coursework-banner

NRS 410 Case Study: Mr. C. Assignment

NRS 410 Case Study: Mr. C. Assignment

Case Study: Mr. C.

Obesity is defined as excess body weight for height and is associated with excess adiposity, which can be exhibited metabolically. It is diagnosed with a body mass index (BMI) of greater or equal to 30 kg/m2 (Gadde et al., 2018). Obesity is associated with a high risk of comorbid conditions such as type 2 diabetes, cardiovascular diseases, gastrointestinal disorders, respiratory problems, musculoskeletal disorders, and depression (Fruh, 2017). This paper will discuss the case study of Mr. C, depicting a 32-year-old male patient with a long term history of obesity. The paper will discuss the health risks and health promotion opportunities for Mr. C and end-stage renal disease.

The 32year old Mr. C who has had the challenge of being overweight since childhood presents to the clinic inquiring about the possibility of undergoing bariatric surgery. He has been experiencing leg

NRS 410 Case Study Mr C Assignment
NRS 410 Case Study Mr C Assignment

swelling, shortness of breath during physical activity, and pruritus. He is employed at the catalog telephone center and reports to have both high blood pressure and sleep apnea that he has been managing by restriction of sodium intake. His laboratory assessment reveals deranged kidney functions, hyperglycemia, and dyslipidemia whereas his physical assessment shows morbid obesity and high blood pressure. The purpose of this assignment is to explain Mr. C’s clinical manifestation and the risks he faces due to obesity, then discuss the functional health patterns identified in the case study, describe the staging of end-stage renal disease (ESRD) and ESRD prevention strategies that could be employed for Mr. C.

Clinical Manifestations Present In Mr. Chas

Mr. C H a history of obesity since childhood but has no history of metabolic diseases. He has gained approximately 100 pounds over the past 2-3 years. Pertinent positive subjective findings include sleep apnea, high blood pressure, increasing exertional dyspnea, ankle edema, and pruritus. Positive physical exam findings include a height of 68 inches and a weight of 134.5 kg, which adds to a BMI of 46.4, which falls under obesity. Mr. C also has an elevated blood pressure, tachypnea, and 3+ pitting edema on bilateral feet and ankles, which suggest right-sided heart failure. Laboratory tests reveal hyperglycemia and hyperlipidemia. In addition, he has high serum creatinine and BUN levels, which could be a result of impaired kidney function.

Potential Health Risks for Obesity That Are Of Concern for Mr. C.

Obesity puts Mr. C at a high risk of developing numerous chronic conditions which occur as comorbidities of overweight and obesity. Mr. C has potential health risks involving the respiratory, cardiovascular, renal, and metabolic systems. Obesity reduces the lung expansion capacity and chest wall compliance resulting in decreased lung capacity (Gadde et al., 2018). Impairment in the respiratory system resulting in obstructive sleep apnea and Obesity hypoventilation syndrome due to increased work of breathing. Symptoms of concern in the respiratory system include a high respiratory rate of 26, shortness of breath on activity, and sleep apnea. A decreased lung capacity results in reduced oxygen supply to the body tissues, which directly affects the cardiovascular system (Gadde et al., 2018). Consequently, the heart is forced to pump at an increased rate resulting in an increased cardiac output.

A high cardiac output results in high blood pressure, evidenced by Mr. C’s history of high blood pressure and a BP of 172/98. An increased cardiac output results in hypertrophy of the myocardium and eventually, heart failure (Fruh, 2017). Health concerns of heart failure in Mr. C include increasing exertional dyspnea and pitting edema on the lower limbs.  High blood pressure and heart failure result in decreased blood supply to the kidneys resulting in impaired kidney function and eventually, kidney failure (Gadde et al., 2018). Mr. Chas a health concern for acute and chronic kidney disease since he has elevated levels of serum creatinine and BUN. High triglycerides and total cholesterol levels and low HDL results in increased resistance of body cells to insulin. This results in hyperinsulinemia and hyperglycemia, which eventually contributes to type 2 Diabetes. Mr. C is at risk of Type 2 Diabetes, evidenced by an elevated fasting blood glucose.

Bariatric surgery is the only treatment approach for obesity that provides marked and relatively sustainable weight loss in persons with obesity and associated comorbidities. Bariatric surgery is indicated if other nonsurgical attempts at weight loss have failed (Wolfe, Kvach & Eckel, 2016). Bariatric surgery is recommended in cases of a BMI greater than 40 or a BMI of 35-40 with obesity comorbidities (Wolfe, Kvach & Eckel, 2016). Bariatric surgery is an appropriate intervention for Mr. C since he has a BMI of 46.4. Besides, he has obesity-associated comorbidities such as Obstructive Sleep Apnea, hypertension, dyslipidemia, Diabetes, Impaired Renal Function, and congestive heart failure.

Assessment of Functional Health Patterns and Actual/Potential Problems

Activity-Exercise Pattern: Mr. C has: Altered tissue perfusion (cardiopulmonary) related to the decreased blood supply, as evidenced by a high respiration rate and shortness of breath with activity. Activity intolerance related to a reduced blood supply to the myocardium, as evidenced by reports of increased shortness of breath with activity. Risk for self-care deficit related to increasing dyspnea with activity. This may result in a decreased ability of Mr. C to perform ADLs and increased dependency on ADLs.

Nutritional-metabolic Pattern: Mr. C has altered nutrition, more than the body’s requirements secondary to a high energy intake than energy expenditure. This is evidenced by reports of an increased weight gain, a history of overweight, and a high BMI. Besides, Mr. C has a potential problem of developing impaired skin integrity as a result of pruritus. Pruritus may result in skin lesions, thus compromising the skin’s integrity and exposing the patient to infections (Fruh, 2017).

Elimination Pattern: Mr. C is at risk of developing an impaired urinary elimination pattern secondary to impaired kidney function. Elevated BUN and creatinine levels suggest reduced kidney function, which may progress to chronic kidney failure and end-stage renal disease.

Sleep-Rest Pattern: Mr. C has an ineffective sleep pattern caused by decreased lung capacity, demonstrated by reports of sleep apnea.

Self-perception/Self-concept Pattern: Risk of Disturbed body image related to large body size. Besides, the disturbed body image may result in lowered self-esteem (Fruh, 2017).

Staging Of End-Stage Renal Disease (ESRD)

ESRD is a chronic illness characterized by a reduced glomerular filtration rate (GFR) of below 15 mL/min. The staging of ESRD is guided by the GFR and albuminuria levels (Benjamin & Lappin, 2018).

Stage 1- There is evidence of kidney damage but a normal GFR above 90 ml/min.

Stage 2- Marked by a GFR of 60-89 ml/min (Benjamin & Lappin, 2018).

Stage 3a- GFR between 45 to 59 ml/min

Stage 3b- GFR between 30 to 44 ml/min (Benjamin & Lappin, 2018).

Stage 4- Marked by a severe reduction in GFR, between 15 to 29 ml/min.

Stage 5 – Evidence of Renal failure and a GFR of below 15 ml/min.

Contributing factors that should be evaluated in ESRD include the presence of proteinuria, dyslipidemia, hyperphosphatemia, and systemic hypertension. Patients should also be assessed for dehydration, uncontrolled diabetes, use of Nephrotoxins, and history of smoking. These factors are known to worsen kidney failure and should be considered when diagnosing and staging ESRD.

ESRD Prevention and Health Promotion Opportunities

ESRD can be prevented by monitoring lipid profile and initiating patients with dyslipidemia on cholesterol-lowering agents such as HMG-CoA reductase inhibitors early in the course of the disease. Preventive care also entails aggressive glycemic control for patients with hyperglycemia, blood pressure control, and cardiovascular risk reduction. Glycemic control helps prevent or delay microvascular complications in the kidneys (Benjamin & Lappin, 2018). Patients should be recommended on smoking cessation and healthy dietary practices to lower the progression of acute kidney disease to ESRD.

Mr. C should be educated on lifestyle modification such as increased physical activity and decreased caloric intake to promote weight loss and blood pressure and glucose levels control. Dietary restrictions should be emphasized, including adhering to a low sodium diet and restricting daily protein intake to slow the GFR decline and improve proteinuria (Lim et al., 2019). He should be recommended on adopting a renal diet, which entails avoiding foods high in phosphorus. Furthermore, he should be educated to avoid nephrotoxic agents such as NSAIDs and aminoglycosides.

Resources Available For ESRD Patients for Non-acute Care

Resources for ESRD patients undergoing non-acute care include dietary counseling to help them adhere to the recommended nutritional guidelines (Johns et al., 2015). Patients are provided with education on treatment options available for ESRD to enable them to make informed choices. A review of medication and adherence is conducted in non-acute care and planning of advanced care (Johns et al., 2015). Besides, patients are provided with resources such as dialysis access placement, and coordination on kidney transplant services is provided.

Multidisciplinary Approach for ESRD Patients

The multidisciplinary approach for ESRD should have a dedicated team of a nephrologist, nurse educator, clinical nurse, nutritionist, specialized pharmacist, and social worker. The nephrologist has a crucial role in evaluating the prognosis of ESRD and reviewing the patient’s treatment plan (Johns et al., 2015). Besides, the nurse educator plays a vital role in educating patients about lifestyle modifications crucial in preventing kidney disease (Benjamin & Lappin, 2018). The clinical nurse has the task of protecting a patient’s arm for future fistula placement in cases of advanced kidney disease by ensuring venipuncture and BP measurements are not performed on the arm (Benjamin & Lappin, 2018). The nutritionist develops and guides patients on the appropriate diet plan specific to their needs.

The pharmacist identifies patients who have a diagnosis of ESRD and provides them with specialized instructions concerning avoiding nephrotoxic medications and agents(Benjamin & Lappin, 2018). Besides, the pharmacist communicates and guides the clinical providers on patient’s medications to restrict drugs that have adverse effects on the kidneys. A social worker assesses a patient’s support system, and the financial capacity required to pay for therapy. They also help ESRD patients to obtain financial resources and essential resources, including housing and transportation services to health facilities.

Conclusion

Mr. C has a history of obesity, which puts him at risk of developing comorbid conditions such as heart failure, obstructive sleep apnea, obesity hypoventilation syndrome, kidney failure, hypertension, and type 2 diabetes. He is a candidate for bariatric surgery based on his high BMI and presence of comorbid conditions. Identified health problems in Mr. C as per the health patterns include altered tissue perfusion, activity intolerance, risk for impaired urinary elimination, disturbed sleep pattern, risk for impaired skin integrity, and risk for disturbed body image. ESRD is staged based on the degree of proteinuria and the glomerular filtration rate. It can be prevented by glycemic and blood pressure control and managing hyperlipidemia. Consequently, patients should be educated on lifestyle modification and dietary restrictions to delay the progression of kidney failure to ESRD.

References

Benjamin, O., & Lappin, S. L. (2018). End-stage renal disease. In StatPearls [Internet]. StatPearls Publishing.

Fruh S. M. (2017). Obesity: Risk factors, complications, and strategies for sustainable long-term weight management. Journal of the American Association of Nurse Practitioners29(S1), S3–S14. https://doi.org/10.1002/2327-6924.12510

Gadde, K. M., Martin, C. K., Berthoud, H. R., & Heymsfield, S. B. (2018). Obesity: pathophysiology and management. Journal of the American College of Cardiology71(1), 69-84. https://doi.org/10.1016/j.jacc.2017.11.011

Johns, T. S., Yee, J., Smith-Jules, T., Campbell, R. C., & Bauer, C. (2015). Interdisciplinary care clinics in chronic kidney disease. BMC nephrology, 16(1), 161.https://doi.org/10.1186/s12882-015-0158-6

Lim, H. S., Kim, H. S., Kim, J. K., Park, M., & Choi, S. J. (2019). Nutritional Status and Dietary Management According to Hemodialysis Duration. Clinical nutrition research8(1), 28–35. https://doi.org/10.7762/cnr.2019.8.1.28

Wolfe, B. M., Kvach, E., & Eckel, R. H. (2016). Treatment of Obesity: Weight Loss and Bariatric Surgery. Circulation Research118(11), 1844–1855. https://doi.org/10.1161/CIRCRESAHA.116.30759

Health problems such as obesity have immense health impacts on the affected populations. Nurses and other healthcare providers utilize patient-centered evidence-based interventions that enable patients to overcome obesity and its associated complications. Therefore, this paper explores a case study involving an obese patient. It explores health risks, prevention, health issues, and resources available for the patient.

Subjective and Objective Clinical Manifestations

Subjective clinical manifestations refer to the patient’s information about experience with a health problem. The subjective clinical manifestations in the case study include being always heavy even when he was a child, gaining about 100 pounds in the last 2-3 years, sleep apnea, high blood pressure, swollen ankles, shortness of breath with activity, and pruritus over the last six months. Objective clinical manifestations refer to the data that healthcare providers obtain during patient assessment. The objective clinical manifestations in the case study include obesity, hypertension, 3+ pitting edema on ankles and bilateral feet, hyperglycemia, hypercholesteremia, elevated triglyceride levels, and serum creatinine and BUN.

Health Risks

Mr. C is increasingly predisposed to health risks for obesity. One of them is diabetes. The client’s fasting blood sugar level is elevated, translating into either hm being diabetic or prediabetic. The other risk identified from the objective data is hypertension. The patient currently has elevated blood pressure. Obesity causes the deposition of fats in the arteries and other small blood vessels, which increase the risk of other cardiovascular complications such as atherosclerosis (Cercato & Fonseca, 2019). Mr. C is also at a high risk of developing stroke as a complication of cardiovascular events such as hypertension. The patient is also at a risk of kidney failure. His serum BUN and creatine levels are currently elevated, which imply that he has reduced renal functions (Stahl & Malhotra, 2022). The additional health risks that Mr. C is predisposed include obstructive sleep apnea and non-alcohol fatty liver disease.

Bariatric surgery is appropriate for Mr. C. Accordingly, obese patients with commodities are the ideal candidates for bariatric surgery. In addition, patients with a BMI of 40 kg/m2 or above without any medical problems and no excessive risk of bariatric surgery are also ideal candidates for the procedure. The other conditions that influence if a patient can undergo bariatric surgery include the presence of other conditions such as hyperlipidemia, hypertension, type 2 diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, asthma, severe urinary incontinence, venous stasis disease, and impaired quality of life would qualify to undergo bariatric surgery (Stahl & Malhotra, 2022). Mr. C meets most of these conditions, hence, bariatric surgery is ideal for him.

Functional Health Patterns

Mr. C has actual and potential health problems that should be prioritized in the nursing care plan. One of the actual health problems is activity intolerance related to excessive body weight gain as evidenced by his shortness of breath with activity. The implication is that his quality of life is lowered since he cannot engage independently in most activities of daily living such as exercising. The second actual health problem is impaired blood glucose control as evidenced by elevated blood glucose level. The elevated blood glucose levels predispose the patient to complications such as renal disease, hypoglycemia, and diabetic retinopathy and neuropathy. The third actual health problem from functional health patterns is impaired renal function as evidenced by elevated BUN and creatinine levels. The impairment could be attributed to hypertension and diabetes, which are due to obesity. This makes it necessary to implement interventions that aim at preserving optimum renal functioning. The fourth actual health problem is impaired cardiac function as evidenced by elevated blood pressure and other markers such as triglyceride and total cholesterol levels. Interventions that ensure optimum cardiac functioning should be adopted (Blüher, 2020). The last actual problem is altered sleep pattern as evidenced by the patient reporting obstructive sleep apnea. Cumulatively, these health problems affect Mr. C’s health and wellbeing.

Stages of Renal Disease

Renal disease occurs in stages that ultimately results in end-stage renal disease (ESRD). The first stage, stage 1 is characterized by glomerular filtration rate of above 90. This stage is asymptomatic but the kidneys may not be functioning optimally as expected. Stage 2 is characterized by glomerular filtration rate of 60-89. This stage is also asymptomatic and often diagnosed when patients come to the hospital for other health problems such as diabetes and hypertension. Stage 3 is characterized by glomerular filtration rate of 30-59. Patients experience symptoms such as fluid retention, fatigue, and alterations in urinary patterns. Stage 4 is when glomerular filtration rate is severe and ranges between 15 and 29. The symptoms experienced in this stage include vomiting, nausea, edema of the extremities, and impaired cognitive function. A glomerular filtration rate of less than 15 is the fifth stage of kidney failure, also known as ESRD (Ammirati, 2020). The factors that contributed to Mr. C developing ESRD include obesity, hypercholesteremia, elevated triglycerides, hypertension, and diabetes.

ESRD Prevention and Health Promotion Opportunities

The health education offered to Mr. C on ESRD prevention should focus on several aspects. One of them is the need for weight loss. Weight loss should be a priority to reverse additional complications such as hypertension and diabetes mellitus type 2. The other aspect of health education that should be of focus is dietary modification. Mr. C she be educated about the importance of avoiding diets rich in sodium. Sodium increases fluid retention, worsening the complications of renal disease and cardiac system. The other aspect of health education is avoiding over the counter medications. Over the counter medications such as acetaminophen are nephrotoxic. As a result, the patient should be educated on the importance of avoiding any medications that may damage the kidneys further. Mr. C should also be educated about the importance of maintaining active physical activity. Accordingly, physical activity should be encouraged, as it promotes weight loss, cardiac functioning, and glycemic control (Gonsalez et al., 2019; Lv & Zhang, 2019). Lastly, Mr. C should avoid alcohol intake or abuse of any substance, which may alter the normal kidney functioning.

Resources for ESRD Patients

Patients with ESRD have access to a wide range of resources they can utilize for their health. They include social support groups, hospice care, home health, and clinical toolkits that have been developed to guide clinicians in providing the care that the affected patients need. The other resource is the ESRD networks that help patients to access their needed services such as dialysis and kidney transplant services.

Conclusion

This paper has explored Mr. C’s case study. It has examined his clinical manifestations and health risks associated with obesity. The paper has also explored the prevention strategies for ESRD and its stages as well as resources available for the patient. Mr. C should implement interventions that minimize the risk of obesity complications. Nurses should also link him with the available community resources.

 

 

References

Ammirati, A. L. (2020). Chronic Kidney Disease. Revista Da Associação Médica Brasileira, 66, s03–s09. https://doi.org/10.1590/1806-9282.66.S1.3

Blüher, M. (2020). Metabolically Healthy Obesity. Endocrine Reviews, 41(3), bnaa004. https://doi.org/10.1210/endrev/bnaa004

Cercato, C., & Fonseca, F. A. (2019). Cardiovascular risk and obesity. Diabetology & Metabolic Syndrome, 11(1), 74. https://doi.org/10.1186/s13098-019-0468-0

Gonsalez, S. R., Cortês, A. L., Silva, R. C. da, Lowe, J., Prieto, M. C., & Silva Lara, L. da. (2019). Acute kidney injury overview: From basic findings to new prevention and therapy strategies. Pharmacology & Therapeutics, 200, 1–12. https://doi.org/10.1016/j.pharmthera.2019.04.001

Lv, J.-C., & Zhang, L.-X. (2019). Prevalence and Disease Burden of Chronic Kidney Disease. In B.-C. Liu, H.-Y. Lan, & L.-L. Lv (Eds.), Renal Fibrosis: Mechanisms and Therapies (pp. 3–15). Springer. https://doi.org/10.1007/978-981-13-8871-2_1

Stahl, J. M., & Malhotra, S. (2022). Obesity Surgery Indications And Contraindications. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK513285/