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In Partial Fulfillment Of the Requirements For the subject NCM 108A Related Learning Experience
NURSING CARE PLAN
SUBIMTTED BY: Ambroce, Alyza Marie A. BSN 4 – C4
SUBMITTED TO: EJERCITO BALAY-ODAO, RN Clinical Instructor
JANUARY 04, 2013
I.PATIENTS PROFILE:ako na bahala mgdagdag dito NAME: Lumawod, Armando Villanueva AGE: 57 SEX: Male CIVIL STATUS: Married
ADDRESS: Brgy. Nangapungan San Quintin Pangasinan RELIGION: Roman Catholic NATIONALITY: Filipino BIRTHDAY: September 28, 1955 PLACE OF BIRTH: Bacolod, Negros Occidental OCCUPATION: Caretaker DATE OF ADMISSION: December 30, 2012 TIME OF ADMISSION: 01:50 pm ADMITING PHYSICIAN: Dr. Torio ADMITTIN DIAGNOSIS: T/C Viral Hepatitis vs. Cholecystitis
Move and Maintain posture. Circulation. Diagnostic tests were done Ultrasound which reveals tumor in the liver. revealing a result of UTI and reddish colored urine. Bromhexine HCl and Paracetamol ( drug dose is unrecalled). CT scan which reveals Colon CA.CULTURAL HISTORY AND ENVIRONMENTAL HISTORY: The patient works in Bacolod as a caretaker of livestock. “14 Basic Needs” (Breathing.II.up and was advised for admission.HEALTH HISTORY: CHIEF COMPLAINT: Abdominal Pain HISTORY OF PRESENT CONDITION: 1 week prior to admission. During his admission. NURSING DIAGNOSIS CLASSIFICATION OF PROBLEM 1. Undress and Dress. Eat and Drink. He the went for a check-up at Pangasinan Hospital and urinalysis was made. the patient is admitted at present. Avoid danger. Hence. Communication. The next day after admission the patient was then referred to BEGH for transfer. elimination. Play and Learn) to prioritize patient’s identified problems. Maintain body temperature. he decided to stay in their house at Pangasinan together with his wife and children’s III. Worship. Sleep and Rest. since 16 y/o sya ngyoyosi na sya SOCIO. Work. the patient experienced abdominal pain with febrile episodes. After 2 days of consultation. the patient was continuously observed and medications prescribed are still given. LIST OF PRIORITIZED NURSING PROBLEMS WITH JUSTIFICATION: I used the theory of Virginia Henderson. the patient was then given medications such as Cefuroxime. PAST MEDICAL HISTORY: The patient does not have any history of hospitalization or surgery. He lives in Bacolod without his family. The patient claims of alcohol drinking every night and with history of smoking . Keep Clean. Prior to admission. the patient returned again to the hospital for check. Metoclopromide. FAMILY HISTORY AND PERSONAL PROFILE: The patient claims no history of DM but has a history of heart disease from the mother’s side. Stage 4.. Acute Pain related Actual This is the first prioritized JUSTIFICATION . medications given were: Ranitidine.
The patient is on 02 inhalation 1. Actual This is the third problem since it has something to do with perfusion. crackles are heard on lower lung fields. The insertion of IC caused trauma to the urethra and it also relaxed the sphincter which then caused the difficulty I urination control . Ineffective Airway Clearance related to retained bronchial secretions 3. according to ER books. This s supported by prolonged capillary refill during assessment. it is considered as the 5th vital sign and this must be addressed immediately 2. Urge urinary incontinence related to tissue trauma secondary of IFC insertion Actual This is the second prioritized problem.2LPM/NC. Actual In Henderson’s 14 basic needs eliminating body wastes was ranked 3rd.to tension in the walls of abdomen secondary to Abdominal distention problem because pain is a subjective data that only the patient can tell. Impaired gas exchange related to ventilation perfusion imbalance secondary to altered oxygen capacity of the blood 4.
5. moving and maintaining desirable position is ranked as the fourth. The patient skin is disrupted. 2013 PROTHROMBIN TIME: . keeping the body clean is important.the body must be clean and well groomed and it must be free from any infection. Since the patient has IFC and IV line he is prone of having infection Kulang pa la toh ng seld care deficit tpos constipation tpos disturb sleeping pattern tpos impaired breathing pattern. therefore there is also destruction of skin layers and invasion of body structures Actual 8. In Henderson’s 14 basic needs. Risk for Infection related to tissue trauma Potential According to Henderson . tpos ung sa nutrition niya JANUARY 01. Patient has limited movement because of abdominal pain. 6. Activity Intolerance related to restricted mobility Actual In Henderson’s 14 basic needs. Fatigue related to altered physical mobility 7. Impaired skin integrity related to tissue trauma secondary to IFC insertion Actual Fatigue is also felt by patient because of the abdominal pain he is experiencing.
2013 COMPUTED TOMOGRAPHY SCAN: . 2012 ULTRASOUND: Results: Normal Pancreas.51-0. Metastasis Bile gravel suggest correlation with CT Scan JANUARY 01.20 NORMAL VALUES MALE: 135-180 g/L 0. Hepatic nodules primary vs.40-0.67 MALE: O.020 Transparency: slightly turbid DECEMBER 31. 2012 URINALYSIS: Color: orange Mucous thread: few Urates: moderate Reaction: 5.0 Specific gravity: 1. Spleen and Kidneys.57 NORMAL VALUES 10-17 seconds 1-2 JANUARY 03 2013 RESULTS 67 0.PROTHROMBIN TIME INR RESULTS 19 1.54 % HEMOGLOBIN LEUKOCYTES ERYTHROCYTE DECEMBER 31.89 0.
2012 X-RAY: Results: True or Apparent Cardiomegaly elevated Right hemidiaphragm DECEMBER 31.328 non-reactive AFP (Cobas e411).36 66 NORMAL VALUES 2.3 98-107 SODIUM POTASSIUM CHLORIDE JANUARY 02.5-5.Electrochemiiluminiscence Assay Result 159 iu/m Normal value:0.50 62-132 BUN CREATININE DECEMBER 31. if still clinically indicated DECMBER 30.9 95. 2012 RESULTS 197 211 397 NORMAL VALUES 9. 2012 RESULTS 130.Conclusion: Enhancing irregular ceca and ascending colon masses.50-6.0-5.7 3. probably metastasis correlate CT findings with other imaging modalities like colonoscopy and barium enema.IgM Result: 0.80 .0-48 u/L 5. biopsy also suggested. 2013 Anti HAV. consider malignancy multiple partially enhancing hepatic tumors. 2012 RESULTS 4.0-49 u/L 40-150 u/L SGOT/AST SGPT/ALT ALP DECMBER 30.8 NORMAL VALUES 135-148 3.
29 NORMAL VALUES 3.25 mmol/L 0.07-7.70 ng/ml JANUARY 01.10 mmol/L 3.773 ng/ml Normal value: 0.CORAS e4m Analyzer Result: 0.81 mmol/L FBS TOTAL CHOLESTEROL TRIGLYCERIDE DECEMBER 30 2012 X-RAY: Lungs are hypocierated.00 – 4.76 7. heart appears enlarged Right hemidiaphragm is increase.28 3.4-1. 2013 RESULTS 6.6-6. bones are intact True or Apparent Cardiomegaly elevated Right hemidiaphragm MEDICATIONS: VITAMIN K KETOROLAC REGULAR INSULIN for CBG >180 mg/dl D5050 for CBG of < 80 mg/dl TRAMADOL CEFTRIAXONE OMEPRAZOLE PARACETAMOL NCP 1: Acute Pain related to tension in the walls of abdomen secondary to Abdominal distention .
it is not radiating. spleen. The abdomen is an anatomical area that is bounded by the lower margin of the ribs and diaphragm above.com Perform and demonstrate relaxation technique such as deep breathing exercises. duration. small intestine. frequency. 5 cm >with normoactive bowel sounds >with pain medication of Ketorolac IV EXPLANATION OF THE PROBLEM Abdominal pain is pain that is felt in the abdomen. liver. and the flanks on each side. and pancreas. aggravated when moving and relieved by sleeping. gallbladder. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (such as the skin and abdominal wall muscles). >with guarding behavior noted over the abdomen >with grimacing noted when moving >with distended abdomen >with abdominal girth of 97. Changes in these vital signs often indicate acute pain and discomfort To have a necessary data about pain felt by the patient Assess pain scale. the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity. characteristic. O> irritable when in pain >with moist and warm skin touch > with limited movement >needs total assistance in moving >muscle strength of 4/5 in both upper and lower extremity. Organs of the abdomen include the stomach. the pelvic bone (pubic ramus) below. colon. onset. or by loss of the blood supply to an organ. NURSING INTERVENTIONS RATIONALE EVALUATION Monitor Vital Signs To obtain baseline data.Abdominal pain is caused by inflammation. location. distention of an organ. OBJECTIVES STO: After 4-6 hours of nursing intervention. the pain felt by the patient will decreased from 8/10to 6/10 by doing nonpharmacological methods to help control pain such as DBE and doing diversional activities LTO: After 3 days of nursing intervention Patient will rate pain as a 2/10 or less at the time of discharge and will be sent home on low dose oral pain medications. Facilitates the comfort of the . burning in characteristic.ASSESSMENT S> “Masakitpadinyongtiyanko” patient rated pain as 8/010. and precipitating factors of pain Observe for non verbal cues of pain To evaluate severity of pain Provide opportunities for rest by promoting less environmental stimulation Rest can decreases discomfort thus restores the energy of the patient Relaxation techniques promotes comfort to patient and to refocus attention Reference: MS by Black 7th edition Scrib.
medicines and blood products as ordered Aids in maintaining adequate circulating volume and to help maintain necessary body functions as the action of drug works NCP 2: Risk for Infection related to tissue trauma A E ON RE SXBUAV SPJ RT A ELESI L S ACI OU SNT NNA MA I GA T ETV LI NI EI EO T OS N N N T E O R F V E T N H T E I O P N R S O B L E M S SBT MC > e O o h c : n a “ a Encourage patient to verbalize concerns Reduction of anxiety promotes comfort .patient Promote bed rest in a comfortable position Change the position of the patient frequently Promotes comfort and prevention of bed sore Administer fluids.
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