Case Scenario - Acute Kidney Injury – Essay Example

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The consent should be obtained from the carer about the medical intervention proposed. The nursing care should include, Specific communication, Drugs and nutritional plan, Investigation plan, Psychological and emotional requirements and Physical and rehabilitation requirement. The principles of the Mental Capacity Act 2005: Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise. A person must be given all practicable help before anyone treats them as not being able to make their own decisions.

Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision. Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms (legislation. gov. uk, 2005). Assessment Assessment requires good communication skill. It is the right of patient and carer in need. This can be analysed using Assessment Tools and the ability to observe and document Physical, Social and Psychological changes.

Tract and trigger system is a useful tool in assessment. Track and trigger systems rely on periodic measurement of observations (tracking) of patient, with predetermined action care till certain thresholds are reached (triggering). Care plan: primary requirement include recording patient’s details in the case sheet. The patient’s name, sex and age are recorded first. Recording, past history prior to post operative care and events, give valuable input in assessing the nursing and medical care requirements. Patient’s details: Name of patient: Jean Sex: Female Age: 42 years Patient’s history: 1.

Medical history prior to admission to A&E: Down’s syndrome, hypertension, uncontrolled type2 diabetes mellitus, hypercholesterolemia 2. Subsequent history after admission: Myocardial infarction diagnosed; immediate traditional Cardiac Artery Bypass Grafting done using Heart-Lung Bypass Machine which keeps blood and oxygen circulating the body; heart was stopped for one hour using medicine; which allows surgeon to operate on still heart. Heart Function restored after surgery. Present admission: Present medical status: Post-operative care after CABG after admission to A&E ward for chest tightness and shortness of breath. Significant events: Event Observed: First day: nil Second day: Oliguria, elevated creatinine Diagnosis: Acute Kidney Injury Probable cause: hypotension, diabetes, cardiac surgery, radio contrast dye Medical intervention during next 24 hrs: Monitoring (LO 1 & 4) and Nursing Care (LO 2 & 3).

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