ONGOING APPRAISAL

DAY I

December 18, 2010

On the first day of appraisal, Mrs. Florencia was seen sleeping on bed in side lying position.
She was wearing a blue shirt and white jogging pants. She was weak and pale in appearance and
with complaints of mild dizziness and easy fatigability and has no longer complaint of nape pain.
An intact heparin lock was inserted at her right cephalic vein which was used as an intravenous
access for intermittent or emergency medication administration.

She was ordered to have uremic diet by Dr. Rasos because it is the kind of diet that is
indicated to her condition and the laboratory result of her BUN was much higher than the normal
level. She had an oral intake of 850 mL and urine output of 800 mL. She voided for 8 times and did
not defecate that day. Unable to get the weight.

Her vital signs ranged from:

Blood pressure: 130/80-140/80
Pulse rate: 70-71 bpm
Respiratory rate: 20-23 bpm
Body temperature: 36.3-36.6 degree Celcius

She was seen and examined by Dr. Rasos around 12pm and made new orders such as for
repeat CBC; Na, K, Ca ionized; BUN and creatinine; for ABG to determine if there are abnormal
changes in their levels.

The patient spent her time sleeping, sitting on the bed, and chatting with her mother.

Mrs. Florencia took in Metoprolol 50mg BID, Calcie 500mg BID as her maintenance for
hypertension, NaHCO3 650mg 1tab TID, FeSO4 1tab TID, and Folic Acid 500mg 1tab OD for iron
supplement and for the correction of her anemia. She was still for referral to nephrology
deparment for further evaluation and management. She was subjected for dialysis but with no
consent yet because she still indecisive as verbalized “agdialysis ak kano ngem diba nu ubraen da
dejay ket inggat tungpal biag?” The sample for her fecal occult blood was forwarded to laboratory.
 At 3am, she had blood transfusion of third and last unit of PRBC type O+ with S.N. of 10-
4430 because her blood components are still low and there were no BT reactions noted.

DAY II

December 19, 2010

Mrs. Florencia was seen sitting on bed and chatting with her mother and relatives. She was
wearing white shirt and green pajamas. She was still pale and weak in appearance and no
complaints of dizziness and easy fatigability. An IV fluid of PNSS 1L @600cc level was regulated to
KVO inserted at her right cephalic vein.

She is still in uremic diet. The oral intake of the patient was 700 mL and the urine output
was 1050 mL. She voided for 9 times and defecated once that day. Unable to get the weight.

The vital signs ranged from:

Blood pressure: 120/80-150/90 mmHg
Pulse rate: 70-75 bpm
Respiratory rate: 22-24 bpm
Body temperature: 36.2-36.6 degree Celcius

The patient was seen and examined by Dr. Rasos at 2:05pm and with new orders were
made as follows: facilitate BT of another 1unit to complete for 4unit PRBC because blood
component levels were still low; for repeat CBC 6hours post BT to determine changes in her blood
component levels; still for referral on the nephrology department for further evaluation and
management. She was for discharge after repeat CBC 6hours post BT.

At around 10pm, she was given again the 4 th and last unit of PRBC type O - with a S.N. of
GSGH 13257. There were no BT reactions noted and she was given Furosemide 20mg after each
unit. She was given the same medications as yesterday.
DAY III

December 20, 2010

Mrs. Florencia was seen sitting on bed. She was wearing gray shirt and blue pants. She was
still pale and she has verbalized that there was an improvement, “mejo mayat riknakon ken haan
nak unay agkakapsuten”. An intact heparin lock was inserted at her right cephalic vein.

She is still in uremic diet. The oral intake of the patient was 760mL and the urine output
was 700 mL. She voided 4 times and defecated once that day. Unable to get the weight.

The vital signs ranged from:

Blood pressure: 120/80- 140/80 mmHg
Pulse rate: 70-74 bpm
Respiratory rate: 22-24 bpm
Body temperature: 36.6- 36.9 degree Celcius

The patient was seen and examined by Dr. Rasos at 2:40pm and ordered that Mrs. Ligaya
may go home and has to come back on January 3, 2011 for follow-up check-up and prescribed
following home medicines:

1. CaC03 500 mg/tab 1 tab BID

2. NAHC03 650 mg/tab 1 tab TID

3. FeSO4 tab 1 tab TID

4. Folic Acid 500 mg/tab 1 tab OD

She went home at around 5:30 pm per wheelchair in fair in appearance accompanied by
relatives.