Jump to content

need help with clinical worksheet

Posted

i have clinical tomorrow and i went today to the hospital to collect information on my patient. she is diagnosed with degenerative joint disease and valgus deformity. She had abnormal lab values of L3.15 RBC, L28 HCT,L9.3 HGB, H129 Glucose, H1.31 Creatinine, L41 Est GFR Non-African American, L 49, Est GFR African American and L8.2 Calcium. I have to have these these values on my sheet and the "rationale" as to why my patient has an abormal value. I know low GFR values are related to kidney disease but there was no mention of kidney disease in her charts. I just don't know what they want for these rationales. She had surgery the 29th. could this be related to any of the abnormal values. The GFR values confuse me the most. Wouldn't they include some kind of mention of the state of her kidneys in the chart if her GFR values are abnormal? What kind of rationales can I relate to these abnormal values?

JROregon, ASN, BSN, RN

Specializes in Infusion. Has 5 years experience.

As we age, our kidneys tend to do a poorer job. I don't know how old your patient is though. The fact that the patient may be diabetic (that one high glucose number isn't as helpful as several days worth or an Ha1c #) could be the problem. High blood pressure that is poorly controlled would be another reason. I would see a lot of this with my older >65 or diabetic patients quite ofter but never see a mention of kidney disease in the history.

AgentBeast, BSN, RN

Specializes in Cardiology and ER Nursing. Has 8 years experience.

Usually the physicians progress notes paint a pretty good picture of a patient's situation. I'd have a look at those if you have access to them.