Health History - Case Study Template

This article presents a case study template for health history assessment of a patient with UTI, T2DM, hypertension, and chronic kidney disease. It includes cues collected during the interview, new assessments that can be conducted, and the interpretation of the results. The article also discusses the nursing problems, goals, and actions that can be taken to improve the patient's condition.

Health History
Gender Male
Age 40
Current Medical History
What current medical conditions do you
have?
He is associated with urinary tract infection (UTI) with severe suprapubic pain and fever. He is
associated with reduced urine output and increased urgency.
Data related to his vital signs and other clinical symptoms which was collected from his case reports:
RR 23, Sats 94% on RA,
Circulation: HR 95 bpm,
BP 176/100 mmHg,
He described his pain as achy, burny and gripping. His daytime frequency is 11-13 and nocturia is 4-
5voids.
Dark-colored urine.
Past Medical/Surgical History
What is you past medical/surgical history?
Medical History
T2DM, Ex-smoker (5 years before), HTN,
Hyperlipidaemia, chronic kidney disease stage
3 (Baseline eGFR 40 ml/min/1.73m2), chronic
venous leg ulcer to L) leg, anxiety. No known
declared allergies (NKDA). He is obese (BMI
32) and drinks 1 bottle of wine every night.
He is using antimuscarinics, trimethoprim-
sulfamethoxazole, tricyclic antidepressants
Surgical History
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and oxycodone. He reported chills and fever.
He has had 2 prior UTIs in the past year,
which were successfully treated each time
with trimethoprim-sulfamethoxazole (TMP-
SMX) 160 mg/800 mg twice a day for 3 days.
The last UTI was 4 months ago which was
associated with pyelonephritis.
Medications
What medications do you take?
List medications and dosages (where possible)
He is administered with medications such as paracetamol (650 mg), oxycodone (20 mg extended
release tablets per day), metformin (500 mg every 12 hours) and captopril (25 mg PO q 8-12 hr).
Do you live alone/with someone? With someone
Are you able to care for yourself?
Do you need help with showering?
Do you need help with toileting?
Do you need help with dressing?
Yes
No
No
No
Do you have a vision impairment?
Do you wear glasses?
What type of glasses are they?
Yes
No
Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
No
No
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Do you wear dentures?
Are they upper/bottom dentures?
No
Do you drink alcohol?
How often do you drink?
How many drinks do you have each day?
Yes
1 bottle per night
Do you smoke?
How many cigarettes do you smoke a day?
Ex-smoker
Do you follow a special diet?
What is the special diet?
What is your height?
What is your weight?
Yes
Diabetic diet
150 cm
75 kg
Do you have any mobility issues?
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
No
No
Do you have any wounds?
Where are they?
Yes
1) Nursing assessment tool used – Result –
Anthropometric measurements method was implemented for Mr. John for the nutritional and dietary
assessment. Different parameters such as body weight, % body weight change, Mid upper arm
circumference, skin fold thickness, and Mid arm muscle circumference. Change in body weight is
directly proportional to the alteration in the fluid balance. In patients with UTI, chances of sudden
change in body weight are high attributable to fluid loss due urine output and vomiting. Alteration in
body fluid is also responsible for Skin fold thickness. Skin fold thickness can be assessed using
calibrated skin fold calliper and it can be considered as surrogate marker of fat mass (Fryar, Gu,
Ogden, and Flegal, 2016; Gavriilidou, Pihlsgård, and Elmståhl, 2015).
2) Nursing assessment tool used – Result – Pain assessment was performed for Mr. John using PQRST algorithm. Pain assessment is
one of the significant factors for him because patients with UTI are usually associated with acute
pain. Pain assessment is also beneficial in planning early intervention and prescribing appropriate
analgesic for pain management. PQRST algorithm comprises of questions such as P =
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Provocation/Palliation, Q = Quality/Quantity, R = Region/Radiation, S = Severity Scale and T =
Timing. Pain assessment for Mr. John was performed at multiple time points and average was
considered for interpretation because PQRST algorithm is based on the subjective parameters.
Henceforth, physical and psychological condition of patient might alter the pain assessment. It has
been observed that pain assessment in Mr. John was consistent at different time points of the day.
Pain was recorded as 8 on scale of 0-10 for Mr. John which can be considered as the severe pain
(Varndell, Fry, and Elliott, 2017).
Assessment 1 – Case Study Template
1) Consider the Individual (25 words)
According to Levett-Jones et al. (2014), this is the initial stage of clinical reasoning cycle. During this stage, nurse interact with patient to
understand past and present clinical condition of the patient.
2) Collect cues/Information
Current information- including your 2 assessments: (cues collected during the interview) (250 words)
Cues from the nutritional and dietary assessment and pain assessment were collected during the interview. Patients with nutritional imbalance might
be associated with excessive energy intake and obesity which can lead to hypertension. Information about hypertension in Mr. John was gathered
from his anti-hypertensive medication which is captopril 25 mg PO q 8-12 hr. Captopril in beneficial in reducing hypertension to normal level.
However, it was observed that hypertension was not reduced in case of Mr. John after consumption of Captopril. In addition to this Mr. John was
exhibiting signs and symptoms of hypertension such as headache, fatigue, vision problem, and breathing difficulty. It is evident that acute pain is
responsible for exaggeration of hypertension (Saccò et al., 2013). Mr. John was also verbalised that he was experiencing amplified symptoms of
hypertension during pain episodes. HR also augment during augmented pain. Cues about pain were gathered from the administered analgesic
medicines. Oxycodone was being prescribed for Mr. John with the dose of 20 mg extended release tablets per day for the management of pain
(Gabayan et al., 2017). Cues about T2DM was gathered from the administered antidiabetic medication to Mr. John. Mr. John mentioned that he was
associated with T2DM, since, last four years. For the initial two years, he was managing glucose level with diet and exercise. However, since last
two years, he was being administered with metformin for glucose level control. He was being administered with metformin 500 mg every 12 hours.
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However, his previous reports demonstrated that, his glucose level was not being controlled even after metformin consumption. Cues about T2DM
were also gathered from its symptoms like frequent urination, increased thirst, frequent feeling hungry, feeling tired, and blurry vision (Nitzan et
al., 2015).
Gather new information: (identify 3 other assessments that you could conduct regarding this person and the importance of these
assessments) (200 words)
Fluid balance significantly get affected in patients with UTI; hence, it essential to carry out fluid balance assessment in Mr. John. This assessment
also would be beneficial in planning early intervention to maintain normovolumic condition (Chuang, 2016). It is advisable to perform fluid balance
assessment in Mr. John because fluid imbalance can lead to conditions such as pulmonary oedema, hyponatraemia or hypovolaemic shock. (Mok,
Wang, and Liaw, 2015; Davies, Leslie, and Morgan, 2017; McGloin, 2015). Neurological assessment in case of Mr. John can provide important
clue because it assesses consciousness level and mental status using Glasgow Coma Scale. Pain for the extended duration and high glucose level for
extended duration can lead to neurological and psychological abnormalities such as disturbed orientation to person, time and place. Examination of
urine culture samples is essential in case of Mr. John to identify type of infected microorganism.
Examination of type infected microorganism is essential in his case. Identification of infected microorganism would be helpful for the
administration of appropriate antibiotic for Mr. John (Kauffman, 2014).
Recall (using literature identify and describe 3 cues in relation to physiology, pathophysiology, pharmacology, epidemiology, therapeutics,
contexts of care or ethics that will assist you to further understand this personal health) (300 words)
Hypertension is significant complication associated with urinary tract infection. Hypertension can lead to reduced supply of blood to the urinary
tract; consequently, a smaller number of White Blood Cells might reach to the urinary tract to fight against infected microorganisms. Hypertension
in Mr. John was being managed using Captopril which act as competitive inhibitor of angiotensin I-converting enzyme (ACE) which converts
angiotensin I to angiotensin II. Dosage regimen should be adjusted for captopril in UTI and renal dysfunction patients, mainly due to its excretion
through kidneys.
In patients with UTI, elimination rate of captopril gets reduced. Hence, captopril gets longer duration to reach steady-state. Therefore, dosage
regimen should be adjusted in such a way that captopril should be administered with reduced frequency in UTI patients (Antunes et al., 2016).
It is evident that UTIs are frequently occur in T2DM patients because raised glucose level increase susceptibility to UTI. In addition to this, raised
glucose level also result in reduced blood supply to urinary tract. Hence, a smaller number of White Blood Cells reach to urinary tract to act against
infected microorganisms. Mechanism of action of metformin is reduction in hepatic glucose production, reduction in intestinal glucose absorption
and improvement in insulin sensitivity through augmented peripheral glucose uptake and utilization. Metformin is contraindicated in patients with
high GFR. Moreover, risks and benefits of metformin should be assessed on regular basis in patients with low GFR. Hence, it is necessary to
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monitor GFR in patients with metformin consumption (Thomas and Gregg, 2017).
Urethral infection is usually associated with dysuria which is pain during urination. Suprapubic pain also occurs in patients with bladder infection.
It is necessary to consume abundant amount of water in addition to analgesic consumption; for the management of UTI related pain. Mechanism of
action if Oxycodone is to bind to receptors which inhibit adenylyl-cyclase and hyperpolarisation of neurons which reduces neuron excitability.
Oxycodone consumption lead to bladder relaxation and urine retention; hence, urine output should be monitored on regular basis (Coluzzi, 2018).
3) Process information
Interpret –(Identify the normal versus abnormal values of 5 cues collected during the assessment and describe your client/patients
assessment/history results) (100 words)
Normal values of BP in adults should be 120/80 mmHg. Nevertheless, observed BP in Mr. John was 160/100 mmHg. Blood glucose level in normal
adults should be below 140 mg/dL. Nevertheless, measured glucose level in Mr. John was 280 mg/dL. In patients with oliguria, urine output is
usually less than 400 ml per day. Recorded urine output in Mr. John was 300 ml in the last 24 hours. On PQRST scale, recorded pain scale for Mr.
John was 8 which indicate severe pain. Urine culture analysis of Mr. John indicated that he was infected with Staphylococcus saprophyticus.
Discriminate – (Identify the two most important results/cues and why you consider they are important) (150 words)
In Mr. John, clue about pain is important because pain management is an important aspect in UTI patients. Pain management not only improve
physical but also psychological well-being of the patient. Pain management is necessary in UTI patients; since, pain with variable intensities
continue in UTI patients for more than 6 months. Pain in UTI patients can be demonstrated as burning on urination, facial grimace, guarding
behaviour, protective and reduced physical activity and spasm in lower back and bladder area (Coluzzi, 2018). In addition to pain, fluid balance is
also important clue for UTI patients; since, fluid balance maintains potassium, sodium and water balance. Moreover, fluid balance is essential for
vital signs in the normal range. Most importantly, normal fluid balance is beneficial in removing microorganisms from the body; since, fluid
balance lead to difficulty in adherence of microorganisms to human cells (Prowle, Kirwan, and Bellomo, 2014; Pinnington, Ingleby, Hanumapura,
and Waring, 2016).
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4) Identify problems/issues
(50 words)
What is the issue for the patient/
individual?
5) Establish Goals ( 50
words)
What do you want to achieve as an
outcome?
SMART Goals
6) Take Action ( 100 words)
What will you do here in the way
of care for the patient/individual?
7) Rationalise your nursing
action (300 words total)
Why have you chosen the actions
you want to do for the
patient/individual? With references
to support your rationales
First Nursing Problem
Acute pain associated with UTI.
One Nursing Goal –
Minimise pain sensation and
reduce pain intensity on pain scale
equal to or less than 3 through
assessing pain using PQRST
algorithm before and post
administration of pain medicines;
also implementing non-
pharmacological interventions,
within 3 weeks.
First action –
Observe and monitor both verbal
and non-verbal communications in
Mr. John. Ensure Mr. John
verbalising and reporting pain
immediately. Acknowledge, the
pain reporting by Mr. John and
report the same to the physician.
Rationale –
Patients with pain are usually not
eager to report or verbalise about
their pain. In such scenario,
information collected through non-
verbal communication can be more
beneficial for pain assessment.
Hence, necessary information can
be communicated to physician to
plan appropriate intervention for
pain management. Accurate
assessment and regular monitoring
are essential in patients with
persistent pain because it might
lead mental health issues such as
depression and anxiety. In
addition to this, accurate reporting
of pain would be helpful in
building positive therapeutic
relationship among patient and
healthcare professional (Duke,
Botti, and Hunter, 2012).
Second action – Rationale -
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Ensure Mr. John is consuming pain
medicines as per schedule and he is
adhering to the pain medicines
consumption. In addition to this,
evaluate and monitor safety and
efficacy of pain medicines. Safety
assessment should be performed
by observing patient and efficacy
should be evaluated through
PORST algorithm prior to and
after administration of pain
medicines.
Medicines for pain are useful in
reducing pain intensity and
sensation. Patients those who
consume multiple medicines,
usually do not exhibit adherence to
medicines consumption. Since,
assessment of pain using objective
parameter is complex; subjective
scale such as PQRST algorithm
should be used for the efficacy
assessment of pain medicines. It
has been reported that pain
medicines are associated with
multiple side effects including
psychological effects; hence, side
effects of these medicines should
be monitored (Pham et al., 2017).
Second Nursing Problem
Risk of fluid balance.
One Nursing Goal –
Ensue normovolumic condition
and minimise possibility of
hypovolemic and hypervolemic
condition by assessing fluid intake
and elimination of fluid; and to
maintain correct records on fluid-
balance chart; moreover, ensure
normalisation of fluid balance in 3
weeks time either through
administration of diuretic drugs or
administering appropriate
First action –
Both fluid balance chart and fluid
prescription chart should be
updated in timely manner. Data
related to quantity and schedule of
fluid and electrolyte administration
should be updated in timely
manner. Data related to urine
elimination should be entered in
these charts in timely manner.
Urine elimination record should be
updated for both quality and
Rationale –
Information available on the fluid
balance chart and fluid prescription
chart would be beneficial in
administration of accurate quantity
of fluid. Administration of
optimum amount of fluid would be
beneficial in minimising chances
of either hypovolemia or
hypervolemia development.
Information available on these
charts are also beneficial in
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electrolytes and water. quantity of urine. Information
collected for urine elimination
should be compared with reference
values of the patients of same age
group. Record and monitor body
weigh in timely manner.
selecting appropriate electrolytes.
Body weight is directly
proportional to fluid imbalance.
Fluid imbalance is attributable to
sudden or inappropriate change in
the body weight. Hence, fluid
imbalance can be effectively
monitored through monitoring
fluid imbalance (McGloin, 2015).
Second action –
Administer IV solutions such as
albumin, 0.9 % Nacl, dextran, and
lactated Ringer’s solution.
Rationale –
Plasma protein concentration
deficit can be effectively corrected
through administration of albumin
and dextran administration. Renal
clearance can be improved through
administration of 0.9 % Nacl
which is responsible for circulatory
improvement. Hypotonic solution
(0.45 % Nacl) is beneficial in
administering electrolytes and free
water to remove metabolic wastes
through renal excretion
(Pinnington, Ingleby, Hanumapura,
and Waring, 2016).
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8) Reflect on process and new learning (250 words)
Levett-Jones et al. (2014) mentioned reflection stage as the last step in clinical reasoning cycle. Reflection is useful in the assessment and review of
the clinical practice. Reflection step is beneficial in refining, changing and improving the process of clinical practice. In case of Mr. John, cognitive
behavioural therapy (CBT) can be beneficial in improving his clinical condition; since, he is associated with psychological issues. Mr. John could
have been provided with education about infection prevention. Education about infection prevention would be useful for him to prevent infection in
the future and it is an achievable goal which can be implemented even in the absence of healthcare professional. In future, I would like to involve
family members of patients with UTI. Hence, education about care of UTI patients to family members would be effective strategy. In addition to
this, quality of care can be effectively improved through providing collaborative work of family members and healthcare professionals. Moreover,
education about infection prevention should be provided to family members because they can play significant role in infection prevention. If I
would have experience of working on CBT; I would have used it in minimising anxiety and depression in Mr. John which mainly occurred in him
due to persistent pain. Improvement in Mr. John would have been effectively achieved through improving his adherence to multiple medication
consumption.
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Reference List
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Chuang, C.L. (2016). Fluid Management in Acute Kidney Injury. Contributions to Nephrology, 187, 84-93.
Coluzzi, F. (2018). Assessing and Treating Chronic Pain in Patients with End-Stage Renal Disease. Drugs, 78(14), 1459-1479.
Davies, H., Leslie, G.D., and Morgan, D. (2017). A retrospective review of fluid balance control in CRRT. Australian Critical Care, 30(6), 314-
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Pham, P.C., Khaing, K., Sievers, T.M., Pham, P.M., Miller, J.M., …Pham, P.T. (2017). 2017 update on pain management in patients with
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