Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 twelvemonths 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 autochthonic 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 unhurried role experienced hyperpyrexia exceeding 41 degrees Celsius and intervened with paracetamol alone . afterwards which , the fever subsided but diarrhea pursued , which cause the forbearing s dehydrated features . The uncomplaining lost appetite , decreased innate action , and experienced disturbed sleep pattern . Upon adit , the patient role manifests fever , signs moderate to severe signs of evaporation , fragile , 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 roughshod 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) roving stimulus and output The take chances for dehydration is justified by the minimal fluid ingestion obtained by the client against presence of emesis and micturition , which seemingly surpasses the fluid intake of the patientUpon admission ) puking (4x ) Weakness ) Naus eaINO : gossip : 900cc , O : 300cc ,: 600cc! , Output : 700cc , U : 700ccImpaired viva voce mucus tissue layer relate to ineffective vocal hygienics The presence of stomatitis affects the patient s ingestion and then , affecting nutritionary pattern .

The patient has been assessed to incur knowledge deficit in terms of oral hygieneObservation Presence of 3 nodules containing suppuration dictated at the focal ratio lip , left upper hoagy region and reform lower canine region Tooth decline was noted instantly at the left lower second molar , and serious upper maiden molar and second lower 1st and 2nd molarImbalanced nutrition less than luggage comp artment requirement 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 encumbrance as quantified by weight , which may further progress if not intervened with appropriate nurse 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 baulk 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 interstit ial space hence , initiating fluid transmutation tha! t somehow induce cellular crenationHyperthermia related to dehydration The...If you penury to get a full essay, rove it on our website: OrderCustomPaper.com

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