0818: Client reports severe shortness of breath and swelling in his lower extremities. He reports a 3-day history of fatigue and decreased urine output. During the assessment, the client was alert and fully oriented. He has 2+ pitting pedal edema in the lower extremities. 2+ peripheral pulses in the upper extremities. Bibasilar crackles upon auscultation. Skin is warm, dry, and normal for ethnicity. Normoactive bowel sounds in all quadrants. Vital signs: T 98° F (36.7°C), P 89, RR 18, BP 164/95, pulse oximetry reading 96% on room air.
- Capillary blood glucose 121 mg/dL (6.72 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
- Serum creatinine 2.5 mg/dL (221 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
- Serum BUN 36 mg/dL (12.9 mmol/L) ([10–20 mg/dL (3.6–7.1 mmol/L)]
- Serum potassium: 5.2 mEq/L [3.5–5 mEq/L (3.5–5 mmol/L)]
- Urinalysis: Mild proteinuria, no hematuria
24 hour fluid intake: 1560 mL
24 hour fluid output: 250 mL
- hypertension
- hyperlipidemia
- coronary artery disease
- glaucoma
- diabetes mellitus (type two)
- carvedilol 6.25 mg p.o. daily
- multivitamin 1 tablet p.o. daily
- lisinopril 10 mg p.o. daily
- simvastatin 10 mg p.o. daily
- ergocalciferol 10000 units p.o. daily
- ethyl eicosapentaenoic acid 2 grams p.o. daily
The nurse is reviewing the client’s assessment data to prepare the client’s care plan.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client’s progress.
Actions to Take: Prepare the client for peritoneal dialysis. | Request a prescription for sodium chloride (normal saline) 500 mL bolus. | Obtain an order to discontinue the lisinopril. | Obtain a prescription for a continuous infusion of regular insulin. | Request a prescription for a diuretic.
Potential Conditions: Nephrotic syndrome | Hyperglycemia hyperosmolar syndrome | Acute kidney injury | Chronic kidney disease
Parameters to Monitor: Peripheral pulses | Capillary blood glucose | Serum potassium | Temperature | Lung sounds
Actions to Take: Prepare the client for peritoneal dialysis. | Request a prescription for sodium chloride (normal saline) 500 mL bolus. | Obtain an order to discontinue the lisinopril. | Obtain a prescription for a continuous infusion of regular insulin. | Request a prescription for a diuretic.
Parameters to Monitor: Peripheral pulses | Capillary blood glucose | Serum potassium | Temperature | Lung sounds
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