You are on page 1of 9

Functional Health Pattern

Nursing Care Plan
Submitted to:
Mr. Kennith Misamis, RN

Submitted by:
Francis Adrian Palalon

February 17, 2017

Name: R.B.

Birthdate: August 9, 1957

Age: 59 y/o

Nationality: Filipino

Civil Status: Married

Date Admitted: February 14, 2017

Chief Complaint: A day PTA, patient experienced body weakness which prompted consultation and laboratory tests.

2 days PTA patient had LBM associated with body weakness.
1 day PTA patient experienced tremors associated with body weakness which prompted consultation and laboratory tests.

General Impression:

Received patient sitting on bed with 800ml PNSS regulated at 33 gtts/min. Patient is well-groomed, awake and properly oriented to date, time and place.
Able to respond to questions asked coherently and actively.
Cues Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective: Deficient fluid volume At the end of 5 hours 1) Assess vital signs, - To obtain baseline date At the end of 5 hours
Gikapoy man sige akong related to volume rendering nursing including temperature, and monitor for rendering nursing
lawas nya gamay daw ko depletion (diuretic interventions, the pulse, and respirations. condition. interventions the goal
potassium ingun ang phase) secondary to patient will: was completely unmet.
doctor, as verbalized by hypokalemia 2) Monitor I & O hourly. - To assess the fluid
the patient. - maintain fluid volume balance trend, which is
at a functional level as reflective of renal
Objective: evidenced by individually function.
- restlessness adequate urine output
- dry skin and good skin turgor; 3) Assess hydration - Flat neck veins,
- decreased urine output state: note skin turgor complaints of thirst, &
- Labs: - display normal serum and condition of buccal decreased LOC may
K+ - 2.8 (L) potassium level and membranes. signal volume depletion.
Creatinine 2.15 (H) electrolyte levels;
BUN 32 (H) 4) Avoid rapidly placing - Because postural
- verbalize the patient in an upright hypotension may result.
understanding of position.
causative factors and
purpose of therapeutic 5) Provide meticulous - To prevent skin
interventions and skin & oral care. breakdown and oral care
medications; to soothe dry mucous
- demonstrate behaviors
to monitor and correct 6) Encourage nutritious - To promote hydration
deficit, as indicated, diet and adequate water and prevent decreased
when condition is intake. fluid volume.
7) Administer aggressive - To increase volume and
fluid and electrolyte maintain normal
replacements as electrolyte and acid-base
ordered. balance.

8) Administer meds:

NaHCO3 1 tab TID - Potent systemic


Telnisartan 40mg OD - Used for treating HPN.

Omepram 40mg 1 tab - Used as an antacid.

OD ac

Febuxostat 80mg OD - Used for treating gout

caused by excessive
levels of uric acid in the
USUAL INITIAL (2-15-17) ONGOING (2-16-17)


- Patients health for the past 3 months is good as - Patient does not complain of any pain (PATIENT TRANSFERRED)
Vital signs:
T: 36.3 C
- eats nutritious foods and water to improve P: 76 bpm
health RR: 20 cpm
BP: 130/80 mmHg

- complete immunizations Medications:

- Cefuroxime 350mg IVTT q 8h
- NaHCO3 1 tab TID
- does not anticipate problems caring for himself - Febuxostat 80mg OD
- Nenalog 600mg 1 tab TID
Labs: - Telmisartan 40mg OD
- Creatinine 2.15 (H) - Omepram 40mg 1 tab OD ac
- BUN 32 (H) - Catarnet 75mg 1 tab q 6h
- WBC 4.8 (L)


- Patient has no ordered diet.
- patient usually eats vegetables, fish, meat, etc
in breakfast, lunch, or dinner - Patient ate rice, buttered chicken, vegetables
and banana
-patient eats a lot of rice about 2 cups
- Patient drank plenty of water
- did not experience indigestion, nausea or
- no food restrictions or allergies

- patients not taking any food supplements

- no problems in ability to eat


Bladder - Patient urinated 4 times today
- no problems or complaints with the usual
pattern of urinating - No assistive devices used.

- usually urinates 4-5 times a day

- no assistive devices used

Bowel - Have not yet defecated since admission
- usually moves bowel during night time with
brownish in color and not watery - No assistive devices used.

- no assistive devices used

Skin - Skin turgor is normal, temperature, color and
- patients skin condition: texture are normal
> light-brown
> warm to touch
> normal skin turgor
> absence of any edemas or lesions
- Patient is able to ambulate independently
- patient is not working now
- No complaints of pain
- no limitations in ability to ambulate, dress,
toileting, or bathing self

- no complaints in dyspnea or fatigue

- Patients sleeping pattern is normal
- patient usually sleeps around 10PM to 5AM
- Sleeps 7-8 hours
- 7-8 hours of sleep at night
- No difficulties in sleeping
- no sleeping aids used or any medications or
foods - No sleeping aids used

- no difficulties in sleeping


- No deficits in sensory perception (hearing, sight,
- no deficits in sensory perception (hearing, sight, or touch)
or touch)
- Patient is able to speak coherently
- does not wear eyeglasses or any hearing aids
- No complaints of vertigo or insensitivity to
- no complaints of vertigo or insensitivity to superficial pain or cold/heat
superficial pain or cold/heat
- Patient wants to recover and be discharged
- patients is concerned of his own health soon

- describes himself as a hardworking person


Communication - Patient speaks Cebuano and English
- patient speaks Cebuano and English
- Patient speaks coherently
- speech is clear and relevant
- Able to express self verbally and physically
- able to express self verbally
Relationships - Patient is together with his wife and children
- patients significant other speaks Cebuano.
- Patients wife is taking care of him now
- patient lives with his wife and children

- turns to relatives or siblings in times of need

- no signs of any type of abuse (physical, verbal,



- Patient is able to anticipate a change in his
- Patient is able to anticipate a change in his sexual relations
sexual relations - Patient is married with two daughters
- Patient is married with two daughters

- Patient makes decisions with his wife
- patient usually makes decisions with the family
- Patient is not entirely worried of his condition
- no loss in life for the past year right now.

- patient likes about himself as hardworking

- does not have anything to change in his life

- when patient is under stress or any problems he

seeks help from his family


- Patient is Roman Catholic
- patient is Roman Catholic
- Patient is praying for his fast recovery of his
- patient finds source of strength and meaning condition.
from God

- verbalizes that God is very important to his life

- seldom goes to church in Sunday

- no religious practices or rituals were observed