NU142 Unit 10 Final Case Study Example

A Week of Flu Meets Three Chronic Diseases: A Final Case Study of a Composite 68-Year-Old Man With Diabetes, High Blood Pressure and Stage 3 Kidney Disease Admitted With Influenza, Dehydration and Acute Kidney Injury, From Data to Discharge

[Student Name]

Purdue University Global

NU142: Medical-Surgical Nursing I

Unit 10 Final Case Study

[Instructor Name]

[Date]

The patient is composite; values are bracketed where illustrative, and medication decisions belong to the prescriber and pharmacist.

The Patient

[Mr. G.], a composite 68-year-old retired machinist, has had fever, body aches, cough and vomiting for five days. Through it all he kept up his usual regimen: metformin [1,000] mg twice a day, glipizide [5] mg each morning, and for blood pressure lisinopril [20] mg with hydrochlorothiazide [25] mg. He has eaten very little and drunk only small sips. His wife brought him in because he was dizzy and nearly fell. On arrival: temperature [38.3] C, heart rate [114], blood pressure [92/56] sitting, falling to [76/48] standing. A rapid test is positive for influenza A.

The Data

Creatinine [3.1] mg/dL, baseline [1.5]; blood urea nitrogen [58]; potassium [5.6] mmol/L; sodium [131]; bicarbonate [17]; lactate [3.2] mmol/L; glucose [54] mg/dL on arrival, rising to [310] after juice and a dextrose infusion. Urine output [150] mL in the first six hours. Chest X-ray clear.

Linking Each Abnormality to Its Cause

Dehydration from vomiting, fever and poor intake reduced blood flow to his kidneys. Three of his medicines made that worse: hydrochlorothiazide kept removing salt and water; lisinopril, which reduces the kidneys' ability to maintain filtration when blood flow falls; and, in the setting of reduced kidney function, metformin accumulated. The result is acute kidney injury on top of his chronic kidney disease, shown by the doubled creatinine and low urine output (Harding et al., 2023).

The high potassium reflects the kidney injury plus lisinopril, which reduces potassium excretion. The low bicarbonate and raised lactate suggest metabolic acidosis, from poor perfusion and possibly from metformin accumulating with poor kidney function, a rare but serious effect. The low glucose on arrival came from glipizide, which stimulates insulin release regardless of intake, in a man who had barely eaten; sulfonylureas are cleared more slowly when kidney function falls, prolonging their effect. Once treated, his glucose swung high because of infection and stress, as stress hormones released during acute illness raise glucose production (Kitabchi et al., 2009).

Every pill he took to stay well that week was, in its own way, working against a body that was dehydrated and could not clear drugs.

Ranking the Problems

1. Deficient fluid volume with hypotension and acute kidney injury: the immediate threat to perfusion and his kidneys.

2. Hyperkalemia: a potassium of [5.6] with kidney injury can rise further and cause dangerous rhythms.

3. Unstable blood glucose: hypoglycemia from glipizide can recur for hours, then hyperglycemia from infection.

4. Influenza: infection control and antiviral treatment, adjusted for kidney function.

5. Fall risk from orthostatic hypotension.

6. Knowledge deficit about managing medicines when sick.

The Plan

IV fluids with careful monitoring of urine output, lung sounds and weight. Hold metformin, lisinopril, hydrochlorothiazide and glipizide, as the prescriber ordered. Cardiac monitoring and repeat potassium; treatment per protocol if it rises. Glucose checks every one to two hours at first, because glipizide's effect can outlast the first correction, then before meals and at bedtime, with correction insulin for high values. Oseltamivir with the dose reduced for his kidney function, as the pharmacist advised (Burchum & Rosenthal, 2022). Droplet precautions. Fall precautions with assistance for every transfer.

Evaluation

After 48 hours of fluids, his creatinine fell to [1.9], potassium to [4.6], bicarbonate to [22], and urine output was above [60] mL per hour. His standing blood pressure was [118/72] without dizziness. Glucose stabilized in the [140] to [190] range on correction insulin. Before discharge, lisinopril and hydrochlorothiazide remained on hold pending follow-up labs; metformin was restarted once his creatinine approached baseline, and glipizide was replaced at the prescriber's direction with an agent less likely to cause low glucose.

Discharge Teaching: Sick-Day Rules

The teaching addresses the gap that led to the admission. He and his wife receive a written list of the medicines to pause on days when he is vomiting, has diarrhea or cannot eat and drink normally: metformin, lisinopril, hydrochlorothiazide and his diabetes pill, restarting them after [24] to [48] hours of eating and drinking normally. He is told to keep drinking fluids, check his glucose every four hours while sick, and call his clinic if he cannot keep fluids down for more than [12] hours, if his glucose stays below [70] or above [300], or if he becomes dizzy on standing. They repeat the list back, and his wife places it on the refrigerator. Teaching that names specific medicines and specific thresholds gives the family something to act on when he is too unwell to think clearly.

Conclusion

His admission shows how three well-managed chronic conditions can become dangerous together during an ordinary illness. Interpreting the data required connecting each abnormality to its cause, and the most important intervention, teaching which medicines to pause when sick, was one that could have kept him at home.

References

Burchum, J. R., & Rosenthal, L. D. (2022). Lehne's pharmacology for nursing care (11th ed.). Elsevier.

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis's medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 32(7), 1335-1343. https://doi.org/10.2337/dc09-9032