1535: Client returned from hemodialysis via stretcher to assigned room. The client was alert, oriented x 4. Denied any pain. He stated he felt ‘tired and dizzy.’ The client reported that the dizziness occurred if he quickly changed positions. The client was assessed, and vital signs were obtained.

Temperature 97° F (36° C)

Pulse 94/minute; irregular 

Respirations 14/minute 

Blood Pressure 91/58 mm Hg

Oxygen saturation 92% on room air

Neurological:

Alert and completely oriented; reports dizziness. Pupils, equal, round, and reactive to light.

Cardiovascular:

Peripheral pulses intact; no edema; S1/S2 heart tones. Positive bruit and thrill in left arm A/V fistula. Gauze dressing applied that is dry with scant amount of dry blood

Respiratory:

Diminished lung sounds, occasional cough

GI/GU:

Normoactive bowel sounds in all quadrants. Anuria.

Skin:

Warm and dry

• End-stage renal disease (ESRD)
• Uncontrolled hypertension
• Chronic obstructive pulmonary disease
• Atrial fibrillation