UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Shawn Hekkanen

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

XXX

male

Assignment Date: 10/29/2015

Agency: TGH - SBN

Age: 34

Admission Date: xx/xx/2015

Marital Status: married 14 years

Primary Medical Diagnosis with ICD-10 code:

Kidney replaced by transplant (V42.0)

Primary Language: English

Level of Education: AA Business Administration

Other Medical Diagnoses: (new on this admission)

Kidney Transplant Status (Z94.0)

Occupation (if retired, what from?): security guard (currently legally

disabled, SSI/SSDI/Medicaid)
Number/ages children/siblings: son-11 y.o.; daughter 2 y.o.
3 sisters 36 y.o., 25 y.o, 18 y.o.
2 brothers 34 y.o., 15 y.o.

Served/Veteran: none

Code Status: Full Code

Living Arrangements: live with wife & 2 kids in a single story

1,400 square foot home, with two car garage and front
door/backdoor. Small step up at front door and 3 steps up to back
door. Metal gate around house.

Advanced Directives: none

If no, do they want to fill them out? refused
Surgery Date: 10/28/2015
Procedure: kidney transplant

Culture/ Ethnicity /Nationality: African American

Religion: Christianity (general)

Type of Insurance: Medicaid

1 CHIEF COMPLAINT:
I have been on dialysis for two years, Monday, Wednesday and Friday. I am here for a kidney transplant from a donor
match.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 34 year old male admitted 10/27/2015, for kidney transplantation on 10/28/2015. Last hemodialysis was on
10/26/2015. He has a left upper arm arteriovenous fistula for hemodialysis scheduled for Mondays, Wednesdays, and
Fridays. Pre-transplant workup included abdominal computerized tomography (CT) scan, CT chest, echocardiogram,
prostate-specific antigen (PSA) test, and follow-up chest x-ray. On 10/14/2013, the abdominal CT revealed small bilateral
pleural effusions, atrophic kidney, a renal cyst pelvic ascites, and anasarca. On 5/13/2014, the chest CT revealed a noncalcified subpleural nodule in right upper lobe, with small right pleural effusion and pulmonary vascular congestion.
There was also a pericardial effusion, indications of anemia, and confirmation of anasarca. On 2/12/2015, the
echocardiogram revealed moderate left ventricular hypertrophy, with ejection fraction of 55-60%, with grade 1 diastolic

University of South Florida College of Nursing Revision August 2013

dysfunction. The PSA test was normal. Also on 2/12/2015, the chest x-ray revealed an average size cardiomediastinal
area with lungs that expand and aerate well, as well as no acute cardiopulmonary findings. The vascular stent grafts
placed in 1990 project at the left upper thorax. No other abnormalities were found in the tests.
Chronic kidney disease was originally diagnosed in patients 20s and hemodialysis first began in 2006. Patient reports
that doctors told him that burns suffered from a house fire in 1990 stressed his kidneys, leading to Focal Segmental
Glomerulosclerosis (FSGS) and related anemia. It is unknown if patient report is accurate. Burns are to multiple sites,
including forearms and back. The burns Burns are to an unspecified degree, and patient was in a coma. Due to thoracic
empyema, he required chest tube drainage. His first Deceased Donor Kidney Transplantation (DDKT) occurred in
January 2011. Kidney was from a 29-year old female. His first pre-transplant workup revealed cardiomyopathy and
hematuria, with a negative bladder biopsy. At least five episodes of acute rejection resulted in hospitalizations,
culminated into transplant nephrectomy in February 2014. Most recent diagnosis of Stage V chronic kidney disease
(CKD) has been diagnosed since 1/2014, requiring chronic dialysis. Last dialysis was 10/26/2015, a day before surgery.
He has had anuria since 1/2014. Evaluation for another transplant began in March 2014. Social work clearance was
completed 10/2014. Financial clearance was completed 2/2015. Kidney transplant operation occurred on 10/28/2015,
and donor was a nine-year old female, who died of a head injury.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
1/1990
1/1990
5/2005
2006
4/2007
2009
1/21/2011
10/14/2013
2/2014
3/2014
10/28/2015

Operation or Illness
Skin graft r/t burn
Cardiac catheterization, multiple stents
Inguinal Hernia repair
Chronic Kidney Disease diagnosed by Focal Segmental Glomerulosclerosis (FCGS).
AV fistula Left Upper Arm. Started hemodialysis.
Cholecystectomy
AV fistula Left Upper Arm repair
1st Deceased Donor Kidney Transplantation (DDKT)
Bladder biopsy for hematuria and part of pretransplant workup - negative
Abdominal CT atrophied native kidney
Nephrectomy after multiple rejections
Chest x-ray 6mm subpleural RUL nodules nonspecific
2nd DDKT- left abdomen

University of South Florida College of Nursing Revision August 2013

Father

55

Mother

son

52
36
,
25
,
18
34
,
15
11

daughter

Brothers

Sisters

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

relationship

Comments:
Patients father is diagnosed with heart disease, HTN, and diabetes Type II. No other known health issues of family were reported or
recorded in chart.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) 2010
Adult Tetanus (Date) 2010
Influenza (flu) (Date) 10/8/2015
Pneumococcal (pneumonia) (Date) 2010
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

YES

NO

Type of Reaction (describe explicitly)

morphine
penicillins

Swelling in tongue and throat

Swelling in tongue and throat

Lactose intolerant

Diarrhea, cramping

Medications

Other (food, tape,

latex, dye, etc.)

University of South Florida College of Nursing Revision August 2013

 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Chronic kidney disease (CKD) is indicated by progressively deteriorating kidney function, as noted by declining
glomerular filtration rate (Huether & McCance, 2012). There are five stages of chronic kidney disease. This patient was
diagnosed with end-stage kidney disease, stage V. Symptoms include hypertension, increased creatinine level, increased
urea level, erythropoietin deficiency anemia, hyperphosphatemia, increased triglycerides, metabolic acidosis,
hyperkalemia, salt retention, and water retention (Huether & McCance, 2012). Compensatory glomerular increased
filtration, hypertrophy, and hypertension of malfunctioning excretion increases glomerulosclerosis, tubular inflammation,
tubular remodeling to fibrosis, and uremia. Proteinuria is caused by hypertension and increased capillary permeability, as
there is a heightened angiotensin II response with progressive nephron injury, thus damaging remaining working
nephrons. Related clinic findings may include bone fractures, pulmonary edema, kussmaul respirations, left ventricular
hypertrophy and other cardiomyopathy, hypertension, artherosclerosis, pericarditis, encephalopathy, loss of muscle mass,
loss of motor function, anemia, platelet disorders, anorexia, nausea, vomiting, gastrointestinal bleeding, peptic ulcers,
pancreatitis, itching, abnormal pigmentation, increased infections, increased risk of cancer, and sexual dysfunction. This
patient has a history of pulmonary edema, left ventricular hypertrophy, and anemia (Huether & McCance, 2012). Fluid
and electrolytes are imbalanced, especially sodium and potassium, which are primarily excreted by the urine. Phosphate is
also increased as serum calcium is decreased, which causes alterations in bone. Patients with CKD should be watched for
the development of diabetes mellitus, which can result in prolonged half-life of insulin. Evaluation is based upon a patient
history, presenting signs and symptoms, elevated blood urea nitrogen (BUN), elevated creatinine, and urinalysis. To reveal
atrophic kidney, tests may include an ultrasound, CT scan, or x-ray. Renal biopsy will confirm diagnosis.
Focal segmental glomerulosclerosis involves fibrous tissue that has scarred the filtration passages within glomeruli of the
kidney (Huether & McCance, 2012). There is a genetic component and African Americans are most often affected
(Huether & McCance, 2012). This patient is African American. The condition may also be caused by an infection, which
was likely to have occurred when patient was burned in 1990. The condition is also related to hydronephrosis, obesity,
sickle cell disease, heroin use, bisphosphonates use, and anabolic steroids use. Symptoms include proteinuria, decreased
appetite, generalized edema, and weight gain. Diagnostic evaluations include kidney biopsy, urinalysis, urine microscopy,
blood and urine kidney function tests, and protein in the urine without after ruling out diabetes (Huether & McCance,
2012). Treatments include medications that suppress inflammation, lower blood pressure, diuretics, lower cholesterol,
lower triglycerides, antibiotics for infections, and vitamin D supplementation (Huether & McCance, 2012). A low sodium,
low fat, low potassium, restricted fluid, and low protein diet should be used. Recommended daily protein is one gram of
protein per kilogram of body weight. Fluid restriction and dialysis three days per week are regularly used. Most patients
are diagnosed with chronic kidney disease within ten years. This patient received his first kidney transplant after five
years of dialysis, starting in 2006.

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name: Normal Saline (sodium chloride)

Concentration 0.9% (9mg/mL)

Route: IV

Dosage Amount 1000mL per bag

Frequency: continuous (120mL/hr)

Pharmaceutical class: mineral/electrolyte replacement

Home

Hospital

or

Both

Indication: A priming fluid for hemodialysis. Hydration and normalize serum sodium and chloride levels. Aid to stabilize hemodynamics and exhibit pressure
on the transplanted kidney to perfuse and filter urine.
Side effects/Nursing considerations: Pulmonary edema, edema, hypernatremia, hyponatremia, hypokalemia. Assess for fluid retention, lung crackles,
hypertension, daily weight. Monitor I & O. Assess for fever, flushed skin, mental irritability.
Name Famotidine (PEPCID)

Concentration 0.4mg/mL (as calculated)

Route IV

Dosage Amount 20mg (50mL)

Frequency twice daily

Pharmaceutical class: histamine h2 antagonists

Home

Hospital

or

Both

Indication: Prevention of stress induced upper GI bleeding and stress ulcers. Prevention of aspiration by prophylactic treatment of heartburn, acid indigestion,
and sour stomach. Prophylaxis for GERD and peptic ulcer disease.

University of South Florida College of Nursing Revision August 2013

Side effects/Nursing considerations: Confusion, dizziness, drowsiness, headache, constipation, diarrhea, nausea, gynecomastia, agranulocytosis, aplastic anemia,
arrhythmias. Assess for abdominal pain and tenderness. Monitor CBC. May cause false negatives for allergens and may cause false positive for urine protein.
Name HYRDROmorphone (DILAUDID)

Concentration 0.2mg/mL

Dosage Amount
Basal dose: no basal rate;
PCA dose: 0.2mg (1mL)
Frequency bolus available q10min

Route IV
Pharmaceutical class opioid analgesic

Home

Hospital

or

Both

Indication Moderate to severe pain.

Side effects/Nursing considerations: Confusion, dizziness, constipation, sedation, blurred vision, double vision, headache, unusual dreams, hallucinations,
urinary retention, hypotension, bradycardia, dry mouth, tolerance, physical/psychological dependence. Assess vital signs periodically during administration, If
respirations less than 10 then consider decreased dose. Auscultate bowel function and increase fluids for constipation. Assess cough/lung sounds. Heightened fall
risk.
Name methylprednisolone sodium succinate (SOLUMEDROL)
Route IV
Pharmaceutical class corticosteroids

Concentration 125mg/2mL

Dosage Amount 1.6 mL (100mg)

Frequency once (1104)

Home

Hospital

or

Both

Indication: Immunosuppressant for kidney transplant.

Side effects/Nursing considerations: Depression, euphoria, fever, infection, peptic ulceration, anorexia, vomiting, headache, personality changes, restlessness,
fluid retention, and thromboembolism. Assess for restlessness and fluid retention in extremities and lung sounds. Monitor I&O. Monitor serum electrolytes &
glucose.
Name mycophenolate (CELLCEPT)

Concentration 1,0000mg in dextrose 5% 250mg

Route IV piggyback

Dosage Amount 1000mg (250mL)

Frequency every 12 hours at 125mL/hr (2 hour infusion time)

Pharmaceutical class immunosuppressant

Home

Hospital

or

Both

Indication Immunosuppressant for kidney transplant.

Side effects/Nursing considerations: progressive multifocal leukoencephalopathy, GI bleed, edema, fever, infection, cough, dyspnea, cough, dizziness, headache,
paresthesia, hyperglycemia, hyperkalemia, hypocalcemia, hypokalemia, hypomagnesemia, anorexia, hypertension, hypotension, tachycardia, renal dysfunction.
Name senna docusate (SENOKOT-S) 8.6-50mg

Concentration
8.6mg sennosides
50mg docusate

Route oral

Dosage Amount one tablet

8.6mg sennosides
50mg docusate
Frequency twice daily

Pharmaceutical class stimulant laxative; stool softener

Home

Hospital

or

Both

Indication: Treatment of constipation/constipating drugs. Reduce intra-abdominal pressure and strain after surgery.
Side effects/Nursing considerations: cramping, diarrhea, nausea, discoloration of urine, electrolyte abnormalities, laxative dependence. Assess for abdominal
distension, ausculate bowel sounds before palpation, assess COCA of stool, assess pattern of bowel function.
Name sodium bicarbonate
Route IV
Pharmaceutical class alkalinizing agent

Concentration 25mEqNaHCO3 in 0.45%

Dosage Amount titrated
sodium chloride
Frequency continuous; titrate dosage q hourly, 1mL medication= 1mL
urine output until urine output reaches 1000mL then 3/4 mL medication =
1mL urine output
Home

Hospital

or

Both

Indication Used to alkaline urine and promote excretion of less acidic metabolites. Lower acidity of urine. Correct acid-base balance. Decrease gastric
discomfort.
Side effects/Nursing considerations Edema, flatulence, gastric distension, metabolic alkalosis, hypernatremia, hypocalcemia, hypokalemia, sodium/water
retention, tetany, cerebral hemorrhage. Notify nephrologist if urine output less than 50mL/hr.
Name sulfamethoxazole-trimethoprim (BACTRIM,
SEPTRA)
Route oral
Pharmaceutical class folate antagnonists; sulfoamides

Concentration:
Dosage Amount: 1 tablet
Sulfamethoxazole 400mg
Sulfamethoxazole 400mg
Trimethoprim 80mg
Trimethoprim 80mg
Frequency one tablet q Monday, Wednesday, Friday
Home

Hospital

or

Both

Indication Prevention of bacterial infections in immunosuppressed patients.

Side effects/Nursing considerations Hypotension, fatigue, hallucinations, headache, insomnia, psych depression, hyperkalemia, hyponatremia,
pseudomembranous colitis, hypoglycemia, stevens-johnson syndrome, agranulocytosis, anemia, crystalluria, thrombocytopenia, leukopenia. Assess for infection
with vital signs and all wounds. Monitor I & O. Monitor bowel function. Assess for rash.
Name valGANciclovir (VALCYTE)
Route oral

Concentration 450mg/tablet

Dosage Amount 1 tablet

Frequency q Monday, Wednesday, Friday

University of South Florida College of Nursing Revision August 2013

Pharmaceutical class antivirals

Home

Hospital

or

Both

Indication Prevention of cytomegalovirus with transplant patients, such as heart, kidney, pancreas.
Side effects/Nursing considerations seizures, headache, neutropenia, thrombocytopenia, ataxia, paresthesia, abdominal pain/diarrhea, anemia. Take with food.
Do not break or crush. CMV is diagnosed by ophthalmoscopy for gold standard and cultured blood, urine. Assess for infection with signs in throat, dysuria,
fever, chills, back pain. Assess for dental bleeding and bruising. Avoid IM and rectal temperatures.
Name albuterol nebulizer
Route

Concentration 5mg/1mL

aerosol

Dosage Amount

10mg (2mL)

Frequency once 0315 today

Pharmaceutical class:

Home

Hospital

or

Both

Indication: Treatment of hyperkalemia. By MAR, 4 doses before dilution for treatment of hyperkalemia.
Side effects/Nursing considerations: nervousness, restlessness, headache, paradoxical bronchospasm, chest pain, nausea, vomiting, hyperglycemia, hypokalemia,
insomnia, hypertension, arrhythmias. Assess lung sounds and vital signs before and after, especially paradoxical wheezing. Lower potassium serum
concentration is transient until excretion of higher than normal potassium levels.
Name alemtuzumab (CAMPATH)

Concentration 30mg /100mL in 0.9%NS

Route IV

Dosage Amount 30mg

Frequency once 0923

Pharmaceutical class monoclonal antibodies

Home

Hospital

or

Both

Indication Used as a accelerator/catalyst for immunosuppression for kidney transplant.

Side effects/Nursing considerations; depression, dizziness, drowsiness, weakness, abdominal pain, HTN, hypotension, headache, tachycardia, constipation,
stomatitis, sweating, rash, edema, neutropenia, marrow hypoplasia, anemia, back/skeletal pain, infection. Monitor for infusion reactions such as hypotension,
shortness of breath, bronchospasm, chills, and rash. Pre-medicate with oral antihistamine prior to initial dose and dose changes. CBC and platelet counts at
least weekly. Assess CD4 counts to stay greater than 200 cells/mm 3. Inspect solution for clarity, color, and expiration. Medication prone to patient injury.
Name dextrose 50% IV syringe

Concentration 50g/100mL (50,000mg/100mL)

Route IV

Dosage Amount 25g (50mL), (25,000mg)

Frequency once 0307

Pharmaceutical class carbohydrates

Home

Hospital

or

Both

Indication Provides hydration and calories while patient is NPO after surgery. To start on clear liquids today. Given prior to insulin for treatment of
hyperkalemia. Hyperkalemia due to impaired urinary elimination after kidney transplant
Side effects/Nursing considerations: Fluid overload, hypokalemia, hypomagnesemia, hypophosphatemia, glycosuria, hyperglycemia. Assess hydration status
before administration. Monitor I&O, electrolytes. Assess for hyperglycemia and patient response.
Name insulin aspart (NOVOLOG)

Concentration 100units/1mL

Route subcutaneous injection

Pharmaceutical class pancreatics

Dosage Amount 2-10 units

Frequency up to three times daily with food and bedtime

Home

Hospital

or

Both

Indication Tight glucose control for hyperglycemia to aid recovery after kidney transplant. Sliding scale starting at blood sugar 150mg/dL and add 2 units for
every increase +50mg/dL blood sugar until max of 10units.
Side effects/Nursing considerations Assess for hypoglycemia symptoms, such as sweating, pale skin, tachycardia, anxiety, headache, tingling, restlessness. For
blood sugar below 60mg/dL, repeat accu chek. If patient still below 60mg/dL blood sugar, while patient NPO, give D50W 50mL as IV push. Retest BG in
15minutes, retreat as necessary, retest q 1-2hours. Monitor body weight.
Name insulin regular (HUMILIN R, NOVOLIN R)
injection 10 units
Route IV
Pharmaceutical class pancreatics

Concentration 0.5-1unit/1mL for IV push

Dosage Amount 10units

Frequency once 0307

Home

Hospital

or

Both

Indication Treatment of hyperkalemia for temporary reduction by uptake into cells, thus reduction of serum potassium.
Side effects/Nursing considerations: Assess for hypoglycemia symptoms, such as sweating, pale skin, tachycardia, anxiety, headache, tingling, restlessness. For
blood sugar below 60mg/dL, repeat accu chek. If patient still below 60mg/dL blood sugar, while patient NPO, give D50W 50mL as IV push. Retest BG in
15minutes, retreat as necessary, retest q 1-2hours. Monitor body weight.
Name fentanyl (SUBLIMAZE)

Concentration 50mcg/1 mL (50,000mg/1mL)

Route IV

Dosage Amount 50mcg (50,000mg)

Frequency q5minutes PRN

Pharmaceutical class opioid agonist

Home

Hospital

or

Both

Indication Post operative analgesia for acute pain. Use if Dilaudid is ineffective or contraindicated, for severe pain 7-10.
Side effects/Nursing considerations: confusion, blurred/double vision, apnea, respiratory depression, hypotension, arrhythmias, facial itching, muscle rigidity,
n/v, laryngospasm, drowsiness, circulatory depression, bradycardia. Monitor vital signs, especially respiratory depression. Heightened fall risk. May cause
increased lab values of amylase and lipase
Name hydrALAZINE (APRESOLINE)

Concentration 20mg/1mL

Dosage Amount 5mg (0.25mL)

University of South Florida College of Nursing Revision August 2013

Route IV

Frequency q 4hours PRN, repeat if SBP goal not met up to 4 doses.

Pharmaceutical class vasodilator

Home

Hospital

or

Both

Indication For treatment of moderate to severe hypertension, SBP greater than 160.
Side effects/Nursing considerations: hypotension, n/v, diarrhea, sodium retention, tachycardia, angina, dizziness, headache, rash, joint pain, orthostatic
hypotension. Heightened fall risk. Monitor vital signs. Monitor CBC and electrolytes. Assess feet and ankles for fluid retention.
Name furosemide (LASIX) in 0.9%NS 50mL

Concentration 125mg/50mL (2.5mg/mL)

Route IV

Dosage Amount 125mg(50mL)

Frequency once 0300

Pharmaceutical class loop diuretic

Home

Hospital

or

Both

Indication Relief of edema and hypertension due to renal disease.

Side effects/Nursing considerations: orthostatic hypertension, blurred vision, headache, anorexia, constipation, n/v, excessive urination, stevens-johnson
syndrome, itching, rash, hives, anemia, agranulocytosis, muscle cramps, paresthesia, hypokalemia, hypovolemia, metabolic alkalosis, higher BUN,
hyperglycemia. Assess fluid status. Monitor weight, I&O, lung sounds, mucous membranes, turgor, vital signs. Heightened fall risk when transferring, do with
staff assistance. Take rests in between lying, sitting, standing.
Name labetalol (NORMODYNE)

Concentration 5mg/1mL

Route IV

Dosage Amount 5mg (1mL)

Frequency q5min PRN, repeat if goal not met for maximum of 4 doses.

Pharmaceutical class beta blocker

Home

Hospital

or

Both

Indication Treatment of hypertension, SBP greater than 160 with HR greater than 60.
Side effects/Nursing considerations: fatigue, weakness, anxiety, drowsiness, hypotension, bradycardia, wheezing, arrhythmias, pulmonary edema, CHF,
constipation, hyperglycemia, hypoglycemia, joint pain, back pain, hyperglycemia, muscle cramps/tingling, blurred vision, dry eye, mental status changes.
Monitor vital signs before administration, goal is SBP less than 160, hold if heart rate lower than 60. Monitor fluid overload, I&O, edema, dyspnea, weight gain,
JVP. Glucagon used to treat bradycardia and hypotension. Notify provider if max of 4 doses does not meet SBP goal or if held before goal due to HR.
Name metoclopramide HCl (REGLAN)

Concentration 5mg/1mL

Route IV

Dosage Amount 5mg (1mL)

Frequency q 6 hours PRN

Pharmaceutical class antiemetic

Home

Hospital

or

Both

Indication If Zofran is ineffective for nausea and/or vomiting. Prevention of aspiration.

Side effects/Nursing considerations. Drowsiness, EPS, neuroleptic malignant syndrome, anxiety, depression, HTN, hypotension, arrhythmias, constipation,
diarrhea, gynecomastia, agranulocytosis, neutropenia. Assess for abdominal distension, bowel sounds before and after administration, vital signs, too. May raise
serum prolactin and aldosterone(sodium retention, thus fluid retention, thus higher BP).
Name metroprolol (LOPRESSOR)

Concentration 1mg/mL

Route IV

Dosage Amount 5mg (5mL)

Frequency q6 hours PRN

Pharmaceutical class beta blocker

Home

Hospital

or

Both

Indication Treatment of HTN with SBP above 180mmHg or DBP above 100mmHg, prevention of MI due to lack of circulatory flow related to increased
vascular resistance.
Side effects/Nursing considerations: fatigue, weakness, anxiety, depression, bradycardia, pulmonary edema, heart failure, blurred vision, stuffy nose,
constipation, dry mouth, flatulence, heartburn, increased liver enzymes, hyperglycemia, hypoglycemia, joint pain. Monitor vital signs before, after therapy.
Monitor fluid retention by I&O, daily weights, lung sounds, JVP, edema. Hold for heart rate below 60bpm and place on telemetry
Name ondansetron (ZOFRAN)
Route

Concentration 4mg/2mL

Intravenous

Dosage Amount 2mL

Frequency PRN every 6 hours

Pharmaceutical class five ht3 antagonist

Home

Hospital

or

Both

Indication Prevention of nausea and vomiting , after kidney transplant. Prevention of aspiration/pnemonia
Side effects/Nursing considerations: Headache, dizziness, weakness, constipation, creation of torsade de pointes arrhythmia, EPS, abdominal pain, dry mouth,
increased liver enzymes, hypokalemia, hypomagnesemia, bradycardia. Single dose IV over 2-5 minutes as undiluted solution. May cause transient increase in
serum bilirubin, AST, ALT.

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Analysis of home diet (Compare to My Plate and
NPO morning and switched to clear liquid this shift
Diet pt follows at home? Was a low protein, low sodium, Consider co-morbidities and cultural considerations):
low saturated fat diet
24 HR average home diet:
Patients grains intake is 31% of his recommended daily
value. His intake is 3.1 oz eq of the recommended 10oz
Breakfast: white toast, 3 egg omelet, sausage, juice
equivalents. Patients vegetables intake is 19% of his
(orange/apple)
recommended daily value. His intake is 0.7cup equivalents
of the recommended 3.5 cup equivalents. Patients fruit
Lunch: Boars Head turkey cold cut sandwich on wheat
intake, due to drinking apple and orange juice, is 119% of
bread, Lays potato chips
his recommended daily value. His intake is 3.0 cup
equivalents of the recommended 2.5 cup equivalents.
Dinner: New Orleans style shrimp & sausage jambalaya
Patients dairy intake is 18% of the recommended daily
value. His intake is 0.5cup equivalents of the recommended
Snacks: potato chips, kids fruit snacks, snickers bar
3.0 cup equivalents. His protein intake is 284% of the
recommended daily value. His intake is 19oz eq of the
Liquids (include alcohol):
recommended 7.0oz equivalents. The patient probably
Orange juice, apple juice, water, coffee
inaccurately reported his daily intake, and probably instead
stated his ideal daily menu. Patient was on a low protein,
low sodium diet. The stated daily intake of protein would
not be acceptable. Within his culture, he can stick to the
New Orleans jambalaya and eliminate the turkey sandwich
and switch he eggs to fruits and vegetables. Patient should
not intake his fruits only in juice form, because this
eliminates vitamins and fiber, and adds simple sugar. He is
advised to eat about 8.0 teaspoons of healthy oils per day,
such as extra virgin olive oil. Weekly, he is advised to eat
3.0 cups of dark green vegetables, 2.5cups of orange
vegetables, 7.0 cups of starchy vegetables, and 8.5 cups of
any vegetables. He needs to aim for at least half the
recommended value of 10oz eq per day. Patient likely
reported his food intake inaccurately. Sodium intake is also
more than three times above the recommended value, and
he is supposed to be on a low sodium diet. Patient is
believed to have stated inaccurate data regarding his protein
intake.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My wife is my biggest help. My parents sometimes take care of my kids to help me, too.
How do you generally cope with stress? or What do you do when you are upset?
I like to watch TV, read books. I also coach baseball and coach football, for my son. I like to read biographies. We have

University of South Florida College of Nursing Revision August 2013

family get-togethers at restaurants, and cookouts.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I want to be able to travel again, but I have a social life here. I dont feel like I am having any of psychological
difficulties. I just got to be patient and give it up to God.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship?
No
Have you ever been talked down to? No
Have you ever been hit punched or slapped? No
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No.
If yes, have you sought help for this? N/A
Are you currently in a safe relationship? Yes, my wife is an amazing woman.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

Eriksons stage of intimacy versus isolation has the conflict of young adults seeking to share an identity with another
person intimately (Sigelman & Rider, 2012). A person must have an individual identity that is well-formed by this stage,
or the person may fear intimacy. This may lead to loneliness and isolation. This patient is 34 years old and his
psychosocial development is congruent with Eriksons stage of intimacy vs. isolation. The patient XXX reports that his
illness is primarily a hindrance to vacation with his family and friends, thus the primary reason for health is to share more
experiences with his closest relationships. His identity of a family man and father leads him to look forward to not just
having a new kidney for vacation, but returning to work in the same field. He professes a committed relationship of 14
years, and has two children, including a daughter of two years. He coaches various sports that his son plays. He also
reports playing tea parties with his daughter. He appears to have no difficulty professing his needs to his wife, but
needs are stated simply and are not over-needy. His wife appears to be mutually supportive with him. He is approaching
his new kidney as a plan of care that will allow him to lead a fuller life, planning to travel on a long vacation in about a
year. Hemodialysis over the past two years since removal of his first transplant is reportedly viewed as just a period in
my life. The burns he suffered in 1990 that may have caused the kidney malfunction are not viewed as a negative
experience. When asked if his life would have been different without that incident, he said, I think I would be doing kind
of the same thing with my life anyway. I love my family. I love to work. I stay active by walking six miles at least twice
a week. I have kept my body ready to return to work, now that I have received from a good donor.

University of South Florida College of Nursing Revision August 2013

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

This patient underwent each evaluation with calm presentation. The patient responded positively to all needed diagnostics,
treatment, and care. His developmental age has kept pace with his natural age. He appears to share mutual intimacy with
his wife of 14 years. He is able to state his needs to his family and treatment team, without negative emotion or negative
reciprocation. He reports no difficulty in generally following his recommended diets, though it is impossible that he
accurately reported his 24 hour diet that he had prior to transplant. He reports having maintained an active exercise
regimen of walking approximately six miles at least twice a week during the last two years of hemodialysis three times
per week. He reports feeling grateful that medical interventions are available for him to experience the best parts of life,
which includes food, family, fun, and God.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I was badly burned in a house fire when I was a teenager. My kidneys were damaged because they became overworked. I
did not have kidney failure until awhile after the incident.
What does your illness mean to you?
I became a security guard, and I also used to be a fire inspector. It did not stop me from being able to provide for my
family, and I intend to go back to work. My faith is a great source of strength to me to help guide me. However,
sometimes my illness has been a great hindrance, because I cant go on a vacation with my kids.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?___Yes. _________________________________________________________
Do you prefer women, men or both genders? __Females._________________________________________________
Are you aware of ever having a sexually transmitted infection? __No.____________________________________
Have you or a partner ever had an abnormal pap smear?____Not that I know of.
Have you or your partner received the Gardasil (HPV) vaccination? _____No._________________________ ______
Are you currently sexually active? ___Yes.________________________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? My wife has her tubes tied now. We are monogamous.______________________________
How long have you been with your current partner?___14 years.
Have any medical or surgical conditions changed your ability to have sexual activity? __No.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.

University of South Florida College of Nursing Revision August 2013

10

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life? I surrender my life up to God. That is my strength.
Do your religious beliefs influence your current condition? Its my reality. I could not heal without God._
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what? N/A
How much?(specify daily amount)

Yes
No
For how many years? 0 years
(age

thru

If applicable, when did the

patient quit?

Pack Years: N/A

Does anyone in the patients household smoke tobacco?
No. If so, what, and how much? N/A

Has the patient ever tried to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
~360mL every weekend (2-3 beers
Beer, bud lite
per rotating weekends)
If applicable, when did the patient quit?

For how many years?

(age 21 years old
years old)

thru 23

2004

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
For how many years? I just tried it a
How much?
maybe 2-3 times.
Tried it, several inhalations, no
age 15 years old
THC
ingesting
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Not currently. I am on disability. I have not been exposed to dangerous chemicals, not to my knowledge. There is the
potential for getting physical, as a security guard. I want to return to duty for my agency, but I am not ready to focus on
that.

University of South Florida College of Nursing Revision August 2013

11

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:30
Bathing routine: per patient, wipes
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia-mild
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2-3 x/day
2x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry (intermittent rare)
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2/12/2015
Other:

Central Nervous System

or

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

productive

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression (history in 1990)
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

12

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No.

Any other questions or comments that your patient would like you to know?
No.

University of South Florida College of Nursing Revision August 2013

13

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey:

Height: 62
Pulse: 74

Temperature: (route taken?)

Oral sublingual
98.4F

Respirations:

16

Weight: 171.6lbs (78kg) Pain: (include rating & location)

BMI: 22 (normal range) 4 with acute instances
of 7
Blood
Left abdomen/site of
Pressure: 142/106

Left arm, sitting

(include location)

kidney transplant
surgery

SpO2 : 97%
Is the patient on Room Air or O2:
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Peripheral IV site Type: over-the-needle 22G

Location: Right metacarpal vein
Date inserted: 10/28/2015
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Sodium bicarbonate (680mL/hr-titrated hourly by output of foley catheter)
Peripheral IV site Type: over-the-needle 16G Location: Right median vein underside of arm Date inserted: 10/28/2015
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without
nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 12 inches & left ear- 12 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: straight teeth, history of braces at 12 years old, no cavities, regular oral care per patient
Comments:

University of South Florida College of Nursing Revision August 2013

14

Pulmonary/Thorax:
CL

CL
CL

CL

CL

CL

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: left 5th ICS mid-clavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No ECG tracing available. Patient is sinus rhythm with regular S1 S2. No clicks, no gallops, no murmurs. Patient has no
history of MI, no chest pain, and no chest pressure.

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: +2
Carotid: +2
Brachial: Not assessed
Radial: +2
Femoral: Not assessed
Popliteal: +2
DP: +2
PT: Not done
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: feet, ankles
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: pink
Previous 24 hour output:
200 mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness - (Not assessed due to new kidney transplant)
Last BM: (date 10 / 27 / 2015
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: X Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5_____ RUE ___5____ LUE ____5___ RLE

& ____5___ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
tereognosis(not assessed, graphesthesia(not assessed), and proprioception intact
Gait smooth, regular with
symmetric length of the stride(did not walk during my shift)
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Not done
Biceps: Not done
positive absent Babinski: positive absent

Brachioradial: Not done

Patellar: Not done

Achilles: Not done

Ankle clonus:

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
Creatinine
Normal:0.57-1.11mg/dL
10/28: 7.8
10/29: 7.7

Potassium
Normal: 3.5-5.3mmol/L
10/28: 6.3
10/29: 5.5

Dates

Trend
Slight improvement,
indicating that kidney is
likely waking up and
excreting properly.

Trending towards
normal. No clinical
manifestations of
arrythmia.

Analysis
This is the primary lab
value that indicates
effectiveness of kidney
function. A high value
indicates kidney
insufficiency and would
indicate that the kidney
is not working. Even a
0.1 decrease is
significant considering
that patient has not had
dialysis since prior to
surgery and he was
anuric prior to surgery.
High or low levels of
potassium are a primary
indicator of potential for
arrhythmias. Patient
also has diastolic
dysfunction history,
which affects preload, so
it is important, as well
as hypertrophy of the

Sodium
Normal: 135-145mEq/L
10/28: 129
10/29: 132

Trending towards
normal. No clinical
manifestations of
hyponatremia.

BUN
Normal: 22-29mEq/L
10/28: 34
10/29: 28

Trending towards
normal. No clinical
manifestations.

Hemoglobin
Normal: 12.2-16.2g/dL
10/28: 9.7
10/29: 9.9

Trending towards
normal. Patient reports
low level of fatigue.

Hematocrit
Normal: 37.7-47.9%
10/28: 30.9
10/29: 31.2

Trending towards
normal. No clinical
manifestations.

White Blood Cell Count

Normal: 4600-10,200
10/28: 13.48
10/29: 12.47

Trending towards
normal. No clinical
manifestations of
infection.

left ventricle. Potassium

is excreted through
urine, so decrease shows
the kidney is starting to
function properly.
Low sodium most often
indicates raised level of
fluid volume.
Hyponatremia can
affect mental status
changes.
Blood urea nitrogen can
be affected by many
other things such as a
high protein meal.
However, patient was
NPO yesterday. BUN is
excreted in the urine. He
is not muscle wasting so
soon after stopping his
active lifestyle.
Hemoglobin carry
oxygen to the organs
and ensure cellular
respiration and
prevention of
hypoxemia. A drop in
hemoglobin is related to
hematocrit, which is
related to creation of
red blood cells.
Hematocrit is the
proportion of red blood
cells in the blood. A low
level of hematocrit is
related to hypoxemia.
Patients body had
inflammaion after
invasive surgery,
resulting in raised WBC
count. An infection
would result in
continued higher levels.
Since levels are
decreasing, patients
inflammation may be
decreasing. Patient is
also on
immunosuppressive
drugs, and lower than

normal levels may

predicate infection

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is on NPO and is to be switched to clear liquids today. He was able to take his oral medications. He is
also to get up to the chair today. However, he is to leave the foley catheter in for four days after surgery on10/28.
This may limit his mobility. His urinary inputs and outputs are being recorded along with color and clarity. Accu
checks are being completed hourly on this patient. A biopsy of the kidney may be done. A CT of abdomen may
be done to detect possible infections, fluid collections, or other problems. An MRI of the abdomen may be done
for similar results, but also shows soft tissues better with three dimensional imagery. An ultrasound may be done
to find fluid collections and to aid confirmation of normal vasculature functioning to kidney. He will be kept on
an chronic immunosuppressant regimen that will start with intravenous and move to oral. He will be monitored
for transplant related infections and opportunistic infections, such as CMV, EBV, and candidiasis. He is on
antiviral medications. Patient will get a biopspy completed. Lab tests like CBC, CMP, therapeutic drug levels of
immunosuppressants,

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Risk of for ineffective renal perfusion r/t complications from kidney transplant procedure AEB urinary output amount,
color, and consistency, as well as temperature monitoring for fever, creatinine and blood urea nitrogen(BUN) monitoring,
pain or tenderness around transplanted kidney, hypertension and fluid retention, especially around eyelids, hands, feet, legs,
or ankles.
2. Ineffective immune protection r/t immunosuppressive therapy AEB white blood cell count.

3. Acute pain r/t surgical site of incision AEB patient verbal report.
4. Nausea and vomiting r/t irritation to gastrointestinal system after patient started clear liquid diet AEB patient verbal
report.
5. Impaired skin integrity r/t decreased mobility after transplant surgery AEB patients observed decreased activity after
surgery from prior reported lifestyle.

 15 CARE PLAN
Nursing Diagnosis: Risk of for ineffective renal perfusion r/t complications from kidney transplant procedure AEB urinary output amount, color, and
consistency, as well as increased local or core temperature, pain or tenderness around transplanted kidney, and fluid retention, especially around eyelids, hands,
feet, legs, or ankles.

Patient Goals/Outcomes
Urinary drainage through foley
catheter will equal 30mL/hour or
greater, and catheter will cause
minimal irritation.

Urinary drainage will be of

increasingly normal color and

Nursing Interventions to Achieve

Goal
Patient will be titrated on
bicarbonate for equal urinary
output. Patients hypertension will
be controlled by medication
interventions to limit activity of
sympathetic nervous system.
Patient will report that he had a
calm, controlled environment to
limit activity of sympathetic
nervous system. Patients input and
output will be recorded hourly,
including intravenous fluid input.
Patients foley catheter will be
assessed during the shift for
appropriate attachment and
insertion, without abnormalities
and limited alterations in
discomfort.

Rationale for Interventions

Provide References
Bicarbonate encourages the body
to not have metabolic acidosis,
which is a potential complication.
(Osborn, Wraa, Watson, &
Holleran, 2014). Hypertension is
another potential complication of
kidney insufficiency d/t volume
overload or RAAS system (Osborn
et al., 2014). A calm controlled
environment is advantageous to
controlling patient stress, which
controls psychologically influenced
changes in blood pressure (Ackley,
& Ladwig, 2007). Normal urinary
drainage is considered to be a
minimum of 30mL/hour (Osborn et
al., 2014).

The color of patients urine will be

regularly noted in drainage tube

Patient s urine after transplant has

some hematuria due to surgery

Evaluation of Goal on Day care is

Provided
Patient was effectively titrated with
bicarbonate for hourly changes in
urinary output. Patients systolic
blood pressures were maintained in
the 140s and low 150s throughout
the shift. Patient reported that he
appreciated the door being closed
and the nursing contacts being
predictable. Patient reported all of
his items were kept within reach,
whether he was in bed or chair.
Patient reported that he felt had a
calm environment maintained.
Patient reported limited frustration
during shift. Patients input/output
was averaged between 200-300mL
per hour throughout the shift.
Patients foley catheter maintained
proper placement and patient
reported no added discomfort.
Patient was aided by staff to
transfer to chair from bed in order
limit catheter movement
discomfort. Since patient is to have
the foley catheter left a minimum
of four days, it is extremely
important to limit discomfort.
Patients urine changed from pink
to dark yellow. It separated in the

clarity.

before collection bag, since

collection bag has previous pink
urine drainage.

Patient will be free from edema.

(Osborn et al., 2014). As the kidney

begins to activate, the urine should
become more yellow (Osborn et
al., 2014).

Patient will be continually assessed

for edema and swelling by self
report, as well as objective
assessment with palpation of
general problem areas, which can
include eyelids, hands, feet, legs,
and ankles.
Patient will maintain a normal core Patients temperature will be taken
temperature, as well as no localized hourly, with repeat temperatures
spots of temperature change,
taken for outlier readings. Notice
especially at site of kidney
will be taken of fluid output in
transplant.
relation to temperature readings,
ensuring that bicarbonate is being
titrated equal to most recent fluid
output. The provider will be
notified in the case of increased
temperature not related to lapsed
fluid titrations.

Common sites of edema are

assessed for obvious sites of fluid
retention likely related to
insufficient urinary output after
kidney transplant (Osborn et al.,
2014).

Patient will be free from sudden

changes in pain in regard to
character, intensity, or referred pain
at the site of surgery.

Changes in pain after

transplantation can indicate
rejection or infection (Osborn et
al., 2014).

Patient will asked about changes in

pain, including character, intensity,
and site. Patients pain will be
assessed hourly. Usage of PCA
pump will be noted for frequency
changes. Palpation will be done
around abdomen and chest that is
neighboring surgical site. Patient
will be asked about activities
surrounding any increases in pain
or tenderness.

Signs of infection or rejection

include temperature changes in
core or at transplant site (Osborn et
al., 2014).

collection bag, but color difference

was most easy to note in the
drainage tube. Urine was clear,
indicating absence of infection or
sediment.
Patients extremities and face were
assessed to be free from edema
throughout the shift.

Patients temperatures averaged

98.4F throughout the shift. No
outlier temperature readings were
recorded, as attention was paid to
timing of oral fluid intake after
clear liquids started at end of shift.
Bicarbonate was titrated properly.
The provider did not have to be
notified of core or local
temperature changes. The skin was
lightly palpated around dressing on
left abdomen.
Patient reported no character
changes in pain except sharpness
when pain suddenly became a 7
with sudden movement. Pain was
chronic around 4. Patient was
encouraged to use PCA pump more
often prior and after physical
therapy in chair. Patient wore an
abdominal binder ordered for him.
He demonstrated ability to
correctly secure the device. Patient
was guarding of incision site.
Patient denied referred pain.

Abdominal assessments started

away from surgical site to
approaching. No increase in radius
of pain or guarding.
Reestablish electrolyte balance, as
Blood samples will be taken daily. As kidney activates, normal
Blood samples were taken. All
well as other lab levels. Lab results Blood will not be taken from 22G. processes that involve kidney
expected abnormal values
will show levels trending towards
Daily CBC will be analyzed for
should normalize, including
approaching normal levels
normal, signifying transplant
trends. CMP will also be taken for
erythropoietin release and
including potassium, creatinine,
acceptance.
trends.
excretion of electrolytes (Osborn et sodium, hemoglobin, and
al., 2014).
hematocrit. Patient was given
240mg of Lasix IV during
afternoon shift yesterday to drop a
6.3 potassium level to 5.5, as well
as other values noted in lab value
section.
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult Patient already is active with disability monthly benefit.
X Dietary Consult Patient will benefit from a kidney transplant diet, maintaining low sodium. Patient will no longer be on a low protein diet but lab
levels will be watched. Patient must also be careful of supplementation.
X PT/ OT Patient reports that he would accept outpatient or home physical therapy referral to maintain his strength during recovery. Patient will
have to incrementally increase activity and not stress kidney, especially since blood pressure is high. He is currently at low level risk of skin
breakdown because of his youth, but he has a much decrased level of activity from normal.
Pastoral Care
Durable Medical Needs
X F/U appts Follow-up to be scheduled with nephrology and surgeon. Patient will be transported by wife for appointments. He is on Medicaid, so
previous difficulty with purchasing transplant medications prior to 2013 should not be an issue.
X Med Instruction/Prescription: Patients medications are all available through Medicaid. Prescriptions will be needed for life for immunosuppression
with potential for exacerbations that may lead to hospital admission. Patient was able to verbally demonstrate knowledge of side effects of
medications and importance of daily maintenance. Patient avoids crowds other than his family and is careful to bring hand sanitizer on outings. He
does not directly touch his eyes, nose or mouth without washing his hands.
are any of the patients medications available at a discount pharmacy? (not an issue)
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Ineffective immune protection r/t immunosuppressive therapy, surgical incision, and imperfect match for kidney tranplant AEB white blood
cell count.

Patient Goals/Outcomes
Patients immunosuppression will
be maintained at a therapeutic level
to prevent transplant rejection.

Nursing Interventions to Achieve

Goal
Patients total WBC and
differentiated WBC count will be
monitored for informing the
provider of therapeutic level of
immunosuppression.

Patients surgical incision will be

free of infection and intact.

Patients dressing will be kept

clean and dry, being regularly
assessed. Site will be assessed for
pain and dehiscence. Provider will
be notified of any abnormalities.
Patient will be kept on supervised
activity, and physical therapy will
maintain body tone.

Patient will not get a nosocomial

infection.

Patient will be encouraged to turn,

cough, and deep breath, with a
pillow pressed on surgical site.
Patient will be taught to wear a
mask and gloves as appropriate, as
immunosuppression progresses.
Patient will use incentive
spirometer twice per hour to
prevent lung complications postsurgery.
Patient was given printed materials
on cancer risks associated with
post-operation transplant. Patient
was educated on clothing with SPF
value, use of hats, and encouraged

Patient will be educated about long

term increased risk of cancer, such
as skin cancer.

Rationale for Interventions

Provide References
Patient will be at risk for infection
once immunosuppressive drugs are
regularly administered (Osborn et
al., 2014). He is being administered
cytotoxic drugs, such as cellcept.
Lab levels will be below normal.
Immunosuppression will be for
lifetime.
Patients surgical incision requires
regular assessment due to
proximity to surgery (Ackley, &
Ladwig, 2007). Patient may have
delayed wound healing as a
complication of the surgery and
medications.
Patient teaching for
immunosuppressed patients should
encourage proper hygiene and
contact precautions, especially
while in hospital (Ackley, &
Ladwig, 2007).

Protecting the skin from excessive

sun exposure is important to
limiting potential for skin cancer
(Sigelman & Rider, 2012). After 15
minutes of sun exposure to area of

Evaluation of Interventions on
Day care is Provided
This patient has an increase in
neutrophils and total granulocytes.
He has a decrease in lymphocytes
and monocytes. His WBC is
interpreted as elevated due to
inflammation from surgery.
Immunosuppression is in its early
stages.
Patients surgical incision was well
padded and without evidence of
drainage through the dressing.
Physical therapy was able to
exercise patient without change to
dressing, still intact and dry.
Increased pain after physical
therapy subsided using PCA pump
at first, and did not return.
Patients lungs are clear, all fields.
Patient verbalized agreement to
perform regular hand sanitation and
how to ask for contact precaution
materials, as needed. Patient
cooperated with suggestion to use
incentive spirometer every half
hour. He reached top level on all
recorded events.
Patient reports that he covers
himself from sun, and that he
understands how to find clothing of
SPF value. Patient verbalized
dangers of sun exposure as

to continue using sun screen.

Patient will be educated on a diet
post-transplant.

Patient will be referred to dietician

and be offered printed materials on
low sodium diet, eat complex
carbohydrates that take longer to
digest, limit saturated fat intake
from sources such as fried and
dairy foods, and eat protein rich
foods for a period of recovery after
surgery.

lightest skin, many people achieve

adequate vitamin D absorption.
Steroid medications limit the
bodys ability to use carbohydrates,
which may cause diabetes (Osborn
et al., 2014). Protein rich foods will
help build up muscle tissue.

increased due to being posttransplant.

Patient discussed the high protein
foods that he likes to eat. During
dietary assessment, he probably
was confused about what diet he
will have immediately following
allowing regular solid foods,
compared to diet prior to surgery.

DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult Patient already is active with disability monthly benefit.
X Dietary Consult Patient will benefit from a kidney transplant diet, maintaining low sodium. Patient will no longer be on a low protein diet but lab
levels will be watched. Patient must also be careful of supplementation.
X PT/ OT Patient reports that he would accept outpatient or home physical therapy referral to maintain his strength during recovery. Patient will
have to incrementally increase activity and not stress kidney, especially since blood pressure is high. He is currently at low level risk of skin
breakdown because of his youth, but he has a much decrased level of activity from normal.
Pastoral Care
Durable Medical Needs
X F/U appts Follow-up to be scheduled with nephrology and surgeon. Patient will be transported by wife for appointments. He is on Medicaid, so
previous difficulty with purchasing transplant medications prior to 2013 should not be an issue.

X Med Instruction/Prescription: Patients medications are all available through Medicaid. Prescriptions will be needed for life for immunosuppression
with potential for exacerbations that may lead to hospital admission. Patient was able to verbally demonstrate knowledge of side effects of
medications and importance of daily maintenance. Patient avoids crowds other than his family and is careful to bring hand sanitizer on outings. He
does not directly touch his eyes, nose or mouth without washing his hands.
are any of the patients medications available at a discount pharmacy? Yes No (not an issue)

15 CARE PLAN
Patient Goals/Outcomes
Encouraged to use more dilaudid
with PCA to have better physical
therapy.
TCDB due to limited mobility due
to fall precautions and high blood
pressure & foley
Infection risk, risk for cancers, esp.
skin. Risk for GI problems n/v,
leukopenia, infxns (bac & viral)
Short term complications delayed
wound healing, hypotension,
respiratory failure, fever
Exact output replaced with bicarb
every hourfor 12 hours, currently
200-300mL/hr output
Get to chair
Abdominal binder
Lasix IV piggyback 240mg normal
is 40mg
Retain

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Ackley, B. J. & Ladwig, G. B. (2007). Nursing diagnosis handbook: An evidence-based
guide to planning care (8th ed.). St. Louis: Mosby/Elsevier.
Choose MyPlate. (n.d.). Retrieved November 15, 2015, from http://www.choosemyplate.gov/
Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St. Louis, MO: Elsevier
Mosby.
Osborn, K., Wraa, C., Watson, A., Holleran, R. (Eds.). (2014). Medical-surgical nursing: Preparation for
practice (2nd ed.). Upper Saddle River, New Jersey: Pearson.
Sigelman, C.K., & Rider, E.A. (2012). Life-span human development (7th ed.). Belmont, California:
Wadsworth Cengage Learning.
Unbound Medicine, Inc. (2015). Nursing Central (Version 1.26). [Mobile application software]. Retrieved from
http://itunes.apple.com