Case Study: Nutrition / Sensory & Sleep Peter, a 55-year-old…

Case Study: Nutrition / Sensory & SleepPeter, a 55-year-old finance investor complaint of his inability to sleep over the past 3 years. A few weeks ago, he developed a sore throat lasting for 3 to 4 days, a headache for 2 weeks which was not resolving with Tylenol ES 2 tabs Q4 hours. Additional symptoms included feeling “chills and hot,” poor appetite, diarrhea x 3 days, an intermittent fever with a temperature of 40OC. He now has a persistent cough with episodes of difficulty breathing.Pet was assessed in ED and admitted with dehydration, delirium and pneumonia pending chest X-ray results. He tested positive for COVID-19.Vitals: T=38.7oC, RR = 18, BP=90/60mmHG, PR = 55 beats/min. Oxygen saturation is 92% and was put on O2 at 2L/min.Lab results: All normal with the exception of Hgb = 112, Na=144 and creatinine levels elevated.Medical History: HTN, hyperlipidemia, gout, kidney disease, right ventricle cardiomegaly (enlarged heart), osteoporosis, osteoarthritis, degenerative knee ligaments with chronic pain, anemia NYD and anxiety. He has a history of insomnia complicated by her chronic anxiety.Medications:Allopurinol 200mg 1 tab dailyAtenolol 50 mg 1 tab dailyPerindopril 8 mg 1 tab dailyActonel 1 tab PO on Sundays onlyDuring the 4-week hospital stay, Peter had COVID-19 delirium resulting to his inability to eat his meals. His taste buds were impacted from the virus and disliked the hospital food. He is also challenged with keeping his fluids and is now at risk for malnutrition and dehydration. An IV of NS at 50cc/hr via PIV was started due to his creatinine levels increasing. With his history of kidney disease, he is at high risks for developing renal failure.Peter had difficulty sleeping due to the hospital environment. He experiences about 3 to 5 awakenings every night. With each awakening, he needs at least 30 minutes to fall asleep again.Further assessment by the health care team indicated that Peter has continuously complained of “feeling tired, unable to concentrate on certain tasks at home and work.” Upon discussion with his daughter, it was determined that the sleeplessness and sleepiness has been an ongoing issue for approximately 8 months.His daughter reported that over the past 5 months, sleep and daytime fatigue have increased in severity and frequency. Peter now wakes up three or more times per night at least 5 nights per week, and on most nights has difficulty falling asleep (takes hisabout 40 minutes to an hour). He has tried to maintain an active social but observed hismother to have increased irritability and lack of motivation.Peter has always been a poor sleeper during times of stress, but nearly always improved after a few days. For this reason, he had insomnia and had, on occasion, taken over-the-counter medications. He also notes an increase in his caffeine intake (4 cups of coffee and 1-3 diet colas per day) when at home.Further assessment with Peter indicates that there are episode of daytime fatigue and admits that he is unable to concentrate at work. This is worrisome for Peter as deals with reputable clients with large investments. In order to stay awake during work, Tim Horton or Starbucks are his frequent stops for some coffee break. He admits of having at least 5 to 6 cups of coffee during his work. Peter is very concern that he will lose his clients if they find out he has difficulty concentrating and processing tasks at work.As bedtime approaches, he becomes very tense and worries about the prospect of another sleepless night. “Sleep has become a real frustration. Every night, when I lie in bed, I have to try very hard to sleep. I keep watching the clock”. His daughtercomplained that she, too, was sleeping poorly because she was disturbed by her father’s restlessness. Plagiarism Free Papers
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