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Tom Richardson
Diagnosis: kidney stones
DOB: 2/3/1978
MRN: 86916080
Room: 101
Tom Richardson is a 46-year-old client who reports generalized weakness, flank pain, and
pain upon urination. The client states that last evening, "I was having trouble urinating and
feeling pressure along with burning. Today the pain is worse, and my urine is blood tinged."
The abdomen and bladder are distended with hyperactive bowel sounds. The client is
experiencing nausea and vomiting and last ate this morning. The skin is warm, pale, and
diaphoretic. Skin turgor is greater than 2 seconds. The client reports pain is "8" on a 0 to 10
pain scale. They have a history of type II diabetes mellitus. The client is alert, oriented to
person, place, and time. Vital signs are: temperature 37.9 degrees C (100.1 degrees F),
blood pressure 175/105 mm Hg, heart rate 112/minute, respiratory rate 28/min, and oxygen
saturation on room air is 92 - - Maslow's Hierarchy of Needs: High Priority
Airway, Breathing, Circulation: High Priority
Safety and Risk Reduction: High Priority
Urgent vs Nonurgent: High Priority
Chronic vs Acute/Stable vs Unstable: High Priority
Initial Nursing Assessment
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