Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 categorys 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 primordial 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 affected role role experienced hyperpyrexia exceeding 41 degrees Celsius and intervened with paracetamol alone . posterior which , the fever subsided but diarrhea pursued , which cause the diligent of s dehydrated features . The patient lost appetite , decreased innate(p) action , and experienced disturbed sl eep pattern . Upon admission fee , the patient manifests fever , signs moderate to severe signs of desiccation , listless , and irritablePAST medical examination HISTORYPatient is a known hypertensive since year 2002 , 5 /P CVD last 2002 slurred speech , geriatric , previous smoking carriage and negative alcohol deglutition 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 overleap on the ground with dismissal of environment snarl in his left face . There argon no headaches , seizures and dizzinessNURSING DIAGNOSISNursing diagnosing RationaleRisk for dehydration associate to token(prenominal) changeable stimulus and output The risk of infection for dehydration is justified by the minimal fluid stirring obtained by the client against presence of emesis and urination , which seemingly surpasses the fluid white plague of the patientUpon admission ) puking (4x ) Weakness ) NauseaINO : stimulation : 9! 00cc , O : 300cc ,: 600cc , Output : 700cc , U : 700ccImpaired viva voce mucus membrane relate to ineffective spontaneous 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 purulency dictated at the pep pill lip , left upper hoagy region and obligationly lower canine region Tooth decline was noted in short at the left lower second molar , and right upper beginning(a) molar and second lower 1st and 2nd molarImbalanced nut rition 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 underweighting as quantified by weight , which may further progress if not intervened with appropriate treat 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 wrong of the patient s skin integrity is due to the abnormality in physiological hydration , wherein the cellular body are deprived with fluid re placements in the interstitial space hence , initiati! ng fluid unfirm that somehow induce cellular crenationHyperthermia related to dehydration The...If you postulate to get a full essay, rove it on our website: OrderCustomPaper.com

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