A Nursing Care Plan

Presented to
Maam Binayan
Clinical Instructor
Saint Louis University

In Partial Fulfillment
For Related Learning Experience
Surgical Ward
By:
BSN III-A Group 1
Group Members:

A. Patients Profile
1. Demographic data:

Name: Tresemo, Herminia Orlino

Gender: Female
Age: 65
Civil Status: Married
Birthday: July 23,1948
Birthplace: Quezon City
Address: Lower OM Gufa ,Baguio City
Nationality: Filipino
Next of Kin: Fecino S. Tresemo
Latest Hospitalization: January 7,2010
Date of admission: August 15,2013 ,8:15 pm
Admitting Physician: Dr. Manalo
Attending Physician: Dr.Irmscher
Diagnosis: cervicogenic vertigo.Mild degenerative cervical osteotropathy
Chief Complaint :Body weak:

2. History of Present Illness

1 Day prior to admission (August 14,2013) the patient experienced sudden dizziness after
eating breakfast and felt body weakness, But didnt bother it ,Instead ,the patient just rested after
lunch ,the patient stood up(immediately standing) and the patient felt dizzy again and complained of
pain on the nape area. This sought the patient and her husband to have a check up,few hours PTA, the
patient felt dizzy and body weakness after prolonged standing and walking .CBC was done. The patient
was CMS cervicogenic vertigo. The Doctor advised her for confinement for further monitoring.

3. History of Past Illness

The patient doesnt have trauma or surgery .(+) HPN,No DM ,No maintenance.

4.Social and Environmental History

The patient is a housewife and has a sedentary life, Patient is a non smoker and non alcohol drinker.
Patient loves to eat fatty foods like Chicharon, no significant exposure to substance or pollution.

Past Medical History

Family History
The patient has a family history of HPN on the maternal side respectively,Uncle.there is no history od
DM and Cancer of any kind.

DRUG STUDY
Generic and
Brand Name

Dosage

Class

Indication

Mechanism of
Action

Side
Effects

PROBLEM PRIORITIZATION
LIST OF PRIORITIZED PROBLEMS

PRIORITIZATION OF PROBLEMS:
Classificatio
n
(Under
Maslows
Hierarchy of
Needs)

Problem

Justification

PATHOPHYSIOLOGY of Cervical Spondylosis

Sources: