain PR: the patient was reminded to drink water.
Rationale: knowing the cause of refusal can facilitate how the nurse can intervene and manage because sometimes the cause can be solved. 6- I: Collaborate with the kitchen (after consulting with the patient's MD) to include fruits that have increased water
PR: the patient does not like needles and does not want to be poked, so he is not letting us start an IV on him. content, like oranges, melons, grapes, cucumbers, and watermelon, and decrease food high in sodium.
Management/Intervention: decrease in oxygen Rationale: some fruits can include high water content, which can help increase the patient's hydration.
and/or sugar in brain
3- I: Be firm about taking vital signs, lab work, and giving medications to improve the patient's health. PR: the patient had finished all his fruit plate for lunch.
tissue
permanent
Rationale: sometimes difficult patients can have these habits of manipulating and refusing for no reason, so it is essential to educate the patient, Irreversible brain
damage
Evaluation: At the end of the shift, the goal was not met AEB, the patient's Urine output was still concentrated and
be firm, and have strict, respectful boundaries. dark, and the patient did not finish the 700-1000ml plan set for him (he had 340ml only).
decreased Oxygen and
PR: VS were taken throughout the day, and antifungal powder was applied. glucose in the brain Dementia

4- I: Simplify complex care and involve the patient to make sure that information is easy to understand for the patient Modification:
If untreated Seizure -A temporary solution can be convincing the patient to allow us to start an IV on him to provide him with some IV
Rationale: The patient is hard of hearing, so one of the reasons for non-compliance can be not knowing what the nurse or the MD is saying to alteration on
fluids
him, which can increase the patient's frustration and non-compliance. neurotrasmission
Coma - round more frequently with the collaboration with the PCT, like every hour, to remind the patient about fluid intake
PR: simplifying care was involved when care was provided to the patient; I explained that I had to apply the antifungal powder to his groin and and have him drink it in front of us if possible.
armpit areas to help decrease the rash and redness. impaired cerebral Death - ask the patient about his water temperature preference; he might like it with extra ice, so he is not drinking as
metabolism much.
Patient education: - Include fruits for breakfast, lunch, and dinner instead of desserts high in sugar.
- collaborate with the kitchen to make smoothies for the patient.
5- I: Educate the patient about their diagnosis and be patient. neural and cellular
behaving out of character and -reassess the hydration status and I&O.
Rationale: The complexity of the information, the patient's cognitive limitation, and lack of access to resources can make information harder for dysfunction
act differently than their normal
the patient to understand, so providing printed form and using simplicity in explanation can help the patient's adherence and understanding of behavior baseline
their diagnosis.
lack of concentration
PR: I did not involve education about their diagnosis; neither did the nurse.
6- I: Educate the patient about the risks of not taking the medications and the benefits of taking their medication. confusion
Rationale: knowing the risks of noncompliance can increase the patient's awareness about the danger of not taking their medication. neurobehavioral and disorganized thinking
brain dysfunction
PR: The patient was not given education about risks and benefits on the day of care. cognitive symptoms
decreased
fatigue
mobility
Evaluation: at the end of the shift, the goal was partially met AEB patient allowed me to take his VS at (08:00-12:00-16:00), the patient agreed to furgetfulness
apply the antifungal powder but not the rest of his medications. The patient refused to do his lab work and refused to start an IV on him. Swollen legs (Edema
problem thinking in the right and left Risk for DVT
lower extremeties)
Modification: alteration of
-Involve the social worker or the patient's psychiatrist if available. consiousness
-Investigate more about whether the patient has someone close to him whom he would like to see (having a close friend or family member can Heparin 5000units/ml
Improve the patient's behavior and compliance with the medication regimen) under HIPPA guidelines. SQ q12hrs BID (pt
refused)
-Educate the patient about their diagnosis and the risks of not taking their medications.

Mini NANDA #3: Depression R/T Loneliness, mental illness, hearing problem,
mood swings, medication side effects when taken AEB, the patient does not
MINI NANDA #1: Impaired skin integrity R/T poor hygiene, altered mental have family, kids, or friends (he was kicked out from home at a younger age),
auditory hallucinations, labile mood, HOH and does not have a hearing aid, love
status, self-care deficit, and self-neglect, fungal infection AEB rash on the
Mini NANDA #2: risk for DVT R/T patient's spending time alone, the patient takes Quetiapine/Seroquel
bilateral groin, pt has right groin stitches, very malodorous moist and
Interventions:
bleeding skin tag, rash and redness around armpits. Tinea Cruris spread on immobility, Obesity, comorbidities, Pt has non-
armpits, groin, and left abdomen. pitting edema in his RLE and LLR, the patient is 1- The patient is HOH; being unable to hear what people are saying can increase
255lbs and barely moves, the patient has BP of the risk of depression, so it is important to use small, short words when speaking
Interventions:
1- Tinea cruris infection can be found around the groin area a lot because 152/89, hyperlipidemia causes an increased risk to the patient.
References 2- Collaborate with the PT, OT, and PCT to keep the patient busy, exercising and
the site is generally moist in males, so it is essential to maintain good of clot formation.
walking to decrease their time spent alone.
Boss, J. B., & Huether, S. E. (2019). Alterations in cognitive systems, cerebral hemodynamics, and motor function. In McCance & Huether’s Pathophysiology: the hygiene and keep the area dry and clean. Interventions:
1- Apply SED to help decrease the swelling and prevent 3- use therapeutic communication and give a lot of support, allowing the patient to
2- Apply topical antifungal medication, Clotrimazole Betamethasone
biologic basis for disease in adults and children (pp. 517–518). Elsevier. clot formation in the lower extremities. speak, ask open-ended questions, ask the patient what they enjoy doing, and try
(Lotrisone) Topical BID on armpits and groin twice a day, and apply the
2- Educate the patient about taking the prescribed to offer it at the hospital if possible.
Harding, M. M., Kwong, J., & Hagler, D. (2020). Lewis’s medical-surgical nursing: assessment and management of clinical problems. Elsevier. powder when the area is moist. Heparin SQ 5000 units/ml to prevent clot formation. 4- find out if the patient has any spiritual beliefs and offer the religious support that
3- Educate the patient to clean the area after voiding, keep the site dry, 3- Educate the patient to do AROM exercises in bed
Swearingen, P. L. (2016). All-in-one nursing care planning resource: Medical-surgical, pediatric, maternity, and psychiatric-mental health. Elsevier.
never wear tight clothes, and keep legs separated when in bed. the hospital has.