Chronic & End-stage Renal Failure

CONCEPT: Fluid and Electrolytes NUR 213

End of Shift Report

0700

You will be caring for a 54 year old male who was admitted 2 days ago through the Emergency Department with community acquired RLL pneumonia. He has a past medical history which includes CAD, HTN, DM (Type II) and ESRD for which he receives dialysis 3 times per week. Per his schedule he is due for a dialysis run today and orders are written per his nephrologist.

Assessment shows that lungs have coarse crackles in the right lower lobe but otherwise uneventful.

His vital signs on admit were:

  • BP 168/88
  • HR 98
  • RR 26
  • Temp 38.4
  • O2 sat 94% on 2 liters of oxygen per nasal cannula
  • Pain 6/10 when asked to take a deep breath otherwise about a 2/10

What information do you want to know regarding this patient’s ‘story’?
What questions could you ask to better understand what is going on with this gentleman? / What information could you look up in the chart to better understand his story? / Where would you look in his records to find the information you want to know?
What did you hear in report that made you ‘sit up and take NOTICE’?
Based on report, what data would you want to interpret from his records? / Where would you look in his records to find the information you want to interpret?
What did you ‘NOTICE’ in the orders/care plan that you may want more information about?
What data would you want to interpret from his records? / Where would you look in his records to find the information you want to interpret?
What did you ‘NOTICE’ on the MAR/medication orders that you may want more information about?
What data would you want to interpret from his records? / Where would you look in his records to find the information you want to interpret?

Orders/Care Plan

  • Vital signs every 4 hours and prn
  • Call MD if SBP>180 or < 90, HR <60 or >100, RR > 30, temp > 39.5
  • Activity as tolerated
  • Renal diet
  • Daily weights
  • Strict intake and output
  • Incentive spirometer every 2 hours while awake
  • IV: Saline lock
  • CBG’s ac and hs
  • Daily CBC
  • Daily CMP
  • Meds:
  • Unasyn 3gm daily IV every 24 hours
  • Zosyn 3gm IV every 8 hours
  • Metoprolol 25mg po TID
  • Lisinopril 20 mg po daily
  • Metformin 500mg daily
  • Sliding scale insulin per moderate protocol
  • Morphine sulfate 2-4mg IV every 4 hours prn pain
  • Hydrocodone 1-2 tabs po every 3-4 hours prn pain
  • Tylenol 325-650mg po every 6 hours prn pain or temperature
  • Dialysis 3 times per week per team – goal to dry weight of 89kg with each run