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INTRODUCTION
b) OBJECTIVES
Predisposing Factors:
• Age
• Heredity
Signs and Symptoms of ARF
The patient may manifest the following:
• Oliguria
• Tachycardia and hypotension
• Dry mucous membranes and flat neck veins
• Lethargy
• Cool, clammy skin
• Azotemia
• Electrolyte imbalances
• Nausea and vomiting
• Constipation
• Irritability and Fatigue
A.PERSONAL HISTORY
D.PHYSICAL ASSESSMENT
A. General Appearance
Mr. Romeo Velasco is 57 year old. He was brought to JBLMRH last
December 11, 2005 with a chief complaint of general body weakness.
Appears to be untidy (uncombed hair).Vital signs are as follows: BP:
120/80, CR: 90, RR: 22.
B. Review of Systems
SKIN: fair complexion, dry skin, no jaundice, cold to touch and
patient is pale
HEAD: head is proportional to the body, no tenderness observed,
and no inflammation
EYES: (+) Perrla, eyebrows are well-distributed, no cataract
observed, eyelids are able to blink
EARS: are symmetrical, no tinnitus, no discharges, no lesion
NOSE AND SINUSES: no epistaxis, no discharges, and no
tenderness observed
MOUTH AND THROAT: dry lips, hoarseness of voice, tongue can
be protruded, and no inflammation observed
NECK: able of full neck motion without pain, there is no
inflammation upon palpation, no lump and no swollen lymph node
RESPIRATORY: no sputum and no asthma
CARDIAC: hypertensive
GASTROINTESTINAL: low appetite, allergic to penicillin
URINARY: has oliguria (with average urine output of 10mL/hour)
GENITAL: not assessed
PERIPHERAL VASCULAR: nail beds are pale, with an impaired
capillary refill time
MUSKULOSKELETAL: with impaired mobility
NEUROLOGIC: general body weakness
HEMATOLOGIC: redness, pain in areas where transfusion was
done, has a decrease hgb count upon laboratory results
PSYCHIATRIC: patient is nervous and anxious
NO HISTORY OF FAMILIAL DISEASES
Aries Velasco
III. ANATOMY AND PHYSIOLOGY
KIDNEYS
The kidneys are bean shaped organs, each about the size of a
tightly clenched fist. They lie on the posterior abdominal wall, behind
the peritoneum, with one kidney on either side of the vertebral column.
Structures that are behind the peritoneum are said to be
retroperitoneal. A connective tissue renal capsule surrounds each
kidney. Around a renal capsule is a thick layer of fat, which protects
the kidney from mechanical shock. On the medial side of each kidney
is the hilum, where the renal artery and nerves enter and where the
renal vein and ureter exit the kidney. The hilum opens into cavity
called the renal sinus, which contains blood vessels, part of the system
for collecting urine and fat
The kidney is divided into an outer cortex and an inner medulla,
which surround the renal sinus. The bases of several cone- shaped
renal pyramids are located at the boundary between the cortex and
the medulla, and the tips of the renal pyramids project towards the
center of the kidney. A funnel shaped structure called a calyx
surrounds the tip of each renal pyramid. The calyces from all the renal
pyramids join to form a larger funnel called the renal pelvis. The renal
pelvis then narrows to form a small tube, the ureter, which exits the
kidney and connects to the urinary bladder. Urine passes from the
kidney and connects to the urinary bladder. Urine passes from the tips
of the renal pyramids into the calyces. From the calyses urine collects
in the renal pelvis and exits the kidney through the ureter.
The functional unit of the kidney is the nephron and there are
approximately 1.3 million of them in each kidney. Each nephron
consists of a renal corpuscle, a proximal tubule, a loop of Henle, or
nephronic loop and a distal tubule. Fluid enters the renal corpuscles
and then flows into the proximal tubule. From there it flows into the
loop of Henle, each loop of Henle has a descending limb, which
extends towards the renal sinus and an ascending limb. Which extends
back toward the cortex. The fluid flows through the ascending limbs of
the loop of Henle to the distal tubule. Many distal tubules empty into a
collecting duct, which carries the fluid from the cortex, through the
medulla. Many collecting ducts empty intro a papillary duct and the
papillary ducts empty their contents into a calyx.
The renal corpuscles and both convoluted tubules are in the
renal cortex. The collecting duct and loop of Henle enter the medulla.
Approximately 15 % of the nephrons called juxtamedullary nephrons
have loop of Henle that extends deep into the medulla of the kidney.
The other nephrons called cortical nephrons have loop of Henle that do
not extend deep into the medulla.
The renal corpuscles of the nephrons consist of Bowman’s
capsule and the glomerulus. Bowman’s capsule consist of the enlarge
end of the nephron, which is extended to form a double walled
chamber. The indention is occupied by a tuft of capillaries called
glomerulus, which resembles a ball of yarn. The cavity of Bowman’s
capsule opens into the proximal tubule, which carries fluid away from
the capsule. The inner layer of Bowman’s capsule surrounds the
glomerulus and consists of specialized cells called podocytes. The
outer layer of the Bowman’s capsule consists of simple squamous
epithelial cells.
The glomerular capillaries have pores in their walls, and the
podocytes have cell processes with gaps between them. The
endothelium of the glomerular capillaries, the podocytes and the
basement membrane between them form a filtration membrane. In the
first step of urine formation, fluid called filtrate is filtered from the
glomerular capillaries into Bowman’s capsule through the filtration
membrane.
Most of the nephron and collecting duct are made up of simple
cuboidal epithelium. However, the thin segments of the descending
and ascending limbs of Henle’s loop have very thin walls up of simple
squamous epithelium. The cells of proximal, thick segment of the
ascending limb of Henle’s loop, distal tubules and collecting ducts have
microvilli and many mitochondria. The proximal tubule, thick segment
of the ascending limb of Henle’s loop and the collecting duct actively
transport molecules and ions across the wall of the nephron. The thin
segment of the descending limb of the Henle’s loop is very permeable
to water and solutes and the thin segment of the ascending limb is
permeable to solutes but not to water.
The ureters are small tubes that carry urine from the renal pelvis
of the kidney to the posterior inferior portion of the urinary bladder.
The urinary bladder is a hallow muscular container that lies in the
pelvic cavity just posterior to the symphysis. Its function to store urine
and its size depends on the quantity of urine present. The urinary
bladder can hold from a few millimeters to a maximum of about 1000
ml of urine. When the urinary bladder reaches a volume of a few
hundred ml, a reflex is activated, which causes the smooth muscle of
the urinary bladder to contract and most of the urine flows out of the
urinary bladder through the urethra
The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle shaped portion of the urinary bladder located
between the opening of the ureters and the opening of the urethra is
called tragone. The urethra carries from the urinary bladder to the
outside of the body.
The ureters and the urinary bladder are lined with transitional
epithelium, which is specialized to stretch. As the volume of the
urinary bladder increases the epithelial cells, and the number of
epithelial cell layers decreases. As the volume of the urinary bladder
decreases, transitional epithelial cells assume their columnar shape
and form a greater number of cell layers.
The walls of the ureter and urinary bladder are composed of
layer of smooth muscle and connective tissue. Regular waves of
smooth muscle contractions in the ureters produce the force that
causes urine to follow from the kidneys to the urinary bladder.
Contractions of smooth muscle in the urinary bladder force urine to
flow from the bladder through the urethra.
At the junction of the urinary bladder and urethra, the smooth
muscle of the bladder wall forms the internal urinary sphincter in
males. No well defined internal urinary is found in females. Elastic
fibers at the junction of the urinary bladder and urethra keep urine
from passing through the urethra until the urinary bladder pressure
increases. The internal urinary sphincter of males is under involuntary
control. Contraction of the internal urinary sphincter during ejaculation
prevents semen from entering the urinary bladder and keeps urine
from flowing through the urethra. The external urinary sphincter is
formed of skeletal muscle that surrounds the urethra as the urethra
extends through the pelvic floor. The external urinary sphincter is
under involuntary and voluntary control. It controls the flow of urine
through the urethra.
In male, the urethra extends to the end of the penis, where it
opens to the outside. The female urethra is much shorter
(approximately 4 cm) than the male urethra (approximately 20 cm)
and opens into the vestibule anterior to the vaginal opening.
BUN, CREATININE, Na, K Cl, and for Urinalysis. The patient was advice
cause hypertension, thus the doctor order manidipine for the patient.
PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE (Client Center)
Nephrotoxins
Increase WBC,
Neutrohils, Lymphocytes Circulatory Inadequacy
Symphatetic Response
Uremia /Severe Increase BUN and
Anemia Creatinine
Increase Renin and
Med’s given
Angiotensin II
Decrease K, Na Hypokalcemia
Hypertension
C. DIAGNOSTIC AND LABORATORY PROCEDURES
HEMATOLOGY
NCP#1
Subjective: >Fatigue >A decrease >After 4 >Establish rapport >to facilitate >After 4
Objective: related to in Hgb count hours of client and hours of
>Patient is decreased Hgb would be a nursing student nurse nursing
conscious and count. factor in intervention, interaction intervention,
coherent having fatigue the patient goal was met
>with ongoing because RBC will as evidenced
IV of D5 0.3 plays an demonstrate >Discuss with the >education by:
NaCl 500cc X important role an improve patient the need may provide *clients
KVO in our cells ability to for activity. Plan motivation to verbalization
>Vital signs: and muscle to participate in schedule with the increase of feeling of
BP: 110/80 function desired patient and activity level less fatigue
PR: 79 normally. activities and identify the through and
RR: 20 Patient with he will activities that patient may weakness
Temp: 37.6 ARF may verbalize an leads to fatigue. feel too weak *patient
>Patient suffer to increase initially participates
manifest anemia energy level. in some
generalized because our activities as
body weakness kidney is one >Monitor vital >indicates much as he
>Patient is of the signs physiological could
pale producers of level of *patient is
>Patient is erythropoietin tolerance awake
dizzy that is one
>with poor component for
muscle tone RBC >Encourage the >to gain
>the patient production and patient to eat energy
has a decreased RBC are the
Hgb count of 83. one who >Administer >for the body
(Normal Value is carries oxygen medications such to have
123-175g/L for and nutrients as ferrous sulfate enough RBC
males) to other cells as prescribed to supply the
and muscles muscles and
for them to cells enough
function. A nutrients to
decrease in function
erythropoietin properly
production will
tend to >Encourage/advis >to increase
produce a e the patient to the patients
small amount perform ROM activity level
of RBC that exercise in a step-by-
would lead to step manner
a decreased
supply of >Encourage the >restoration
oxygen to patient to rest of energy
different cells
and muscles in >Promote overall >to correct
the body. health measures the need of
Therefore, such as proper supply of RBC
leading to poor nutrition, and to reduce
muscle tone adequate fluid fatigue by
and a problem intake and gaining
with muscle appropriate energy
contractility vitamin/iron
that could supplement.
make the
client feel that >Maintain >to improve
he is weak. strenuous activity activity
restrictions. tolerance,
avoid
activities that
requires too
much energy
NCP #2
Subjective: >Excess fluid >Kidneys are >After four >Establish >to facilitate >After four
Objective: volume responsible for hours of rapport client and hours, goal
>Patient is related to the elimination nursing student nurse met as
conscious and inability of the of waste interventions; interaction evidenced by:
coherent kidney to products in our *there would *an increase
>with excrete waste body. If there be a stabilized >Monitor vital >to be able to in urine
ongoing IV of products is an alteration fluid volume signs monitor the output from
D5 0.3 NaCl on the normal by increasing changes in 10mL to
500cc X KVO functioning of the urine the condition 30mL/hour
>Vital signs: the kidney, output of the of the client *the client
BP: 110/80 there would be patient verbalized
PR: 79 a problem in *the client >to monitor understandin
RR: 20 the excretion verbalize an >Monitor I and O the normality g of fluid
Temp: 37.2 of waste understanding of urine restriction in
>patient is products. of individual output his diet and
oliguric Making the dietary/fluid began to
average of waste to stay restriction >Assess appetite >to be able to implement it
10mL/hour in the and note for know other *patient is
>Hgb: 73 circulation and nausea or reason which awake
Hct: 0.20 excessive fluid vomiting contributes to *patient
(Normal may be the his condition always stay
Values: result because on bed
Hgb is 125- there are only >Restrict Na and >to avoid
175g/L and Hct intake but a fluid intake as further excess
I 0.40-0.52 for limited indicated fluid
male) amount of accumulation
>patient is output >Administer
restless because of the medications such >to promote
damaged of as diuretics as elimination of
malfunctioning ordered waste
kidney. products
Subjective: >Risks for >Risk for >After 5 >Establish > To gain the >Goal met
Objective: infection infection is the hours of rapport cooperation of because the
>Patient is related to state in which patient and the patient
patient as well
conscious and environmenta an individual is student nurse during the
as the SO
coherent l condition at risks for interaction interaction practicing the
>with being invaded the patient interventions
ongoing IV of by pathogenic will verbalize >Encourage the > To reduce or given
D5 0.3 NaCl organisms / understandin pt. and the S.O minimize the
500cc X KVO microorganisms g and identify to practice transfer of
>Vital signs: due to poor intervention proper hand microorganism
BP: 110/80 environmental to reduce risk washing s
PR: 79 sanitation to its for infection techniques
RR: 20 surroundings
Temp: 37.2 >Encourage the > To prevent
= poor patient and the the spread of
sanitation SO to practice microorganism
= unable to environmental s in the
meet sanitation surroundings
patients
demands >Encourage the > To avoid
for personal patient to throw insects and
care the garbage or other
= poor trash properly microorganism
hygiene s that carries
= presence viruses
of insects in
the >Instruct the > To increase
surroundin patient to eat body
gs foods rich in Vit. resistance
C like guava,
oranges,
calamansi etc…
>Encourage
compliance to > For
drug regimen protection
against
infection
NCP #4
Subjective: >Ineffective >Ineffective >After 5 >Establish >To gain the >Goal was
Objective: therapeutic therapeutic hours of rapport cooperation partially met
>Patient is regimen regimen is the nursing of the as evidence
conscious and managemen state in which intervention patient by the patient
coherent t related to the patient was the patient during the cooperation in
>with ongoing financial unable to meet and the SO interaction some of the
IV of D5 0.3 NaCl status the demands in will >Provide intervention
500cc X KVO prevention and understand information >To know given.
>Vital signs: curing of illness the about the the
BP: 110/80 because of importance patients importance
PR: 79 financial in the condition of
RR: 20 problem compliance therapeutic
Temp: 37.2 of drugs and regimen and
= refuse to other the value of
take the therapeutic treatment
medication regimen. >Encourage to program
given identify the
= limited patients and >To identify
social significant others causative
interaction perception and factor
= lack of expectation of
interest treatment
=uncooperativ regimen
e
NCP #5
Subjective: >Knowledge >Knowledge >After 5 >Establish >To gain the >Goal met
“ Bisa deficit deficit is the hours of rapport cooperation because the
kung mangan related to state in which nursing of the patient
babi” disease the patient lack intervention patient participates in
condition of information the patient during the learning
Objective : about his verbalize interaction process.
>Patient is condition understandin
conscious and g about his >Assess for the >To evaluate
coherent condition patient’s if the patient
>with readiness to is ready to
ongoing IV of learn learn the
D5 0.3 NaCl concept of
500cc X KVO wound
>Vital signs: cleaning
BP: 110/80 >Determine
PR: 79 client’s ability to >To assess
RR: 20 learn. what level of
Temp: 37.2 teaching we
=uncoopera are going to
-tive impose.
= lack of >Determine
interest blocks to >To identify
= the pt. learning. (Like possible
frequently language hindrances
ask about barriers, physical that would
his condition factors and affect in the
= eating physical stability) teaching and
food which learning
are process
restricted on >Provide
his diet information >To
about the understand
patient condition the condition
of the
patient
>Encourage the
patient to follow
the right diet >To avoid
secondary
problem and
complication
NCP # 6
Subjective : Imbalanced Imbalanced After 4 hours >ascertain >to Goal was met
nutrition nutrition related of client and understanding of determine as evidenced
Objective : less than to therapeutic student nurse individual what by the clients
>Patient is body dietary interaction nutritional needs information to
verbalization
conscious and requirement restrictions; as the client will be provide
of
coherent s related to evidenced by be able to the client/SOunderstanding
>with disease lack of interest verbalize >discuss eating of the
ongoing IV of condition in food/eating understandin habits, including >to appeal to therapeutic
D5 0.3 NaCl g of the food preferences clients likes & dietary
500cc X KVO therapeutic desires restrictions
>Vital signs: dietary >assess drug
BP: 110/80 restriction interactions and >these
PR: 79 use of diuretics factors may
RR: 20 be affecting
Temp: 37.2 appetite, food
>body intake, or
weakness absorption
-numbness in >assist in
the lower developing >to correct
extremities individualized underlying
-dizziness diet regimen causative
-fatigue factors
-dry skin >explain to the
-pale client the >in order to
prescribed diet facilitate
understandin
g and gain
the clients
participation
to the diet
regimen
>provide oral
liquid >these will
preparation help in
providing
nutrients to
the client
Subjective Impaired Usually occurs After 4 hours >assess clients >to be able Goal was met
urinary with urinary of client and understanding of to provide as evidenced
Objective: - elimination tract student nurse condition appropriate by the clients
>Patient is related to obstruction that interaction information verbalization
conscious and disease affects the the client will that are of
coherent condition kidneys be able able needed by understanding
>with bilaterally such to verbalize the client
ongoing IV of as prostatic understandin of condition
D5 0.3 NaCl hyperplasia g of condition >provide time >provide
500cc X KVO for the client to hard candy or
>Vital signs: have question gum
BP: 110/80 and answer them >in order to
PR: 79 in the simplest facilitate
RR: 20 understandable understandin
Temp: 37.2 form g
>oliguria
>irritability > Determine
>decreased clients previous
urine output elimination >in order to
pattern of assess
elimination and deviation
compare with
current situation
>palpate bladder
>to assess
>Emphasize retention
importance of
keeping the area >to reduce
clean and dry risk of
infection
and/or skin
breakdown
NCP # 8
>Introduce >provide
client to those role models,
with similar / encourage
shared interest problem
and other solving.
supportive
people
NCP #9
INTRAVENOUS FLUID
Discontinue drug if
hypersensitivity
reactions occur.
Report skin rash,
unusual bleeding or
bruising, following
of skin or eyes,
changes, in voiding
patterns.
DRUG DATE ACTION INDICATIO DOSAGE SIDE NURSING
ORDERED N EFFECTS RESPONSIBILITIE
S
Inform patient
about the following
side effects that
may occur.
Monitor for
difficulty breathing,
hallucinations,
tremors, loss of
coordination,
unusual
disturbances, and
irregular heartbeat.
DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIE
S
Monitor serum
phosphorus levels
periodically during
long-term oral
therapy.
Advice client to
take drug between
meals and at
bedtime. Chew
tablets thoroughly
before swallowing,
and follow with a
glass of water or
milk.
Advice client to
report loss of
appetite; nausea,
vomiting,
abdominal pain,
constipation, dry
mouth, thirst,
increased voiding.
DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIE
S
Administer with
food or milk to
prevent GI upset.
Monitor difficulty
breathing, night
cough, swelling of
extremities, slow
pulse, confusion,
depression, rash,
fever and sore
throat.
Name of Mechanis Indication Dosage, Contraindicatio Side Nursing
Drug m of Route of n Effects/Advers Implicatio
Action administratio e Effects n
n and
Frequency
(Date
Oredered)
The drug is
commonly
used orally
with
potassium
wasting
diuretics to
maintain
potassium
levels.
Watch out
for adverse
reactions.
SPECIAL PROCEDURES
DATE
ORDERED / PROCEDURE RESULT PROCEDURE NURSING
DATE DESCRIPTION RESPONSIBILITIE
PERFORMED S
December 11, > Blood > No allergic > Blood > Watch for allergic
2005 Transfusion reactions transfusion is reactions
(1 “u”) performed to > Watch for signs
supply any of shock
blood loss or
any deficiency
in RBC.
December 12, > Blood > No allergic > Blood > Watch for allergic
2005 Transfusin reactions transfusion is reactions
> Watch for signs
(1 “u”) performed to of shock
supply any
blood loss or
any deficiency
in RBC
Doctor’s Order
Name: Romeo Velasco Age: 57 Male Civil
Status: M
Address: Sasmuan, Pampanga Ward: Med
Hospital #: 130290
4:20pm
Start Kalium Durules 1 tab. TID
December 14, 2005
BP = 180/ 100mmHg: CR = 94bpm; (+) anorexia
Manidipine 200mg / tab OD
For H/H.
For removal of NGT.
Start tube feeding at 1600 kcal in 6 divided doses.
Continue meds.
VS q 4°
12.14.5 6:50pm
BP = 140/90 mmHg CR = 82bpm T = 37.2 °C
(+) upper arm twitching (-) DOB (-) chest pain
May remove NGT.
For K and Albumin
*Urinalysis*
>Color: Light
Yellow
>Reaction – Acidic
>Specific Gravity
– 1.020
>Coarse Granular
– 2.4/LPF
>Puss Cells –
8.1/HPF
>RC – 3.5/HPF
>Epithelial cells –
few
Medication >CaCO3 Continue meds: New Meds: New Meds: New Meds: MGH
s 500mg/tab TID >CaCO3 >Kalium >Manidipine >Metoprolo Home meds:
>Paracetamol 300 500mg/tab TID Durule 200mg/tab OD l 50mg/tab >Erythropoietin
mg IV BT meds: 1tab TID Continue meds: TID 5,000 u/ sc
>Diphenhydramid >Diphenhydramid Continue >CaCO3 Continue once a week
e 50mg IV 30 e 50mg IV 30 meds: 500mg/tab TID meds: >CaCO3 / tab
mins prior to BT mins prior to BT >CaCO3 >Kalium Durule >Manidipin TID.
>Furosemide >Furosemide 500mg/ tab 1tab TID e >Manidipine
80mg IV Post BT 80mg IV Post BT TID BT meds: 200mg/tab
20mg /tab OD
>Diphenhydramid OD
e 50mg IV 30 >CaCO3
mins prior to BT 500mg/tab
>Furosemide TID
80mg IV Post BT >Kalium
Durule 1tab
TID
IVF >D5 0.3 NaCl >PNSS 500cc X >PNSS 500cc X >D5 0.3
500cc X KVO KVO KVO NaCl X KVO
>PNSS 500cc X
KVO
Special >1st unit BT >2nd unit BT >3rd unit BT
Procedure 9:40PM 11:30AM 9:00PM
s
NORMAL VALUES:
* Normal Values
M: 125 – 175g/L
Hgb
F: 115 – 155g/L
M: 0.40 – 0.52
Hct
F: 0.38 – 0.48
WBC
Neutrophils 0.45 – 0.65
Lymphocyte 0.20 – 0.35
Stab 0.02 – 0.05
Platelet
RBS 3.85-9.0mmol/L
BUN 1.7-8.3
M: 60 – 120
Creatinine
F: 58 – 100
Sodium 135 – 145
Potassium 3.5 – 5.0
Calcium 2.02 – 2.60
Phosphorus 0.81 – 1.62
Chloride 101 – 111
FBS 4.1 – 6.1 mmol/L
MCH 27 – 33 pg
MCV 82 – 92 fl
MCHC 31 – 36 g/dL
Reticulocyte count 1 – 5%
PATIENTS DAILY PROGRESS
12-11-05
He was hooked with an IVF of D5 0.3 NaCl 500cc x KVO, started KCl drip 10
meqs + 90 cc PNSS x 1°x 4 doses then for serum K 1° after the last dose.
# Anemia
1st unit of 3 U pack RBC was transfused. Pre BT meds are given and they are as
follows: Paracetamol 300 mg IV, Diphenhydramine 50 g IV 30 mins prior to BT
and furosimide 80 g IV was given post BT.
# Glucoserum
12-12-05
The patient BP was 110/70. There was (+) body weakness and (-) N/V. Serum K
after 4th dose KCl was repeated. Low salt, low protein diet was prescribed.
For renal UTZ, H/H was repeated within 6 hours post BT.
12-13-05
7:30 am
There was (-) pallor. The patient was for H/H
4:20 pm
12-14-05
The patients vital signs are as follows; BP: 180/100, CR: 94. Manidipine 200 mg
1 tab OD was started. For H/H. Tube feeding was 1600 kcal in 6 divided doses.
The NGT was removed due to the anxiety of the patient.
12-14-05
6:50 pm
The patients vital signs were as follows BP: 140/90, CR: 82, T: 37.2°C. There
was positive arm twitching, negative DOB, negative chest pain. He was
for K, Ca, and Albumin count.
12-15-05
The patient BP was 170/90. Metropolol 50 mg 1 tab BID was started. For H/H
post BT.
The patient was lying on bed and not talking and would not open his eyes. He
refused H/H, and all his oral meds.
12-16-05
The patient BP was 110/80. The he was sitting on bed, and verbalizes that he
does not remember that he had refused all to take all his medications. There
was (+) dizziness and loss of appetite due to therapeutic diet prescribed. He is
still refusing dialysis.
May go home. Home meds were as follows: Erythropoietin 5,000 IU SC once a
week, CaCO3 1 tab TID, and Manidipine 20 mg 1 tab OD.
He was scheduled to have his checked up on Jan.11, 2006. The patient was
discharged at 4:30 pm.
VII. DISCHARGE PLANNING
Medications:
• Erythropoietin 5000 IU, SC once a week
• CaCO3 1 tab TID
• Manidipine 20mg 1 tab OD
Exercise:
• Encouraged to perform ROM exercise
• Limit activities that requires too much movement
• May perform ADL in a limited range
Treatment:
• Medication as prescribed by ROD
• Low salt – low fat diet and Uremic diet
Health Teaching:
• Advised patient to eat nutritious food like fruits, fish and
vegetables.
• Advised to limit salt and fat intake
• Advised patient to monitor intake and output.
• Advised patient to perform light exercises
Out-Patient Visit
• Instructed patient to be back on January 11, 2006 for
follow up check-up.
Diet:
• Low fat – low salt diet, Uremic diet
VIII: Conclusion and Recommendation
Reaction:
Presented by :
Group - 1
Presented to:
Mr. John Paul Cuengco, R.N