Reference no: EM133653248
Assignment:
Mr. Johnson is a 68-year-old, African American male. He is divorced and has 2 sons. He has a history of hypertension, DM 2, and erectile dysfunction. He was treated by his PCP 3 days ago for a UTI. His home medications include salicylic acid 81 mg daily, Sulfamethoxazole-trimethoprim 800 mg-160 mg BID, Metformin 500mg TID, Metoprolol 50 mg twice daily, and Viagra as needed.
His sister brought him to the emergency department with confusion and oliguria. His sister states she has been encouraging fluids because she thought he was dehydrated. He has gained 6 lbs. over the past 3 days.
He has 4+ pitting edema in his legs and fine crackles throughout his lungs. The patient's VS are BP 180/110, HR 85, oxygen saturation 91% on RA, Temp 99.6, and RR 22. The patient's labs are Potassium 6.8 mEq/L and magnesium 3.2 mEq/L. Hgb 8.0, Hct 23.4, BUN 65, Creat 5.2. WBCs 12,000, and BS 180. His urinalysis revealed white blood cells (WBC) too numerous to count and trace red blood cells (RBC) urine specific gravity 1.06.
Recognize cues (Priority Assessment findings)
- What information is relevant/irrelevant?
- What information is MOST important?
- What information is of immediate concern?
Analyze Cues
- What client conditions are consistent with the cues? Are there cues that support or contraindicate a particular condition?
- Why is a particular cue or subset of cues of concern?
- What other information would help establish the significance of a cue or set of cues?
- Prioritize Hypotheses