0900

A 72-year-old male presents with decreased urine output, bilateral leg swelling, fatigue, weakness, mild nausea, poor appetite, and dark, concentrated urine over the past two days. His daughter reports increased confusion and lethargy this morning. Medical history includes hypertension, type 2 diabetes, coronary artery disease (post-stent), and stage 3 chronic kidney disease. Home medications include lisinopril, metformin, atorvastatin, furosemide, and ibuprofen as needed. Upon assessment, the client is fatigued and oriented to person and place, with delayed responses. 2+ pitting edema is noted in both lower extremities, and skin is dry and cool. Breath sounds are clear, heart rhythm is regular, and the abdomen is soft and non-tender with active bowel sounds. No fever, chest pain, respiratory symptoms, or acute distress is noted.

0915

Client settled into room. Vital signs obtained. Ordered labs obtained, client tolerated well.

0905

• Complete Blood Count (CBC)
• Basic Metabolic Panel (BMP)
• Glomerular Filtration Rate (GFR)

0915

Client settled into room. Vital sign obtained. Ordered labs obtained, client tolerated well.

0930

Healthcare provider notified of laboratory results.

0915

Client settled into room. Vital sign obtained. Ordered labs obtained, client tolerated well.

0930

Healthcare provider notified of laboratory results.

1000

The healthcare provider reviewed the client’s lab results and clinical presentation. A diagnosis of acute kidney injury (AKI), likely related to recent nephrotoxic medication use, has been confirmed.

1030

• Place the client on continuous cardiac monitoring
• Obtain serum potassium level every 6 hours
• Start a 24-hour urine collection
• Provide client education on low-potassium foods
• Insert an indwelling urinary catheter for output tracking
• Administer sodium polystyrene sulfonate 30 g PO once now
• Schedule a nephrology consult for later in the day
• Administer atorvastatin 20 mg PO once daily as scheduled