Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 courses oldGENDER : MaleADDRESS : Malipanpan , San Ildefonso BulacanMARITAL BIRTH DATE : 11 /24 /1943RELIGION : Roman CatholicNATIONALITY : FilipinoCHIEF COMPLAINT : LBMDATE OF ADMISSION : 09 /08 /07 8pmFINAL DIAGNOSIS : Non-Inflammatory AGEPHYSICIAN : Dr . PesebreHISTORY OF former(prenominal) ILLNESSAccording to aboriginal data obtained , 2 twenty-four hourss PTA , the unhurried manifests bar of defecating repayable to increased frequency up to 6-10 times per day . The uncomplaining role experienced hyperpyrexia exceeding 41 degrees Celsius and intervened with paracetamol alone . posterior which , the fever subsided but diarrhea pursued , which cause the longanimous s dehydrated features . The unhurried lost appetite , decreased pictorial action , and experienced disturbed sle ep pattern . Upon door , the persevering manifests fever , signs moderate to severe signs of vapor , wobbly , and irritablePAST medical examination HISTORYPatient is a known hypertensive since year 2002 , 5 /P CVD last 2002 slurred speech , geriatric , previous smoking carriage and negative alcohol drinking drinker . Patient was obviously well , but 1 day PTA (21 0600H Nov 6 man patient was having conversation w / their neighbor , patient on the spur of the moment trim down on the ground with dismissal of environment snarl in his left face . There argon no headaches , seizures and dizzinessNURSING DIAGNOSISNursing diagnosis RationaleRisk for dehydration associate to token(prenominal) changeful stimulus and output The endangerment for dehydration is justified by the minimal fluid consumption obtained by the client against presence of emesis and micturition , which simply surpasses the fluid wasting disease of the patientUpon admission ) puking (4x ) Weakness ) NauseaINO : excitant : 900cc , O : 300cc ,! : 600cc , Output : 700cc , U : 700ccImpaired viva voce mucus membrane connect to ineffective spontaneous hygienics The presence of stomatitis affects the patient s ingestion and then , affecting nutritional pattern .

The patient has been assessed to incur knowledge deficit in terms of oral hygieneObservation Presence of 3 nodules containing suppuration dictated at the top(prenominal) lip , left upper hoagy region and objurgate lower canine region Tooth decline was noted short at the left lower second molar , and set upper first molar and second lower 1st and 2nd molarImbalanced nutrition less than luggage compartment requirement related to physiological difficulty as manifeste d by presence of pus The nutrition of the patient is greatly compromised overdue to damage nutritional intake caused by the presence of stomatitis in the patient s buccal mucosa . The patient is under system of weights as quantified by weight , which may further progress if not intervened with appropriate treat managementDeficient fluid volume related to imbalance fluid intake and output The patient experiences increased loss of fluid and electrolytes via urination , vomiting , and increased frequency of laxation , which is in a form of liquid . Consequently , the designer predisposes the client to dehydration , and can be life jeopardise without appropriate nurse interventionsImpaired skin integrity related to impaired fluid circulation The injustice of the patient s skin integrity is due to the abnormality in physiological hydration , wherein the cellular body are deprived with fluid replacements in the interstitial space hence , initiating fluid duty period that somehow induce cellular crenationHyperthermia related to deh! ydration The...If you desire to get a full essay, rove it on our website: OrderEssay.net

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