POMR

CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

S: 1. CKD stage V 1. 1 HT • Urinalisis Non-farmacology: Planning Planning Education:

• 4 weeks ago, patient went to the Islamic newly nephoscelerosis • Usg abdomen • Low salt < 2 Monitoring: - Educate the patient
Hospital, got another ultrasound, and was 1.2 PNC + dan urologi g/day, protein 0.8 • Sign and about the disease.
given medicine for 1 month to keep her Nepholithiasis g/kgBW/day symptom,
kidneys from getting dialysis Vital Sign,
O Farmacology: • Input, urine
• TD 140/100 • Routine output., fluid
• HR 87 hemodialysis balance
• RR 19 (Tuesday and • Ureum,
• T 35.7 Friday) creatinine,
• SpO2 98% room air Urinalysis

• Lab:
• Ureum ; 143
• Creatinin ; 12.50

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 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

S: 2. Anemia 2. 1 Related no 1 blood smear PRC transfusion : 774 -Monitoring Sign - Educate the patient
• The patient feels increasing weak mycrocytic 2.2 iron deficiency cc and symptom, about condition
especially in about two week hyorocromic anemia Folic acid 1 x 5 mg Vital Sign, GCS,
Complete Blood
Lab: Count,
• MCV : 74,4 % Bleeding
• Leukosit : 2,66 juta/ uL manifestations
• Hematrokrit : 19,9
• RDW :3,5

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 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

S: 4. Hypertension stage - - Farmakologis Monitoring Sign - Educate the patient

• The patient's family has a history of hypertension 1 • Amlodipine 1x10 and symptom, about condition
• Patient taking reguler medications : amlopine mg Vital Sign, ECG
• Candesartan
O: 1x16mg
TD 140/100 mmhg

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 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

S: 4. Hyponatremia - - Farmacology: • Monitoring - Educate the patient

• The patient had nausea vomit hyperosmolar • Nacl 0,9% Sign and about condition
euvolemia • PO domperidon symptom,
Lab 10mg/8 jam Vital Sign,
Natrium : 133 Meq/L • Recheck
laboratory
(Natrium)

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