ATI: RN Adult Medical Surgical Kidney Disease Exam for 2024

ATI: RN Adult Medical Surgical
Kidney Disease Exam for 2024
Using the SBAR format, identify the info. Nurse Allyson
received from report that will enable her to provide safe care to
Mr. Jones.

S- Situation
The ED admitted Mr. Jones at 4:30 AM for SOB and weakness.
After treatment, he is transferring to the telemetry unit.
B - Background
60 year old African-American male with a history of peripheral
vascular disease, type 2 diabetes, chronic kidney disease,
coronary artery disease, and atrial fibrillation.
A provider recently discharged him from the facility after he
treated Mr. Jones for atrial fibrillation and a type 2 diabetic ulcer
of the right foot.
Mr. Jones did not complete prescribed antibiotics after his
discharge.
He is non compliant in managing his diabetes. He smokes one
pack of cigarettes a day and uses alcohol 3 to 5 times a week.
A - Assessment
Mr. Jones is awake, alert, and orientated x3. Current vitals are:
BP 112/70, P: 158, R: 34, T: 99.1, and O2 sat 91% on 2 L via
nasal cannula. ECG indicates atrial fibrillation; placed on
telemetry. Chest x-ray: opacities greater in the right lung than
left lung. Altered lab values include: sodium 128, potassium 5.1,
BUN 44, creatinine 3.0, and glomerular filtration rate 25.
His total bilirubin was 2.8, calcium 8.7, WBCs 16.1,
hemoglobin 9.3, hematocrit 28.2, and blood glucose 71.
We did a digoxin level, which was 0.6.
He has a soiled dressing on his right foot and is a stage III ulcer.
A #20 gauge IV catheter was inserted peripherally in his left
forearm and a nurse gave him 1,000 mL of 0.9% sodium
chloride. Intake: 1,000 mL Output: None. No family present.
Nurse Allyson is preparing to perform a sterile dressing chang