ARCHIE M.

ASTORGA BSN32 DLSHSI NURSING CASE STUDY

PROF. REGIEBE VICENCIO GROUP 4 - 1300

I. II. III.

ADMISSION/ FINAL DIAGNOSIS End Stage Renal Disease; Pneumonia HEALTH HISTORY

A. Demographic (Biographical Data) 1. 2. 3. 4. 5. 6. 7. Clients initials: COS Gender: Male Age, Birth date and Birthplace: 45y/o | March 22,1932 | Imus, Cavite Marital (Civil) Status: Married Race and Nationality: Malay, Filipino Religion: Catholic Address and Telephone Number: Big Pallace Athena Classic, Anabu 2-D, Imus, Cavite 8. 9. Educational Background: College Graduate Occupation (usual and present): Self-Employed

10. Usual Source of Medical Care: Prescribed medication, Hospital 11. Date of Admission: July 29, 2012; 07:05am

B. Source and Reliability of Information There are two reliable sources used in obtaining the information about the patient. The primary source of information is the patients daughter, G.C.S. and his wife A.C.S., since the patient was unable to communicate well due to his condition. The secondary source of information is the patients chart which consist most reliable data on his current condition.

C. Reasons for Seeking Care or Chief Complaints Cessation of urine output. Bilateral flank pain. Cough with greenish-like sputum. Sharp pain on chest. Difficulty of breathing.

D. History of Present Illness or Present Health The interview was performed August 1, 2012 in DLSUMC 1300. The patients daughter stated that a day prior to admission patient was experiencing cough and difficulty of breathing. They rush the patient in DLSUMC on July 29, 2012. Patient was recommended for admission, but relatives later decided for patient to stay home due to financial problems.

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ARCHIE M. ASTORGA BSN32 DLSHSI E. Past Medical History or Past Health

PROF. REGIEBE VICENCIO GROUP 4 - 1300

According to his daughter the patient had his 5 hospitalizations in UMC. He was then diagnosed with conditions of Diabetes Mellitus, Arthritis, Polycystic kidney, and Chronic Renal Failure. His Physician recommended him to undergo hemodialysis for his condition. Maintenance, medications and supplements was also advised for him. His daughter was not sure if the patient completed the immunization. The patient has no allergy with any foods or medications. The patient doesnt smoke and drink liquor. F. Family History PATERNAL 79y/o
Renal Dse. Asthma

MATERNAL 88y/o CA
Unrecalled Age DM, HPN

69y/o

45y/o

39y/o

24y/o

19y/o

Analysis: Patients daughter was interviewed to obtain this data since the patient was unable to communicate well. According to patients daughter, patient has possibly acquired his condition from his ascendants. Both of his parents deceased from severe form of diseases. His father had renal disease but the daughter had no idea what kind of disease it was. His mother had ovarian CA and was unable to have further medical support due to lack of funds. Data gathered was later validated by the patients wife. Both are reliable source of information. Page | 2

ARCHIE M. ASTORGA BSN32 DLSHSI G. Socio-Economic History Name C.O.S G.C.S A.G.S Relationship with Client Patient Daughter Wife

PROF. REGIEBE VICENCIO GROUP 4 - 1300

Monthly Income/ Occupation None Not disclosed/ working Student None

H. Developmental History (Psychosocial Assessment) Patients Age: 45 years old Developmental Stage: Middle Adulthood Developmental Task: Generativity vs. stagnation Patient C.O.S. is in the stage of middle adulthood from 40 65 years old according to Eriksons psychosocial theory. In this stage the patient is experiencing crisis between Generativity and Stagnation. Generativity is the concern in establishing and guiding the next generation. Socially-valued work and disciplines are also expressions of generativity. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation. Analysis: * Psychological assessment in not applicable to the patients condition. I. Review of Systems and Physical Examination 1. ROS and PE SYSTEM A. General / overall health R.O.S. PHYSICAL EXAM. Patient is lying on bed Stupor, unable to communicate well. Non-ambulatory.

V/S taken as follow: T= 36.2c PR(Apical)= 64bpm RR= 21cpm BP=100/70mmHg B. Integument SKIN:

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300 Brown complexion Dry skin in both upper and lower extremities Poor skin turgor Warm to touch HAIR: Normal hair distribution NAILS: (-) clubbing of fingernails Capillary refill <2 secs.

C. Head

Symmetrical, smooth, firm Temporomandibular joint was felt bilaterally with full ROM

D. Eyes

Symmetrical blinking Bulbar conjunctiva clear Round and equal iris Nontender lacrimal apparatus Whitish discoloration found on both iris (+) Arcus Senilis (+) Pupillary reflex

E. Ears

Ears are equal in size bilaterally No hearing impairment (-) Discharges on external ear (-) Tenderness

F. Nose and Sinuses

Symmetrical appearance with the face (-) Nasal discharge Pink and moist mucosa with no lesions

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300 (-) Lesions in turbinates and septum (-) Nasal flaring Non tender nasal sinuses Sinuses are clear upon illumination

G. Mouth and Throat

Dry lips (+) Loss of voice (+) Mouth secretions (+) Hoarseness (+) Gag reflex (-) Lesions on lips and mouth (+) Decayed, missing teeth Moist mucous membrane Pharyngeal tonsils are not inflamed

H. Neck

(+) full ROM Smooth, firm and nontender thyroids (-) Cervical lymph node enlargements

I.

Breast Axillary

and

No lumps and masses on breast (-) Axillary lymph nodes enlargement

J. Respiratory

Difficulty of breathing (-) Wheezing (+) Crackles on L lung

K. Cardiovascular

Identical apical and radial pulse @64bpm, Abnormal heart sounds Sometimes irregular rhythm Page | 5

ARCHIE M. ASTORGA BSN32 DLSHSI L. Urinary

PROF. REGIEBE VICENCIO GROUP 4 - 1300 Urine color: (+) Absence of urine

M. Genitalia

(+) Hydrocele (-) Lesions on penis and scrotum

N. Musculoskeletal

Slouching posture (+) poor ROM and muscle strength of lower extremities

O. Neurologic

Unable to responds to most questions and statements appropriately. Not oriented to time, place, and person CN I: None CN III, IV, V: None CN VI: None CN VII: None CN VIII: None CN IX: None CN X: None CN XI: None CN XII: None

P. Hematologic

(-) Bleeding (-) Bruising

Q. Endocrine

(-) Excessive sweating (+) Heat and cold tolerance

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ARCHIE M. ASTORGA BSN32 DLSHSI 2. LABORATORY STUDIES / DIAGNOSTICS

PROF. REGIEBE VICENCIO GROUP 4 - 1300

Procedure /Date

Indications

Normal Values / Findings

Actual Findings and Interpretatio n

Nursing Responsibilities (PRE, INTRA, POST)

This routine mainly includes the care and treatment of patients with hematological diseases, although some may also work at the Date & Time hematology laboratory Received: viewing blood 08/01/12 films and bone marrow slides under 08:31am the microscope, interpreting various hematological test results. Date & Time Released: Hematologic Test 08/01/12 09:30pm Hemoglobin measures the amount of hemoglobin. It is essential to transport oxygen from the lungs to the body tissues.

Hgb: F: 123-153 g/dl M: 140-175 g/dl Hct: F: 0.36-0.45 g/dl M: 0.41-0.50 g/dl RBC: F: 4.0-5.0 x 1012/L M: 4.6-5.5 x 1012/L WBC: 5.0-10.0 x 109/L

115g/dL

PRE: Inform the patient of the necessity of the procedure.

0.34g/dL

Inform the patient about the procedure

----------

INTRA: Cleanse and dry puncture site Hold syringe or evacuation tube with needle Gently invert the Page | 7

20.2 x 10 /L

ARCHIE M. ASTORGA BSN32 DLSHSI Hematocrit measures the volume percent of blood that is composed of red cells. Red Blood Cell Count measures RBC that carries oxygen from the lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled. White blood cell count Measures the WBC count in the body responsible for protection for infections.

PROF. REGIEBE VICENCIO GROUP 4 - 1300 collection tubes several times to blend. Do not shake.

POST: Check the patient and apply cotton in the puncture site. Instruct to lie down and rest.

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300

Chest AP view

07/29/12

Used to visualize the lung fields, used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common films taken; being diagnostic of many conditions and rule out pathology.

Study done shows decrease in amount of air in the right hemithorax.

Haziness in the left lower lobe which may relate to pneumonitis. No other significant interval changes noted

Abnormal AP view

Chest x-rays are also used to visualize air and fluid levels within the lung fields.

PRE: Reduce anxiety in patients particularly those who are very young or confused by informing the procedure Reassure the patient that there is minimal radiation exposure Explain that patient should remove metallic objects prior procedure Check that the patient has emptied the bladder before the test commences Check to see if a female patient is, or could be pregnant. Explain exposure of the unborn fetus to X-rays can be damaging to the child. INTRA: Reassure client that procedure is painless POST: After the test, the patient should be assisted in his activities Position the patient in the most comfortable position that could aid him in breathing normally: highfowlers position Page | 9

ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300

3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level etc.) Date(s) taken Comprehensive actual content/legend *not applicable Actual result

J. Functional Assessment * Not applicable. Patient is unable to communicate. IV. PROBLEM LIST A. ACTUAL or Active

Problem No.

Problem

Date Identified

Date Resolved/ Remarks August 1, 2012

#1

Ineffective Airway Clearance

August 1, 2012

B. HIGH RISK or Potential

Problem No. #2

Problem Pulmonary Arrest

Date identified August 1, 2012

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ARCHIE M. ASTORGA BSN32 DLSHSI III. Nursing Care Plan CUES NURSING DIAGNOSIS Ineffective Airway Clearance related to increased production thick of pulmonary secretions LONG TERM GOAL

PROF. REGIEBE VICENCIO GROUP 4 - 1300

SHORT TERM GOAL Within the 8 hour shift, the patient will be able to attain normal respiratory rate.

INTERVENTION Independent:

RATIONALE

Subjective: No subjective cues obtain due to patients condition Objective: Difficulty of breathing (+) Oral secretions (+) Crackles on both lung field upon auscultation Use of accessory muscles on breathing RR: 21 cpm

Within the hospitalization, patient will establish adequate oxygenation to meet self-care needs.

Assess and monitor respiratory function Maintain sufficient level of humidifier to moisten the oxygen upon inspiration Position patient to semi-fowlers position for comfort and prevent aspiration of secretions. Suctioning of secretions

To note tachypnea or note inspiratory to expiratory ratio To prevent drying of mucous membrane

To increased lung expansion and increased secretions movement to be easily removed To improve patency of airway and prevent aspiration of secretions.

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300

V.

ANATOMY AND PHYSIOLOGY The Kidney

The kidney is invested by a fibrous tunic, which forms a firm, smooth covering to the organ. The tunic can be easily stripped off, but in doing so numerous fine processes of connective tissue and small blood vessels are torn through. Beneath this coat a thin, widemeshed net-work of unstriped muscular fiber forms an incomplete covering to the organ. When the capsule is stripped off, the surface of the kidney is found to be smooth and even and of a deep red color. In infants fissures extending for some depth may be seen on the surface of the organ, a remnant of the lobular construction of the gland. The kidney is dense in texture, but is easily lacerable by mechanical force. If a vertical section of the kidney be made from its convex to its concave border, it will be seen that the hilum expands into a central cavity, the renal sinus, this contains the upper part of the renal pelvis and the calyces, surrounded by some fat in which are imbedded the branches of the renal vessels and nerves. The renal sinus is lined by a prolongation of the fibrous tunic, which is continued around the lips of the hilum. The renal calyces, from seven to thirteen in number, are cup-shaped tubes, each of which embraces one or more of the renal papill; they unite to form two or three short tubes, and these in turn join to form a funnel-shaped sac, the renal pelvis. The renal pelvis, wide above and narrow below where it joins the ureter, is partly outside the renal sinus. The renal calyces and pelvis form the upper expanded end of the excretory duct of the kidney.

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ARCHIE M. ASTORGA BSN32 DLSHSI The Lungs

PROF. REGIEBE VICENCIO GROUP 4 - 1300

The lungs are the essential organs of respiration; they are two in number, placed one on either side within the thorax, and separated from each other by the heart and other contents of the mediastinum. The substance of the lung is of a light, porous, spongy texture; it floats in water, and crepitates when handled, owing to the presence of air in the alveoli; it is also highly elastic; hence the retracted state of these organs when they are removed from the closed cavity of the thorax. The surface is smooth, shining, and marked out into numerous polyhedral areas, indicating the lobules of the organ: each of these areas is crossed by numerous lighter lines. At birth the lungs are pinkish white in color; in adult life the color is a dark slaty gray, mottled in patches; and as age advances, this mottling assumes a black color. The coloring matter consists of granules of a carbonaceous substance deposited in the areolar tissue near the surface of the organ. It increases in quantity as age advances, and is more abundant in males than in females. As a rule, the posterior border of the lung is darker than the anterior. The right lung usually weighs about 625 gm., the left 567 gm., but much variation is met with according to the amount of blood or serous fluid they may contain. The lungs are heavier in the male than in the female, their proportion to the body being, in the former, as 1 to 37, in the latter as 1 to 43. Each lung is conical in shape, and presents for examination an apex, a base, three borders, and two surfaces. The apex is rounded, and extends into the root of the neck, reaching from 2.5 to 4 cm. above the level of the sternal end of the first rib. A sulcus produced by the subclavian artery as it curves in front of the pleura runs upward and lateral ward immediately below the apex. Page | 13

ARCHIE M. ASTORGA BSN32 DLSHSI VI. PATHOPHYSIOLOGY

PROF. REGIEBE VICENCIO GROUP 4 - 1300

Pathophysiology of ESRD As renal function declines, the end products of protein metabolism accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more severe the symptoms are. ESRD occurs when there is less than 10% nephron function remaining. All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired. The rate of decline in renal function and progression of chronic renal failure is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions. (Dr. Belal Hijji, RN, PhD; April 18 & 23, 2012)

Chronic Kidney Disease or ESRD

Non-Modifiable Factors -Hereditary -Age greater than 60 years old -Gender -Race

Modifiable Factors -Diabetic Mellitus

-Hypertension -Increase Protein and Cholesterol Intake -Smoking

LEGEND:

Causative Factors

S / Sx

-Use of analgesics Decreased renal blood flow Primary kidney disease Damage from other diseases

Sequence of events

Lab / Dx

BUN

Decreased Urine outflow obstruction glomerular filtration rate Hypertrophy of remaining nephrons

Serum Creatinine

Dilute Polyuria

Loss of Sodium in Urine

Hyponatremia

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ARCHIE M. ASTORGA BSN32 DLSHSI

Inability to concentrate urine Further loss of nephron function

PROF. REGIEBE VICENCIO GROUP 4 - 1300

Loss of non excretory renal function

2 a

Failure to convert inactive forms of calcium Calcium absorption

Failure to produce erythropoietin

Impaired insulin action

Production of lipids Advanced atherosclerosis

Immune disturbances

Disturbances in reproduction

Anemia Pallor

Erratic blood glucose levels

Delayed wound healing

Infection

Libido

Infertility

Hypocalcemia

Osteodystrophy

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ARCHIE M. ASTORGA BSN32 DLSHSI

2 a

PROF. REGIEBE VICENCIO GROUP 4 - 1300

Loss of excretory renal function

Excretion of nitrogenous waste

Decreased sodium reabsorption in tubule

Decreased phosphate excretion

Decreased potassium excretion

Decreased hydrogen excretion

Uremia

Water Retention

Hyperkalemia

Hyperphosphatemia

Metabolic acidosis

Hypertension Heart Failure Edema Decreased calcium absorption Hyperparathyroidism Decreased potassium excretion CNS changes Pruritus Altered Taste Bleeding Tendencies

BUN, Creatinine Uric Acid

Protenuria

Peripheral nerve changes

Pericarditis

Increased potassium

Website: nurseslabs.com

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300 Pathophysiology of Pneumonia

There are different categories of pneumonia. Two of these types are hospital-acquired and community-acquired. Common types of community-acquired pneumonia are pneumococcal pneumonia and Mycoplasma pneumonia. In some people, particularly the elderly and those who are debilitated, pneumonia may follow influenza. Hospital-acquired pneumonia tends to be more serious because defense mechanisms against infection are often impaired. Some of the specific pneumonia-related disorders include: aspiration pneumonia, pneumonia in immunocompromised host and viral pneumonia.
Modifiable Factors: Decreased bactericidal ability of the alveolar macrophages Extreme virulence of the bacteria Increased susceptibility of host to infection

Acute inflammation occurs that causes excess water and plasma proteins go to the dependent areas of the lower lobes.
Cough with mucus-like, greenish, or pus-like sputum chills, fever, easy fatigue, chest pain, headache, loss of appetite, nausea and vomiting, malaise, rales

RBCs, fibrin, and polymorphonuclear leukocytes infiltrate the alveoli. Containment of the bacteria within the segments of pulmonary lobes by cellular recruitment.

Tests include: chest Xray, sputum gram stain, CBC, arterial blood gases, thoracic CT, routine sputum culture, pulmonary ventilation/perfusion scan, pleural fluid culture, lung needle biopsy.

Consolidation of leukocytes and fibrin within the affected area.

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300 Stage of congestion: Engorgement of alveolar spaces with fluid and hemorrhagic exudates LEGENDS:

Proliferation and rapid spread of organism through the lobe

Causative Factors

S / Sx

Stage of red hepatization: Coagulation of exudates occurs resulting to the red appearance of the affected lung
Stage of gray hepatization: The decrease in number of RBC in the exudates is replaced by neutrophils; which infiltrate the alveoli making the lung tissue to be solid and grayish in color. PNEUMONIA

Sequence of events

Lab / Dx

Websites: www.healthcentral.com rnspeak.com

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ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300

VII.

MEDICAL SURGICAL MANAGEMENT

1. Procedure

Procedure/Date

Indication/Analysis NGT is indicated for gastric intubation via the nasal passage. It is a common procedure that provides access to the stomach for diagnostic and therapeutic purposes. For diagnostic purposes used for evaluation of upper gastrointestinal (GI) bleeding (presence, volume). Also for aspiration of gastric fluid content. For therapeutic purposes of gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often via the oropharynx. Also for the relief of symptoms and bowel rest in the setting of small-bowel obstruction. Aspiration of gastric content from recent ingestion of toxic materials, administration of medications, osteorized feeding and bowel irrigation.

Nursing Responsibilities (PRE, INTRA, POST) PRE Ensure a signed consent for NGT. Prepare equipments. Explain the procedure. Place on a semi-fowler's position. Provide freedom of movement. Check if the tubing is kinked. INTRA Keep the tube from hanging dependent below the level of entrance to the drainage bottle. Note the amount & kind of solution used. POST Note the color, amount & consistency of drainage. Note the patient's reaction to the procedure. Perform oral care every 2 hours. Document

NGT August 01, 2012

Mechanical Ventilator August 01, 2012

Ventilation and protection of airway. A

PRE

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ARCHIE M. ASTORGA BSN32 DLSHSI compromised airway, or an airway at risk of compromise, may be identified by physical examination and ancillary testing.

PROF. REGIEBE VICENCIO GROUP 4 - 1300 Explain importance of mechanical ventilator to patient. Performing frequent assessments including level of consciousness and vital signs. INTRA Verifying prescribed ventilator settings and the appropriate alarm limits. Also properly secure the endotracheal tube and respond to and troubleshoot ventilator alarms, follow infection control guidelines, and identify complications or mechanical problems associated with mechanical ventilator, such as an air leak or kink in the ventilator circuit. Ensuring emergency equipments, such as manual resuscitation bags and oropharyngeal and nasopharyngeal airways, are immediately available. Assessing the adequacy of the cardiac output. Maintaining adequate perfusion is paramount. POST Evaluating the adequacy of oxygenation with use of a pulse oximetry. Assessing the adequacy of ventilation. It is essential to monitor the patient's PaO2, PaCO2, and acid-base balance. Monitoring the patientPage | 20

ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300 ventilator interaction.

Pulse oximeter August 01, 2012

Indirectly monitors the oxygen saturation of a patient's blood and changes in blood volume in the skin, producing a photoplethysmogram. The pulse oximeter may be incorporated into a multiparameter patient monitor. Most monitors also display the pulse rate. Portable, batteryoperated pulse oximeters are also available for transport or home bloodoxygen monitoring.

PRE Review the manufacturers instruction for assembly. INTRA Clip the pulse oximeter in the appropriate site to monitor the oxygen levels. Secure the pulse oximeter to prevent it from dislodging. POST Continue monitoring patients pulse oximeter reading for hypoxemia of below 95%.

2. Pharmacotherapeutics / Medicines (IV Fluids, Drugs) GN (BN) Classification Stock Levofloxacin Anti-infective; Antibiotic; 500mg Treatment for patients with pneumonia and other respiratory infection. 500mg q48 Indication Dosage and Frequency Nursing Responsibilities / Implication (PRE, INTRA, POST) Do C&S test prior to beginning therapy and periodically. Withhold therapy and report to physician immediately any of the following: Skin rash or other signs of a hypersensitivity reaction. CNS symptoms such as seizures, restlessness, confusion, hallucinations, depression; skin eruption following sun exposure; symptoms of colitis such as persistent diarrhea; joint pain, inflammation, or rupture of a tendon; hypoglycemic reaction in diabetic on an oral Page | 21

ARCHIE M. ASTORGA BSN32 DLSHSI

PROF. REGIEBE VICENCIO GROUP 4 - 1300 hypoglycemic agent.

Clopidogrel Antiplatelet 75mg

Treatment of patients at risk forischemic events history of MI,ischemic stroke,peripheral artery disease. 75mg Once a day

Monitor blood studies: CBC, Hgb, Hct, prothrombin time, cholesterol if the patient is on long-term therapy; thrombocytopenia and neutropenia may occur. Monitor liver function studies: AST, ALT, bilirubin, creatinine if patient is on long-term therapy. Check if patient has pernicious anemia. Patients w/ chronic renal failure & receiving acetylsalicylic acid. Hematologic remission may occur while neurological manifestations remain progressive. Serum B12 levels should be regularly assessed in elderly & patients w/ condition leading to vit B12 depletion. Check for renal impairment, hypoparathyroid disease, hypercalcemiaassociated diseases. Calcium absorption is impaired in achlorhydria; use an alternate salt and take with food. Caution when used in patients with a history of kidney stones. Check for liver function studies: AST, ALT, bilirubin, creatinine if patient is on long-term therapy. Page | 22

Iberet Folate Supplement 1 tab

Treatment & prevention of Fe-deficiency & concomitant folic acid deficiency w/ associated deficient intake or increased need for vit. Bcomplex in nonpregnant adults. 1 tab Twice a day

Calcium carbonate Calcium-containing antacid 1 cap

Treatment for patients with hyperacidity and hyperphosphatemia in chronic renal failure. 1 cap Twice a day

Meropenem Carbapenems 500mg/vial

Treatment of susceptible infections including intraabdominal infections, meningitis, respiratory tract infections,

ARCHIE M. ASTORGA BSN32 DLSHSI septicemia, skin infections & UTI in immune compromised patients. 500mg/vial q24 IV

PROF. REGIEBE VICENCIO GROUP 4 - 1300

VIII.

PROGRESS NOTES

* Not applicable. Time spent with the patient was insufficient to come up with this topic.

IX.

DISCHARGE HEALTH TEACHING PLANS

* Not applicable. Time spent with the patient was insufficient to come up with this topic.

IX. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT Date: August 01, 2012 Received patient in DLSUMC 1300 SICU 1314-B, lying on bed. Patient was hooked in mechanical ventilator, pulse oximeter, and cardiac monitor. Also had NGT and a suctioning machine on side of patients bed. Patient has right arm precaution due to presence of edema and his AV fistula. Patient had undergone hemodialysis the day before he was received. Patient often complains difficulty of breathing because of secretions that block his airway, suctioning was prioritized as the main intervention. Patient became irritated by the time his relatives visited him which made his vital signs to alter. Patient has no urine output due to his condition. There is enlargement of his scrotal sacs. Feeding and medications was administered on time. Patient was strictly monitored within the shift.

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