Professional Documents
Culture Documents
PATIENT'S DATA
A. PATIENT'S PROFILE
B. Family Background
Patient Hernia was born on April 2, 1932, she was married to Apolinario
has 4 children namely Alberto (married) with 2 children, Juliana (married) 1
child, Ricardo (married) 2 children, Lourdes (single parent) 1 child. Mrs.
Herminia is unemployed according to her they have hypotension as their
hereditery, while on her husband side was hypertension. Their only means to
subdue it, if not eradicate, was to avoid nutriments that can heighten the
disease. Their family experienced minor illnesses such as cough, colds and
fever. Taking Paracetamol tablet is their only remedy for these illnesses.
F. ASSESSMENT
PHYSICAL ASSESSMENT
A. VITAL SIGNS
11/16/10 TEMPERATURE PULSE RATE RESPIRATORY BLOOD
RATE PRESSURE
04:00:00 PM 35.8ºc 62bpm 21cpm 140/90 mmHg
08:00:00 PM 36 ºc 61bpm 21cpm
12:00:00 PM 37.3ºc 70bpm 20cpm
11/17/10
04:00:00 AM 36.2ºc 65bpm 18cpm 120/80 mmHg
08:00:00 AM 36ºc 70bpm 19cpm 120/80 mmHg
12:00:00 AM 36.5ºc
04:00:00 PM 36.6ºc 70bpm
08:00:00 PM 36.6ºc 18cpm 120/70 mmHg
12:00:00 PM 36.2ºc 21cpm 120/90 mmHg
11/18/10
04:00:00 AM 36.2ºc 60bpm 19cpm 130/80 mmHg
08:00:00 AM 36.6ºc
12:00:00 AM 36.4ºc 110/80 mmHg
04:00:00 PM 36.2ºc
08:00:00 PM 36.4ºc
12:00:00 PM 36.3ºc
11/19/10
04:00:00 AM 36.3ºc 70 bpm 19cpm 120/80 mmHg
08:00:00 AM 36.4ºc 75bpm 20cpm 120/80 mmHg
12:00:00 AM 36.1ºc
04:00:00 PM 37.6ºc 78bpm 21cpm 120/80 mmHg
08:00:00 PM 37ºc 120/90 mmHg
12:00:00 PM 36.2ºc
11/20/10
04:00:00 AM 36.7ºc 75bpm 20cpm 120/80 mmHg
08:00:00 AM 37.3ºc 140/80 mmHg
12:00:00 AM 38ºc 76bpm 23cpm 130/80 mmHg
04:00:00 PM 36.6ºc 75bpm 20cpm 130/80 mmHg
08:00:00 PM 36.8ºc
12:00:00 PM 36.4ºc 80bpm 20cpm 110/70 mmHg
11/21/10
04:00:00 AM 37ºc 80bpm 20cpm 110/80 mmHg
08:00:00 AM 36.6ºc 80bpm 20cpm 140/90 mmHg
12:00:00 AM 36.3ºc
04:00:00 PM 36.5ºc 80bpm 20cpm 130/80 mmHg
08:00:00 PM 36.2ºc
12:00:00 PM 36.4ºc 130/90 mmHg
11/22/10
04:00:00 AM 36.7ºc 80bpm 20cpm 130/90 mmHg
120/90 mmHg
08:00:00 AM 36.2ºc
12:00:00 AM 36.6ºc 90bpm 20cpm 140/90 mmHg
130/90 mmHg
04:00:00 PM 37.4ºc 96bpm 25cpm 130/80 mmHg
140/100 mmHg
08:00:00 PM 37ºc
12:00:00 PM 36.8ºc 130/90 mmHg
130/80 mmHg
11/23/10
04:00:00 AM 36.7ºc 90bpm 23cpm 140/100 mmHg
08:00:00 AM 36.5ºc 80bpm 20cpm 140/80 mmHg
140/80 mmHg
12:00:00 AM 36.4ºc
04:00:00 PM 36.5ºc
08:00:00 PM 37.2ºc 90bpm 25cpm 130/90 mmHg
12:00:00 PM 36.6ºc 140/90 mmHg
11/24/10
04:00:00 AM 37.8ºc
08:00:00 AM 36.8ºc 90bpm 26cpm 160/80 mmHg
12:00:00 AM 36.8ºc 85bpm 140/90 mmHg
04:00:00 PM 37.2ºc 85bpm 25cpm 140/90 mmHg
08:00:00 PM 36ºc 130/90 mmHg
12:00:00 PM 36.8ºc
B. Neurologic Status
Patient is responsive,coherent and cooperative. Oriented in name or
person, time, date and place.
C. Cardiovascular System
Patient has increase heart rate 108 bpm .Abnormal blood pressure
140/80 mmHg . She experienced chest pain with no heart murmurs upon
auscultation.
D. Respiratory system
Patient respiratory rate 33 cpm which evidenced she experienced
difficulty in breathing and shortness of breath. And rule out she has a community
aquired pnuemonia high risk.
E. Gastrointestinal System
Patient experienced abdominal pain in the right upper quadrant with
hematochezia and melena. In a soft diet and no dark colored foods. With
nasogastric tubing attached to nose.
G. Musculoskeletal System
Patient needs assistance in activity in daily living because of muscle
weakness with limited range of motion. Without any deformities.
H. Integumentary System
Patient has a poor skin turgor , pallor noted and dry skin. Hair is evenly
distributed all over the body. With bed sore moist, red color at the back with
unpleasant odor.
B. Neurologic Status
Patient is responsive,coherent and cooperative. Oriented in name or
person, time, date and place.
C. Cardiovascular System
Patient has increase heart rate 110 bpm. Abnormal blood pressure
130/90mmHg.She experienced chest pain with no heart murmurs upon
auscultation.
D. Respiratory system
Patient respiratory rate 33 cpm which evidenced she experienced
difficulty in breathing and shortness of breath. And rule out she has a community
aquired pnuemonia high risk.
E. Gastrointestinal System
Patient experienced abdominal pain in the right upper quadrant with
hematochezia and melena. In a soft diet and no dark colored foods. With
nasogastric tubing attached to nose.
G. Musculoskeletal System
Patient needs assistance in activity in daily living because of muscle
weakness with limited range of motion. Without any deformities.
H. Integumentary System
Patient has a poor skin turgor , pallor noted and dry skin. Hair is evenly
distributed all over the body. With bed sore moist, red color at the back with
unpleasant odor.
B. Neurologic Status
Patient is responsive,coherent and cooperative. Oriented in name or
person, time, date and place.
C. Cardiovascular System
Patient has increase heart rate 102bpm. Abnormal blood pressure
130/90 mmHg. She experienced chest pain with no heart murmurs upon
auscultation.
D. Respiratory system
Patient respiratory rate 38cpm. which evidenced she experienced
difficulty in breathing and shortness of breath. And rule out she has a community
aquired pnuemonia high risk.
E. Gastrointestinal System
Patient experienced abdominal pain in the right upper quadrant with
hematochezia and melena. In a soft diet and no dark colored foods. Patient
removed the NGT without any supervision of the doctor or nurse.
F. Genito- urinary System
Patient has a foley catheter attached to uro bag with yellow out put. In
intake and output monitoring q shift.
G. Musculoskeletal System
Patient needs assistance in activity in daily living because of muscle
weakness with limited range of motion. Without any deformities.
H. Integumentary System
Patient has a poor skin turgor , pallor noted and dry skin. Hair is evenly
distributed all over the body. With bed sore moist, red color at the back with
unpleasant odor.
PSYCHOSOCIAL ASSESSMENT
Patient is friendly and always cooperating. According to patient she has
no enemy in her neighbor and she is not a strict type of mother. She likes to stay
in home and manage her little garden.
CHAPTER 9
DISCHAGE PLAN
M-edication
E-xercise
T-reatment
H-ygiene
O-ut patient
D-iet
S-piritual
MEDICATION
Instruct to continue the medication as prescribed by the doctor.
EXERCISE
Encouraged patient to demonstrate exercise such as turning side to side every 2
hours.
TREATMENT
HYGIENE
Encouraged to do proper hygiene. Advised to clean the bed sore everyday or as
indicated.
OUT-PATIENT
Instruct patient to continue medical care as ordered. Follow up check up for
proper intervention for continue healing progress.
DIET
Instructed to eat in exact time. Advised to eat nutritious foods rich in vitamins,
protein, and minerals to help strengthen the immune system. Advised not eat
dark colored foods and avoid alcohol beverages. Instructed to increase oral fluid
intake.
SPIRITUAL
Given emotional support as well as advised to pray to strengthen spiritual needs.
Family advised to support patient emotional, spiritual, physical, and psychosocial
needs.