TORIO, ALYSSA ASHLEY B.

FDAR: Diabetes mellitus

F Unstable blood glucose level related to lack to adherence of diabetes
management
D
7:00am Received patient awake lying in bed with ongoing IVF of PNSS 20 gtts/min
infusing well at the left hand. “parang sumasakit ulo ko” as verbalized by the patient.
Observed that the patient is diaphoretic, pale and irritable. Patient’s skin is cold and
clammy with capillary refill within 2 seconds. CBG result 55 mg/dl. Urinalysis result
reveals presence of ketones in urine as of November 20,2020. Fluid intake is
approximately 1500 ml and urine output of 700 ml during the 8 hour shift. Initial V/S: BP
100/60, spo2 of 90%, RR 30 cpm, PR 120bpm, afebrile.
7:30am D50W 50 ml given as ordered.
A Assessed patient’s integumentary status. Monitored vital signs and recorded,
monitored blood glucose, monitored fluid input and output. Checked the laboratory
results. Assisted in giving D50W as prescribed. Advised the patient to report any
untoward signs and symptoms, encouraged to eat 30 minutes after the insulin given.
Advised to always carry hard candies anytime, to exercise for 30 minutes 3-5 times a
week to maintain body weight. Reiterated the importance of drug compliance and
healthy eating habits.
R
3:00pm Blood is in normal glucose level; 85 mg/dl. Not in any type of distress, skin
is warm to touch, not diaphoretic. Latest vital signs BP 120/80, RR 18cpm, PR 80 bpm,
spo2 of 98%.
FDAR: CKD stage 5
F Impaired renal tissue perfusion related to decrease oxygen transport to distant
organ
D
7:00 am Received awake lying in bed with ongoing IVF of PNSS 1L x KVO, no
complaints of pain. Observed the patient to be weak and restless. Edematous lower
extremities, dry and cracked lips noted. Capillary refill within 2 seconds and skin is
warm to touch. Latest Laboratory result shows elevation in BUN=42mg/dl and
creation=80mg/dl as of November 20, 2020. Chest x-ray reveals no congestions in the
lungs. Fluid intake of 800ml, Urine output is approximately 100 ml and pinkish in colour
as characterized by the patient. Vital signs BP: 130/90, RR: 20cpm , PR: 80bpm, temp:
36.6 spo2 of 98%.
10:00 am Withhold medications prior to hemodialysis.
A Assessed integumentary status. Assessed urine characteristic. Monitored vital
signs and monitor input and output, checked laboratory result. Offered fluids. Positioned
the patient into comfortable place. Advised to elevate lower extremities up to 2 pillows
high, to lessen protein intake especially red meat and to avoid salty foods. Advised to
drink 1-1.5 litters everyday as ordered by the physician. Encouraged to avoid crowd and
to always wear masks to prevent infections.
R
3:00PM Not in any type of distress latest BP: 110/70 RR: 20 cpm, PR: 60bpm.
Acknowledge health teachings given.

FDAR: CVD
F Impaired bed mobility related body weakness
Received patient awake lying in bed. “ wala naming masakit sakin, hindi lang ako
makagalaw ng maayos” as verbalized by the patient. Oriented to time, place and
person. Presence of gag reflex, and cough reflex. Unable to perform activities of daily
living, like as changing clothes, needs assistance to perform ADL’s. Right upper
extremity and right lower extremity is unable to perform full range of motion, the patient
can’t move from side to side. Initial vitals sign BP: 120/90, PR 66 bpm, RR:22 cpm,
SPo2 of 99%.
A Assessed level of consciousness, assessed reflexes. Monitored vitals signs and
recorded. Assisted in performing ADL’s, assisted in clients positioning, performed
passive ROM to the patient, offered fluids. Advised the patient’s watcher to perform
passive ROM to the patient and to increase fluid intake as tolerated and as not
contraindicated. Encouraged the patient to exercise his right side extremities to prevent
hypotrophy.
R Not in respiratory distress, still needs assistance in performing ADL’s. able to
raise right upper extremity and right lower extremity but not to its full extent