UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Shawn Hekkanen |

|Patient Assessment Tool . |Assignment Date: 10/29/2015 |

| ( 1 PATIENT INFORMATION |Agency: TGH - SBN |

|Patient Initials: XXX |Age: 34 |Admission Date: xx/xx/2015 |

|Gender: male |Marital Status: married 14 years |Primary Medical Diagnosis with ICD-10 code: |

| | |Kidney replaced by transplant (V42.0) |

|Primary Language: English | |

|Level of Education: AA Business Administration |Other Medical Diagnoses: (new on this admission) |

| |Kidney Transplant Status (Z94.0) |

|Occupation (if retired, what from?): security guard (currently legally disabled, | |

|SSI/SSDI/Medicaid) | |

|Number/ages children/siblings: son-11 y.o.; daughter – 2 y.o. | |

|3 sisters – 36 y.o., 25 y.o, 18 y.o. | |

|2 brothers – 34 y.o., 15 y.o. | |

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|Served/Veteran: none |Code Status: Full Code |

|Living Arrangements: live with wife & 2 kids in a single story 1,400 square foot home, with |Advanced Directives: none |

|two car garage and front door/backdoor. Small step up at front door and 3 steps up to back |If no, do they want to fill them out? refused |

|door. Metal gate around house. | |

| |Surgery Date: 10/28/2015 |

| |Procedure: kidney transplant |

|Culture/ Ethnicity /Nationality: African American | |

|Religion: “Christianity” (general) |Type of Insurance: Medicaid |

|( 1 CHIEF COMPLAINT: |

|“I have been on dialysis for two years, Monday, Wednesday and Friday. I am here for a kidney transplant from a donor match.” |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |

|Patient is a 34 year old male admitted 10/27/2015, for kidney transplantation on 10/28/2015. Last hemodialysis was on 10/26/2015. He has a left upper arm |

|arteriovenous fistula for hemodialysis scheduled for Mondays, Wednesdays, and Fridays. Pre-transplant workup included abdominal computerized tomography (CT) scan,|

|CT chest, echocardiogram, prostate-specific antigen (PSA) test, and follow-up chest x-ray. On 10/14/2013, the abdominal CT revealed small bilateral pleural |

|effusions, atrophic kidney, a renal cyst pelvic ascites, and anasarca. On 5/13/2014, the chest CT revealed a non-calcified subpleural nodule in right upper lobe, |

|with small right pleural effusion and pulmonary vascular congestion. There was also a pericardial effusion, indications of anemia, and confirmation of anasarca. |

|On 2/12/2015, the echocardiogram revealed moderate left ventricular hypertrophy, with ejection fraction of 55-60%, with grade 1 diastolic dysfunction. The PSA |

|test was normal. Also on 2/12/2015, the chest x-ray revealed an average size cardiomediastinal area with lungs that expand and aerate well, as well as no acute |

|cardiopulmonary findings. The vascular stent grafts placed in 1990 project at the left upper thorax. No other abnormalities were found in the tests. |

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|Chronic kidney disease was originally diagnosed in patient’s 20’s and hemodialysis first began in 2006. Patient reports that doctors told him that burns suffered |

|from a house fire in 1990 stressed his kidneys, leading to Focal Segmental Glomerulosclerosis (FSGS) and related anemia. It is unknown if patient report is |

|accurate. Burns are to multiple sites, including forearms and back. The burns Burns are to an unspecified degree, and patient was in a coma. Due to thoracic |

|empyema, he required chest tube drainage. His first Deceased Donor Kidney Transplantation (DDKT) occurred in January 2011. Kidney was from a 29-year old female. |

|His first pre-transplant workup revealed cardiomyopathy and hematuria, with a negative bladder biopsy. At least five episodes of acute rejection resulted in |

|hospitalizations, culminated into transplant nephrectomy in February 2014. Most recent diagnosis of Stage V chronic kidney disease (CKD) has been diagnosed since |

|1/2014, requiring chronic dialysis. Last dialysis was 10/26/2015, a day before surgery. He has had anuria since 1/2014. Evaluation for another transplant began |

|in March 2014. Social work clearance was completed 10/2014. Financial clearance was completed 2/2015. Kidney transplant operation occurred on 10/28/2015, and |

|donor was a nine-year old female, who died of a head injury. |

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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation

|Date |Operation or Illness |

|1/1990 |Skin graft r/t burn |

|1/1990 |Cardiac catheterization, multiple stents |

|5/2005 |Inguinal Hernia repair |

|2006 |Chronic Kidney Disease diagnosed by Focal Segmental Glomerulosclerosis (FCGS). |

| |AV fistula Left Upper Arm. Started hemodialysis. |

|4/2007 |Cholecystectomy |

|2009 |AV fistula Left Upper Arm repair |

|1/21/2011 |1st Deceased Donor Kidney Transplantation (DDKT) |

| |Bladder biopsy for hematuria and part of pretransplant workup - negative |

|10/14/2013 |Abdominal CT – atrophied native kidney |

|2/2014 |Nephrectomy after multiple rejections |

|3/2014 |Chest x-ray 6mm subpleural RUL nodules nonspecific |

|10/28/2015 |2nd DDKT- left abdomen |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |Patient’s father is diagnosed with heart disease, HTN, and diabetes Type II. No other known health issues of family were reported or recorded in chart. |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date) 2010 | | |

|Adult Tetanus (Date) 2010 | | |

|Influenza (flu) (Date) 10/8/2015 | | |

|Pneumococcal (pneumonia) (Date) 2010 | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | | |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |morphine |Swelling in tongue and throat |

| |penicillins |Swelling in tongue and throat |

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|Other (food, tape, latex, dye, |Lactose intolerant |Diarrhea, cramping |

|etc.) | | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment) |

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|Chronic kidney disease (CKD) is indicated by progressively deteriorating kidney function, as noted by declining glomerular filtration rate (Huether & McCance, |

|2012). There are five stages of chronic kidney disease. This patient was diagnosed with end-stage kidney disease, stage V. Symptoms include hypertension, increased|

|creatinine level, increased urea level, erythropoietin deficiency anemia, hyperphosphatemia, increased triglycerides, metabolic acidosis, hyperkalemia, salt |

|retention, and water retention (Huether & McCance, 2012). Compensatory glomerular increased filtration, hypertrophy, and hypertension of malfunctioning excretion |

|increases glomerulosclerosis, tubular inflammation, tubular remodeling to fibrosis, and uremia. Proteinuria is caused by hypertension and increased capillary |

|permeability, as there is a heightened angiotensin II response with progressive nephron injury, thus damaging remaining working nephrons. Related clinic findings |

|may include bone fractures, pulmonary edema, kussmaul respirations, left ventricular hypertrophy and other cardiomyopathy, hypertension, artherosclerosis, |

|pericarditis, encephalopathy, loss of muscle mass, loss of motor function, anemia, platelet disorders, anorexia, nausea, vomiting, gastrointestinal bleeding, |

|peptic ulcers, pancreatitis, itching, abnormal pigmentation, increased infections, increased risk of cancer, and sexual dysfunction. This patient has a history of |

|pulmonary edema, left ventricular hypertrophy, and anemia (Huether & McCance, 2012). Fluid and electrolytes are imbalanced, especially sodium and potassium, which |

|are primarily excreted by the urine. Phosphate is also increased as serum calcium is decreased, which causes alterations in bone. Patients with CKD should be |

|watched for the development of diabetes mellitus, which can result in prolonged half-life of insulin. Evaluation is based upon a patient history, presenting signs |

|and symptoms, elevated blood urea nitrogen (BUN), elevated creatinine, and urinalysis. To reveal atrophic kidney, tests may include an ultrasound, CT scan, or |

|x-ray. Renal biopsy will confirm diagnosis. |

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|Focal segmental glomerulosclerosis involves fibrous tissue that has scarred the filtration passages within glomeruli of the kidney (Huether & McCance, 2012). There|

|is a genetic component and African Americans are most often affected (Huether & McCance, 2012). This patient is African American. The condition may also be caused |

|by an infection, which was likely to have occurred when patient was burned in 1990. The condition is also related to hydronephrosis, obesity, sickle cell disease, |

|heroin use, bisphosphonates use, and anabolic steroids use. Symptoms include proteinuria, decreased appetite, generalized edema, and weight gain. Diagnostic |

|evaluations include kidney biopsy, urinalysis, urine microscopy, blood and urine kidney function tests, and protein in the urine without after ruling out diabetes |

|(Huether & McCance, 2012). Treatments include medications that suppress inflammation, lower blood pressure, diuretics, lower cholesterol, lower triglycerides, |

|antibiotics for infections, and vitamin D supplementation (Huether & McCance, 2012). A low sodium, low fat, low potassium, restricted fluid, and low protein diet |

|should be used. Recommended daily protein is one gram of protein per kilogram of body weight. Fluid restriction and dialysis three days per week are regularly |

|used. Most patients are diagnosed with chronic kidney disease within ten years. This patient received his first kidney transplant after five years of dialysis, |

|starting in 2006. |

( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]

|Name: Normal Saline (sodium chloride) |Concentration 0.9% (9mg/mL) |Dosage Amount 1000mL per bag |

|Route: IV |Frequency: continuous (120mL/hr) |

|Pharmaceutical class: mineral/electrolyte replacement |Home Hospital or Both |

|Indication: A priming fluid for hemodialysis. Hydration and normalize serum sodium and chloride levels. Aid to stabilize hemodynamics and exhibit pressure on the |

|transplanted kidney to perfuse and filter urine. |

|Side effects/Nursing considerations: Pulmonary edema, edema, hypernatremia, hyponatremia, hypokalemia. Assess for fluid retention, lung crackles, hypertension, |

|daily weight. Monitor I & O. Assess for fever, flushed skin, mental irritability. |

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|Name Famotidine (PEPCID) |Concentration 0.4mg/mL (as calculated) |Dosage Amount 20mg (50mL) |

|Route IV |Frequency twice daily |

|Pharmaceutical class: histamine h2 antagonists |Home Hospital or Both |

|Indication: Prevention of stress induced upper GI bleeding and stress ulcers. Prevention of aspiration by prophylactic treatment of heartburn, acid indigestion, |

|and sour stomach. Prophylaxis for GERD and peptic ulcer disease. |

|Side effects/Nursing considerations: Confusion, dizziness, drowsiness, headache, constipation, diarrhea, nausea, gynecomastia, agranulocytosis, aplastic anemia, |

|arrhythmias. Assess for abdominal pain and tenderness. Monitor CBC. May cause false negatives for allergens and may cause false positive for urine protein. |

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|Name HYRDROmorphone (DILAUDID) |Concentration 0.2mg/mL |Dosage Amount |

| | |Basal dose: no basal rate; |

| | |PCA dose: 0.2mg (1mL) |

|Route IV |Frequency bolus available q10min |

|Pharmaceutical class opioid analgesic |Home Hospital or Both |

|Indication Moderate to severe pain. |

|Side effects/Nursing considerations: Confusion, dizziness, constipation, sedation, blurred vision, double vision, headache, unusual dreams, hallucinations, |

|urinary retention, hypotension, bradycardia, dry mouth, tolerance, physical/psychological dependence. Assess vital signs periodically during administration, If |

|respirations less than 10 then consider decreased dose. Auscultate bowel function and increase fluids for constipation. Assess cough/lung sounds. Heightened fall |

|risk. |

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|Name methylprednisolone sodium succinate (SOLU-MEDROL) |Concentration 125mg/2mL |Dosage Amount 1.6 mL (100mg) |

|Route IV |Frequency once (1104) |

|Pharmaceutical class corticosteroids |Home Hospital or Both |

|Indication: Immunosuppressant for kidney transplant. |

|Side effects/Nursing considerations: Depression, euphoria, fever, infection, peptic ulceration, anorexia, vomiting, headache, personality changes, restlessness, |

|fluid retention, and thromboembolism. Assess for restlessness and fluid retention in extremities and lung sounds. Monitor I&O. Monitor serum electrolytes & |

|glucose. |

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|Name mycophenolate (CELLCEPT) |Concentration 1,0000mg in dextrose 5% 250mg |Dosage Amount 1000mg (250mL) |

|Route IV piggyback |Frequency every 12 hours at 125mL/hr (2 hour infusion time) |

|Pharmaceutical class immunosuppressant |Home Hospital or Both |

|Indication Immunosuppressant for kidney transplant. |

|Side effects/Nursing considerations: progressive multifocal leukoencephalopathy, GI bleed, edema, fever, infection, cough, dyspnea, cough, dizziness, headache, |

|paresthesia, hyperglycemia, hyperkalemia, hypocalcemia, hypokalemia, hypomagnesemia, anorexia, hypertension, hypotension, tachycardia, renal dysfunction. |

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|Name senna docusate (SENOKOT-S) 8.6-50mg |Concentration |Dosage Amount one tablet |

| |8.6mg sennosides |8.6mg sennosides |

| |50mg docusate |50mg docusate |

|Route oral |Frequency twice daily |

|Pharmaceutical class stimulant laxative; stool softener |Home Hospital or Both |

|Indication: Treatment of constipation/constipating drugs. Reduce intra-abdominal pressure and strain after surgery. |

|Side effects/Nursing considerations: cramping, diarrhea, nausea, discoloration of urine, electrolyte abnormalities, laxative dependence. Assess for abdominal |

|distension, ausculate bowel sounds before palpation, assess COCA of stool, assess pattern of bowel function. |

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|Name sodium bicarbonate |Concentration 25mEqNaHCO3 in 0.45% sodium chloride |Dosage Amount titrated |

|Route IV |Frequency continuous; titrate dosage q hourly, 1mL medication= 1mL urine |

| |output until urine output reaches 1000mL then 3/4 mL medication = 1mL urine |

| |output |

|Pharmaceutical class alkalinizing agent |Home Hospital or Both |

|Indication Used to alkaline urine and promote excretion of less acidic metabolites. Lower acidity of urine. Correct acid-base balance. Decrease gastric |

|discomfort. |

|Side effects/Nursing considerations Edema, flatulence, gastric distension, metabolic alkalosis, hypernatremia, hypocalcemia, hypokalemia, sodium/water |

|retention, tetany, cerebral hemorrhage. Notify nephrologist if urine output less than 50mL/hr. |

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|Name sulfamethoxazole-trimethoprim (BACTRIM, SEPTRA) |Concentration: |Dosage Amount: 1 tablet |

| |Sulfamethoxazole 400mg |Sulfamethoxazole 400mg |

| |Trimethoprim 80mg |Trimethoprim 80mg |

|Route oral |Frequency one tablet q Monday, Wednesday, Friday |

|Pharmaceutical class folate antagnonists; sulfoamides |Home Hospital or Both |

|Indication Prevention of bacterial infections in immunosuppressed patients. |

|Side effects/Nursing considerations Hypotension, fatigue, hallucinations, headache, insomnia, psych depression, hyperkalemia, hyponatremia, pseudomembranous |

|colitis, hypoglycemia, stevens-johnson syndrome, agranulocytosis, anemia, crystalluria, thrombocytopenia, leukopenia. Assess for infection with vital signs and all|

|wounds. Monitor I & O. Monitor bowel function. Assess for rash. |

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|Name valGANciclovir (VALCYTE) |Concentration 450mg/tablet |Dosage Amount 1 tablet |

|Route oral |Frequency q Monday, Wednesday, Friday |

|Pharmaceutical class antivirals |Home Hospital or Both |

|Indication Prevention of cytomegalovirus with transplant patients, such as heart, kidney, pancreas. |

|Side effects/Nursing considerations seizures, headache, neutropenia, thrombocytopenia, ataxia, paresthesia, abdominal pain/diarrhea, anemia. Take with food. Do |

|not break or crush. CMV is diagnosed by ophthalmoscopy for gold standard and cultured blood, urine. Assess for infection with signs in throat, dysuria, fever, |

|chills, back pain. Assess for dental bleeding and bruising. Avoid IM and rectal temperatures. |

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|Name albuterol nebulizer |Concentration 5mg/1mL |Dosage Amount 10mg (2mL) |

|Route aerosol |Frequency once 0315 today |

|Pharmaceutical class: |Home Hospital or Both |

|Indication: Treatment of hyperkalemia. By MAR, 4 doses before dilution for treatment of hyperkalemia. |

|Side effects/Nursing considerations: nervousness, restlessness, headache, paradoxical bronchospasm, chest pain, nausea, vomiting, hyperglycemia, hypokalemia, |

|insomnia, hypertension, arrhythmias. Assess lung sounds and vital signs before and after, especially paradoxical wheezing. Lower potassium serum concentration is |

|transient until excretion of higher than normal potassium levels. |

|Name alemtuzumab (CAMPATH) |Concentration 30mg /100mL in 0.9%NS |Dosage Amount 30mg |

|Route IV |Frequency once 0923 |

|Pharmaceutical class monoclonal antibodies |Home Hospital or Both |

|Indication Used as a accelerator/catalyst for immunosuppression for kidney transplant. |

|Side effects/Nursing considerations; depression, dizziness, drowsiness, weakness, abdominal pain, HTN, hypotension, headache, tachycardia, constipation, |

|stomatitis, sweating, rash, edema, neutropenia, marrow hypoplasia, anemia, back/skeletal pain, infection. Monitor for infusion reactions such as hypotension, |

|shortness of breath, bronchospasm, chills, and rash. Pre-medicate with oral antihistamine prior to initial dose and dose changes. CBC and platelet counts at least |

|weekly. Assess CD4 counts to stay greater than 200 cells/mm3. Inspect solution for clarity, color, and expiration. Medication prone to patient injury. |

|Name dextrose 50% IV syringe |Concentration 50g/100mL (50,000mg/100mL) |Dosage Amount 25g (50mL), (25,000mg) |

|Route IV |Frequency once 0307 |

|Pharmaceutical class carbohydrates |Home Hospital or Both |

|Indication Provides hydration and calories while patient is NPO after surgery. To start on clear liquids today. Given prior to insulin for treatment of |

|hyperkalemia. Hyperkalemia due to impaired urinary elimination after kidney transplant |

|Side effects/Nursing considerations: Fluid overload, hypokalemia, hypomagnesemia, hypophosphatemia, glycosuria, hyperglycemia. Assess hydration status before |

|administration. Monitor I&O, electrolytes. Assess for hyperglycemia and patient response. |

|Name insulin aspart (NOVOLOG) |Concentration 100units/1mL |Dosage Amount 2-10 units |

|Route subcutaneous injection |Frequency up to three times daily with food and bedtime |

|Pharmaceutical class pancreatics |Home Hospital or Both |

|Indication Tight glucose control for hyperglycemia to aid recovery after kidney transplant. Sliding scale starting at blood sugar 150mg/dL and add 2 units for |

|every increase +50mg/dL blood sugar until max of 10units. |

|Side effects/Nursing considerations Assess for hypoglycemia symptoms, such as sweating, pale skin, tachycardia, anxiety, headache, tingling, restlessness. For |

|blood sugar below 60mg/dL, repeat accu chek. If patient still below 60mg/dL blood sugar, while patient NPO, give D50W 50mL as IV push. Retest BG in 15minutes, |

|retreat as necessary, retest q 1-2hours. Monitor body weight. |

|Name insulin regular (HUMILIN R, NOVOLIN R) injection 10 |Concentration 0.5-1unit/1mL for IV push |Dosage Amount 10units |

|units | | |

|Route IV |Frequency once 0307 |

|Pharmaceutical class pancreatics |Home Hospital or Both |

|Indication Treatment of hyperkalemia for temporary reduction by uptake into cells, thus reduction of serum potassium. |

|Side effects/Nursing considerations: Assess for hypoglycemia symptoms, such as sweating, pale skin, tachycardia, anxiety, headache, tingling, restlessness. For |

|blood sugar below 60mg/dL, repeat accu chek. If patient still below 60mg/dL blood sugar, while patient NPO, give D50W 50mL as IV push. Retest BG in 15minutes, |

|retreat as necessary, retest q 1-2hours. Monitor body weight. |

|Name fentanyl (SUBLIMAZE) |Concentration 50mcg/1 mL (50,000mg/1mL) |Dosage Amount 50mcg (50,000mg) |

|Route IV |Frequency q5minutes PRN |

|Pharmaceutical class opioid agonist |Home Hospital or Both |

|Indication Post operative analgesia for acute pain. Use if Dilaudid is ineffective or contraindicated, for severe pain 7-10. |

|Side effects/Nursing considerations: confusion, blurred/double vision, apnea, respiratory depression, hypotension, arrhythmias, facial itching, muscle rigidity, |

|n/v, laryngospasm, drowsiness, circulatory depression, bradycardia. Monitor vital signs, especially respiratory depression. Heightened fall risk. May cause |

|increased lab values of amylase and lipase |

|Name hydrALAZINE (APRESOLINE) |Concentration 20mg/1mL |Dosage Amount 5mg (0.25mL) |

|Route IV |Frequency q 4hours PRN, repeat if SBP goal not met up to 4 doses. |

|Pharmaceutical class vasodilator |Home Hospital or Both |

|Indication For treatment of moderate to severe hypertension, SBP greater than 160. |

|Side effects/Nursing considerations: hypotension, n/v, diarrhea, sodium retention, tachycardia, angina, dizziness, headache, rash, joint pain, orthostatic |

|hypotension. Heightened fall risk. Monitor vital signs. Monitor CBC and electrolytes. Assess feet and ankles for fluid retention. |

|Name furosemide (LASIX) in 0.9%NS 50mL |Concentration 125mg/50mL (2.5mg/mL) |Dosage Amount 125mg(50mL) |

|Route IV |Frequency once 0300 |

|Pharmaceutical class loop diuretic |Home Hospital or Both |

|Indication Relief of edema and hypertension due to renal disease. |

|Side effects/Nursing considerations: orthostatic hypertension, blurred vision, headache, anorexia, constipation, n/v, excessive urination, stevens-johnson |

|syndrome, itching, rash, hives, anemia, agranulocytosis, muscle cramps, paresthesia, hypokalemia, hypovolemia, metabolic alkalosis, higher BUN, hyperglycemia. |

|Assess fluid status. Monitor weight, I&O, lung sounds, mucous membranes, turgor, vital signs. Heightened fall risk when transferring, do with staff assistance. |

|Take rests in between lying, sitting, standing. |

|Name labetalol (NORMODYNE) |Concentration 5mg/1mL |Dosage Amount 5mg (1mL) |

|Route IV |Frequency q5min PRN, repeat if goal not met for maximum of 4 doses. |

|Pharmaceutical class beta blocker |Home Hospital or Both |

|Indication Treatment of hypertension, SBP greater than 160 with HR greater than 60. |

|Side effects/Nursing considerations: fatigue, weakness, anxiety, drowsiness, hypotension, bradycardia, wheezing, arrhythmias, pulmonary edema, CHF, constipation, |

|hyperglycemia, hypoglycemia, joint pain, back pain, hyperglycemia, muscle cramps/tingling, blurred vision, dry eye, mental status changes. Monitor vital signs |

|before administration, goal is SBP less than 160, hold if heart rate lower than 60. Monitor fluid overload, I&O, edema, dyspnea, weight gain, JVP. Glucagon used to|

|treat bradycardia and hypotension. Notify provider if max of 4 doses does not meet SBP goal or if held before goal due to HR. |

|Name metoclopramide HCl (REGLAN) |Concentration 5mg/1mL |Dosage Amount 5mg (1mL) |

|Route IV |Frequency q 6 hours PRN |

|Pharmaceutical class antiemetic |Home Hospital or Both |

|Indication If Zofran is ineffective for nausea and/or vomiting. Prevention of aspiration. |

|Side effects/Nursing considerations. Drowsiness, EPS, neuroleptic malignant syndrome, anxiety, depression, HTN, hypotension, arrhythmias, constipation, diarrhea,|

|gynecomastia, agranulocytosis, neutropenia. Assess for abdominal distension, bowel sounds before and after administration, vital signs, too. May raise serum |

|prolactin and aldosterone(sodium retention, thus fluid retention, thus higher BP). |

|Name metroprolol (LOPRESSOR) |Concentration 1mg/mL |Dosage Amount 5mg (5mL) |

|Route IV |Frequency q6 hours PRN |

|Pharmaceutical class beta blocker |Home Hospital or Both |

|Indication Treatment of HTN with SBP above 180mmHg or DBP above 100mmHg, prevention of MI due to lack of circulatory flow related to increased vascular |

|resistance. |

|Side effects/Nursing considerations: fatigue, weakness, anxiety, depression, bradycardia, pulmonary edema, heart failure, blurred vision, stuffy nose, |

|constipation, dry mouth, flatulence, heartburn, increased liver enzymes, hyperglycemia, hypoglycemia, joint pain. Monitor vital signs before, after therapy. |

|Monitor fluid retention by I&O, daily weights, lung sounds, JVP, edema. Hold for heart rate below 60bpm and place on telemetry |

|Name ondansetron (ZOFRAN) |Concentration 4mg/2mL |Dosage Amount 2mL |

|Route Intravenous |Frequency PRN every 6 hours |

|Pharmaceutical class five ht3 antagonist |Home Hospital or Both |

|Indication Prevention of nausea and vomiting , after kidney transplant. Prevention of aspiration/pnemonia |

|Side effects/Nursing considerations: Headache, dizziness, weakness, constipation, creation of torsade de pointes arrhythmia, EPS, abdominal pain, dry mouth, |

|increased liver enzymes, hypokalemia, hypomagnesemia, bradycardia. Single dose IV over 2-5 minutes as undiluted solution. May cause transient increase in serum |

|bilirubin, AST, ALT. |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? |Analysis of home diet (Compare to “My Plate” and |

|NPO morning and switched to clear liquid this shift | |

|Diet pt follows at home? Was a low protein, low sodium, low saturated fat diet |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: |Patient’s grains intake is 31% of his recommended daily value. His intake is 3.1 |

| |oz eq of the recommended 10oz equivalents. Patient’s vegetables intake is 19% of |

| |his recommended daily value. His intake is 0.7cup equivalents of the recommended|

| |3.5 cup equivalents. Patient’s fruit intake, due to drinking apple and orange |

| |juice, is 119% of his recommended daily value. His intake is 3.0 cup equivalents |

| |of the recommended 2.5 cup equivalents. Patient’s dairy intake is 18% of the |

| |recommended daily value. His intake is 0.5cup equivalents of the recommended 3.0 |

| |cup equivalents. His protein intake is 284% of the recommended daily value. His |

| |intake is 19oz eq of the recommended 7.0oz equivalents. The patient probably |

| |inaccurately reported his daily intake, and probably instead stated his ideal |

| |daily menu. Patient was on a low protein, low sodium diet. The stated daily |

| |intake of protein would not be acceptable. Within his culture, he can stick to |

| |the New Orleans jambalaya and eliminate the turkey sandwich and switch he eggs to|

| |fruits and vegetables. Patient should not intake his fruits only in juice form, |

| |because this eliminates vitamins and fiber, and adds simple sugar. He is advised|

| |to eat about 8.0 teaspoons of healthy oils per day, such as extra virgin olive |

| |oil. Weekly, he is advised to eat 3.0 cups of dark green vegetables, 2.5cups of |

| |orange vegetables, 7.0 cups of starchy vegetables, and 8.5 cups of any |

| |vegetables. He needs to aim for at least half the recommended value of 10oz eq |

| |per day. Patient likely reported his food intake inaccurately. Sodium intake is |

| |also more than three times above the recommended value, and he is supposed to be |

| |on a low sodium diet. Patient is believed to have stated inaccurate data |

| |regarding his protein intake. |

|Breakfast: white toast, 3 egg omelet, sausage, juice (orange/apple) | |

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|Lunch: Boar’s Head turkey cold cut sandwich on wheat bread, Lay’s potato chips | |

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|Dinner: “New Orleans style” shrimp & sausage jambalaya | |

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|Snacks: potato chips, kid’s fruit snacks, snicker’s bar | |

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|Liquids (include alcohol): | |

|Orange juice, apple juice, water, coffee | |

|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as reference. |

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? |

|“My wife is my biggest help. My parents sometimes take care of my kids to help me, too.” |

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|How do you generally cope with stress? or What do you do when you are upset? |

|“I like to watch TV, read books. I also coach baseball and coach football, for my son. I like to read biographies. We have family ‘get-togethers’ at restaurants, |

|and cookouts.” |

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| |

| |

|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|“I want to be able to travel again, but I have a social life here. I don’t feel like I am having any of psychological difficulties. I just got to be patient and |

|give it up to God.” |

| |

| |

| |

|+2 DOMESTIC VIOLENCE ASSESSMENT |

| |

|Consider beginning with: “Unfortunately many children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I am|

|going to ask some questions that help me to make sure that you are safe.” |

| |

|Have you ever felt unsafe in a close relationship? |

|”No” |

| |

|Have you ever been talked down to? ”No” |

|Have you ever been hit punched or slapped?  “No” |

| |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  ”No.” |

|If yes, have you sought help for this?  N/A |

|Are you currently in a safe relationship? “Yes, my wife is an amazing woman.” |

| |

| |

|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |

|patient’s age group: |

| |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|Erikson’s stage of intimacy versus isolation has the conflict of young adults seeking to share an identity with another person intimately (Sigelman & Rider, 2012).|

|A person must have an individual identity that is well-formed by this stage, or the person may fear intimacy. This may lead to loneliness and isolation. This |

|patient is 34 years old and his psychosocial development is congruent with Erikson’s stage of intimacy vs. isolation. The patient XXX reports that his illness is |

|primarily a hindrance to vacation with his family and friends, thus the primary reason for health is to share more experiences with his closest relationships. His|

|identity of a family man and father leads him to look forward to not just having a new kidney for vacation, but returning to work in the same field. He professes |

|a committed relationship of 14 years, and has two children, including a daughter of two years. He coaches various sports that his son plays. He also reports |

|playing “tea parties” with his daughter. He appears to have no difficulty professing his needs to his wife, but needs are stated simply and are not over-needy. |

|His wife appears to be mutually supportive with him. He is approaching his new kidney as a plan of care that will allow him to lead a fuller life, planning to |

|travel on a long vacation in about a year. Hemodialysis over the past two years since removal of his first transplant is reportedly viewed as “just a period in my |

|life.” The burns he suffered in 1990 that may have caused the kidney malfunction are not viewed as a negative experience. When asked if his life would have been|

|different without that incident, he said, “I think I would be doing kind of the same thing with my life anyway. I love my family. I love to work. I stay active |

|by walking six miles at least twice a week. I have kept my body ready to return to work, now that I have received from a good donor.” |

| |

| |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

| |

|This patient underwent each evaluation with calm presentation. The patient responded positively to all needed diagnostics, treatment, and care. His developmental |

|age has kept pace with his natural age. He appears to share mutual intimacy with his wife of 14 years. He is able to state his needs to his family and treatment |

|team, without negative emotion or negative reciprocation. He reports no difficulty in generally following his recommended diets, though it is impossible that he |

|accurately reported his 24 hour diet that he had prior to transplant. He reports having maintained an active exercise regimen of walking approximately six miles at|

|least twice a week during the last two years of hemodialysis three times per week. He reports feeling grateful that medical interventions are available for him to |

|experience the “best parts of life,” which includes “food, family, fun, and God.” |

| |

| |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|“I was badly burned in a house fire when I was a teenager. My kidneys were damaged because they became overworked. I did not have kidney failure until awhile after|

|the incident.” |

| |

| |

|What does your illness mean to you? |

|“I became a security guard, and I also used to be a fire inspector. It did not stop me from being able to provide for my family, and I intend to go back to work. |

|My faith is a great source of strength to me to help guide me. However, sometimes my illness has been a great hindrance, because I can’t go on a vacation with my |

|kids.” |

| |

| |

|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

| |

|Have you ever been sexually active?___”Yes.” _________________________________________________________ |

|Do you prefer women, men or both genders? __”Females.”_________________________________________________ |

|Are you aware of ever having a sexually transmitted infection? __”No.”____________________________________ |

|Have you or a partner ever had an abnormal pap smear?____”Not that I know of.” |

|Have you or your partner received the Gardasil (HPV) vaccination? _____”No.”_________________________ ______ |

| |

|Are you currently sexually active?   ___”Yes.”________________________ |

|When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  ”My wife has her tubes tied now. |

|We are monogamous.”______________________________ |

| |

|How long have you been with your current partner?___”14 years.” |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity?  __”No.” |

|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|“No.” |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life? “I surrender my life up to God. That is my strength.”

Do your religious beliefs influence your current condition? “It’s my reality. I could not heal without God.”_

______________________________________________________________________________________________________

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? N/A |How much?(specify daily amount) |For how many years? 0 years |

| | |(age thru ) |

| | | |

|Pack Years: N/A | |If applicable, when did the patient quit? |

| | | |

|Does anyone in the patient’s household smoke tobacco? “No.” If so, what, and how |Has the patient ever tried to quit? N/A |

|much? N/A | |

| |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? |How much? (give specific volume) |For how many years? |

|Beer, “bud lite” |~360mL every weekend (2-3 beers per rotating |(age 21 years old thru 23 |

| |weekends) |years old) |

| | | |

| If applicable, when did the patient quit? |2004 | |

| |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

| |How much? |For how many years? “I just tried it a maybe 2-3 |

| | |times.” |

|THC |Tried it, several inhalations, no ingesting |age 15 years old |

| | | |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

| | | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|“Not currently. I am on disability. I have not been exposed to dangerous chemicals, not to my knowledge. There is the potential for getting physical, as a security |

|guard. I want to return to duty for my agency, but I am not ready to focus on that.” |

| |

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| |

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| |

| |

( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| Changes in appearance of skin | GERD Cholecystitis | Fever |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen SPF:30 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: per patient, wipes |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia-mild |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

| Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: |

| Post-nasal drip |Normal frequency of urination: x/day |Other: |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 2-3 x/day | | Diabetes Type: |

| Routine dentist visits 2x/year | | Hypothyroid /Hyperthyroid |

|Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

| Cough - dry (intermittent rare) or productive |Women Only | CVA |

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

| Pneumonia | Date of last gyn exam? | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? 2/12/2015 | menopause age? | Meningitis |

|Other: |Date of last Mammogram &Result: |Other: |

| |Date of DEXA Bone Density & Result: | |

|Cardiovascular |Men Only |Mental Illness |

|Hypertension | Infection of male genitalia/prostate? | Depression (history in 1990) |

| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? | Anxiety |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: |

| CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

| | | |

|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|“No.” |

| |

| |

| |

| |

| |

| |

|Any other questions or comments that your patient would like you to know? |

|“No.” |

| |

| |

| |

| |

|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |

|General Survey: |Height: 6’2” |Weight: 171.6lbs (78kg) BMI: 22 |Pain: (include rating & location) |

| | |(normal range) |“4” with acute instances of “7” |

| | | |Left abdomen/site of kidney transplant |

| | | |surgery |

| |Pulse: 74 |Blood | |

| | |Pressure: 142/106 | |

| | |Left arm, sitting | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations: 16 | | |

|Oral – sublingual | | | |

|98.4°F | | | |

| |SpO2 : 97% |Is the patient on Room Air or O2: |

|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

| |

| |

|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

| awake, calm, relaxed, interacts well with others, judgment intact |

| |

|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

| clear, crisp diction |

| |

|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

| Skin is warm, dry, and intact | |

| Skin turgor elastic | |

| No rashes, lesions, or deformities | |

| Nails without clubbing | |

| Capillary refill < 3 seconds | |

| Hair evenly distributed, clean, without vermin | |

| | |

| | |

| | |

| | |

| Peripheral IV site Type: over-the-needle 22G Location: Right metacarpal vein Date inserted: 10/28/2015 |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? Sodium bicarbonate (680mL/hr-titrated hourly by output of foley catheter) |

| Peripheral IV site Type: over-the-needle 16G Location: Right median vein underside of arm Date inserted: 10/28/2015 |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

| Central access device Type: Location: Date inserted: |

|Fluids infusing? no yes - what? |

| |

|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |

| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |

| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

| PERRLA pupil size / 3mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 12 inches & left ear- 12 inches |

| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: straight teeth, history of braces at 12 years old, no cavities, regular oral care per patient |

|Comments: |

|Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric |

| | | Lungs clear to auscultation in all fields without adventitious sounds |

| |CL – Clear |Percussion resonant throughout all lung fields, dull towards posterior bases |

| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |

| |CR - Crackles | Color: white pale yellow yellow dark yellow green gray light tan brown red |

| |RH – Rhonchi | |

| |D – Diminished | |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

|Cardiovascular: No lifts, heaves, or thrills PMI felt at: left 5th ICS mid-clavicular line |

|Heart sounds: S1 S2 Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

|No ECG tracing available. Patient is sinus rhythm with regular S1 S2. No clicks, no gallops, no murmurs. Patient has no history of MI, no chest pain, and no chest |

|pressure. |

| Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

|Apical pulse: +2 Carotid: +2 Brachial: Not assessed Radial: +2 Femoral: Not assessed Popliteal: +2 DP:|

|+2 PT: Not done |

|No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |

|Location of edema: feet, ankles pitting non-pitting |

|Extremities warm with capillary refill less than 3 seconds |

| |

| |

| |

| |

| |

|GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

|Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation |

|Urine output: Clear Cloudy Color: pink Previous 24 hour output: 200 mLs N/A |

|Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance |

|CVA punch without rebound tenderness - (Not assessed due to new kidney transplant) |

|Last BM: (date 10 / 27 / 2015 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

|Hemoccult positive / negative (leave blank if not done) |

|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |

| Other – Describe: |

| |

| |

|Musculoskeletal: X Full ROM intact in all extremities without crepitus |

|Strength bilaterally equal at __5_____ RUE ___5____ LUE ____5___ RLE & ____5___ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

|vertebral column without kyphosis or scoliosis |

|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |

| |

| |

| |

|Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

|CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative |

|tereognosis(not assessed, graphesthesia(not assessed), and proprioception intact Gait smooth, regular with symmetric length of the stride(did not walk during my |

|shift) |

|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

|Triceps: Not done Biceps: Not done Brachioradial: Not done Patellar: Not done Achilles: Not done Ankle clonus: |

|positive absent Babinski: positive absent |

| |

| |

| |

| |

|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |

|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |

|is done preop) then include why you expect it to be done and what results you expect to see. |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|Creatinine |

|Normal:0.57-1.11mg/dL |

|10/28: 7.8 |

|10/29: 7.7 |

| |

|Slight improvement, indicating that kidney is likely waking up and excreting properly. |

|This is the primary lab value that indicates effectiveness of kidney function. A high value indicates kidney insufficiency and would indicate that the kidney is not |

|working. Even a 0.1 decrease is significant considering that patient has not had dialysis since prior to surgery and he was anuric prior to surgery. |

| |

|Potassium |

|Normal: 3.5-5.3mmol/L |

|10/28: 6.3 |

|10/29: 5.5 |

| |

| |

|Trending towards normal. No clinical manifestations of arrythmia. |

|High or low levels of potassium are a primary indicator of potential for arrhythmias. Patient also has diastolic dysfunction history, which affects preload, so it is|

|important, as well as hypertrophy of the left ventricle. Potassium is excreted through urine, so decrease shows the kidney is starting to function properly. |

| |

|Sodium |

|Normal: 135-145mEq/L |

|10/28: 129 |

|10/29: 132 |

| |

|Trending towards normal. No clinical manifestations of hyponatremia. |

|Low sodium most often indicates raised level of fluid volume. Hyponatremia can affect mental status changes. |

| |

|BUN |

|Normal: 22-29mEq/L |

|10/28: 34 |

|10/29: 28 |

| |

|Trending towards normal. No clinical manifestations. |

|Blood urea nitrogen can be affected by many other things such as a high protein meal. However, patient was NPO yesterday. BUN is excreted in the urine. He is not |

|muscle wasting so soon after stopping his active lifestyle. |

| |

|Hemoglobin |

|Normal: 12.2-16.2g/dL |

|10/28: 9.7 |

|10/29: 9.9 |

| |

|Trending towards normal. Patient reports low level of fatigue. |

|Hemoglobin carry oxygen to the organs and ensure cellular respiration and prevention of hypoxemia. A drop in hemoglobin is related to hematocrit, which is related to|

|creation of red blood cells. |

| |

|Hematocrit |

|Normal: 37.7-47.9% |

|10/28: 30.9 |

|10/29: 31.2 |

| |

|Trending towards normal. No clinical manifestations. |

|Hematocrit is the proportion of red blood cells in the blood. A low level of hematocrit is related to hypoxemia. |

| |

|White Blood Cell Count |

|Normal: 4600-10,200 |

|10/28: 13.48 |

|10/29: 12.47 |

| |

|Trending towards normal. No clinical manifestations of infection. |

|Patient’s body had inflammaion after invasive surgery, resulting in raised WBC count. An infection would result in continued higher levels. Since levels are |

|decreasing, patient’s inflammation may be decreasing. Patient is also on immunosuppressive drugs, and lower than normal levels may predicate infection |

| |

| |

| |

| |

| |

| |

| |

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| |

| |

| |

| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |

|frequency if applicable.) |

|Patient is on NPO and is to be switched to clear liquids today. He was able to take his oral medications. He is also to get up to the chair today. However, he is |

|to leave the foley catheter in for four days after surgery on10/28. This may limit his mobility. His urinary inputs and outputs are being recorded along with color |

|and clarity. Accu checks are being completed hourly on this patient. A biopsy of the kidney may be done. A CT of abdomen may be done to detect possible infections, |

|fluid collections, or other problems. An MRI of the abdomen may be done for similar results, but also shows soft tissues better with three dimensional imagery. An |

|ultrasound may be done to find fluid collections and to aid confirmation of normal vasculature functioning to kidney. He will be kept on an chronic immunosuppressant|

|regimen that will start with intravenous and move to oral. He will be monitored for transplant related infections and opportunistic infections, such as CMV, EBV, and|

|candidiasis. He is on antiviral medications. Patient will get a biopspy completed. Lab tests like CBC, CMP, therapeutic drug levels of immunosuppressants, |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

|1. Risk of for ineffective renal perfusion r/t complications from kidney transplant procedure AEB urinary output amount, color, and consistency, as well as |

|temperature monitoring for fever, creatinine and blood urea nitrogen(BUN) monitoring, pain or tenderness around transplanted kidney, hypertension and fluid |

|retention, especially around eyelids, hands, feet, legs, or ankles. |

| |

| |

|2. Ineffective immune protection r/t immunosuppressive therapy AEB white blood cell count. |

| |

| |

|3. Acute pain r/t surgical site of incision AEB patient verbal report. |

| |

| |

|4. Nausea and vomiting r/t irritation to gastrointestinal system after patient started clear liquid diet AEB patient verbal report. |

| |

| |

|5. Impaired skin integrity r/t decreased mobility after transplant surgery AEB patient’s observed decreased activity after surgery from prior reported lifestyle. |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: Risk of for ineffective renal perfusion r/t complications from kidney transplant procedure AEB urinary output amount, color, and consistency, as well as increased local or core temperature, pain or tenderness around transplanted kidney, and fluid retention, especially around eyelids, hands, feet, legs, or ankles.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |

| | |Provide References | |

|Urinary drainage through foley catheter will equal |Patient will be titrated on bicarbonate for equal |Bicarbonate encourages the body to not have metabolic|Patient was effectively titrated with bicarbonate for|

|30mL/hour or greater, and catheter will cause minimal|urinary output. Patient’s hypertension will be |acidosis, which is a potential complication. (Osborn,|hourly changes in urinary output. Patient’s systolic |

|irritation. |controlled by medication interventions to limit |Wraa, Watson, & Holleran, 2014). Hypertension is |blood pressures were maintained in the 140’s and low |

| |activity of sympathetic nervous system. Patient will |another potential complication of kidney |150’s throughout the shift. Patient reported that he |

| |report that he had a calm, controlled environment to |insufficiency d/t volume overload or RAAS system |appreciated the door being closed and the nursing |

| |limit activity of sympathetic nervous system. |(Osborn et al., 2014). A calm controlled environment |contacts being predictable. Patient reported all of |

| |Patients input and output will be recorded hourly, |is advantageous to controlling patient stress, which |his items were kept within reach, whether he was in |

| |including intravenous fluid input. Patient’s foley |controls psychologically influenced changes in blood |bed or chair. Patient reported that he felt had a |

| |catheter will be assessed during the shift for |pressure (Ackley, & Ladwig, 2007). Normal urinary |calm environment maintained. Patient reported |

| |appropriate attachment and insertion, without |drainage is considered to be a minimum of 30mL/hour |limited frustration during shift. Patient’s |

| |abnormalities and limited alterations in discomfort. |(Osborn et al., 2014). |input/output was averaged between 200-300mL per hour |

| | | |throughout the shift. Patient’s foley catheter |

| | | |maintained proper placement and patient reported no |

| | | |added discomfort. Patient was aided by staff to |

| | | |transfer to chair from bed in order limit catheter |

| | | |movement discomfort. Since patient is to have the |

| | | |foley catheter left a minimum of four days, it is |

| | | |extremely important to limit discomfort. |

|Urinary drainage will be of increasingly normal color|The color of patient’s urine will be regularly noted |Patient’ s urine after transplant has some hematuria |Patient’s urine changed from pink to dark yellow. It |

|and clarity. |in drainage tube before collection bag, since |due to surgery (Osborn et al., 2014). As the kidney |separated in the collection bag, but color difference|

| |collection bag has previous pink urine drainage. |begins to activate, the urine should become more |was most easy to note in the drainage tube. Urine was|

| | |yellow (Osborn et al., 2014). |clear, indicating absence of infection or sediment. |

|Patient will be free from edema. |Patient will be continually assessed for edema and |Common sites of edema are assessed for obvious sites |Patient’s extremities and face were assessed to be |

| |swelling by self report, as well as objective |of fluid retention likely related to insufficient |free from edema throughout the shift. |

| |assessment with palpation of general problem areas, |urinary output after kidney transplant (Osborn et | |

| |which can include eyelids, hands, feet, legs, and |al., 2014). | |

| |ankles. | | |

|Patient will maintain a normal core temperature, as |Patient’s temperature will be taken hourly, with |Signs of infection or rejection include temperature |Patient’s temperatures averaged 98.4°F throughout the|

|well as no localized spots of temperature change, |repeat temperatures taken for outlier readings. |changes in core or at transplant site (Osborn et al.,|shift. No outlier temperature readings were recorded,|

|especially at site of kidney transplant. |Notice will be taken of fluid output in relation to |2014). |as attention was paid to timing of oral fluid intake |

| |temperature readings, ensuring that bicarbonate is | |after clear liquids started at end of shift. |

| |being titrated equal to most recent fluid output. The| |Bicarbonate was titrated properly. The provider did |

| |provider will be notified in the case of increased | |not have to be notified of core or local temperature |

| |temperature not related to lapsed fluid titrations. | |changes. The skin was lightly palpated around |

| | | |dressing on left abdomen. |

|Patient will be free from sudden changes in pain in |Patient will asked about changes in pain, including |Changes in pain after transplantation can indicate |Patient reported no character changes in pain except |

|regard to character, intensity, or referred pain at |character, intensity, and site. Patient’s pain will |rejection or infection (Osborn et al., 2014). |sharpness when pain suddenly became a “7” with sudden|

|the site of surgery. |be assessed hourly. Usage of PCA pump will be noted | |movement. Pain was chronic around “4.” Patient was |

| |for frequency changes. Palpation will be done around | |encouraged to use PCA pump more often prior and after|

| |abdomen and chest that is neighboring surgical site. | |physical therapy in chair. Patient wore an abdominal |

| |Patient will be asked about activities surrounding | |binder ordered for him. He demonstrated ability to |

| |any increases in pain or tenderness. | |correctly secure the device. Patient was guarding of |

| | | |incision site. Patient denied referred pain. |

| | | |Abdominal assessments started away from surgical site|

| | | |to approaching. No increase in radius of pain or |

| | | |guarding. |

|Reestablish electrolyte balance, as well as other lab|Blood samples will be taken daily. Blood will not be |As kidney activates, normal processes that involve |Blood samples were taken. All expected abnormal |

|levels. Lab results will show levels trending towards|taken from 22G. Daily CBC will be analyzed for |kidney should normalize, including erythropoietin |values approaching normal levels including potassium,|

|normal, signifying transplant acceptance. |trends. CMP will also be taken for trends. |release and excretion of electrolytes (Osborn et al.,|creatinine, sodium, hemoglobin, and hematocrit. |

| | |2014). |Patient was given 240mg of Lasix IV during afternoon |

| | | |shift yesterday to drop a 6.3 potassium level to 5.5,|

| | | |as well as other values noted in lab value section. |

|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult Patient already is active with disability monthly benefit. |

|X Dietary Consult Patient will benefit from a kidney transplant diet, maintaining low sodium. Patient will no longer be on a low protein diet but lab levels will be watched. Patient must also be careful of |

|supplementation. |

|X PT/ OT Patient reports that he would accept outpatient or home physical therapy referral to maintain his strength during recovery. Patient will have to incrementally increase activity and not stress kidney, |

|especially since blood pressure is high. He is currently at low level risk of skin breakdown because of his youth, but he has a much decrased level of activity from normal. |

|□Pastoral Care |

|□Durable Medical Needs |

|X F/U appts – Follow-up to be scheduled with nephrology and surgeon. Patient will be transported by wife for appointments. He is on Medicaid, so previous difficulty with purchasing transplant medications prior to 2013|

|should not be an issue. |

|X Med Instruction/Prescription: Patient’s medications are all available through Medicaid. Prescriptions will be needed for life for immunosuppression with potential for exacerbations that may lead to hospital |

|admission. Patient was able to verbally demonstrate knowledge of side effects of medications and importance of daily maintenance. Patient avoids crowds other than his family and is careful to bring hand sanitizer on |

|outings. He does not directly touch his eyes, nose or mouth without washing his hands. |

|□ are any of the patient’s medications available at a discount pharmacy? (not an issue) |

|□Rehab/ HH |

|□Palliative Care |

± 15 CARE PLAN

Nursing Diagnosis: Ineffective immune protection r/t immunosuppressive therapy, surgical incision, and imperfect match for kidney tranplant AEB white blood cell count.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Patient’s immunosuppression will be maintained at a |Patient’s total WBC and differentiated WBC count will|Patient will be at risk for infection once |This patient has an increase in neutrophils and total|

|therapeutic level to prevent transplant rejection. |be monitored for informing the provider of |immunosuppressive drugs are regularly administered |granulocytes. He has a decrease in lymphocytes and |

| |therapeutic level of immunosuppression. |(Osborn et al., 2014). He is being administered |monocytes. His WBC is interpreted as elevated due to |

| | |cytotoxic drugs, such as cellcept. Lab levels will be|inflammation from surgery. Immunosuppression is in |

| | |below normal. Immunosuppression will be for lifetime.|its early stages. |

|Patient’s surgical incision will be free of infection|Patient’s dressing will be kept clean and dry, being |Patient’s surgical incision requires regular |Patient’s surgical incision was well padded and |

|and intact. |regularly assessed. Site will be assessed for pain |assessment due to proximity to surgery (Ackley, & |without evidence of drainage through the dressing. |

| |and dehiscence. Provider will be notified of any |Ladwig, 2007). Patient may have delayed wound healing|Physical therapy was able to exercise patient without|

| |abnormalities. Patient will be kept on supervised |as a complication of the surgery and medications. |change to dressing, still intact and dry. Increased |

| |activity, and physical therapy will maintain body | |pain after physical therapy subsided using PCA pump |

| |tone. | |at first, and did not return. |

|Patient will not get a nosocomial infection. |Patient will be encouraged to turn, cough, and deep |Patient teaching for immunosuppressed patients should|Patient’s lungs are clear, all fields. Patient |

| |breath, with a pillow pressed on surgical site. |encourage proper hygiene and contact precautions, |verbalized agreement to perform regular hand |

| |Patient will be taught to wear a mask and gloves as |especially while in hospital (Ackley, & Ladwig, |sanitation and how to ask for contact precaution |

| |appropriate, as immunosuppression progresses. Patient|2007). |materials, as needed. Patient cooperated with |

| |will use incentive spirometer twice per hour to | |suggestion to use incentive spirometer every half |

| |prevent lung complications post-surgery. | |hour. He reached top level on all recorded events. |

|Patient will be educated about long term increased |Patient was given printed materials on cancer risks |Protecting the skin from excessive sun exposure is |Patient reports that he covers himself from sun, and |

|risk of cancer, such as skin cancer. |associated with post-operation transplant. Patient |important to limiting potential for skin cancer |that he understands how to find clothing of SPF |

| |was educated on clothing with SPF value, use of hats,|(Sigelman & Rider, 2012). After 15 minutes of sun |value. Patient verbalized dangers of sun exposure as |

| |and encouraged to continue using sun screen. |exposure to area of lightest skin, many people |increased due to being post-transplant. |

| | |achieve adequate vitamin D absorption. | |

|Patient will be educated on a diet post-transplant. |Patient will be referred to dietician and be offered |Steroid medications limit the body’s ability to use |Patient discussed the high protein foods that he |

| |printed materials on low sodium diet, eat complex |carbohydrates, which may cause diabetes (Osborn et |likes to eat. During dietary assessment, he probably |

| |carbohydrates that take longer to digest, limit |al., 2014). Protein rich foods will help build up |was confused about what diet he will have immediately|

| |saturated fat intake from sources such as fried and |muscle tissue. |following allowing regular solid foods, compared to |

| |dairy foods, and eat protein rich foods for a period | |diet prior to surgery. |

| |of recovery after surgery. | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

| |

|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult Patient already is active with disability monthly benefit. |

|X Dietary Consult Patient will benefit from a kidney transplant diet, maintaining low sodium. Patient will no longer be on a low protein diet but lab levels will be watched. Patient must also be careful of |

|supplementation. |

|X PT/ OT Patient reports that he would accept outpatient or home physical therapy referral to maintain his strength during recovery. Patient will have to incrementally increase activity and not stress kidney, |

|especially since blood pressure is high. He is currently at low level risk of skin breakdown because of his youth, but he has a much decrased level of activity from normal. |

|□Pastoral Care |

|□Durable Medical Needs |

|X F/U appts – Follow-up to be scheduled with nephrology and surgeon. Patient will be transported by wife for appointments. He is on Medicaid, so previous difficulty with purchasing transplant medications prior to 2013|

|should not be an issue. |

|X Med Instruction/Prescription: Patient’s medications are all available through Medicaid. Prescriptions will be needed for life for immunosuppression with potential for exacerbations that may lead to hospital |

|admission. Patient was able to verbally demonstrate knowledge of side effects of medications and importance of daily maintenance. Patient avoids crowds other than his family and is careful to bring hand sanitizer on |

|outings. He does not directly touch his eyes, nose or mouth without washing his hands. |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No (not an issue) |

± 15 CARE PLAN

Nursing Diagnosis:

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Encouraged to use more dilaudid with PCA to have | | | |

|better physical therapy. | | | |

|TCDB due to limited mobility due to fall precautions | | | |

|and high blood pressure & foley | | | |

|Infection risk, risk for cancers, esp. skin. Risk for| | | |

|GI problems n/v, leukopenia, infxns (bac & viral) | | | |

|Short term complications –delayed wound healing, | | | |

|hypotension, respiratory failure, fever | | | |

|Exact output replaced with bicarb every hourfor 12 | | | |

|hours, currently 200-300mL/hr output | | | |

|Get to chair | | | |

|Abdominal binder | | | |

|Lasix IV piggyback 240mg normal is 40mg | | | |

|Retain | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

| |

|Consider the following needs: |

|□SS Consult |

|□Dietary Consult |

|□PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appts |

|□Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

References

Ackley, B. J. & Ladwig, G. B. (2007). Nursing diagnosis handbook: An evidence-based

guide to planning care (8th ed.). St. Louis: Mosby/Elsevier.

Choose MyPlate. (n.d.). Retrieved November 15, 2015, from

Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St. Louis, MO: Elsevier

Mosby.

Osborn, K., Wraa, C., Watson, A., Holleran, R. (Eds.). (2014). Medical-surgical nursing: Preparation for

practice (2nd ed.). Upper Saddle River, New Jersey: Pearson.

Sigelman, C.K., & Rider, E.A. (2012). Life-span human development (7th ed.). Belmont, California:

Wadsworth Cengage Learning.

Unbound Medicine, Inc. (2015). Nursing Central (Version 1.26). [Mobile application software]. Retrieved from



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