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 when 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 which is dry with a 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
The nurse reviews the nursing note, vital signs, assessment, and medical history
➢ Which clinical data is most concerning to the nurse? Select all that apply.
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