J.K has acute kidney failure with Rhabdomyolysis. Acute kidney failure happens when the kidneys are suddenly not able to sift waste products from the blood. This results to accumulation of waste and affects the chemical balance of the blood. Rhabdomylosis is caused by skeletal muscles injury (Grau, Poch, &Bosch, 2009). The injury of the skeletal muscles results to the production of different intracellular muscle ingredients. In this case, J.K had an acute renal failure with Rhabdomyolysis because of cocaine and heroin use. Cocaine and heroin cause damage to myocyte. Damage to the myocyte leads to an entry of sodium into the cell. It also leads to an accumulation of cytosolic calcium because of the direct injury to the cell and increased activity of sodium and calcium exchange mechanism that tries to remove sodium from the cell in exchange for calcium (Grau, Poch, &Bosch, 2009). The high intracytoplasmic calcium concentration has undesirable effects such as stimulation of phospholipaseA2 which leads to production of toxic metabolites and death of cells. This in turn, results to release of myocytes constituents into the circulation and causes complications like acute renal failure. Patients having acute renal failure with Rhabdomyolysis like J.K show different symptoms. They include hypocalcaemia, hyperkalemia and acidosis. Efflux of intracellular content into the circulation after myoocytes injury causes hyperkalemia, hyperuricaemia and hyperphosphataemia. Patients have hypocalcaemia because of the accumulation of calcium in the injured muscle. Acidosis, hyperkalemia and hypocalcaemia are dangerous. In addition, patients have muscle pain and swelling like J.K (Grau, Poch, &Bosch, 2009).
The suitable diagnostic test for Rhabdomyolysis is determining creatine kinase level in the blood. A patient having Rhabdomylosis has a higher level of creatine kinase than the normal level. The creatine kinase is released by the injured muscles. Other diagnostic tests such as Electrocardiography and urinalysis can be used to differentiate Rhabdomyolysis from hemolysis and other conditions. Electrocardiography can be used to determine the potassium levels as high levels of potassium indicate severe Rhabdomyolysis.. The electrocardiography shows whether the high potassium levels are affecting heart conduction as depicted by the T wave changes. Urinalysis aids in detecting abornomalities that depict renal failure and other conditions that cause damage of red blood cells and hemolysis. In case of kidney injury, the urine shows urinary casts that are granular and pigmented. A blood test is conducted to show the increasing levels of creatinine and urea. Urea and creatinine are used to measure the functions of the kidney and high levels indicate abnormal functioning of the kidney. Additionally, understanding the history of the patient is essential in diagnosing the disease. In this case, the nurse practitioner will ask J.K if he has had an injury and trauma as they cause Rhabdomyolysis. Also, the nurse practitioner will ask the patient if he has a muscle disorder (Rodriguez, Arevalo & Hinojosa, 2012).
The nurse practitioner should administered intravenous fluid like isotonic saline to J.K to prevent acute renal failure. In this case, intravenous fluids are recommended if the renal failure is due to lack of fluids.0.9% saline solution is recommended (Rodriguez, Arevalo & Hinojosa, 2012). Medications like diuretics are used to prevent fluid retention if the patient has fluid retention that causes swelling of the legs. Further, administering diuretics including mannitol improves urinary flow and avoid obstructive myoglobin casts. Mannitol flushes of nephrotoxic substance via the renal tubes and creates the gradient needed to extract accumulated fluids in the injured muscle. The mannitol dosage depends on the severity of the patient condition, fluid needs and urinary output.100g/24 hours of mannitol will be given to the patient through injection to attain the right response. The doctor can prescribe calcium, glucose or polystyrene sulfonate to J.K since the kidney is not filtering the potassium from the blood and hence the high potassium level. J.K can have a dialysis to remove excess toxins and fluid in the body (Rodriguez, Arevalo & Hinojosa, 2012).
Hypothyroidism
K.L has hypothyroidism. Hypothyroidism is a condition in which the thyroid gland does not produce enough amounts of thyroid hormones (Kotsis, Papakatsika & Stabouli, 2010). Inadequate iodine and thyroid stimulating hormone lead to low production of thyroid hormones. The hypothalamic, pituitary and thyroid axis play a vital function in maintaining the output of the thyroid. The hypothalamus produces the thyrotropin releasing hormone and the hormone stimulates the pituitary gland to produce the thyroid stimulating hormone. The thyroid stimulating hormone stimulates the thyroid (Kotsis, Papakatsika & Stabouli, 2010). The functioning of the thyroid gland is impaired if the pituitary and hypothalamus is damaged. The thyroid hormone affects the regulation of blood pressure. Blood pressure is altered during thyroid activity and this affects the systolic and diastolic blood pressure. Thyroid hormone causes an increase in the basal metabolic rate in all organs and hence changes in cardiac output due to the increased metabolic demands. It also causes changes in blood pressure. Excess thyroid increases systolic blood pressure. Low levels of thyroid hormone result to high blood pressure, increased chlorosterol levels and increased homocysteine which causes heart diseases. Low thyroid hormone leads to less energy and fatigue and weight gain as the body does not convert all the calories into energy. In this case, K.L has high serum chlorosterol level. His serum chlorosterol level is 322, LDL of 200, HDL of 36 and TG of 400. Also, his fasting glucose is 140. K.L also has gained weight for the past years and has been diagnosed with hypertension due to low thyroid hormone (Kotsis, Papakatsika & Stabouli, 2010).
The best method to diagnose hypothyroidism is by measuring the thyroid stimulating hormone and the free thyroxine. High levels of thyroid stimulating hormone show insufficient thyroid hormone levels. Also, serum cholesterol can be measured to diagnose hypothyroidism as the serum levels are high in patients with hypothyroidism. There are other physical tests that can be important in diagnosing the condition. The doctor can do a physical examination to identify hypothyroidism signs including enlarged thyroid glands (Allahabadia, Razvi, Abraham & Franklyn, 2009). Hypothyroidism can be treated using levothyroxine sodium and triiodothyronine. Levothyroxine sodium functions like the thyroid hormone and lowers the thyroid stimulating hormone to a normal level. Levothyroxine improves symptoms related to thyroid deficiency including inadequate energy, weight gain and feeling cold. The dosage for levothyroxine is based on weight and age and the right dosage for K.L is 1.7 mcg/kg/day. The nurse practitioner should monitor the blood level to ensure appropriate dosage. (Allahabadia, Razvi, Abraham & Franklyn, 2009).
Dysmenorrhea
P.W has Dysmenorrhea. The endometrium thickens during a menstrual cycle in preparation for pregnancy. The uterine tissue sheds if fertilization does not take place. Prostaglandins are released during menstruation because of the damage of the endometrial cells. The prostaglandins cause contraction of the uterus. The contraction of the uterine muscles prevents the supply of blood to the endometrium tissue (Sharma, Malhotra, Taneja & Saha, 2008). The deprivation of oxygen and contractions cause pain and cramps. Patients having dysmenorrhea show symptoms similar to P.W symptoms. That is nausea, vomiting, headache, dizziness and hypersensitivity to light. Other symptoms include passage of blood clots, heavy bleeding and abnormal bleeding. Dysmenorrhea is diagnosed by examining the medical history of the patient. In this case, the doctor determines whether the patient has had a history of pain during menstruation (Sharma, Malhotra, Taneja & Saha, 2008). Dysmenorrhea can be diagnosed using different tests. A pap test is crucial in identifying reproductive diseases. A gynecologic ultrasonography and MRI are use to identify abornomalities in the reproductive organs such as ovaries, vagina and pelvic. P.W can manage Dysmenorrhea using medications. NSAIDs are used to relieve pain. Some of the NSAIDs used include diclofenac, ibuprofen, ketoprofen etc. Also, hormonal contraceptives can be used to alleviate menstrual pain. Dysmenorrhea can be managed through lifestyle modification and exercise. P.W should engage in regular physical activity to prevent Dysmenorrhea (Sharma, Malhotra, Taneja & Saha, 2008).
Reference
Allahabadia, A.,Razvi, S., Abraham, P.,& Franklyn, J. (2009). Diagnosis and treatment of primary hypothyroidism. BMJ ,338
Grau, J.M., Poch, E., &Bosch, X. (2009). Rhabdomyolysis and Acute Kidney Injury. The new England journal of medicine,361:62-72
Kotsis, V., Papakatsika, S., & Stabouli, S. (2010). Hypothyroidism and hypertension. Expert Rev Cardiovasc Ther, 8(11):1559-65
Rodriguez,G.,Arevalo,G.,& Hinojosa,M.(2012).Renal Replacement Therapy in Acute Kidney Failure due to Rhabdomyolysis. Case reports in critical care,3
Sharma, P., Malhotra, C., Taneja, D.K., & Saha, R. (2008). Problems related to menstruation amongst adolescent girls. Indian J Pediatr, 75 (2): 125–9
