Client info: 50-year-old African American male
[Age/Gender/Ethnicity] [Religious Affiliation]
Hospital Day: 05/16/22
Diet: Renal
Post-op Day: 05/17/22
Admitting Diagnosis: Acute flank pain
Co-Morbidities: End stage renal disease, anemia, hypertension, anxiety, chronic kidney disease, depression
Erickson’s Developmental Stage: Generativity vs. Stagnation
Physical Head-To-Toe Assessment: highlight any abnormal findings
HT:
188 cm
EENT
Cardiovascular
Pulmonary
Gastrointestinal
GU
Extremities
Integumentary
WT: 134 KG
EYES: PERRLA, no ptosis, no yellowing of
sclera, no redness, no swelling
BMI:
38.07
Nose: NC within nares, mucous
membranes moist, no lesions, no
septum deviation
EARS: no lesions, no swelling, no foreign
Mouth/Throat: dry mucous membranes,
object
no lesions, no exudate
Heart sounds: within defined limits, no S3, S4, or murmurs, regular rhythm with
tachycardia
Neck vessels: no JVD
Peripheral vascular: +1 edema in all extremities bilaterally
Lymph systems: no lymphadenopathy
Thorax: symmetrical, no barrel chest
Breath sounds: clear breath sounds, no wheezing, no retractions, slight dry cough, no
congestion
Respiratory rate/ description: 18
O2 saturations: 97% on nasal cannula
Inspection: rounded, no scars or lesions
Auscultation: hypoactive bowel sounds
Palpation: generalized tenderness in all quadrants
Gender: male
Upper extremities
Musculoskeletal
FROM, strength 5 / 5
Neurological
general weakness, strength 4 / 5
Lower extremities
Musculoskeletal
FROM, strength 5 / 5
Neurological
general weakness, strength 4 / 5
Skin
+1 edema bilaterally all extremities, AV fistula and IV in RUE,
surgical staples between L3 and L5, warm, dry, intact other than
incisions
Hair
no hair on scalp, otherwise evenly distributed
Nails
Additional data:
pink, no clubbing
patient is A&ox4, obese, agitated, and untidy.
Pathophysiology of condition/disease process:
Chronic kidney disease: Irreversible kidney damage that prevents the kidneys from filtering the blood of toxins
effectively. if progressed far enough, patient may need dialysis to survive. Risk factors include diabetes, high
blood pressure, heart disease, and family history.
Laboratory Values: (include latest value by date and value; highlight any abnormal values; to include if
available in parentheses; previous value/date of the previous value.
CBC w/diff
DOA
Date:
05/14/22
WBC
6.38
RBC
3.22 L
Hgb
10.4 L
Hct
32.7 L
RDW%
64.4 H
Neutrophils
63.1
Lymphocytes 19.0 L
Monocyte
12.1 H
Eosinophil
4.7
Basophil
0.3
Immature
0.8
granulocyte
Date:
05/16/22
Date:
05/18/22
7.26
3.40 L
10.8 L
33.7 L
63.4 H
58.7
23.6 L
12.3 H
4.3
0.4
0.7
8.91
3.14 L
9.9 L
31.8 L
66.1 H
72.8 H
9.8 L
15.9 H
0.9
0.2
0.4
Renal Serum
DOA
Date:
Date:
05/13/22
Creatinine
Urea
Total protein
Albumin
Uric Male
acid Female
Phosphate
Calcium
Bicarbonate
Potassium
Sodium
8.85 H
7.6
3.5
8.5 H
9.0
5.1
140
Date:
Electrolytes DOA
Date:
05/14/22
Sodium
140
Potassium
5.7 H
Chloride
99
Calcium
9.2
Magnesium
Phosphorus
BUN
55H
Creatinine
10.84 H
Renal
Urine
(per 24
hours)
NA
DOA
Date:
Date:
05/16/22
Date:
140
5.1 H
100
9.0
2.6
8.5 H
41 H
8.85 H
Date:
Date:
[Any other labs that were performed for example cardiac enzymes, blood cultures, etc.]
urinalysis: glucose 2+, protein 3+, leukocyte esterase small, WBC 18
Nursing Diagnosis #2: Ineffective Gas Exchange
R/T: Noncompliance, opioid treatment
AEB: Restlessness, dyspnea, and dropping SATs upon removal
Short term Goal: Patient will verbalize understanding of oxygen therapy by the end of the 12 hour shift.
Long term Goal: Patient will be able to reestablish normal to baseline respiratory function by the end of
hospital stay.
Interventions: minimum of (4)
-
Monitor oxygen saturation continuously, using a pulse oximeter.
Position patient with the head of the bed elevated in a semi-Fowler’s position as tolerated.
Provide adequate education on the importance of oxygen therapy.
Monitor the effects of sedation and analgesics on the patient’s respiratory pattern.
Evaluation of Goal: Patient consistently asking for pain medication. Patient instructed that excessive use will
lead to respiratory failure. Patient insisted and nurse was given permission to administer one more dose. Upon
re-evaluation, patient’s SATs were dropping below 93% as the NC was no longer in the nares. Patient strictly
instructed to keep cannula on and was educated about the importance of oxygen therapy. Patient verbalized
understanding that he cannot have Vancomycin and Promethazine simultaneously and will not be allowed to
have another dose until 6 more hours. Patient goal partially met.
Nursing Diagnosis #2: Acute pain
R/T: Lumbar spine surgery
AEB: Reporting pain (no physical signs)
Short term Goal: Patient will be able to control pain by the end of the 12 hour shift.
Long term Goal: Patient will be able to go back to his baseline (no or minimal pain) after 4-6 weeks.
Interventions: minimum of (4)
-
Review expected manifestations and changes in the intensity of pain.
Assess intensity, description, location, radiation of pain, changes in sensation. Instruct in use of rating
scale (0-10).
Instruct patient and assist with patient-controlled analgesia (PCA).
Demonstrate and encourage the use of relaxation skills like deep breathing.
Evaluation of Goal: Patient continuously asking for pain medication even after being educated about the
adverse effects of taking medications simultaneously. Patient exhibiting no visible signs of being in pain but
insisting on pain and nausea medication. Patient goal not met.
Nursing Diagnosis #3: Risk for trauma
R/T: temporary weakness of spine
AEB: Possible orthostatic hypotension and/or weakness
Short term Goal: Patient will be able to recognize the need four and seek assistance with activity as
appropriate.
Long term Goal: Patient will be able to maintain proper alignment of the spine and reestablish baseline within
four to six weeks.
Interventions: minimum of (4)
-
Apply lumbar brace or cervical collar as appropriate.
Avoid sudden stretching, twisting, flexing, or jarring of spine.
Check blood pressure; Note reports of dizziness or weakness. Recommend patient change position
slowly.
Have patient wear fall prevention socks when ambulating.
Evaluation of Goal: Patient got up to use the bathroom without notifying the nurse and was immediately
educated to call the nurse before getting up for anything. Patient was able to call the nurse anytime he needed to
get up throughout the rest of the day. Patient goal met.
Diagnostic Procedures Performed:
(include latest value by date and value; highlight any abnormal values; to include if available in parenthesis;
previous value/date of the previous value.)
[Any other procedures performed during admission assessment to include procedures done in clinics leading up
to admission and any other procedures done while hospitalized.]
Procedure Date
CXR
CT Scan
CT lumbar spine without contrast – 05/13/22
Findings
Normal lordosis, L5 to S1.
Laminectomy changes L2 to
L5 period post operative
scarring. Kidneys show cysts
laterally. Stable post-op
decompressive changes with
no acute osseous
abnormalities. Prominent soft
tissue narrowing at L4 and L5
EKG
MRI
(list other
procedure)
Psychosocial: highlight any identified concerns
Marital status: Married
Educational status: NA
Employment status: NA
Living arrangements: Own home
Additional issues/areas of concerns identified: NA
Scheduled Medications: (to include any IVF and rate of delivery) List name of medication and dose and
schedule time to be given.
Medication
Dose
Route
Time
Indication
Clonidine
0.2 MG
PO
9:00 AM
Blood pressure
Hydralazine
100MG
PO
9:00 AM
Blood pressure
Sertraline
25MG
PO
9:00 AM
Anxiety, depression
Sevelamer
1600
MG
PO
Not given
Food binder
10ML
IV
9:00 AM
Hydration & laxative
0.4 MG
PO
4:00 PM
BPH
sodium
chloride
Tamsulosin
Other
PRN Medications:
Medication
Acetaminophen
Diazepam
Hydrocodone
Hydroxyzine
Promethazine
Dose
Route
Indication
500MG PO
Fever greater than 100.5
5MG
PO
Anxiety
10-325
PO
25MG
PO
Itching, allergic reaction
12.5
MG
IV
Nausea/vomiting
Pain 7-10
Other
Naloxone
0.4 MG IV
Opioid reversal
Discharge Planning:
List which interdisciplinary teams and consults would need to be initiated in order for the patient to be
discharged home. Along with community services consults that should be initiated.
Doctor states patient needs to be discontinued from PCA pump to oral pain medications. Patient scheduled to be
discharged tomorrow but doesn't seem likely due to consistent requests for pain medication. Nephrologist also
needs to be consulted to clear patient before discharge.
References
Ackley, B. J., Ladwig, G. B., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis
handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes (9th ed.).
Elsevier.