Subjective and Objective data: The subjective data in this case includes extreme fatigue and anorexia. The objective data, on the other hand, incorporates vomiting, diarrhea, H & H, BUN, and K+. The patient’s BUN 17 is within the normal range (7-20 mg/dl), K is increased (normal levels are 3.7-5.2 mEq/L), and her H & H are reduced at 9(11.7-13.8 mg/dl) and 28 (38-46%). Patients with CKD present with symptoms affecting many body systems. These symptoms occur due to accumulation of toxic products in the body such as urea although the aetiology of some of the symptoms such as fatigue, nausea, anorexia, and vomiting is yet to be fully elucidated.
Considerations: The age, socio-economic, and cross-cultural considerations for this patient are as follows: the results of the creatinine clearance tests for this patient should be interpreted with caution because they are influenced by age and muscle mass; renal function also decreases with age. The dietary patterns particularly intake of protein, sodium, and potassium containing foods should be considered and the patient prescribed for culturally acceptable foods for CKD. Recent intake of drugs that affect renal function such as non-steroidal anti-inflammatory drugs and antibiotics should be considered during assessment. The occupation of the patient or the social support available to the patient also needs to be considered because chronic renal failure requires long-term costly treatments.
Information: Other information required for a more definite diagnosis includes the estimated glomerular filtration rate to assess the degree of renal impairment, urine albumin-to-creatinine ratio to assess the severity of the CKD, serum creatinine levels, weight to assess fluid retention, serum electrolyte levels to assess salt retention and electrolyte variations, and blood pressure measurements to rule out fluid and salt retention.
Objective and subjective data: The objective data in this case includes low-grade fever and vomiting. The subjective data incorporates anorexia and vomiting. These findings reflect a deviation from normal parameters.
Considerations: The age, socioeconomic, and cross-cultural factors that should be considered in this case include dietary content and habits, cost implications of the therapeutic regimen, health beliefs and behaviors, and the occupation of the client.
Information: Other information needed for a more accurate diagnosis includes physical assessment to elicit any abdominal tenderness, fullness, or, signs of dehydration, serum electrolytes due to the history of vomiting, full hemogram to rule out infections, liver and pancreatic function tests due to the history of fat intolerance, abdominal ultrasound or CT scan, and endoscopy.
Nursing diagnosis: Risk for fluid volume deficit related to excessive fluid loss subsequent to vomiting.
Objective and subjective data: The data provided in this case that is intermittent burning and stabbing pain above the stomach after eating a large meal or heavy lifting, cough, and bitter taste in the mouth is subjective data. These symptoms reflect deviation from normal parameters.
Information: Other information required for a more definite diagnosis in this case includes the findings of physical assessment particularly in regard to epigastric tenderness, barium meal, endoscopy to reveal any ulcers or inflammatory lesions, stool tests for occult blood, and Helicobacter pylori test.
Nursing diagnosis: Acute pain related to irritation of damaged tissues by gastric acid as evidenced by verbalized complains.
Considerations: The age, socioeconomic, and cross-cultural factors to be considered for this patient includes eating patterns, cultural appropriateness of recommended foods, and social habits such as smoking and drinking.
