Submitted by:

Otto Niel B. Acosta

Student Nurse

Submitted to:
Mr. Jake Diputado Bsn,RN.
Clinical Instructor, School of Nursing
Name: Thelma A. Geraldo Sex: Female
Age: 60 years old Civil Status: Married
Birth date: April 12, 1950 Religion: Roman Catholic
Nationality: Filipino Occupation: Business woman (fish vendor)
Address: Polo, Dapitan City
Parents:
Father: DEAD (hypertension)
Mother: DEAD

Chief Complaint: Nausea and vomiting, Body weakness and loss of appetite
Admitting Diagnosis: Acute renal failure
Date of Admission: August 2, 2010
Time of Admission : 9:35 AM

History of Present Illness:

2 weeks prior to admission the patient experienced loss of appetite, nausea and vomiting ,and body weakness. Thinking that these
signs and symptoms were just minor discomforts, she remedied herself with “Cocobawil”. After noticing no changes but rather the
severity of the condition, she decided to be admitted in Misamis Occidental Provincial Hospital, Oroquieta City for 4 days. The patient felt
better a bit, but it didn’t alleviate the signs and symptoms that she was experiencing, so she returned home and was admitted in DJRMH.

History of Past Illness:

 FHP Usual Pattern Initial Pattern
(August 2, 2010)
Health Client perceives health as good. And is satisfied with the usual Client is weak and sleeping.
Perception- health status. Does not smoke cigarettes, nor drinks alcoholic Memory is average.
Health beverages, and does not use drugs. She as Hypertension . She Have a good vision and hearing, and
Management does not have any major problems in her work and goes along normal taste, smelling and a good sense
Pattern well with her employer. Have fair living rates at home. of touch.
Exercise includes walking and doing household chores. Uses Skin is slightly dry, long nails and has no
herbal plant “Cocobawil” for constipation and GI discomfort. abnormal body odors.
Abdomen is taut and shiny
Ascites is present
Edema present
Hematology results:
Hct – 0.27 (F 0.37-0.47)
Neutrophils- 0.88 (0.55-0.65)
Eosinophils – 0.01 (0.03-0.05)
  Vital signs:
T- 35.8˚C
P- 91 bpm
R- 20 cpm
BP- 160/80 mmhg
 Doctor’s Order:
Pls. Admit patient to Medical Ward
Low-protein Diet, Low Fat Diet and
Low Salt Diet
TPR q Shift
Start IVF of PNSS 1 L @KVO rate
Labs:
 ABS, PLT
 U/A
BP monitoring q˚2
I&O q˚shift
For referral to internist for
further examination
RBS monitoring q˚6
Nutritional Usually eats vegetables,fish,chicken meat and beef meat. Have an IVF PNSS 1000 mL@ left
Metabolic Drinks 8-10 glasses of water a day. Drinks one glass of milk metacarpal vein
Pattern everyday(Ensure). Multivitamins are taken. Decrease water intake.
Meds:
 Amlodipine 10 mg. 1 tab.
P.O. OD
 Clonidine 75 mg. 1 tab. q˚8
 Ketosteril 600 mg. 2 tabs.
TID
 Cinnarizine 75 mg. 1 cap.
OD
 Esomeprazole 40 mg. 1 cap.
OD
  Eaten lugaw and bread

Elimination Removes bowel once a day, usually in the morning. Stool  Urinalysis results:
Pattern consistency is soft, no constipation, color brownish. Does not Glucose – 121 mg (76-100)
experience bleeding in bowel movements. Urinates Cholesterol – 270 mg (<200mg)
frequently. Urine color is yellowish with no foul smell. Triglyceride – 198 mg (<200mg)
Creatinine – 6.45 (0.5-0.9)
 Decreased urine output
 No defecation
 I&O monitoring#
 INPUT
ORAL – 180 cc
PARENTERAL – 240 cc
 OUTPUT
100cc
Activity Exercise Patient is completely independent (Feeding, bathing/hygiene, Bedrest, restless, and nausea and fatigue.
Pattern dressing/grooming, toileting, ambulation, care of home,
shopping, meal preparation, laundry and preparation). Does
not necessarily require help from another person on
equipment/device. Watches TV everyday as a past time, and
water plants in home. Does walking for 10-20 minutes.
Sleep-Rest Usual sleeping pattern 8PM-6AM, takes 30 minutes short naps Sleeps more frequently.
Pattern during the day. Does not have difficulty going to sleep, does Sleeping pattern is interrupted by taking
not experience insomnia. on-time medications, vital signs.
Cognitive Can make independent decisions. College undergraduate . Depends always on her children’s
Perceptual decision
Pattern
Self Views herself neutrally. She is liked by her friends, loved ones Client is sleeping.
Perception/Self and family. Lonely when problems hits, and does not Supported by her family.
Concept Pattern experience fear frequently. Client is calm and cooperative.
Role Lives with her Family (husband, 1 daughter and 2 sons). Relationship with her family is not
Relationship strained.
 Pattern
Sexuality Client has satisfying sexual relationship with her partner with Husband is always on her side on
Reproductive no reports of problems and difficulties in sexual functioning. confinement.
Pattern Does not use any birth control methods. Does not have history
of vaginal discharge, lesions or bleeding.
Coping Stress Has an average rate in handling stress. The primary way of Client handles stress in a good way and is
Tolerance handling stress is being alone, and sharing it with her positive in her outlook of life.
Pattern husband. Satisfies with the care received at home.
Value-Belief Satisfied with her life. She is a catholic and goes to church Client still look forward in going to
Pattern every Sunday with her husband. And sometimes consults with church every Sunday when she will be
a “quack” doctor and has many superstitious beliefs. discharged.
Abdomen:
Inspection: PERCUSSION:
Abdomen is taut Tympany over the stomach and gas filled bowels
Skin is shiny Dullness in the right and left lower quadrants
assymmetrical contour Kidney punch test performed but no pain felt
Unblemished skin
Uniform in color
Protruberant in shape

Inspection: PALPATION:
Abdomen is taut Generalized tenderness
Skin is shiny Kidneys are not palpable and no pain felt
assymmetrical contour
Unblemished skin
 Uniform in color
Protruberant in shape

ONGOING PATTERN ONGOING PATTERN ONGOING PATTERN

(August 3, 2010) (August 4, 2010) (August 5, 2010)
Client is weak and sleeping. Client is weak and sleeping. Client is weak and sleeping.
Memory is average. Memory is average. Memory is average.
Have a good vision and hearing, and Have a good vision and hearing, and Have a good vision and hearing, and
normal taste, smelling and a good sense normal taste, smelling and a good sense normal taste, smelling and a good sense
of touch. of touch. of touch.
Skin is slightly dry, long nails and has no Skin is slightly dry, long nails and has no Skin is slightly dry, long nails and has no
abnormal body odors. abnormal body odors. abnormal body odors.
Abdomen is taut and shiny Abdomen is taut and shiny Abdomen is taut and shiny
Ascites is present Ascites is present Ascites is present
Edema present Edema present Edema present
 Vital signs:
 Vital signs:  Vital signs: T- 36.5˚C
T- 36.8˚C T- 35.8˚C P- 75 bpm
P- 81 bpm P- 87 bpm R- 18 cpm
R- 20 cpm R- 18 cpm BP- 150/80 mmhg
BP- 140/80 mmhg BP- 140/70 mmhg  Doctor’s Order:
 Doctor’s Order:  Doctor’s Order: Refer to nephrologist
Continue meds HBS UTZ Comtinue meds
IVF 1 L PNSS @ KVO rate IVFTR PNSS @KVO rate IVFTR 1 L PNSS @ KVO rate
 Bisacodyl 10 mg. 1 supp per Continue meds
rectum Refer internal medicine doctor
Metoclopramide 10 mg. 1 amp, for further evaluation and
IVT q˚8 continue monitoring
Lactulose 30cc @ HS Refer accordingly
For FBC insertion
Monitor I&O
Have an IVF PNSS 1000 mL@ left Have an IVF PNSS 1000 mL@ left Have an IVF PNSS 1000 mL@ left
metacarpal vein metacarpal vein metacarpal vein
Decrease water intake. Decrease water intake. Decrease water intake.
Meds: Meds: Meds:
 Amlodipine 10 mg. 1 tab.  Amlodipine 10 mg. 1 tab.  Amlodipine 10 mg. 1 tab.
P.O. OD P.O. OD P.O. OD
 Clonidine 75 mg. 1 tab. q˚8  Clonidine 75 mg. 1 tab. q˚8  Clonidine 75 mg. 1 tab. q˚8
 Ketosteril 600 mg. 2 tabs.  Ketosteril 600 mg. 2 tabs.  Ketosteril 600 mg. 2 tabs.
TID TID TID
 Cinnarizine 75 mg. 1 cap.  Cinnarizine 75 mg. 1 cap.  Cinnarizine 75 mg. 1 cap.
OD OD OD
 Esomeprazole 40 mg. 1 cap.  Esomeprazole 40 mg. 1 cap.  Esomeprazole 40 mg. 1 cap.
OD OD OD
 Eaten oatmeal  Rice and water with sugar  Rice and tinola

 Decreased urine output  Decreased urine output  Decreased urine output

 No defecation  No defecation  No defecation
 CATHERIZATION  CATHERIZATION  CATHERIZATION
 I&O monitoring  I&O monitoring  I&O monitoring
 INPUT  INPUT  INPUT
ORAL - 200 cc ORAL - 100 cc ORAL - 100 cc
PARENTAL – 260 cc PARENTAL – 230 cc PARENTAL – 300 cc
 OUTPUT  OUTPUT  OUTPUT
150 cc 120 cc 50 cc
Bedrest, restless, and nausea and fatigue. Bedrest, restless, and nausea and fatigue. Bedrest, restless, and nausea and fatigue.
Sleeps more frequently. Sleeps more frequently. Sleeps more frequently.
Sleeping pattern is interrupted by taking Sleeping pattern is interrupted by taking Sleeping pattern is interrupted by taking
on-time medications, vital signs. on-time medications, vital signs. on-time medications, vital signs.
Depends always on her children’s Depends always on her children’s Depends always on her children’s
decision decision decision
Client is sleeping. Client is sleeping. Client is sleeping.
Supported by her family. Supported by her family. Supported by her family.
Client is calm and cooperative. Client is calm and cooperative. Client is calm and cooperative.
Relationship with her family is not Relationship with her family is not Relationship with her family is not
strained. strained. strained.
Husband is always on her side on Husband is always on her side on Husband is always on her side on
confinement. confinement. confinement.

Client handles stress in a good way and is Client handles stress in a good way and is Client handles stress in a good way and is
positive in her outlook of life. positive in her outlook of life. positive in her outlook of life.
Client still look forward in going to Client still look forward in going to Client still look forward in going to
church every Sunday when she will be church every Sunday when she will be church every Sunday when she will be
discharged. discharged. discharged.
 ONGOING PATTERN
(August 6, 2010)
Client is weak and sleeping.
Memory is average.
Have a good vision and hearing, and normal taste, smelling and a good sense of touch.
Skin is slightly dry, long nails and has no abnormal body odors.
Abdomen is taut and shiny
Ascites is present
Edema present

 Vital signs:
T- 36.2˚C
P- 90 bpm
R- 20 cpm
BP- 140/70 mmhg
 Doctor’s Order:
Refer to nephrologist
Comtinue meds
IVFTR 1 L PNSS @ KVO rate
Have an IVF PNSS 1000 mL@ left metacarpal vein
Decrease water intake.
 Meds:
 Amlodipine 10 mg. 1 tab. P.O. OD
 Clonidine 75 mg. 1 tab. q˚8
 Ketosteril 600 mg. 2 tabs. TID
 Cinnarizine 75 mg. 1 cap. OD
 Esomeprazole 40 mg. 1 cap. OD
 Oatmeal, bread and rice

 Decreased urine output

 No defecation
 CATHERIZATION
Bedrest, restless, and nausea and fatigue.
Sleeps more frequently.
Sleeping pattern is interrupted by taking on-time medications, vital signs.
Depends always on her children’s decision
Client issleeping.
Supported by her family.
Client is calm and cooperative.
Relationship with her family is not strained.
Husband is always on her side on confinement.

Client handles stress in a good way and is positive in her outlook of life.
Client still look forward in going to church every Sunday when she will be discharged.