I.

PATIENTS PROFILE

NAME: Ms.T.L

AGE: 60 years old

BRITHDATE: October 9, 1950

RELIGION: Roman Catholic

NATIONAILITY: Filipino

CIVIL STATUS: Married

ADDRESS: #76 Lower Atab, Sto. Tomas Baguio City

OCCUPATION: Self-employed

EDUCATIONAL ATTAINMENT: High school undergraduate

PRIMARY CARE GIVER: Children

ADMISSION DATE: 11-08-10

TIME OF ADMISSION: 12:55PM

ADMITTING PHYSICIAN: Dr. Caesar Noel I. Palaganas

ADMITTING DIAGNOSIS: CKDS 5 secondary to DM

FINAL DIAGNOSIS: CKDS 5 secondary to DM Nephropathy

CHIEF COMPLAINTS: Generalized body weakness and difficulty of breathing.

II. CHIEF COMPLAINT/ REASON FOR ADMISSION

This is the case of patient T.L. 60 years old from Sto. Tomas Baguio City was admitted to Baguio
General Hospital due to generalized body weakness and difficulty of breathing.

III. HISTORY OF PRESENT ILLNESS

Present condition started 3 days prior to admission as generalized body weakness with headache and
dizziness. Patient was noted to have +2 edema on the lower extremities. 2 years ago she was
diagnosed of CKDS 5 and since then she was then advised to have hemodialysis 3 times a week.
Due to financial inadequacy she was not able to have her hemodialysis 5 months before admitting
her to the hospital. When she experiencing generalized body weakness and DOB she was then
rushed to BGHMC accompanied by her sister in law. It was noted that DM is common in their
family.

IV. PAST MEDICAL HISTORY

The patient has a history of HPN, maintenance were given and she was able to comply with it, She
was able to modify her diet but sometimes she still consumes salty and fatty foods sparingly. The
patient experiences fever and common colds without any complications. The patient doesn’t have
any allergy to food and drugs.

V. SOCIAL AND ENVIRONMENT

The patient doesn’t smoke but she drinks alcohol at minimal amount and only occassionaly.

VI. FAMILY HISTORY

The family doesn’t have a history of HPN but they have a history of DM and no known history of
CKD. All of her other siblings have DM.

VII. PHYSICAL EXAMINATION

She is approximately 5 ft. in height and weighs about 50 kg. The patient is brown in complexion
with a scaly and wrinkled skin.

AREAS OF ASSESSMENT

I. PSYCHOSOCIAL STATUS

T.L 60 years old is a Roman Catholic from La Union but is currently residing at Sto. Tomas
Baguio City. Her husband was not mentioned during our conversation because of sensitivity.
They have 3 children all of them are boys. All of them are married. 2 of them are residing in
Manila with their own family and the youngest is in Saudi Arabia. Regarding to financial
support She is being supported by her children.

II. MENTAL AND EMOTIONAL STATUS

Patient is able to respond to noise and touch stimuli. She is oriented to time, place and people
around her. She’s able to understand simple instructions. She is asleep most of the time but
cooperates to interventions being done to her.

III. ENVIRONMENTAL

T.L lives with her sister in law and her grandchildren. The hospital environment was quiet
and comfortable for her to rest but due to excessive stimulation when taking v/s she is easily
disturbed. She has a low tolerance to pain.
IV. SENSORY STATUS

The patient is unable to distinguish objects from a far distance but able to distinguish them
when near. Doesn’t wear any eye corrective devices. She can hear and distinguish voices
from near distance. She can smell different odors. She has a decreased in appetite and an
alteration of taste. She can also perceive hot from cold and to what is painful as well.

V. MOTOR STATUS

She needs assistance in performing ADL’s due to her condition and age. She does not have
any deformities.

VI. NUTRITION

The patient usually eats 3 times a day. She consumes 40-60% of food served. She takes in
Ferrous Sulfate and folic acid as a food supplement, She does not have any food allergies.
The patient is prescribed to have a low salt and low fat diet.

VII. FLUID AND ELECTROLYTES

She drinks water in a minimal basis. During our shift no urine output was obtained. She has a
dry skin and lower extremities are edematous. She is receiving an IVF of D5W 500cc x
KVO.

VIII. CIRCULATORY STATUS

During our shift the patient has a pulse rate of 70-84 bpm. Palpated on her right radial pulse
with regular rhythm. Her initial BP is 120/80 mmHg. Nailbeds are pale with capillary refill
of 1-2 secs.

IX. ELIMINATION STATUS

The patient needs full assistance when urinating and defecating. She utilizes the bedpan when
eliminating waste materials. During our shift she wasn’t able to have urine output and
passage of stool.

X. RESPIRATORY STATUS

She has a respiratory rate of 20-24cpm with productive cough, phlegm is whitish in color.
She experiences DOB so she is with oxygen inhalation of 4 LPM via nasal cannula as
ordered. Use of accessory muscles were observed.

XI. TEMPERATURE STATUS

Her body temperature ranges from 36-36.5 degree Celsius via the axilla.

XII. INTEGUMENTARY STATUS

Brown in complexion with scaly and wrinkled skin. With +2 edema on the lower extremities.
With skin turgor of 1-2 secs. Her hair is not well fixed. Fingers are well trimmed.

XIII. COMFORT AND REST STATUS

She sleeps most of the time during our shift. She is easily awaken because of excessive
stimulation due to taking v/s and taking in medications.