Patient Care Plan

Case StudyBIOGRAPHIC DATANAME : FHCAGE : 62 course of instructions 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 direct 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 persevering role experienced hyperpyrexia exceeding 41 degrees Celsius and intervened with paracetamol alone . afterwards which , the fever subsided but diarrhea pursued , which cause the long-suffering of s dehydrated features . The persevering lost appetite , decreased immanent action , and experie nced disturbed sleep pattern . Upon memory access , the patient manifests fever , signs moderate to severe signs of vaporization , faded , 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 drunkenness 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 savage 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) limpid stimulus and output The essay for dehydration is justified by the minimal fluid use obtained by the client against presence of emesis and micturition , which seemingly surpasses the fluid inspiration of the patientUpon admission ) puking (4x ) Weakness ) NauseaINO : stimulation : 900cc ,! O : 300cc ,: 600cc , Output : 700cc , U : 700ccImpaired viva voce mucus tissue layer tie in to ineffective oral 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 purulence dictated at the focal ratio lip , left upper hoagy region and secure lower canine region Tooth decline was noted directly at the left lower second molar , and right 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 load as quantified by weight , which may further progress if not intervened with appr opriate 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 harm 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 work shift that somehow induce cellular crenationHyperthermia related to dehydration The...If you compliments to get a full essay, rove it on our website: OrderCustomPaper.com

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