First ward exposure

[deanikins211]

tommorrow will be our first ward exposure. I just finished visiting my patient a while ago. Her diagnosis is Chronic Kidney disease T/C(dont know how to read) infected fistula and chief complaint is Fever and pain over the right side of the chest

The question is , how should I assess him so that I can make a good Plan of Care and DAR?

thank you

[Daytonite, BSN, RN]

there is information on dar charting on this sticky thread:

• https://allnurses.com/forums/f205/nursing-documentation-168921.html - nursing documentation (in the nursing student assistance forum)

you should be looking up information about chronic renal disease, it's pathophysiology, signs and symptoms and treatment. you want to look for and ask you patient about those symptoms when you do your interview and physical exam. don't forget to assess the patient's ability to do their adls. i worked on a renal unit at the beginning of my career. these patients have a lot of medical problems and complications. assess this fistula as well. the patient has it for hemodialysis, but it can't be used while it is infected, so an alternative access has to be established. sepsis is a complication of infected fistulas. look up the signs and symptoms of sepsis and assess the patient for those as well. just guessing here, but is this patient diabetic? or, have heart disease or hypertension?

• assessment
  
  • a physical assessment of the patient
    
  • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    
  • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    
  • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    

all of the information listed above under assessment is needed to write a care plan.

[deanikins211]

thanks a lot daytonite. Patient is not diabetic but has high blood pressure...his blood pressure is 130/90..