Name: Geraldine Mae F.

Herrera
Section: BSN 3 YA - 5

CASE SCENARIO:
Patient Profile

Name: Juan Dela Cruz

Age: 65 years old
Sex: Male
Civil Status: Married
Address: Valenzuela City
Occupation: Private driver
Date of admission: Nov. 3, 2021
Time: 6:00 AM
Chief Compliant: Pruritis, lower extremity edema, nausea and emesis.

Past Medical History: (+) Hypertension, (+) DM Type II

Day 1:
A 65- year old male, long standing type 2 diabetic and hypertensive, with end
stage renal disease secondary to diabetic nephopathy. He was taken the following
medication such as Losartan 50 mg OD, amlodifine 5 mg OD, glucophage 1,000 mg BID and
glipizide 10 mg BID, lopid 600 mg BID. The patient was advised to undergo dialysis but he was
refused. One week prior to admission patient had felt itchiness all over the body, 3 days after,
patient noticed presence of edema at the lower extremities, 1 hour prior to admission patient
manifested nausea and vomiting. Hence, patient was brought to ER. In the emergency room
vital signs are as follows: BP 180/110, HR 80 bpm, RR 24cpm, Temp 36.8, O2 Sat 95%,
weight of 80 kgs, ht. of 5’2’’. Upon assessment: The patient’s eyes are close but open to
pressure, he can utter some words but do not form sentences, and he was able to localize to
pain. The remainder of the exam was remarkable for 2+ lower extremity edema and superficial
excoriations of his skin from scratching. The Doctors’ ordered the following laboratories: CBC,
Blood Chem, Urinalysis, CBG, Chest X-Ray.
Venoclysis started : IVF of PNSS regulated at strict KVO, the Doctors’ ordered to administered
Metoclopramide 10 mg TIV,and diphenhydramine, nicardipine drip 10mg/amp + 90 cc PNSS to
run for 10mc drops /minute as SD. After an hour stay in the ER, vital signs BP 170/100 HR 90
RR 23. T 37.0 Patient was ordered to be transferred to the Medical Ward for close
observation.
12:00 PM VS BP 170/100 HR 90 RR 23. T 37, Urine Output of 10 ml
The Doctors’ was ordered to insert Urinary Catheterization, and Furosemide 40mg TIV now , for
I & O q1 monitoring.
4PM Laboratory result as follow
LABORATORY RESULT

Chemistry Normal Values Urinalysis

Sodium 133 136 – 146 mmol/L pH 6.0
Potassium 6.2 3.5 – 5.3 mmol/L Specific gravity 1.010
Chloride 100 98 – 108 mmol/L Protein 1+
Glucose negative
BUN 170 7 – 22 mg/dl Acetone negative
Creatinine 16.0 0.7-1.5 mg/dl Occult blood negative
Glucose 108 70-110 mg/dl Bile negative
Calcium 7.2 8.9-10.3 mg/dl Waxy casts
Phosphorous 10.5 2.6-6.4 mg/dl

Doctors’ ordered:
The patient’s become unconscious. No urine output. Doctors’ ordered emergency peritoneal
dialysis. The patient transported to OR for insertion of catheter through the abdominal wall into
the peritoneum,10 to 15 minutes infusion time for 2 liters of dialysate is placed in the peritoneal
cavity for the first exchange and is allowed to remain for 3 hours. Drain for 30 minutes.

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 TASKS: Complete the following activities to provide high quality, individualized care for the
patient following proper and correct protocol / guidelines in the care of clients with peritoneal
dialysis.
1. Comprehensive Assessment (15 mins) – Collect, organize and document information
about the patient. Data will be used to:
a. Complete the client’s health record.
b. Perform a quick and comprehensive assessment of the client’s hospital admission.
c. Implement the relevant and appropriate assessment methods.
2. Implementing Care (20 minutes)
a. Perform the necessary nursing procedures (not limited to): placing client on
peritoneal dialysis monitoring, client oxygenation, obtaining specimen for random
blood sugar test.
b. Prepare, administer, and document the ordered medications. (Recall correct
procedure in medication administration.)
3. Ongoing Care (15 minutes) - document the care that has been provided as follows:
a. Using the FDAR format – so that this is communicated with the healthcare team.
b. Discharge instructions (METHODS)

WORKSHEET
PATIENT RECORDS
PATIENT DETAILS

Name Juan Dela Cruz Age: 65 years old

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 cm
Weight (kg) 80 kgs

Admitting Diagnosis:
End stage renal disease secondary to diabetic nephropathy
History of Present Illness:
- 1 week prior to admission, the patient had felt feels itchiness all over the body
- 3 days after the patient, noticed presence of edema at the lower extremities
- 1 hour prior to admission, the patient manifested nausea and vomiting
- The patient localize pain, 2+ lower extremity edema and superficial excoriations of his skin
from scratching
Family History:
Past Medical History:
DM type 2, hypertension
Allergies:
Medications:
He was taken the following medication such as Losartan 50 mg OD, amlodifine 5 mg OD,
glucophage 1,000 mg BID and glipizide 10 mg BID, lopid 600 mg BID”

Venoclysis started : IVF of PNSS regulated at strict KVO, the Doctors’ ordered to administered
Metoclopramide 10 mg TIV,and diphenhydramine, nicardipine drip 10mg/amp + 90 cc PNSS to
run for 10mc drops /minute as SD.

The Doctors’ was ordered Furosemide 40mg TIV now, for I & O q1 monitoring.
Social History:

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 MEDICATION CHART

PATIENT DETAILS DIAGNOSIS: End stage renal disease secondary to diabetic

nephropathy

Name Juan Dela Cruz Age: 65 years old

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 cm
Weight (kg) 80 kgs

MEDICATION: TIME SUN MON TUES WED THURS FRI SAT

(Dose, Route,
Frequency)
Venoclysis: IVF 6am
of PNSS at strict
KVO
Metoclopramide 6am
long TIV
Dipenhydramine 6am
Nicardipine drip 6am
10mg/amp + 90
cc PNSS to run
for 10mc
drops /minute as
SD
Furosemide 6am
40mg TIV, for I &
O q1 monitoring

NURSE’S NOTES

F: End stage renal disease secondary to D: November 3, 2021 @ 6am

diabetic nephropathy

A: Take Metoclopramide long TIV of PNSS at

strict KVO as ordered by the Doctor

Nicardipine drip 10mg/amp + 90 cc
PNSS to run for 10mc drops /minute as
SD as ordered by the Doctor
Furosemide 40mg TIV, for I & O q1
monitoring as ordered by the Doctor
Blood pressure monitoring
Intake and Output Monitoring
,

R:

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 DISCHARGE PLAN
PATIENT DETAILS DIAGNOSIS: End stage renal disease secondary to diabetic
nephropathy

Name Juan Dela Cruz Age: 65 years old

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 cm
Weight (kg) 80 kgs

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: M: Continue taking Losartan 50 mg OD and amlodifine 5 mg OD to

have normal blood pressure as per Doctor’s order
November 3, 2021 Take Metroclopramide 10mg TIV if nausea and vomiting didn’t
stop as per Doctor’s order
Take diphenhydramine if you have allergy as per Doctor’s order
Time: 6am
E:

T: Monitor blood pressure

Renal Replacement Therapy is required when end – stage
renal disease develops with a GFR of 10 – 15 min.
Check BUN and Creatinine
Ensure that the patient have low protein diet
Encourage ambulation and exercise
Monitor Intake and Output
Check for edema

H: Educate the patient on the importance of glucose control,

exercise, follow up, and a healthy diet
Teach the patient about medication compliance
Educate the patient how to monitor blood glucose level.
Protein intake should be around 0.8 g per kilogram body weight

O:

D: Refer the client to have DASH diet.

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

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