Health Insurance Portability and Accountability Act

Full Answer Section

      Background Mrs. Naganashe has a 15-year history of type II diabetes mellitus and a history of hypertension and hyperlipidemia. She lives on an American Indian reservation and is a proud member of the Odawa tribe. Assessment Vital signs:

• Temperature: 98.6° F (37° C)
• Pulse: 110 beats per minute
• Respiratory rate: 28 breaths per minute
• Blood pressure: 180/110 mmHg
• Oxygen saturation: 92% on room air

Physical exam:

• Naganashe is alert and oriented to person, place, and time.
• She is in moderate respiratory distress.
• Her lungs are crackles bilaterally.
• Her lower extremities are edematous.
• Her skin is warm and dry.

Laboratory findings:

• Blood urea nitrogen (BUN): 100 mg/dL (normal: 7-20 mg/dL)
• Creatinine: 7.0 mg/dL (normal: 0.8-1.5 mg/dL)
• Potassium: 5.5 mEq/L (normal: 3.5-5.0 mEq/L)

Recommendation

• Admit Mrs. Naganashe to the nephrology unit.
• Initiate dialysis treatment.
• Monitor her vital signs and respiratory status closely.
• Administer diuretics and antihypertensive medications as prescribed.
• Provide education to Mrs. Naganashe and her family about the importance of dialysis treatment and adherence to her medication regimen.

Nursing Notes Mrs. Naganashe is a 62-year-old American Indian female with chronic renal failure who was admitted for shortness of breath, swelling, weight gain, and fatigue. She was unable to go to her dialysis treatment this week because her husband had to use their only car for a job interview. On assessment, Mrs. Naganashe was in moderate respiratory distress. Her lungs were crackles bilaterally and her lower extremities were edematous. Her laboratory findings were consistent with acute kidney injury. Mrs. Naganashe was admitted to the nephrology unit and dialysis treatment was initiated. Her vital signs and respiratory status were monitored closely and she was administered diuretics and antihypertensive medications as prescribed. Education was provided to Mrs. Naganashe and her family about the importance of dialysis treatment and adherence to her medication regimen. Mrs. Naganashe tolerated dialysis treatment well. Her respiratory distress improved and her laboratory values began to normalize. She was discharged home with instructions to follow up with her nephrologist for regular dialysis treatments and monitoring.  

Sample Solution

   

SBAR Format Nurse's Note

Situation

Maggie Naganashe, a 62-year-old American Indian female with chronic renal failure, was admitted for shortness of breath, swelling, weight gain, and fatigue. She was unable to go to her dialysis treatment this week because her husband had to use their only car for a job interview.