AQUINO, JOBELYN H.

BSN 3 Y1-20

Patient Records
PATIENT DETAILS
Name Juan Dela Cruz Age: 65 y/o
Gender Male Female
Civil Status Single Married Divorced Widowed
Address Valenzuela City
Date of Birth October 9, 1956
Hospital Number FUMC-123-456
Attending Physician Dr. Lim
Height (cm) 157.48 cm
Weight (kg 80 kg

Admitting Diagnosis: End Stage Renal Disease Secondary to Diabetic Nephropathy

History of Present Illness: (+) Hypertension (+) DM Type II
Family History: (-)
Past Medical History: (+) Hypertension (+) DM Type II
Allergies: (-)
Medications: Losartan 50mg OD, Amlodifine 5mg OD, Glucophage 1000mg BID and
Glipizide 10mg BID, Lopid 600mg BID
Social History: Private Driver
 Medication Chart

PATIENT DETAILS DIAGNOSIS: End Stage Renal Disease Secondary to Diabetic

Nephropathy
Name Juan Dela Cruz Age: 65 y/o
Gender Male Female
Civil Status Single Married Divorced Widowed
Address Valenzuela City
Date of Birth October 9, 1956
Hospital Number FUMC-123-456
Attending Physician Dr. Lim
Height (cm) 157.48 cm
Weight (kg 80 kg

MEDICATION: dose, TIME SUN MON TUES WE THURS FRI SAT

route, frequency D
Diphenhydramine, 6:00am ✓
Nicardipine drip
10mg/amp + 90cc
PNSS to run for 10mc
drops/minute SD
PNSS IVF KVO 6:00am ✓
Metoclopramide 10 mg ✓
6:00am
TIV
Furosemide 40mg TIV 12:00pm ✓

Nurse’s Notes
F: D:
BP monitoring BP taken: BP 180/110
11/3/21 at 6:00am
A:
→ Closely monitored
→ Administered giving antihypertensive drug,
nicardipine drip.
R:
11/3/21 at 7:00am → BP: 170/100. Referred and transferred Medical Ward
for close observation.
 Discharge Plan

PATIENT DETAILS DIAGNOSIS: End Stage Renal Disease Secondary to Diabetic

Nephropathy
Name Juan Dela Cruz Age: 65 y/o
Gender Male Female
Civil Status Single Married Divorced Widowed
Address Valenzuela City
Date of Birth October 9, 1956
Hospital Number FUMC-123-456
Attending Physician Dr. Lim
Height (cm) 157.48 cm
Weight (kg 80 kg

Discharge Goal:
Return to Home (self-care)
Return to Home but needs Assistance
 Transfer to other Level of Institutional Care
Referral to Support Community Services
Home Against Medical Advice

Discharge Plan
Date: Medications
Continuation of Medication
Make sure the patient keeps taking the following drugs as directed:
 Losartan 50 mg OD is used to manage blood pressure.
 Amlodifine 5 mg OD for managing blood pressure
 The therapy of diabetes with 1,000 mg BID of Glucophage
(Metformin).
 Glipizide 10 mg BID for the treatment of diabetes.
 Lopid 600 mg, as directed.

Time:
Exercise/Environment
 Assure the patient of a secure and encouraging atmosphere
at home. Address any environmental elements, such as
allergens or dangers, that could affect their health.
 Persuade the patient to exercise moderately, if that is what
their doctor has advised. Talk about the significance of
keeping your mobility and avoiding difficulties.

Treatment
 Arrange any necessary follow-up consultations for the
patient with their primary care physician, nephrologist, and
endocrinologist. Make sure the patient is aware of the value
of routine checkups.
Health Teachings
 Blood Pressure Control: Inform the client of the importance
of blood hypertension management to avert future kidney
injury and cardiovascular problems.
 Provide diabetes management: including dietary
recommendations, blood sugar monitoring, and management
of insulin or oral medications.
 Outpatient check-up
 Encourage the patient to routinely check their blood pressure
at home and make a record of the results. Show them how to
spot symptoms of health decline.
 Tell the patient to keep an eye out for symptoms of infection,
like fever, chills, or soreness where the catheter was inserted,
and to report any such signs right away.

Discharge
 Protein, phosphorus, sodium, and potassium intake
limitations. Give dietary recommendations and resources for
meal planning.

Spiritual
► Offer the patient emotional support: if necessary, nudge them
toward seeking out spiritual or emotional direction. Talk about the
value of mental health in treating chronic diseases. The patient
should be encouraged to include their family or support system
in their care plan. Support from the family is incredibly helpful in
managing chronic diseases.

Juan Dela Cruz

Patient’s Signature over Printed Name Nurse’s Signature over Printed Name