Case Study:Subjective Data
Case Study:Subjective Data
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Subjective Data
Has been having headaches on and off, with nausea and dizziness
Reported that she hadn’t been taking her medications regularly at home because of ‘forgetfulness’
Has not been urinating a lot
Feels ‘puffy’ in her legs and hands
Objective Data
Physical Examination
Blood pressure 178/96, pulse 110, temperature 98.9° F, respirations 24
Alert and oriented to person, place, and time
Mild jugular venous distention
Fine crackles in bilateral lower lobes
Heart rate regular, no murmurs
Bowel sounds normoactive and present in all four quadrants
2+ edema bilateral lower extremities and hands
Diagnostic Studies
Echocardiogram shows decreased left ventricular function
Urinalysis: Urine dark yellow and cloudy, protein 28 mg/dL, negative for glucose and ketones, positive for casts, red blood cells and white blood cells
24-hour urine output = 380 mL
Laboratory Tests:
Hemoglobin 8 g/dL
Hematocrit 23.8%
RBC 2.57 million/mm3
WBC 4.7 mm3
Sodium 132 mEq/L
Potassium 5.2 mEq/L
Calcium 9 mg/dL
BUN 36 mg/dL
Creatinine 4.9 mg/dL
BNP 182 pg/mL
Question 1
Interpret Mrs. Davies’s laboratory test results and describe their significance.
Question 2
What is the most likely cause of Mrs. Davies’s AKI?
Question 3
What additional tests, if needed, could be done to determine the cause of AKI?
Question 4
What are the priority nursing diagnoses to address the concern of fluid retention?
Question 5
What are the priority nursing interventions for these nursing diagnoses?
