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PATIENT: Praxedes Lemus DIAGNOSIS: End Stage Renal Disease secondary to hypertension

PROBLEM PRIORITIZATION
Cues Subjective: masakit pa din ditto, pointed on the insertion site of the catheter. With a pain scale of 7 with 10 for being the highest and 0 for being the lowest. Objective: Guarding behavior Positioning to avoid pain facial grimacing noted narrowed focus accompanied with reduced interaction with people Restlessness Irritability Measurement: Blood Pressure: 110/70mmHg Pulse Rate: 86bpm Respiratory Rate: 15cpm
Temperature: 36.6oC

Nursing Rank Diagnosis Acute pain 1 related to tissue trauma secondary to catheter insertion for peritoneal dialysis

Justification It falls under Physiologic needs according to Maslows Hierarchy of needs. It is ranked first since this is an actual problem and needs immediate intervention since the client verbalized pain that may impede curing of the disease since it might result to increase anxiety and lead to other problem. It needs immediate intervention since it might rule out worsening of underlying condition or development of complication.

MEDICATIONS:
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Alloprovinol 30 g/ tab OD Calcium Carbonate 600mg 1 tab TID Furosemide 40mg/ tab Losartan 5 mg/ tab 1 tabe OD Simvastatin 20mg/ tab 1 tab OD Atenolol 10g/ tab OD Amlodipine 5mg/ tab OD

DIET:
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Low protein diet Peritoneal dialysis solution


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FLUID:

Subjective: Risk for deficient fluid Verbal report of tiredness volume and exhaustion related to Thirst fluid shifts between Objective: dialysate and Decreased urine output, patients 100ml body Dry mucus membrane Restlessness Fatigue Measurement: Blood Pressure: 110/70mmHg Pulse Rate: 86bpm Respiratory Rate: 15cpm
Temperature: 36.6oC

MEDICATIONS:
-

Alloprovinol 30 g/ tab OD Calcium Carbonate 600mg 1 tab TID Furosemide 40mg/ tab Losartan 5 mg/ tab 1 tabe OD Simvastatin 20mg/ tab 1 tab OD Atenolol 10g/ tab OD Amlodipine 5mg/ tab OD

It is ranked second because it falls under Physiologic needs according to Maslows Hierarchy of needs. And this is an actual problem and needs immediate intervention since fluid deficit is a serious problem that may lead to dehydration that is a life threatening situation. And this signs and symptoms that the client manifested may direct to electrolyte imbalance So early identification of the problem can decrease the occurrence and severity of complications.

DIET:
-

Low protein diet Peritoneal dialysis solution

FLUID:

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