Patient Name: M.C.A.

L Age: 52 y/o Sex: Male Hospital No: 401885

Diagnosis: Chronic Kidney Disease Stage V Secondary to Diabetic Kidney Disease

Assessment Diagnosis Desired Outcomes Interventions Evaluation

Objective: Acute pain related to tissue After the shift, the patient  O2 inhalation  Pain decreased to
 Patient is seen injury secondary to surgical will: administered at 2-3 3/10 on pain scale
clutching his chest intervention as evidenced by  State relief from pain L/Min
restlessness and report of from (10/10 to 5/10  Refered to dr. Ardales  HD resumed
Subjective: 10/10 chest pain on pain scale) with orders made and
 verbalized chest pain carried out
10/10 on pain scale;  Maintain stable vital  Blood flow rate and
post thoracentesis signs ultrafiltration
decreased
 HD temporarily
stopped
 IV fluid of PNSS iL
inserted at right hand
and regulated at KVO
rate
 ISDN 10 mg +90cc
PNSS started as side
drip and regulated at
10 ugtts/min and
titrated as ordered
 ECG done and relayed
result
 Vital signs monitored
and recorded at
separate sheet

Prepared By: Niña Katerina J. Ante, RN