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NURS 5315


Mrs. x is a 65 y/o Hispanic female who presented to the emergency room for a

complaint of shortness of breath and chest pain for the last 2 days. she has been experiencing some nausea, vomiting, shortness of breath and reports that she has missed her last 2 dialysis sessions because she has not had transportation. She was diagnosed with Chronic kidney disease 4 years ago and has been dialysis dependent for the last 12 months.

PMH: Chronic Kidney disease stage 5, anemia, hypertension, preumonia, hyperlipidemia, diabetes mellitus type 2.


Past surgical history: permacath placement and AV fistula


Social History: denies ETOH, tobacco and drug use.


NKDA


Physical exam:

Vitals: 38.1; 97; 18; 183/139

Normocephalic

Alert & oriented x3. Well developed.

Eyes: PEARL. No nystagmus

Neck: Supple, no cervical lymphadenopathy

Cardiovascular: Normal rate and rhythm. No murmur, gallops. 2+/4+ radial, brachial, dorsalis pedis pulses bilaterally. 2+ pitting edema of bilateral lower extremities. 6cm of JVD bilaterally.

Pulmonary: Dyspneic. Lungs with rales.

Abdomen: Soft and nontender, active bowel sounds. No peritoneal signs.

Skin: warm, dry and intact


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