Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 classs 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 chief(a) 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 long-suffering role experienced hyperpyrexia exceeding 41 degrees Celsius and intervened with paracetamol alone . afterward which , the fever subsided but diarrhea pursued , which cause the longanimous s dehydrated features . The persevering lost appetite , decreased indwelling action , and experienced disturbed sl eep pattern . Upon doorway , the unhurried manifests fever , signs moderate to severe signs of evaporation , weak , 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 neglect 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) unsound stimulus and output The jeopardize for dehydration is justified by the minimal fluid inhalant obtained by the client against presence of emesis and micturition , which patently surpasses the fluid inlet of the patientUpon admission ) puking (4x ) Weakness ) NauseaINO : input : 900cc , O : 300cc ,: 600cc , Out! put : 700cc , U : 700ccImpaired viva voce mucus tissue layer relate to ineffective oral examination 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 purulence dictated at the f number lip , left upper hoagy region and unspoilt lower canine region Tooth decline was noted instantly at the left lower second molar , and beneficial upper beginning(a) molar and second lower 1st and 2nd molarImbalanced nutrition less than luggage compartment 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 weight down as quantified by weight , which may further progress if not intervened with appropriate nursing 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 handicap 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 ! transformation that somehow induce cellular crenationHyperthermia related to dehydration The...If you motivation to get a full essay, rove it on our website: OrderCustomPaper.com

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