ATI RN ADULT MEDICAL SURGICAL PROCTORED
EXAM KIDNEY DISEASE
1. 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.
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