Diagnosis of Chronic renal failure

David is a 61-year-old male admitted by his family physician to the medical unit due to a new diagnosis of Chronic renal failure and Type 2 diabetes discovered through routine bloodwork and physical exam at a physical required by his new employer.

David has not seen his family doctor in 20 years.  He was diagnosed with HTN 20 years ago but decided not to treat it with medications.

David denies any other medical history.

Social History

David is married and is employed as a heavy-duty mechanic. He has 3 grown children and 2 grand children.  David drinks beer most evenings but never more than 2 per day.  He has never smoked cigarettes.  He is physically active at his job and enjoys swimming and hiking. His diet includes a lot of red meat, little green vegetables and he enjoys drinking coke.  He drinks 3 to 4 cups of sweetened coffee with cream per day.

Initial impressions:

Presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis.

On physical exam the patient is a well-developed, well-nourished male in moderate distress. HEENT was remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with hypertensive injury. Cardiac exam had an S1, S2 and S4. The remainder of the exam was remarkable for 2+ lower extremity edema and superficial excoriations of his skin from scratching.

Height 175 cm

Weight 76.5 kg

BP 180/110

HR 80

RR 24

T 36.7

O2 sats – 95% on RA.

24-hour urine protein and creatinine – volume 850 ml, protein 600 mg/dl and creatinine 180 mg/dl
Renal ultrasound – Right kidney 9 x 6.0 cm, Left kidney 9.2 x 5.8 cm
Both kidneys illustrate hyperechogenicity and no hydronephrosis.

Patient is allergic to shellfish.

1. what is the data for progress note documentation?

2. what are the assessment and actions?

3. what are the nursing interventions?

4. what are the goals for this patient?