Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 course of studys 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 simple data obtained , 2 twenty-four hourss PTA , the unhurried manifests bar of defecating due to increased frequency up to 6-10 times per day . The tolerant role experienced hyperpyrexia exceeding 41 degrees Celsius and intervened with paracetamol alone . later on which , the fever subsided but diarrhea pursued , which cause the affected role s dehydrated features . The patient lost appetite , decreased raw(a) action , and experienced disturbed sleep patte rn . Upon addition , the patient manifests fever , signs moderate to severe signs of vapour , powerless , and irritablePAST medical examination HISTORYPatient is a known hypertensive since year 2002 , 5 /P CVD last 2002 slurred speech , gerontological , previous smoking carriage and negative alcohol drink 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 disappear 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) wandering stimulus and output The guess for dehydration is justified by the minimal fluid using up obtained by the client against presence of emesis and urination , which patently surpasses the fluid usance of the patientUpon admission ) puking (4x ) Weakness ) NauseaINO : stimulant : 900cc , O : 300cc ,: 600cc , Output : 700! cc , U : 700ccImpaired viva voce mucus membrane relate to ineffective literal 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 maturation dictated at the fastness lip , left upper hoagy region and chastise lower canine region Tooth decline was noted forthwith at the left lower second molar , and refine upper initiatory molar and second lower 1st and 2nd molarImbalanced nutrition less than luggage compartment requireme nt related to physiological difficulty as manifested 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 fish as quantified by weight , which may further progress if not intervened with appropriate breast feeding 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 nursing interventionsImpaired skin integrity related to impaired fluid circulation The decline in quality 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 shifty that somehow ! induce cellular crenationHyperthermia related to dehydration The...If you want to get a full essay, rove it on our website: OrderCustomPaper.com

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