Professional Documents
Culture Documents
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Nursing Care Plan
Submitted to:
Mr. Kennith Misamis, RN
Submitted by:
Francis Adrian Palalon
Age: 59 y/o
Nationality: Filipino
Chief Complaint: A day PTA, patient experienced body weakness which prompted consultation and laboratory tests.
HPI:
2 days PTA patient had LBM associated with body weakness.
1 day PTA patient experienced tremors associated with body weakness which prompted consultation and laboratory tests.
General Impression:
Received patient sitting on bed with 800ml PNSS regulated at 33 gtts/min. Patient is well-groomed, awake and properly oriented to date, time and place.
Able to respond to questions asked coherently and actively.
Cues Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective: Deficient fluid volume At the end of 5 hours 1) Assess vital signs, - To obtain baseline date At the end of 5 hours
Gikapoy man sige akong related to volume rendering nursing including temperature, and monitor for rendering nursing
lawas nya gamay daw ko depletion (diuretic interventions, the pulse, and respirations. condition. interventions the goal
potassium ingun ang phase) secondary to patient will: was completely unmet.
doctor, as verbalized by hypokalemia 2) Monitor I & O hourly. - To assess the fluid
the patient. - maintain fluid volume balance trend, which is
at a functional level as reflective of renal
Objective: evidenced by individually function.
- restlessness adequate urine output
- dry skin and good skin turgor; 3) Assess hydration - Flat neck veins,
- decreased urine output state: note skin turgor complaints of thirst, &
- Labs: - display normal serum and condition of buccal decreased LOC may
K+ - 2.8 (L) potassium level and membranes. signal volume depletion.
Creatinine 2.15 (H) electrolyte levels;
BUN 32 (H) 4) Avoid rapidly placing - Because postural
- verbalize the patient in an upright hypotension may result.
understanding of position.
causative factors and
purpose of therapeutic 5) Provide meticulous - To prevent skin
interventions and skin & oral care. breakdown and oral care
medications; to soothe dry mucous
membranes.
- demonstrate behaviors
to monitor and correct 6) Encourage nutritious - To promote hydration
deficit, as indicated, diet and adequate water and prevent decreased
when condition is intake. fluid volume.
chronic.
Collaborative:
7) Administer aggressive - To increase volume and
fluid and electrolyte maintain normal
replacements as electrolyte and acid-base
ordered. balance.
8) Administer meds:
I. HEALTH-PERCEPTION HEALTH-
MANAGEMENT PATTERN
- Patients health for the past 3 months is good as - Patient does not complain of any pain (PATIENT TRANSFERRED)
verbalized
Vital signs:
T: 36.3 C
- eats nutritious foods and water to improve P: 76 bpm
health RR: 20 cpm
BP: 130/80 mmHg
V. SLEEP-REST PATTERN
- Patients sleeping pattern is normal
- patient usually sleeps around 10PM to 5AM
- Sleeps 7-8 hours
- 7-8 hours of sleep at night
- No difficulties in sleeping
- no sleeping aids used or any medications or
foods - No sleeping aids used
- no difficulties in sleeping
X. COPING-STRESS MANAGEMENT
PATTERN
- Patient makes decisions with his wife
- patient usually makes decisions with the family
- Patient is not entirely worried of his condition
- no loss in life for the past year right now.