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Client Overview The client is a 48 year old Caucasian female. She is status post renal transplant for five years. She also has a history of hypertension. She was diagnosed with Idiopathic Glomerulonephritis at the age of 37 years old. She needed to be placed on dialysis within six months of diagnosis. She was on dialysis for three years prior to her transplant. She received a cadaveric kidney transplant in 1998. Off and on, since her transplant, she has had issues with blood pressure control. Analysis of documentation A complete and comprehensive health history was taken in the pre-transplant process. The patient is usually seen on an on-going basis after transplant, and labs are collected and reviewed every month. Any changes in medications occur during evaluation of monthly labs. Levels of the immunosuppressive medications are evaluated and adjusted as needed. As I reviewed my assessment documentation from a clinic visit, I realized that little had to do with my patient’s well-being. It concentrated on physical findings, lab results and current medications. This patient is on numerous medications, many of which have side effects. I did not ask if she was experiencing any symptoms of side effects. The patient was also not questioned about pain. I asked her a question about current issues that need to be addressed by the physician and these were written on the problem list for the current visit. Needed information Additional information that would make the assessment more complete would have been to review the patient’s blood pressure log to determine whether her antihypertensive medications are sufficient.
Approximate Word count = 1022
Approximate Pages = 4.1
(250 words per page double spaced)
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