A 48-year-old female that was admitted to a medical-surgical…
A 48-year-old female that was admitted to a medical-surgical unit last night following a scheduled right, large toe amputation. Her medical history includes diabetes mellitus type I with multiple complications including peripheral neuropathy, retinopathy, gangrenous toes, and chronic kidney disease for which she manages continuous ambulatory peritoneal dialysis (CAPD). A nurse from the dialysis center arrives at 0615 to assist the client in a dialysate exchange. During the nurse’s pre-procedure assessment, the client states, “I don’t feel good this morning. I am really tired and have pain in my belly. I probably just need to get this exchange done.” The nurse completes the assessment and assists the client to begin draining the effluent which is cloudy and smells foul. The nurse collects a sample of the effluent and reviews the client’s EHR prior to calling the primary health care provider. Time 1600 1700 1745 2120 2230 0200 0615 Unit Pre-op Surgery Post-op MS Vital signs Temperature 98.9° F (37.2° C) 99.5° F (37.5° C) 100.9° F (38.3° C) 101.6° F (38.7° C) 102.3° F (39.1° C) Heart rate 89 beats/min 95 beats/min 88 beats/min 108 beats/min 116 beats/min Cardiac rhythm NSR NSR NSR ST ST Blood pressure 145/67 mm Hg 126/60 mm Hg 120/60 mm Hg 108/57 mm Hg 95/51 mm Hg Respiratory rate 18 breaths/min 18 breaths/min 22 breaths/min 24 breaths/min 28 breaths/min O2 saturation 95% 94% 98% 92% 90% O2 device None None 2L NC 2L NC 4L NC Pain Denies Denies Abdomen 4/10 Abdomen 4/10 Abdomen 6/10 Capillary blood glucose 148 mg/dL (8.2 mmol/L) 136 mg/dL (7.6 mmol/L) 186 mg/dL (10.33 mmol/L) 205 mg/dL (11.39 mmol/L) Labs HbA1C 7.9% RBC 4.8 × 1012/L 4.9 × 1012/L WBC 11,000/mm3 (11 × 109/L) 11,800/mm3 (11.8 × 109/L) Platelet 110,000/mm3 (110 × 109/L) 100,000/ mm3 (100 × 109/L) BUN 72 mg/dL (25.71 mmol/L Creatinine 5.2 mg/dL APTT 33 sec INR 1.3 What assessmet data are relevant to the client’s current condition? (Select all that apply.)
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