Nursing History

I.

Vital Information Name: M.T. Age: 37 years old Sex: Male Civil Status: Married eligion: oman Cat!oli"

#""u$ation: %a&orer Nationality: 'ili$ino (du"ational Attainment: College undergraduate )*st year+ Address: Sto. Nio Sur, Arevalo, Iloilo City Medi"al -iagnosis: (nd Stage enal -isease se"ondary to C!roni" .lomerulone$!ritis/ HCV-/ enal Anemia se"ondary on Maintenan"e 0eritoneal -ialysis C!ief Com$laint: Vomiting, -iarr!ea -ate and Time of Admission: -e"em&er *1, 21*3/ 3:11 am 4ard and 5ed no. : MMS4/ 5ed 6, 4est Visayas State 7niversity Medi"al Center -o"tor: -r. I. Num&er of 0revious Hos$itali8ation: Ten )*1+ Allergies: Allergi" to seafood Sour"es of Information: 0rimary: 0atient !imself Se"ondary: 0atient9s "!art 0atient9s :ife

II.

History of 0resent Illness

2 days $rior to "onfinement )-e"em&er 3, 21*3+ "lient !ad ;ust finis!ed !is dinner around 7$m. He "laimed t!at after eating 3$"s.of gra$es !e vomited 3 e$isodes to a greenis! vomitus a&out one glass $er e$isode. T!is :as a""om$anied :it! < e$isodes $er day of greenis!, loose, :atery stools a&out * "u$ $er e$isode. His :ife stated t!at !e :as given an # S of * liter to $revent de!ydration. He stated t!at !e !ad ex$erien"ed &ody :ea=ness and !am$ered !is A-%s. He stated t!at !e "ould not "onsume t!e meal served &e"ause !e feels nauseated. -uring "onfinement, t!ey see= medi"al advi"e and t!en $res"ri&ed :it! Meto"lo$ramide *>mg ?id &efore meals and at &edtime. T!en, !e :as referred to 4est Visayas State 7niversity Medi"al Center, t!us t!is admission.

( Admission 7$on arriving at t!e 4est Visayas State 7niversity Medi"al Center, Mr. M.T. :as t!en admitted at t!e (mergen"y oom $er :!eel"!air :it! a "!ief "om$laint of vomiting and diarr!ea. It :as -e"em&er >, 21*3 at around 3am a""om$anied &y !is :ife. He :as "onversant, "ons"ious, "o!erent, and oriented. He :as seen &y -r. I.. #rders are made and "arried out as follo:s: 0NSS *% x 31""@H/ Meto"lo$ramide *am$ IVTT ?3H/ Am$i"illin )Sul&a"tam+ 7>1mg IVTT ?3H after negative s=in test/ 'errous sulfate *ta& on"e a day/ Cal"ium "ar&onate *ta& t!ri"e a day. %a&oratory tests as follo:s: C5C/ S. Sodium and 0otassium/ S. Creatinine . He :as t!en admitted to male medi"al servi"e :ard &ed A6 and endorsed to staff nurse on duty.

Mr. M.T. :as in su$ine $osition :it! vital signs ta=en and re"orded as follo:s: tem$erature of 3<.2 degrees Celsius $er rig!t axilla, afe&rile, :it! dry, fla=y s=in/ of 21 "$m, regular in rate and r!yt!m, s$ontaneous and nonBla&ored/ C of 33 &$m, regular in rate and r!yt!m, syn"!ronous :it! 0 / :it! 50 of **1@31mmHg ta=en at left arm.

III.

0ast Medi"al @Surgi"al History

A""ording to Mr. M.T. !e !ad &een !os$itali8ed *1 times. Some :ere due to !is allergi" rea"tions to seafoods and date :as unre"alled. May 21*1 !e :as !os$itali8ed :it! a "!ief "om$laint of &ody :ea=ness in t!e same institution and :as t!en diagnosed :it! HCV-. After it :as managed, !e :as $res"ri&ed Atenolol >1mg on"e a day as maintenan"e.

%ast August 21*2 !e !ad &een admitted to t!e same institution &e"ause of edema and !ad $ro&lems :it! mi"turation, )de"rease urine out$ut+. He :as diagnosed to !ave (nd Stage enal -isease se"ondary to C!roni" .lomerulone$!ritis. Mont!s $rior t!at !os$itali8ation t!e :ife noti"ed t!at !e :as :asting, !e "an9t do !is A-%s &e"ause !e "om$lains t!at !e feels so tired after an a"tivity, as ver&ali8ed &y t!e :ife. He seems $ale, !as distended a&domen, $erior&ital e""!ymosis, irrita&le, anorexi", fever a""om$anied &y "!ills :as o&served &y !er. He !ad undergone !emodialysis Se$tem&er of t!e said year using tem$orary Ma!ur=ar "at!eter via rig!t su&"lavian vein a$$roa"!. He :as admitted and stayed t!ere for t:o :ee=s. After a mont! -e"em&er 21*2, an arteriovenous fistula on !is left :rist and !e !as &een undergoing !emodialysis t:i"e a :ee= from t!en on at M3 -ialysis Center. A$ril 21*3 !e !ad &een admitted again &e"ause !is AV fistula :as damaged and May of t!e said year !e !ad an o$eration for t!e insertion of ten"=!off "at!eter on !is left lo:er a&domen. Novem&er >, 21*3 !e again :as admitted again &e"ause of vomiting and &ody :ea=ness and :as dis"!arged after 3 days of "onfinement.

IV.

Current Healt! Status

A""ording to Mr. M.T. !e is allergi" to seafood su"! as s!rim$s and "ra&s. He stated t!at !e !as already "om$leted !is immuni8ations &ut date and age unre"alled. His :ife "laimed t!at even t!oug! t!eir !ouse :as made u$ of lig!t materials, t!ere :ere no environmental !a8ards $resent. He is a la&orer so !e slee$s at *1:11$m and usually :a=es u$ at around >:11am in order to $re$are for !is :or=. He uses one $illo: at !is !ead. He added t!at !is usual diet "urrently in"ludes more vegeta&les and ri"e &e"ause of !is disease. He also stated t!at !e drin=s *% of :ater $er day. His elimination $attern is t:i"e a day or de$ending on t!e need and :as a&le to defe"ate and urinate freely :it!out diffi"ulty. He also admitted t!at !e is nonBsmo=er and !ad sto$$ed drin=ing al"o!oli" &everages sin"e *C years old . He "laimed t!at !e does not exer"ise due to la"= of time.

V.

'amily History

Has a familial !istory of !y$ertension &ut !as !istory of -ia&etes Mellitus, "an"er, and ast!ma. His grandmot!er in $aternal side !as =idney disease.

VI.

0ersonal History

Mr. M. T. &elong to a nu"lear ty$e of family. 0resently, t!ey are no: living in Sto. Nio Sur, Arevalo, Iloilo City :!i"! is an ur&an area. He is t!e de"isionDma=er in t!eir family )$atriar"!al ty$e+. His mont!ly in"ome ranges from 0!$ 7,111 to 0!$*>,111. He !as t:o daug!ters and one son/ !e "laimed t!at !e !as a good relations!i$ :it! !is family &e"ause !e is a su$$ortive and loving fat!er. 'or !is re"reation, !e used to :at"! television at !ome :it! !is family as a &onding :it! t!em. He attends mass every Sunday at around 3am. Sin"e !e is a fat!er !e &elieves t!at everyt!ing :ill &e alrig!t and :ill re"over from t!e situation !e is ex$erien"ing at $resent and !e :ill "ertainly avoid t!e t!ings t!at "an trigger !is sufferings.

VII.

Stressors

A. 0!ysi"al Stressors

*. T!e IV' !oo=ed on !is rig!t !and ma=es it a !indran"e for !im to move freely in rea"!ing out t!ings. He "o$es u$ :it! t!is &y ;ust as=ing t!e !el$ of !is :ife :!en !e :ants to do somet!ing.

5. 0sy"!ologi"al Stressors

*. 'inan"ial $ro&lem is one of !is $sy"!ologi"al stressor &ut a""ording to :ife t!e sister :!o :or=s in Canada :as t!e one :!o s!oulders all t!eir ex$enses everytime !e :as !os$itali8ed. 2. 5eing a:ay at !ome and !is "!ildren. He "o$es :it! t!is &y "alling t!em fre?uently. 3. Current situation a&out !is !ealt! "ondition. He "o$es &y "om$lying to t!e t!era$euti" regimen and "oo$erates :it! t!e !ealt! "are team mem&ers.