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Posted: February 6th, 2024

The attending physician is thinking that Mr. J.R. has developed an Acute Kidney Injury (AKI)

Description
Discussion Post Response.
Reply to each discussion with at least 250 words each APA format and references.
#1 PN

The attending physician is thinking that Mr. J.R. has developed an Acute Kidney Injury (AKI). Analyzing the case presented name the possible types of Acute Kidney Injury. Link the clinical manifestations described to the different types of Acute Kidney injury.

Acute kidney injury is the decline in renal function that has a sudden, or acute, onset and is reversible if treated promptly (Goyal et al., 2023). There are three types of acute kidney injury, which all have different causes and manifestations:

Prerenal: caused by inadequate blood flow to the kidneys (Goyal, et al., 2023). Some causes of prerenal acute kidney injury are “hypovolemia, hypotension, renal vasoconstriction, and glomerular efferent arteriolar vasodilation” (Goyal et al., 2023). Clinical manifestations this patient presents with, which are commonly associated with prerenal acute kidney injury, are dehydration secondary to nausea, vomiting, diarrhea, and metallic taste due to dehydration.
Intrinsic Renal: this type directly affects the glomerulus or tubules due to acute tubular necrosis or acute interstitial nephritis (Goyal et al., 2023). Bacterial and viral infections are directly correlated with acute interstitial nephritis (Goyal et al., 2023). This patient was diagnosed with gastroenteritis, an infection of the stomach and intestines. Therefore, this is associated with intrinsic renal type of acute kidney injury. Other causes include nephrotoxic agents, such as CT contrast, which this patient did not receive in the days leading up to this diagnosis.
Postrenal: caused by obstruction to the kidneys due to blood clots, kidney stones, or tumors (Goyal et al., 2023). At this time, this patient does not demonstrate symptoms related to postrenal acute kidney injury. Based on the information presented, this patient may be demonstrating prerenal acute kidney injury as evidenced by hypovolemia. He experienced 48 hours of nausea, vomiting, and watery diarrhea, which resulted in dehydration. These symptoms are due to gastroenteritis.

Create a list of risk factors the patient might have and explain why.

This patient presents with several risk factors of acute kidney injury. They include age, fluid status, and certain medications, like bismuth subsalicylate. Adults over 65 years of age are more likely than anyone else to develop acute kidney injury. The fact that J.R. was unable to hold any food or fluids down for the last two days would cause dehydration. Finally, vomiting and severe watery diarrhea are risk factors for this patient developing acute kidney injury, as it limits blood flow to the kidneys and dehydrates the body (American Kidney Fund, 2022). All of these symptoms combined, again, would signify prerenal acute kidney injury.

Unfortunately, the damage on J.R. kidney became irreversible and he is now diagnosed with Chronic kidney disease. Please describe the complications that the patient might have on his Hematologic system (Coagulopathy and Anemia) and the pathophysiologic mechanisms involved.

If damage to the kidneys is severe enough and reaches a cellular level, acute kidney injury can progress to chronic kidney disease. The most common hematologic complication of chronic kidney disease is anemia. This happens due to inadequate production of EPO in the blood, causing a severe drop in red blood cell count (American Kidney Fund, 2023). Iron-deficiency anemia is another complication of chronic kidney disease. Iron produces red blood cells in the body. Blood loss, caused by phlebotomy or dialysis, leads to decreased amount of iron in the body/blood (American Kidney Fund, 2023). Thus, iron-deficiency anemia results.

REPRODUCTIVE FUNCTION

According to the case presented, including the clinical manifestations and microscopic examination of the vaginal discharge, what is the most probably diagnosis for Ms. P.C.? Support your answer and explain why you get to that diagnosis.

Based on the patient’s chief complaints, medical history, and microbio, I would diagnose her with pelvic inflammatory disease secondary to gonorrhea. Symptoms of gonorrhea in women include burning sensation while urinating, increased vaginal discharge that is thick in nature and yellowish-green in color, abdominal pain, pelvic pain, and bleeding between menses (Office on Women’s Health, 2021). It is important to note that most men and women with gonorrhea are asymptomatic, making it difficult to diagnose. That being said, untreated gonorrhea can develop into pelvic inflammatory disease. Pelvic inflammatory disease is an infection of the uterus, fallopian tubes, ovaries, and/or cervix and affects women between 15-24 years of age (Office on Women’s Health, 2021). Symptoms include lower abdominal pain, fever greater than 100F, foul-smelling vaginal discharge, dyspareunia, pain during urination, and irregular menses (Office on Women’s Health, 2021). Microbiology of gonorrhea and pelvic inflammatory disease are the presence of white blood cells in addition to gram-negative intracellular diplococci in vaginal fluid samples (Centers for Disease Control and Prevention [CDC], 2022). P.C.’s labs indicated the presence of both and she reported multiple symptoms correlated with gonorrhea, making a diagnosis of pelvic inflammatory disease secondary to gonorrhea likely.

Based on the vaginal discharged described and the microscopic examination of the sample could you suggest which would be the microorganism involved?

The microorganism responsible for the development of gonorrhea is called N. gonorrhoeae (CDC, 2022). Unfortunately, by the time a woman gets screened and microorganisms suggesting this diagnosis appear in fluid samples, the patient had already begun experiencing symptoms of pelvic inflammatory disease.

Name the criteria you would use to recommend hospitalization for this patient.

There are multiple criteria suggesting the necessity of hospitalization in patients like P.C. They include surgical emergencies, tubo-ovarian abscess, pregnancy, nausea, vomiting, oral temperature greater than 101F, intolerance of outpatient treatment, and oral antimicrobial resistance (CDC, 2022). Because N. gonorrhoeae is becoming more and more resistant to intramuscular and oral antibiotic stewardships, intravenous antibiotics may be necessary in addition to oral antibiotics and require hospitalization to treat (CDC, 2022). Due to the fact that this patient experienced episodes of emesis and demonstrates clinical manifestations that align with pelvic inflammatory disease, she would qualify for inpatient admission.

#LD

Urinary Function:

The attending physician is thinking that Mr. J.R. has developed an Acute Kidney Injury (AKI). Analyzing the case presented name the possible types of Acute Kidney Injury. Link the clinical manifestations described to the different types of Acute Kidney injury.
Acute Kidney injury is a rapid loss of kidney function, and it occurs when the kidney stops working and performing its usual roles (Rahman et al., 2023). The glomerular filtration rates can decline within several hours to days, and although it’s a sudden deterioration, acute kidney injury (AKI) causes a build-up of waste products in the body, which makes it hard for the kidneys to keep the right balance of fluid and electrolytes in the body (Rahman et al., 2023). Hence, regarding this case, J.R. AKI occurs when there is inadequate blood flow to the kidneys. In this case of diarrhea and vomiting, dehydration can lead to reduced blood volume and subsequently decreased renal blood flow, resulting in prerenal AKI.

Create a list of risk factors the patient might have and explain why.
Upon researching J.R.’s case, not much was specified regarding his past medical history; however, current risk factors that he is at risk for associated with the information provided consist of age, high blood pressure, liver disease, and heart failure (El Hadi et al., 2020). J.R. is a 73-year-old man who’s at the third age of adulthood. Unfortunately, his organs start to deteriorate, which can put him at risk of many issues.

Unfortunately, the damage to J.R.’s kidney became irreversible, and he is now diagnosed with chronic kidney disease. Please describe the complications that the patient might have on his Hematologic system (Coagulopathy and Anemia) and the pathophysiologic mechanisms involved.
Chronic kidney disease can result in damaging and dangerous levels that can alter the body’s fluid and electrolytes. Some complications from chronic kidney disease include hyperkalemia, anemia, heart disease, weak bones, and pericarditis (National Institute Diabetes and Digestive and Kidney Diseases, (n.d.). When a patient has chronic kidney disease, they cannot produce EPO, which in turn causes anemia (Shaikh et al., 2023).

Reproductive Function:

According to the case presented, including the clinical manifestation and microscopic examination of the vaginal discharge, what is the most probable diagnosis for Ms. P.C.? Support your answer and explain why you get to that diagnosis.
According to the case presented and the clinical manifestation upon the examination, I would highly suggest that P.C. is experiencing a gonorrhea vaginal infection. Gonorrhea is a sexually transmitted bacterial infection that can cause symptoms like yellow or green discharge and abdominal pain, which happens to be what P.C. is experiencing (Centers for Disease Control and Prevention, 2021). In addition, I also based my diagnosis on her microscopic examination. Her results showed antagonistic yeast, hyphae, or flagellated microbes, positive white blood counts, and gram-negative intracellular diplococci. The diagnosis of gonorrhea is based on one of the following three criteria: gram-negative intracellular diplococci on microscopic examination, growth of gram-negative, and nonculture laboratory test (Centers for Disease Control and Prevention, 2021).

Based on the vaginal discharge described and the microscopic examination of the sample could you suggest which would be the microorganism involved?
Upon conducting my research based on the vaginal discharge described from the microscopic examination shows that P.C. has an infection caused by the Neisseria gonorrhoeae bacterium (Centers for Disease Control and Prevention, 2021).

Name the criteria you would use to recommend hospitalization for this patient.
To be able to suggest hospitalization, a patient regarding this diagnosis must be based on the severity of the case. However, based on P.C.’s diagnosis, I would suggest hospitalization to receive IV antibiotics, monitor the infection, and do a blood culture (Centers for Disease Control and Prevention, 2021). In addition, I highly suggest educating the patient on STDs and how to prevent them in the future. If untreated, it can lead to significant complications, including infertility, increased risk for HIV/AIDs, and even complications in babies (Centers for Disease Control and Prevention, 2021).

___________________
Discussion Responses
#1 PN
Acute kidney injury (AKI) can be categorized into three types based on etiology – prerenal, intrinsic renal, and postrenal (Goyal et al., 2023). Prerenal AKI occurs due to inadequate renal perfusion resulting from factors like dehydration, heart failure, liver disease etc. Intrinsic renal AKI involves direct damage to the renal parenchyma due to toxins, infections etc. Postrenal AKI is caused by urinary tract obstruction.
In this case, the clinical manifestations of nausea, vomiting, diarrhea and subsequent dehydration along with the finding of gastroenteritis point towards prerenal AKI. The decreased effective circulating volume would have led to decreased renal blood flow and ischemia, manifesting as prerenal AKI (Goyal et al., 2023).
Some risk factors for this patient include advanced age (>65 years), dehydration due to inability to maintain oral intake for 48 hours, use of over-the-counter medications like bismuth subsalicylate which can potentially cause nephrotoxicity (American Kidney Fund, 2022).
Complications of chronic kidney disease on the hematologic system include anemia and coagulopathy. Anemia occurs due to reduced erythropoietin levels impairing red blood cell production. Coagulopathy arises from platelet dysfunction and impaired vitamin K absorption seconday to uremia (American Kidney Fund, 2023).
#2 REPRODUCTIVE FUNCTION
Based on the clinical history of vaginal discharge, dysuria and lower abdominal pain along with microscopic finding of polymorphonuclear leukocytes and gram-negative intracellular diplococci, the most probable diagnosis for P.C is pelvic inflammatory disease secondary to gonorrhea (CDC, 2022). The causative organism is Neisseria gonorrhoeae which commonly manifests as an asymptomatic infection in women but can spread to cause pelvic inflammatory disease if left untreated.
Criteria for recommending hospitalization include fever >101F, nausea, vomiting, oral antibiotic resistance, pregnancy, need for parenteral antibiotics or surgical intervention for tubo-ovarian abscess (CDC, 2022). Given P.C’s symptoms of vomiting and clinical picture suggestive of pelvic inflammatory disease, inpatient management is advisable.
#3 LD
The key points regarding urinary and reproductive functions have been thoroughly covered in the previous responses. To summarize – prerenal AKI is likely in patient J.R. given the history of dehydration from vomiting and diarrhea. Chronic kidney disease can lead to anemia and coagulopathy. Pelvic inflammatory disease secondary to gonorrhea is most probable for patient P.C based on history and labs. Hospitalization is recommended due to persistent vomiting and severity of clinical presentation. Please let me know if any part needs further clarification or discussion.

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