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The client’s creatinine and serum potassium were elevated, she was referred to a nephrologist for possible dialysis. Make pathophysiology on how kidney failure happens to a client with acute congestive heart failure. 2. Create CHART (C-hief complaint, H-istory, A-ssessment, R-x/treatment, T-ransport) documentation for the patient. (see 2nd photo for reference)

The client’s creatinine and serum potassium were elevated, she was referred to a nephrologist for possible dialysis. Make pathophysiology on how kidney failure happens to a client with acute congestive heart failure. 2. Create CHART (C-hief complaint, H-istory, A-ssessment, R-x/treatment, T-ransport) documentation for the patient. (see 2nd photo for reference)

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
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QUESTIONS.

1. The client’s creatinine and serum potassium were elevated, she was referred to a nephrologist for possible dialysis. Make pathophysiology on how kidney failure happens to a client with acute congestive heart failure.

2. Create CHART (C-hief complaint, H-istory, A-ssessment, R-x/treatment, T-ransport) documentation for the patient. (see 2nd photo for reference)

 

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This is a case of a 65 year old female with a 10 year history of hypertension and diabetes. She is taking Micardis 40 mg in the morning and Amlodipine 5 mg at night for hypertension. For diabetes she is being given Janumet 100mg/1g 2x a day and Gliclazide 60 mg OD before breakfast. The daughter reported poor compliance with medications. The patient was brought to the emergency room due to difficult of breathing. Condition started 2 days PTA when the patient had easy fatigability going to the comfort room. She started taking all her medications again but she did not seek consult. Symptom persisted until she would have difficulty of breathing when getting out of bed. In the emergency room BP 180/100 HR 110/min RR 35/min 02 sat 93%, Temp 36.8, patient is pale, diaphoretic and in severe respiratory distress. (+) edema up to the knees area, (+) crackles from lower to mid portion of the lungs. In the emergency room, the client was given 02 per canula at 4-5lpm. IVF was initiated. The doctor ordered for Furosemide 40 mg IV stat. CXR was done in the emergency room showing pulmonary edema and heart enlargement
Transcribed Image Text:This is a case of a 65 year old female with a 10 year history of hypertension and diabetes. She is taking Micardis 40 mg in the morning and Amlodipine 5 mg at night for hypertension. For diabetes she is being given Janumet 100mg/1g 2x a day and Gliclazide 60 mg OD before breakfast. The daughter reported poor compliance with medications. The patient was brought to the emergency room due to difficult of breathing. Condition started 2 days PTA when the patient had easy fatigability going to the comfort room. She started taking all her medications again but she did not seek consult. Symptom persisted until she would have difficulty of breathing when getting out of bed. In the emergency room BP 180/100 HR 110/min RR 35/min 02 sat 93%, Temp 36.8, patient is pale, diaphoretic and in severe respiratory distress. (+) edema up to the knees area, (+) crackles from lower to mid portion of the lungs. In the emergency room, the client was given 02 per canula at 4-5lpm. IVF was initiated. The doctor ordered for Furosemide 40 mg IV stat. CXR was done in the emergency room showing pulmonary edema and heart enlargement
Patient Care Report Narratives C: Time: Date: H: A: R: T:
Transcribed Image Text:Patient Care Report Narratives C: Time: Date: H: A: R: T:
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