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Vital Signs
antihypertensive
The nurse is caring for a 52-year-old client coming to the emergency department with peripheral edema, periorbital edema, flank pain, and shortness of breath. The nurse is preparing to notify the provider of the client’s status. Complete the below using the dropdown choices.
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MEDS2-RDC-16
Renal Disorders
Clinical Judgment, Elimination, Fluid and Electrolytes, Oxygenation Perfusion
Evaluation [Evaluating]
Chapter 62: Coordinating Care for Patients with Renal Disorders
Vital Signs
pp. 1452-1459
antihypertensive
Rationale: The client is demonstrating signs of acute kidney injury, oliguric phase. This is identified by low urine output, edema, shortness of breath, hypertension, hyperkalemia, elevated BUN/creatinine, anemia, and hyponatremia. It is anticipated that this client has a compromised GFR due to risk factors of poorly controlled diabetes and reoccurring UTIs. The risks for developing acute kidney injury include infection and medications. Fever, elevated WBCs, flank pain are signs of a kidney infection, and extended to excessive use of NSAIDS will impair kidney function, leading to injury. In evaluating the client data, the nurse should be most concerned about the changing vital signs, including a rising temperature, heart rate, respiratory rate, and blood pressure, as the SpO2 decreases. This indicates a deterioration of oxygenation and perfusion. Priority medical management is the delivery of oxygen and an antihypertensive to prevent tissue hypoxia and stroke. The nurse should also notify the provider about the hyperkalemia, hyperglycemia, anemia, renal impairment shown in the lab results, and the assessment findings of oliguria, edema, crackles, and bounding pulses.
Navigate the EHR trends by looking at how the cues presented relate to each other. Make the connection between the information to reach priority conclusions.
Health Assessment
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Clinical Judgment
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