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COLLEGE OF NURSING
Student: Shawn Hekkanen
XXX
male
Age: 34
Served/Veteran: none
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.
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 noncalcified 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.
Chronic kidney disease was originally diagnosed in patients 20s 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.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
1/1990
1/1990
5/2005
2006
4/2007
2009
1/21/2011
10/14/2013
2/2014
3/2014
10/28/2015
Operation or Illness
Skin graft r/t burn
Cardiac catheterization, multiple stents
Inguinal Hernia repair
Chronic Kidney Disease diagnosed by Focal Segmental Glomerulosclerosis (FCGS).
AV fistula Left Upper Arm. Started hemodialysis.
Cholecystectomy
AV fistula Left Upper Arm repair
1st Deceased Donor Kidney Transplantation (DDKT)
Bladder biopsy for hematuria and part of pretransplant workup - negative
Abdominal CT atrophied native kidney
Nephrectomy after multiple rejections
Chest x-ray 6mm subpleural RUL nodules nonspecific
2nd DDKT- left abdomen
Father
55
Mother
son
52
36
,
25
,
18
34
,
15
11
daughter
Brothers
Sisters
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Environmental
Allergies
Cause
of
Death
(if
applicable
)
Alcoholism
2
FAMILY
MEDICAL
HISTORY
relationship
Comments:
Patients 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)
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
REACTIONS
NAME of
Causative Agent
YES
NO
morphine
penicillins
Lactose intolerant
Diarrhea, cramping
Medications
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)
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.
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)
Route: IV
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.
Name Famotidine (PEPCID)
Route IV
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.
Name HYRDROmorphone (DILAUDID)
Concentration 0.2mg/mL
Dosage Amount
Basal dose: no basal rate;
PCA dose: 0.2mg (1mL)
Frequency bolus available q10min
Route IV
Pharmaceutical class opioid analgesic
Home
Hospital
or
Both
Concentration 125mg/2mL
Hospital
or
Both
Route IV piggyback
Home
Hospital
or
Both
Concentration
8.6mg sennosides
50mg docusate
Route oral
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.
Name sodium bicarbonate
Route IV
Pharmaceutical class alkalinizing agent
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.
Name sulfamethoxazole-trimethoprim (BACTRIM,
SEPTRA)
Route oral
Pharmaceutical class folate antagnonists; sulfoamides
Concentration:
Dosage Amount: 1 tablet
Sulfamethoxazole 400mg
Sulfamethoxazole 400mg
Trimethoprim 80mg
Trimethoprim 80mg
Frequency one tablet q Monday, Wednesday, Friday
Home
Hospital
or
Both
Concentration 450mg/tablet
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.
Name albuterol nebulizer
Route
Concentration 5mg/1mL
aerosol
Dosage Amount
10mg (2mL)
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)
Route IV
Home
Hospital
or
Both
Route IV
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
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 units
Route IV
Pharmaceutical class pancreatics
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)
Route IV
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
Route IV
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
Route IV
Home
Hospital
or
Both
Concentration 5mg/1mL
Route IV
Frequency q5min PRN, repeat if goal not met for maximum of 4 doses.
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
Route IV
Home
Hospital
or
Both
Concentration 1mg/mL
Route IV
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)
Route
Concentration 4mg/2mL
Intravenous
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, Consider co-morbidities and cultural considerations):
low saturated fat diet
24 HR average home diet:
Patients grains intake is 31% of his recommended daily
value. His intake is 3.1 oz eq of the recommended 10oz
Breakfast: white toast, 3 egg omelet, sausage, juice
equivalents. Patients vegetables intake is 19% of his
(orange/apple)
recommended daily value. His intake is 0.7cup equivalents
of the recommended 3.5 cup equivalents. Patients fruit
Lunch: Boars Head turkey cold cut sandwich on wheat
intake, due to drinking apple and orange juice, is 119% of
bread, Lays potato chips
his recommended daily value. His intake is 3.0 cup
equivalents of the recommended 2.5 cup equivalents.
Dinner: New Orleans style shrimp & sausage jambalaya
Patients dairy intake is 18% of the recommended daily
value. His intake is 0.5cup equivalents of the recommended
Snacks: potato chips, kids fruit snacks, snickers bar
3.0 cup equivalents. His protein intake is 284% of the
recommended daily value. His intake is 19oz eq of the
Liquids (include alcohol):
recommended 7.0oz equivalents. The patient probably
Orange juice, apple juice, water, coffee
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.
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.
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
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 dont feel like I am having any of psychological
difficulties. I just got to be patient and give it up to God.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Eriksons 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 Eriksons 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 patients 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 cant 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.
10
Yes
No
For how many years? 0 years
(age
thru
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
~360mL every weekend (2-3 beers
Beer, bud lite
per rotating weekends)
If applicable, when did the patient quit?
thru 23
2004
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
For how many years? I just tried it a
How much?
maybe 2-3 times.
Tried it, several inhalations, no
age 15 years old
THC
ingesting
Is the patient currently using these drugs?
Yes No
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.
11
10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:30
Bathing routine: per patient, wipes
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:
Gastrointestinal
Immunologic
Genitourinary
Anemia-mild
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections
x/day
Hematologic/Oncologic
Metabolic/Endocrine
2-3 x/day
2x/year
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry (intermittent rare)
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2/12/2015
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:
productive
WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression (history in 1990)
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
12
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.
13
Height: 62
Pulse: 74
Respirations:
16
kidney transplant
surgery
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
apathetic
bizarre
agitated
anxious
tearful
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
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
14
Pulmonary/Thorax:
CL
CL
CL
CL
CL
CL
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.
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
Other Describe:
[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]
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
Rombergs 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
positive absent Babinski: positive absent
Ankle clonus:
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
Creatinine
Normal:0.57-1.11mg/dL
10/28: 7.8
10/29: 7.7
Potassium
Normal: 3.5-5.3mmol/L
10/28: 6.3
10/29: 5.5
Dates
Trend
Slight improvement,
indicating that kidney is
likely waking up and
excreting properly.
Trending towards
normal. No clinical
manifestations of
arrythmia.
Analysis
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.
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
Sodium
Normal: 135-145mEq/L
10/28: 129
10/29: 132
Trending towards
normal. No clinical
manifestations of
hyponatremia.
BUN
Normal: 22-29mEq/L
10/28: 34
10/29: 28
Trending towards
normal. No clinical
manifestations.
Hemoglobin
Normal: 12.2-16.2g/dL
10/28: 9.7
10/29: 9.9
Trending towards
normal. Patient reports
low level of fatigue.
Hematocrit
Normal: 37.7-47.9%
10/28: 30.9
10/29: 31.2
Trending towards
normal. No clinical
manifestations.
Trending towards
normal. No clinical
manifestations of
infection.
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 patients 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
Urinary drainage through foley
catheter will equal 30mL/hour or
greater, and catheter will cause
minimal irritation.
clarity.
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
Patients immunosuppression will
be maintained at a therapeutic level
to prevent transplant rejection.
Evaluation of Interventions on
Day care is Provided
This patient has an increase in
neutrophils and total granulocytes.
He has a decrease in lymphocytes
and monocytes. His WBC is
interpreted as elevated due to
inflammation from surgery.
Immunosuppression is in its early
stages.
Patients surgical incision was well
padded and without evidence of
drainage through the dressing.
Physical therapy was able to
exercise patient without change to
dressing, still intact and dry.
Increased pain after physical
therapy subsided using PCA pump
at first, and did not return.
Patients lungs are clear, all fields.
Patient verbalized agreement to
perform regular hand sanitation and
how to ask for contact precaution
materials, as needed. Patient
cooperated with suggestion to use
incentive spirometer every half
hour. He reached top level on all
recorded events.
Patient reports that he covers
himself from sun, and that he
understands how to find clothing of
SPF value. Patient verbalized
dangers of sun exposure as
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: Patients 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 patients medications available at a discount pharmacy? Yes No (not an issue)
15 CARE PLAN
Patient Goals/Outcomes
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
Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Evaluation of Interventions on
Day care is Provided
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 patients 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 http://www.choosemyplate.gov/
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
http://itunes.apple.com