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The nurse is caring for an adult client in the primary care clinic. History and Physical Alert and oriented to person, place, date, and situation. Body mass index (BMI) is 39.2 (obese). Skin is dry, no rashes, bruises, or lesions noted. Lungs have bibasilar crackles, heart sounds regular. Bowel sounds present x 4 quadrants. Significant tenderness at costovertebral angle. Pulses strong and equal x 4 extremities, bilateral 2 pitting edema to feet and ankles. Lab work notable for a decreased glomerular filtration rate (GFR) of 35 mm/L, high blood urea nitrogen (BUN), high creatinine level, and 1 proteinuria. Nurse's Notes Vital Signs Assessment Finding Hypertension Heart Failure For each assessment finding below, click to specify whether the finding is associated with the disease process of hypertension, heart failure, type 2 diabetes, or chronic kidney disease. Each finding may support more than one disease process. Each column must have at least 1 response option selected. Type 2 Diabetes Chronic Kidney Disease BMI of 39.2 (obese). Weight gain of 10 lbs. ( 4.54 kg) in a month. Foamy, dark, tea colored urine. Blood Pressure 164/92. Low GFR; high BUN and creatinine levels.
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