ISBAR

Weekly Patient Care Reflection/Patient Care Planning to be reviewed and discussed with clinical faculty (Adopted from Nurse Tim Inc):

Prioritize the patient’s on your RN’s assigned team, briefly summarize the prioritization

1. regularly assess the patient’s vital signs and initiate early interventions as needed.

2. Monitoring the patient’s input and output.

3. Checking the patient’s electrolyte levels and taking appropriate corrective measures.

4. Adjusting the patient’s medications as needed to prevent further kidney damage.

5. Educating the patient and family about the disease process and potential complications.

Priority Patient brief overview (maintain HIPAA)

The 75-year-old patient was admitted two days ago with respiratory distress and expanded edema in the feet. The admission diagnosis has a history of biventricular HF (last ejection fraction of 50%), obstructive pulmonary disease, atrial fibrillation, high blood pressure, benign prostatic hypertrophy, type 2 diabetes, and stage 3 kidney disease is HF exacerbation. His blood pressure and heart rate have ranged below normal ranges since admission. He has persisting hypokalemia and increased creatinine levels (2.5mEq/L) and (GFR 45mL/min/1.73m²). Vital signs are BP: 100/58mmHg, HR: 57b/min, RR: 22b/min (even and non-bored), SPO2:91% on 2L oxygen via nasal cannula. Blood glucose at 0630 was 100mg/dL

Priority Problem:

Difficulty in breathing, edema of both feet, decreased blood pressure (100/58mmHg), decreased PR 57b/min, increased creatinine, and reduced GFR.

Key Assessment for Priority Problem:

Assess the patient vital signs regularly to note the deviations from the normal ranges and initiate early interventions.

Urea and electrolytes tests should be carried out.

Labs/Diagnostics for Priority Problem:

SPO²  91%

 GFR:45mL/min/1.73m²

Creatinine levels is 2.5mEq/L

B-type natriuretic peptide level (900 pg/mL)

Patient Care Interventions/Rationale:

Administer oxygen supplementation to ensure adequate oxygenation of the vital organs and body tissues and prevent irreversible damage due to hypoxemia.

Hold the administration of medications or reduce the doses to avoid further damage to the kidneys.

Monitor the input and output

Actual/Potential Problems:

Kidney failure and heart failure