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    Fdar Torio

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    Jordz Placi
    1) The patient has diabetes mellitus with an unstable blood glucose level related to lack of adherence to diabetes management. The patient presented diaphoretic, pale, and with a blood glucose level of 55 mg/dl. 2) The second patient has CKD stage 5 related to decreased oxygen transport to distant organs. Presented edematous and with elevated BUN and creatinine. 3) The third patient has CVD and impaired bed mobility related to body weakness. Presented unable to perform activities of daily living independently and with limited range of motion in the right extremities.

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    Fdar Torio

    Uploaded by

    Jordz Placi
    6K views3 pages
    1) The patient has diabetes mellitus with an unstable blood glucose level related to lack of adherence to diabetes management. The patient presented diaphoretic, pale, and with a blood glucose level of 55 mg/dl. 2) The second patient has CKD stage 5 related to decreased oxygen transport to distant organs. Presented edematous and with elevated BUN and creatinine. 3) The third patient has CVD and impaired bed mobility related to body weakness. Presented unable to perform activities of daily living independently and with limited range of motion in the right extremities.

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    1) The patient has diabetes mellitus with an unstable blood glucose level related to lack of adherence to diabetes management. The patient presented diaphoretic, pale, and with a blood glucose level of 55 mg/dl. 2) The second patient has CKD stage 5 related to decreased oxygen transport to distant organs. Presented edematous and with elevated BUN and creatinine. 3) The third patient has CVD and impaired bed mobility related to body weakness. Presented unable to perform activities of daily living independently and with limited range of motion in the right extremities.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    6K views3 pages

    Fdar Torio

    Uploaded by

    Jordz Placi
    1) The patient has diabetes mellitus with an unstable blood glucose level related to lack of adherence to diabetes management. The patient presented diaphoretic, pale, and with a blood glucose level of 55 mg/dl. 2) The second patient has CKD stage 5 related to decreased oxygen transport to distant organs. Presented edematous and with elevated BUN and creatinine. 3) The third patient has CVD and impaired bed mobility related to body weakness. Presented unable to perform activities of daily living independently and with limited range of motion in the right extremities.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    At a glance
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    The key takeaways are the importance of medication compliance, healthy lifestyle, and monitoring of vital signs and lab results for patients with chronic illnesses.

    Common symptoms of diabetes include high blood sugar levels, thirst, frequent urination, fatigue, and blurred vision.

    Nursing interventions for a patient with CKD stage 5 include monitoring intake and output, checking lab results, advising fluid and diet restrictions, and preparing for hemodialysis.

    TORIO, ALYSSA ASHLEY B.

    FDAR: Diabetes mellitus


    F Unstable blood glucose level related to lack to adherence of diabetes
    management
    D
    7:00am Received patient awake lying in bed with ongoing IVF of PNSS 20 gtts/min
    infusing well at the left hand. “parang sumasakit ulo ko” as verbalized by the patient.
    Observed that the patient is diaphoretic, pale and irritable. Patient’s skin is cold and
    clammy with capillary refill within 2 seconds. CBG result 55 mg/dl. Urinalysis result
    reveals presence of ketones in urine as of November 20,2020. Fluid intake is
    approximately 1500 ml and urine output of 700 ml during the 8 hour shift. Initial V/S: BP
    100/60, spo2 of 90%, RR 30 cpm, PR 120bpm, afebrile.
    7:30am D50W 50 ml given as ordered.
    A Assessed patient’s integumentary status. Monitored vital signs and recorded,
    monitored blood glucose, monitored fluid input and output. Checked the laboratory
    results. Assisted in giving D50W as prescribed. Advised the patient to report any
    untoward signs and symptoms, encouraged to eat 30 minutes after the insulin given.
    Advised to always carry hard candies anytime, to exercise for 30 minutes 3-5 times a
    week to maintain body weight. Reiterated the importance of drug compliance and
    healthy eating habits.
    R
    3:00pm Blood is in normal glucose level; 85 mg/dl. Not in any type of distress, skin
    is warm to touch, not diaphoretic. Latest vital signs BP 120/80, RR 18cpm, PR 80 bpm,
    spo2 of 98%.
    FDAR: CKD stage 5
    F Impaired renal tissue perfusion related to decrease oxygen transport to distant
    organ
    D
    7:00 am Received awake lying in bed with ongoing IVF of PNSS 1L x KVO, no
    complaints of pain. Observed the patient to be weak and restless. Edematous lower
    extremities, dry and cracked lips noted. Capillary refill within 2 seconds and skin is
    warm to touch. Latest Laboratory result shows elevation in BUN=42mg/dl and
    creation=80mg/dl as of November 20, 2020. Chest x-ray reveals no congestions in the
    lungs. Fluid intake of 800ml, Urine output is approximately 100 ml and pinkish in colour
    as characterized by the patient. Vital signs BP: 130/90, RR: 20cpm , PR: 80bpm, temp:
    36.6 spo2 of 98%.
    10:00 am Withhold medications prior to hemodialysis.
    A Assessed integumentary status. Assessed urine characteristic. Monitored vital
    signs and monitor input and output, checked laboratory result. Offered fluids. Positioned
    the patient into comfortable place. Advised to elevate lower extremities up to 2 pillows
    high, to lessen protein intake especially red meat and to avoid salty foods. Advised to
    drink 1-1.5 litters everyday as ordered by the physician. Encouraged to avoid crowd and
    to always wear masks to prevent infections.
    R
    3:00PM Not in any type of distress latest BP: 110/70 RR: 20 cpm, PR: 60bpm.
    Acknowledge health teachings given.

    FDAR: CVD
    F Impaired bed mobility related body weakness
    Received patient awake lying in bed. “ wala naming masakit sakin, hindi lang ako
    makagalaw ng maayos” as verbalized by the patient. Oriented to time, place and
    person. Presence of gag reflex, and cough reflex. Unable to perform activities of daily
    living, like as changing clothes, needs assistance to perform ADL’s. Right upper
    extremity and right lower extremity is unable to perform full range of motion, the patient
    can’t move from side to side. Initial vitals sign BP: 120/90, PR 66 bpm, RR:22 cpm,
    SPo2 of 99%.
    A Assessed level of consciousness, assessed reflexes. Monitored vitals signs and
    recorded. Assisted in performing ADL’s, assisted in clients positioning, performed
    passive ROM to the patient, offered fluids. Advised the patient’s watcher to perform
    passive ROM to the patient and to increase fluid intake as tolerated and as not
    contraindicated. Encouraged the patient to exercise his right side extremities to prevent
    hypotrophy.
    R Not in respiratory distress, still needs assistance in performing ADL’s. able to
    raise right upper extremity and right lower extremity but not to its full extent

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