V.

BASELINE DATA

Name: Malayang, Romeo

Address: Brgy. Talok, Bago City, Negross Occ. Ph
Age: 73
No. of dependent: none
Birth of date: Dec. 30, 1936
Birth place: Brgy. Talok, Bago City, Negross Occ. Ph
Gender: Male
Mental status: Unconscious % disoriented to time, place &
person
Religion: Roman Catholic
Educational level: High school under grad.
Nationality: Filipino
Occupation: Husband
Person next to kin: Sister-in-law
Date of Admission: Dec. 4, 2009
Attending Physician: Dr. Alayon
Chief of Complaints: Difficulty in breathing
Date of Surgery (if done): N/A
VII. HEALTH HISTORY

History of Present Illness

R.M. a 73 year old male was admitted in the hospital due to

drowsiness dec. 4 2009; 5 days PTA the patient was
accidentally ruled out Foley catheter and in the 3 days PTA
patient became restless with anorexia. Patient R.M’s sister-
in-law claimed that the R.M had complained of difficulty of
breathing and of having a hypo gastric pain associated with
fever that is on and off. The folk claimed that Mr. R.M. had
no any diseases before admission except of this.

Past Medical History

A.) Childhood Illness:

- None.

B.) Past Hospitalization:

- None.

C.) Serious Illness/Chronic Illness:

- The patient has a Chronic Renal Failure secondary
to Obstructive Uropathy. Negative Hypertension and
Diabetes Mellitus

D.) Previous Surgery:

- None
Family/Social History:

His sister-in-law claimed that R.M. father died due to cardiac

arrest and R.M. brother died in Kidney failure.

General Appearance

HEENT

Neurological (LOC)

Cardiovascular

Respiratory

Breast

Abdomen
Gastrointestinal tract

Musculoskeletal

Endocrine

Integumentary
IX. Laboratory and Radiology

Chemistry result Dec. 08, 2009

Chemistr Result Normal Interpreta Implication

y Values tion
Potassiu 4.7 3.6-
m 5.4mEq/L

Remarks:

CBC result Dec. 07, 2009

CBC Resu Normal Interpretat Implication

lt Values ion
Hematocri .11 M: 0.40-
t 0.54g/L
Hemoglob 39 M: 130-
in 180g/L
WBC 7.5 4.5-
count 11x10⁹/L

Remarks:

Differential Count Dec. 07, 2009

Differential Resu Normal Interpretat Implicati

Count lt Values ion on
Neutrophils 70 50-70%
Lymphocytes 22 25-35%
Monocytes 6 4-8%
Eosinophils 2 1-5%
Platelet count 202 150-
400x10⁹/L

Blood
Grouping/ty Result
ping

ABO AB(+)
RH AB(+)

Remarks:

Laboratory Results Dec. 07, 2009

Clinical Result Normal Interpretat Implicatio

Chemistry Values ion n

Creatinine 1,934. 0.6- Increased

37 1.74mg/dl
Sodium 143 134- Normal
148meq/l
Potassium 4.7 3.6- Normal
5.4meq/l
Ionized(fr 0.88 1.12- Decreased
ee) 1.3meq/l

Remarks:

Arterial Resu Normal Interpretatio Implicati

Blood lt Values n on
Gas
Ph 7.21 7.35-7.45
PCO2 15.6 35-45mmHg
PO2 136. 80-
3 100mmHG
HCO3 10.8 22-26mEq/L
B.E. (-)21 2m Eq/L
.7
O2sat 98.3 97%
%
T40HCO3 /

Remarks:
II. OBJECTIVES

General:

After 3 days of clinical exposure, the student nurse

will be able to:
• Acquire knowledge and understanding about the
causes, diagnostic tests, nursing diagnosis, nursing
management and treatment of Chronic Renal Failure.

Specific:

After 3 days of nurse-client interaction, the client will

be able to:
• Gather information on the facts and causes regarding
Chronic Renal Failure.
• Learn the different measurements on how to cope up
with and manage pain and seizures.
• Comply with all the medications given.

After 3 days of nurse-client interaction, the student

nurse will be able to:
• Identify and provide information about the Chronic
Renal Failure.
• Assess the causes and factors that let to Chronic Renal
Failure.
• Apply effective nursing care to the client.
• Present a health teaching plan with appropriate nursing
interventions and outpatient instructions.
• Encourage client to take medications regularly for
health maintenance.