SOLVED2

Overview Elena Ramirez’s story unfolds in a densely populated urban neighborhood, where economic challenges and vibrant cultural life coexist. As a devoted elementary school teacher and single mother living with her aging parents, Elena is a central figure in her family, deeply committed to the well-being of her loved ones and students. Despite the demands of her roles, Elena’s health has often taken a backseat, overshadowed by her responsibilities and the systemic barriers that define her environment. Living in a food desert, Elena’s access to healthy, affordable food is severely limited. The convenience of processed foods has, over time, contributed to her developing Type 2 diabetes—a condition further complicated by her busy lifestyle and financial constraints. This pre-existing condition, initially manageable, slowly becomes a silent threat to her health. The turning point in Elena’s life comes with the diagnosis of chronic renal failure, a direct consequence of her unmanaged diabetes. This diagnosis brings to light the long-term effects of her condition and the complex interplay between health, access to care, and socioeconomic factors. Elena’s journey from this point is not just a medical battle; it’s a fight against the systemic issues that contributed to her condition. As we delve into Elena’s story, we aim to explore the clinical and personal challenges of living with chronic renal failure against a backdrop of limited healthcare access and cultural dynamics. This narrative highlights the resilience required to face a chronic illness, the importance of family and community support, and the need for systemic change to address health inequities. Elena’s story is a call to recognize the broader social determinants of health and the impact they have on individuals and communities. Hospital Admission: Health & Physical (H&P) Summary Admission Date: [Admission Date] Narrative: Elena Ramirez, a 52-year-old Hispanic female with a known history of Type 2 diabetes and recent diagnosis of chronic renal failure, was admitted under my care on [Admission Date]. The primary reason for her admission is the management of her chronic renal failure, complicated by her longstanding diabetes, and the initiation of hemodialysis through a newly placed fistula in her left arm. Elena has been living in a challenging environment that has limited her access to healthy food options, contributing significantly to the progression of her diabetes and, consequently, her renal disease. Upon admission, Elena presented with symptoms of fatigue, lower extremity edema, and decreased urine output, indicative of her advancing renal failure. Given her diabetes, there is a heightened need for meticulous management of her fluid and electrolyte balance to prevent further complications. Her current state necessitates a comprehensive approach, including the initiation of dialysis, strict glycemic control, and dietary modifications to manage her conditions effectively. In addition to her medical needs, Elena’s case is complex, involving socioeconomic factors that have impacted her health outcomes. These include limited access to nutritious food and comprehensive healthcare services, underscoring the importance of a multidisciplinary approach to her care. Therefore, consultations with nephrology, endocrinology, dietetics, and social work have been arranged to address the multifaceted aspects of her health and social needs. Given Elena’s newly placed fistula, she has been fitted with a limb alert bracelet to protect this arm from unnecessary pressures or procedures, ensuring the fistula’s viability for hemodialysis. No known allergies have been reported, and she is under standard precautions with a full code status. Her advance directives are currently not on file, a discussion facilitated by our social work team is planned to address this aspect of her care. For her hospital stay, the current plan includes regular monitoring of her vital signs and comprehensive nursing assessments to closely monitor her condition and response to treatment. Elena’s diet has been tailored to a low-salt regimen, with swallowing precautions to be assessed, ensuring her nutritional status supports her overall treatment goals. Her respiratory status will be supported with supplemental oxygen, titrated to maintain an O2 saturation above 92%. Physical, occupational, and speech therapies have been ordered to support Elena’s mobility, daily functioning, and nutritional intake, respectively. Wound care instructions have been provided for the daily management of her fistula site, with additional orders for SCDs, TED stockings, and continuous telemetry monitoring to manage risks associated with her condition and treatment. In summary, Elena’s admission is focused on stabilizing her condition through the management of her chronic renal failure and associated complications, addressing her comprehensive healthcare needs, and planning for her long-term care and quality of life improvements. Her treatment and care plan reflects our commitment to providing holistic and patient-centered care, taking into account her medical needs, personal circumstances, and the broader social determinants affecting her health. Demographics:  Age: 52 years  Gender: Female  Race: Hispanic  Marital Status: Single  Religion: [Religion, if applicable]  Code Status: Full Code  Transmission-Based Precautions: Standard Precautions  Advance Directives: None on file  Limb Alert Bracelet: Left arm, due to newly placed fistula for dialysis access  Allergies: No known allergies Attending Physician: Dr. Sofia Morales Additional Consultations:  Nephrology for chronic renal failure management  Endocrinology for Type 2 diabetes management  Dietetics for nutritional support and counseling  Social Work for resource assistance and advance directive discussion Current Plan V/S, Assessment, Frequency:  Vital Signs (V/S): Q8H  Nursing Assessments: Q4H head-to-toe Diet:  Renal & low-sodium diet  Swallowing precautions as assessed by Speech Therapy Line Type(s), Gauge, Placement, Insertion and Change Date:  Peripheral Intravenous (PIV): 20G Left Hand, inserted [Admission Date] (due to change [Change Date]) Drains:  Indwelling Urinary Catheter: [If applicable, specify details] Respiratory:  Supplemental O2: 2L O2 via nasal cannula (NC); titrate to keep O2 sat > 92% Other Therapies Ordered:  Physical Therapy (PT)  Occupational Therapy (OT)  Speech Therapy (ST)  Wound Care for fistula site Frequency of Therapy:  As per individual therapy evaluation and recommendations Labs Ordered:  Comprehensive metabolic panel (CMP)  Complete blood count (CBC)  Hemoglobin A1c  Dialysis adequacy tests (e.g., Kt/V) Mobility Status/Activity Level:  Ambulatory with assistance as needed  Bed/Chair Alarm: Yes, for safety  Assistive Devices: Walker as needed for ambulation Wound Care Orders:  Daily dressing changes for fistula site Other:  Sequential Compression Devices (SCDs): Yes, for DVT prophylaxis  Thrombo-Embolus Deterrent (TED) Stockings: Yes  Telemetry: Continuous cardiac monitoring due to electrolyte imbalances and risk of arrhythmias Medication List Furosemide 40 mg PO daily Calcium acetate 667 mg PO 3 times daily with meals Sevelamer carbonate 800 mg PO 3 times daily with meals Epoetin alfa IM per hemoglobin level, post-dialysis M, W, F Insulin Lispro SQ (Sliding Scale for Blood Glucose): – BG <150 mg/dL: No Lispro - BG 151-200 mg/dL: 4 units subcut - BG 201-250 mg/dL: 6 units subcut - BG 251-300 mg/dL: 8 units subcut - BG >300 mg/dL: Contact physician Insulin Glargine (Lantus) 20 units subcutaneously at bedtime Renal Multivitamin 1 tab PO daily Ferrous Sulfate 200 mg PO daily Atorvastatin 20 mg PO at bedtime Lisinopril 5 mg PO daily Vitals VITALS AM Shift PM Shift NOC Shift Date/Time [Date] 07:00 [Date] 15:00 [Date] 23:00 Temp 98.6°F (37°C) 99.2°F (37.3°C) 100.4°F (38°C) Temp route Oral Oral Oral Blood Pressure 130/80 mmHg 145/90 mmHg 160/95 mmHg BP site/Position Right arm, Sitting Right arm, Sitting Right arm, Sitting Pulse 88 bpm 95 bpm 102 bpm Pulse site Radial Radial Radial Respiratory Rate 18 breaths/min 22 breaths/min 26 breaths/min SPO2 96% 94% 90% Room air Yes No No O2 amount (L/min)- 2 L/min 4 L/min O2 delivery device- Nasal cannula (NC) Nasal cannula (NC) Height 5’2″ 5’2″ 5’2″ Weight 192 lbs 194 lbs 198 lbs Intake & Output Records Intake and Output Record (Yesterday) Shift Fluid Intake (mL) Meal Intake (%) Urinary Output (mL) Bowel Movements AM Shift 07:00 240 (8 oz cup of water) 100% Breakfast 400 None 10:00 120 (4 oz juice)- 300 None Total AM 360 100% 700 0 PM Shift 12:00 240 (8 oz cup of water) 75% Lunch 200 None 15:00 180 (6 oz tea)- 100 None Total PM 420 75% 300 0 NOC Shift 18:00 240 (8 oz cup of water) 50% Dinner 50 None 21:00 120 (4 oz ice chips)- 0 None Total NOC 360 50% 50 0 Daily Total 1140- 1050 0 Intake and Output Record (Today) Shift Fluid Intake (mL) Meal Intake (%) Urinary Output (mL) Bowel Movements AM Shift 07:00 240 (8 oz cup of water) 80% Breakfast 30 None 10:00 120 (4 oz juice)- 20 None Total AM 360 80% 50 0 PM Shift 12:00 240 (8 oz cup of water) 60% Lunch 25 None 15:00 180 (6 oz tea)- 25 None Total PM 420 60% 50 0 NOC Shift 18:00 240 (8 oz cup of water) 40% Dinner 30 None 21:00 120 (4 oz ice chips)- 20 None Total NOC 360 40% 50 0 Daily Total 1140- 150 0 Laboratory Test Results Test Result Normal Range Notes Hemoglobin A1C (HbA1C) 8.2% <5.7% normal, 5.7-6.4% prediabetes, >6.5% diabetes Indicates poor glucose control Complete Blood Count (CBC) – White Blood Cells (WBC) 7.2 x10^9/L 4.5-11 x10^9/L Normal – Hemoglobin (Hgb) 6 g/dL 13.8-17.2 g/dL (men), 12.1-15.1 g/dL (women) Indicative of anemia – Hematocrit (Hct) 20% 40-52% (men), 35-47% (women) Low, consistent with chronic disease anemia – Platelets (PLT) 250 x10^9/L 150-450 x10^9/L Normal Basic Metabolic Panel (BMP) – Sodium (Na+) 132 mmol/L 135-145 mmol/L Hyponatremia – Potassium (K+) 5.8 mmol/L 3.5-5.2 mmol/L Hyperkalemia – Chloride (Cl-) 98 mmol/L 98-106 mmol/L Normal – Bicarbonate (HCO3-) 18 mmol/L 23-29 mmol/L Metabolic acidosis – Blood Urea Nitrogen (BUN) 60 mg/dL 7-20 mg/dL Elevated, indicates reduced kidney function – Creatinine 4.5 mg/dL 0.6-1.2 mg/dL Significantly elevated, indicates kidney failure – Glucose 180 mg/dL 70-99 mg/dL (fasting) Hyperglycemia Renal Function Tests – Glomerular Filtration Rate (GFR) 15 mL/min/1.73m^2 >90 mL/min/1.73m^2 normal Indicates kidney failure (stage 5) – Albumin to Creatinine Ratio (ACR) 300 mg/g <30 mg/g normal Indicates significant albuminuria EKG Strip Clinical Judgment Model (CJM) In this column you will choose a priority diagnosis (Ex: CHF, Diabetes, COPD, etc.) and work through the nursing process using the questions in the left-hand column as a guide. These questions are meant to GUIDE the nursing process and to encourage critical thinking and prioritization Priority #1: Recognize Cues (aka Noticing; Assessment)- • Of the information that you have collected and the assessment that you have performed, what information is most important? • As the nurse, what is of immediate concern that you will make a priority of your care? Analyze Cues (aka Interpreting; Analysis) • What patient problems/conditions/diagnoses are consistent with your assessment findings? • What findings did you expect based on the patient's primary admitting diagnosis or other health conditions? • Are there assessment findings that are of particular concern to you? Why are these a concern? • What additional information would help you better understand the significance of these findings? Prioritize Hypotheses (aka Interpreting; Analysis) • What do you think caused the patient to be admitted? Were the causes medical in nature or were the patient's needs not met at home? • Which possible explanations are the most serious? Generate Solutions (aka Responding; Planning) • What are your nursing interventions for each priority assessment? Explain why you chose those interventions. • What are the potential complications? • How will you prevent these complications? Take Action (aka Responding; Implementation) • How will you implement the planned interventions? What will the nurse do? What can the nurse delegate? • Identify a priority area that the patent needs education on, related to your assignment, and provide rationale. ** "No education needed" is unacceptable ** • What other interdisciplinary teams are involved in the patients care? What is their role in the patients care? Evaluate Outcomes (aka Reflecting; Evaluation) • What signs point to improving/declining/ unchanged status? • Were the interventions effective? • Would other interventions have been more effective SCIENCE HEALTH SCIENCE NURSING NURS 419

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