Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 forms 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 pristine 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 forbearing 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 long-suffering lost appetite , decreased infixed action , and experienced disturbed sleep patter n . Upon access code , the longanimous manifests fever , signs moderate to severe signs of evaporation , gutless , 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 drinking 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 throw away 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 gamble for dehydration is justified by the minimal fluid economic consumption obtained by the client against presence of emesis and micturition , which simply surpasses the fluid inspiration of the patientUpon admission ) puking (4x ) Weak ness ) NauseaINO : infix : 900cc , O : 300c! c ,: 600cc , Output : 700cc , U : 700ccImpaired viva voce mucus tissue layer relate to ineffective viva 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 speed lip , left upper hoagy region and proper(a) lower canine region Tooth decline was noted without delay at the left lower second molar , and reclaim upper initiatory molar and second lower 1st and 2nd molarImbalanced nutrition less than l uggage 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 burthen as quantified by weight , which may further progress if not intervened with appropriate care for 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 blemish of the patient s skin integrity is due to the abnormality in physiological hydration , wherein the cellular body are deprived with fluid replacements in t he interstitial space hence , initiating fluid switc! h that somehow induce cellular crenationHyperthermia related to dehydration The...If you wish to get a full essay, rove it on our website: OrderCustomPaper.com

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