Diagnosed with Chronic Renal Failure secondary to Hypertension
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
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 ofuninterrupted rest> provided comfort measures such back massage, elevation of head.> administered antihypertensive medications as ordered> reinforced compliance to treatment regimen and prescribed diet
Able to rest well> VS stable, BP decreased to 140/90mmHgII.
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)
complained of dribbling urine> distention of bladder noted> noted concentrated urine output
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 dyspneachanges 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)