Kring

D> Diagnosed with Chronic Renal Failure secondary to Hypertension A> Received patient on supine position, awake, afebrile > with pale conjunctiva > appears weak and with easy fatigability > with capillary refilll time of 3-4 seconds > with senile, dry and poor skin turgor > skin slightly cool to touch, slightly pale > VS taken and recorded as follows: T= 36C, PR=90bpm, RR=16cpm, BP=170/90mmHg A> Established rapport > instructed to avoid strenuous activity > provided calm environment > assisted with self-care activities as needed > VS monitoring done and recorded accordingly > instructed significant other to avoid introducing stress to patient and to limit visitors > monitored I&O strictly and recorded > instructed to sit and dangle legs first before standing > maintained activity restrictions; such as bed rest/chair rest; schedule periods of uninterrupted rest > provided comfort measures such back massage, elevation of head. > administered antihypertensive medications as ordered > reinforced compliance to treatment regimen and prescribed diet R> Able to rest well > VS stable, BP decreased to 140/90mmHg II. P> Oliguria D> Diagnosed with chronic renal failure > Decreased urine output less than 30 cc/hour > Potassium- 7.47 increased(3.5- 5.0 mg/dl) > Sodium- 134 decreased (135-145 mg/dl) A> complained of dribbling urine > distention of bladder noted > noted concentrated urine output A> encouraged client to void every 2-4 hrs & when urge is noted >determined the initial fluids and electrolytes level >monitored intake & output hourly >percussed/palpated suprapubic area for bladder distention >observed signs and symptoms of fluid & electrolyte imbalances such as dyspnea changes in ECG and restlessness > referred to medical resident on duty, with orders made and carried out > administered alternate hot and cold compress and demonstrated to watcher > limit fluid intake as necessary > reminded on compliance to treatment regimen and ldiet (low sodium)

> administered diuretics as ordered R> able to pass urine about 200cc after 3 hours > kept watched for further unusualities; none noted III. P> Sleep pattern disturbance D> diagnosed with Chronic Renal Failure secondary to Hypertension > urinary frequency and urgency especially at bedtime (nocturia) approximately 4 times A> received a 74 year old male, conscious, coherent and ambulatory > droopy, weak eyes observed > irritability noted > weakness and lack of tolerance to daytime activity/fatigue > hours of sleep = less than 5 hours A> assessed client's perception of fatigue, needs for sleep, and sleep deficits > assisted patient in planning rest/sleep periods during day > encouraged verbalization of feelings and concerns > guided in observing any previous bedtime ritual > provided information related to positive aspects of sleep and rest > advised daytime recreational activities if not contraindicated > cut down fluids at night as much as possible > provided a calm and restful environmen R> able to sleep for more than 5 hours > gained enough tolerance for daytime activities

Submitted By: Name: Unit:

Deborah S. Malnegro CCU-GC

Score: Date: June 11,2009