ALING ANNA DAY 4 o Start IVF of #1 PNSS 1L at 20gtts/min

ENDORSEMENT via soluset (set the soluset into 30mL)

o TF of PNSS 1L to be infused for 16hrs
• 22 years old at SR (same rate)
• Working as a bank teller o Time taping all IV
• History of ICU for 1 month when she was o Start O2 at 3lmp via nasal cannula
11 years old due to heart enlargement o Start Lasix (Furosemid 10mg/mL)
and congestion withhold if BP is below 100/80mmHg
• History of Acute Renal Failure Stage 1 or pulse rate is above 100bpm, TID
• Creatinine 1.20mg/dL o Start spironolactone (Aldactone 25mg
• History of HTN [hypertension] in the po BID)
family (both parents) o Weigh patient every shift
• Claimed that she loves salty foods like o I&O every shift
sodas and chips and fried foods o Limit oral intake to 600mL only per
day
• Stubborn at times
o Low salt, low fat diet
• Claimed that she is irked with so many
o CK MB + Troponin I
instructions by the doctors
o CBC, Urinalysis, S/E
• Aling Anna, a “hospital flier,” is o 12 leads ECG
admitted to the emergency department o Portable x-ray
with a diagnosis of congested heart o For Pro BNP
failure. She was discharged from the o Monitor the GFR of patient
hospital 10 days ago and comes in today o Limit ambulation
stating, “I just had to come to the o WOF pedal edema
hospital today because I can’t catch
my breath and my legs are as big as
tree trunks.” After further questioning by
you (student nurse) learn that is strictly
following the fluid and salt restriction
ordered during her last hospital
admission. She reports gaining 1-2kg
every day since her discharge.
• Aling Anna was then subject for re-
admission to the medical surgical ward
___________________________________

6:30AM Upon admission Dr. Moi ordered:

o Chief complaint: Shortness of
breath
o Admitting Diagnosis: Congested
Heart Failure
o Possible Diagnosis: Acute Renal
Failure Stage 1 secondary to CHF
o Vital signs monitoring every 2 hours
with MAP pressure (if MAP pressure
is below 60mmHg notify me at once
and hold medication)
8:30 AM after endorsement ALING ANNA 12 NOON: You will be giving the Lasix
was assigned to you (Furosemide 10mg/ml)
• Level of the IV was 750 ml and regulated • Spironolactone (Aldactone 25 mg po)
properly hooked at Right metacarpal • The level of the IV at this point 440 ML
vein with minimal blood noted • The patient was seen eating the
• Patient was cold and clammy served food
• Dryness of the nares noted • A 500ml bottled water was seen at the
• Upon assessment the patient claimed bedside
that she still experiences shortness of
breath VITAL SIGNS @12 NOON
• You also observed that the glass of the Temp Pulse Respi Blood O2 Sat
patient is not calibrated, the previous Rate Rate Pressu
nurse did not advice the patient to limit re
37.0 90 21 190/80 94%
the oral intake. degree beats/min cycles/min mmhg
• G1 bipedal edema noted Celcius IRREGUL
• Capillary Refill of 3 seconds on both AR
BEATING
fingers and toes
• Upon weighing the patient on that time it 2:00 PM The VITAL SIGNS
was 76 kg from 74 kg • The Level of IV 280ML
• The patient was claimed that the urine
VITAL SIGNS @ 8:30AM
output was about 3x going to the
Temp Pulse Respi Blood O2 Sat
Rate Rate Pressu bathroom
re • Stool once
37.5 89 22 190/80 94% • Bipedal Edema still noted
degree beats/min cycles/min mmhg 94% on 2 • The patient was seen sitting at times
Celcius several
occasion • The latest weight is 76 kg
• Capillary Refill of 3 seconds on a
10 AM it was observed by you that patient comparative matter
keeps on standing and going to the
bathroom (and we do have an order of LATEST VITAL SIGNS @2PM
limiting ambulation to the patient) Temp Pulse Respi Blood O2 Sat
• CK MB + Troponin I Rate Rate Pressu
re
• CBC, Urinalysis, S/E, 12 LEADS ECG, 37.5 99 21 170/80 96%
Portable Xray, Pro BNP, GFR of patient degree beats/min cycles/min mmhg
all laboratory done (and results are to be Celcius IRREGUL
referred once the physician would make AR
BEATING
his rounds)
• At this point Level IV is 600 mL
• Patient claimed that she frequently
urinates at the toilets, and forgot to
measures the urine output.

VITAL SIGNS @10AM

Temp Pulse Respi Blood O2 Sat
Rate Rate Pressu
re
37.0 99 21 190/80 95%
degree beats/min cycles/min mmhg
Celcius IRREGUL
AR
BEATING