Bev NCP Today

A Nursing Care Plan
A. Patients Profile
1. Demographic data:
Name:
Gender: male
Age: 45
Civil Status: Married
Birthday: 04/01/1969
Address: Lower OM Gufa ,Baguio City
Nationality: Filipino
Latest Hospitalization: January 7,2010
Date of admission: 09/09/2015,6:40 am
Admitting Clerk: Dr. Rabayo
Diagnosis: CAD Lateral wall Ischemia and DM type 2
Chief Complaint :Fatigue and Scaly of skin
2.Health History
1.Chief Complaint: Napansin kong madali akong mapagod nitong nakaraan na araw kaya
huminto muna aku sa trabaho ko
2. History of Present Illness
1 Day prior to admission ,the patient experienced fatigue after driving 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 This sought the patient and her wife to
have a check up,few hours PTA, the patient felt body weakness after prolonged standing and
walking .CBC was done. The Doctor advised him for confinement for further monitoring.
3. History of Past Illness

A.Past History
The patient doesnt have trauma or surgery .Patient is hypertensive
As a child, he went through chickenpox at 5 years old, and latter on the same year experienced
mumps. No immunizations were undertaken by patient when he was young and claimed no
allergy or hypersensitivity to any food or medication. According to patient., he seldom
experienced colds and cough when he was young. No other childhood illnesses were
expressed by the client.
B.Family History
The patient has a family history of HPN on the maternal side respectively,Uncle. According to
patient, his father and grandmother had been diagnosed of Type 2 Diabetes Mellitus.
F. FAMILY HISTORY
(+) DM
(+)
DM
39
y/o
38
y/o
37y/o
45
y/o
37 y/o
Female
Male
(+) DM
Patient
6y/o
21
y/o
16
y/o
Deceased
C.Social and Environmental History

Patient is a college graduate .He worked as a tricycle driver .Patient live in a non congested
neighborhood .Two storey concrete house with 5 bedrooms.Source of water comes from deep
well and drinking water is from the refilling station. Patient is a non smoker and non alcohol
drinker. Patient loves to eat fatty foods like Chicharon, no significant exposure to substance or
pollution.
PROBLEM PRIORITIZATION
LIST OF PRIORITIZED PROBLEMS
A.Actual
1. Ineffective tissue perfusion (Peripheral) related to increased blood viscosity secondary to
hyperglycemia
2.
3. Impaired skin integrity related to presence of rashes

4. Imbalanced nutrition: less than body requirements related to deficient insulin
5. Disturbed sleep pattern related to prolonged discomfort secondary to disease process
B.Potential
6. Risk for infection related to high glucose levels,decreased leukocyte function.
PRIORITIZATION OF PROBLEMS:
Problem
Justification
1.Ineffective tissue perfusion (Peripheral)

related to increased blood viscosity secondary
to
hyperglycemia
According to Maslows Hierarchy of needs,

we must prioritize the physiological needs
of the patient. We must prioritize those
factors that can cause more discomfort to
the patient.
2.
According to Maslows Hierarchy of needs,

we must prioritize the physiological needs
of the patient. We must prioritize those
factors that can cause more discomfort to
the patient.
Imbalanced
nutrition:
less
than
requirements related to deficient insulin
.As evidence by verbalization of the client

and based on the assessment done that
the client really loss weight. It should be
the 3rd priority, to meet the metabolic
needs of the body by intake of sufficient
nutrients and able to gain weight. Because
of the necessary nursing interventions that
have been done the clients appetite
increased.
body
5. Disturbed sleep pattern related to prolonged

discomfort secondary to disease process
6. Risk for infection related to high glucose

levels,decreased leukocyte function.
As evidence by verbalization of the client

di ako masyado makatulog sa gabi, lagi
akong pagising gising. And based on the
assessment done that there are (+) sunken
eyeballs and weakness. It should be the
4th priority because the client is
experiencing a insufficient time or period of
sleep. The necessary nursing interventions
should be done for the client to be able to
maintain a comfortable environment. After
doing
so,
the
client
verbalized
improvement in sleep pattern and can
sleep now from 4-8 hours.
There is a potential problem that had been

identified during our contact with the client
and this is risk for infection due to the
disruption of the skin which is the primary
defense. Necessary nursing interventions
should be done to prevent infection and
complications
Laboratory Test
Diagnostic/
Laboratory
Procedures
Indication or
Purpose
Results
Normal
Values
Analysis and
Interpretation of
results
Complete
Blood Count
(CBC)
WBC count
Lymphocyte
s
Eosinophils
Hemoglobin
Hematocrit
-Measures the
number of WBCs
in a cubic mm of
blood.
-It is used to
detect infection
or inflammation
and to monitor
clients
response to or
adverse effects
of
chemotherapy
or radiation
therapy.
-To determine
immune
function,
provides a gross
measure in
nutritional
status.
-To fight
infection and
control
mechanism
associated with
allergies and
asthma.
-To evaluate the
hemoglobin
content (iron
status and O2
carrying
capacity) of
erythrocytes by
measuring the
no. of grams of
hemoglobin /dl
of blood.
- Measures the
volume of RBCs
in whole blood
expressed as a
percentage.
- It is also a
useful in the
diagnosis of
anemia,
polycythemia,
11.7 x
10g/L
5-10 x 10
g/L
The result is slightly

above the normal
range which may
signify infection.
0.42
0.20 - 0.40
The result is above

the normal range.
0.01
0.01 - 0.06
The result is within the

normal range.
107g/L
140 - 180
g/L
The result is below the

normal range which
indicates anemia.
0.32
0.40 0.54
The result is below the

normal range which
indicates anemia.
and abnormal
hydration
states.
-Value is roughly
three times the
hemoglobin
concentration.
Diagnostic/
Laboratory
Procedures
Random
Blood Sugar
Indication or
Purpose
Results
Normal
Values
To measure
blood glucose
regardless of
when you last
ate.
145.3
mg/dl
< 140
mg/dl
Diagnostic/
Laboratory
Procedures
Kidney
Function
Test
Indication or
Purpose
Results
Normal
Values
Analysis and
Interpretation of
results
To monitor renal
function,
specifically the
ability of the
kidney to
excrete waste
products
3.7
mg/dl
0.4-1.4
mg/dl
Creatinine level is
above the normal
range which indicates
kidney impairment.
Createnine
Analysis and
Interpretation of
results
The result is above
the normal range
which indicates too
little insulin/ diabetes
mellitus.
Diagnostic/
Laboratory
Procedures
Serum
Electrolytes
Indication or
Purpose
Results
Normal
Values
Analysis and
Interpretation of
results
Sodium (Na)
To reflect
water
balance.
135.2
mmol/L
137 145
mmol/L
Potassium
To evaluate
3.6
3.6 5.0
The result is below

the normal range
which indicates that
there is a relative
increase in the
amount of body
water relative to
sodium.
The result is within
(K)
Chloride (Cl)
fluid and
electrolyte
balances and
identify renal
dysfunction.
Potassium is
critical to
neuromuscula
r function,
specifically
skeletal and
cardiac
muscle
activity.
It reflects a
change in the
dilution or
concentration
of the ECF
and does so
in direct
proportion to
sodium
concentration
.
mmol/L
mmol/L
the normal level

which indicates
normal osmotic
pressure and cardiac
and neuromuscular
electrical
conduction.
97 mmol/L
96 110
mmol/L
The result is within

the normal range
which indicates
normal balance of
fluids.
Sources:
Johnson, Joyce Young Medical- Surgical Nursing 10 th Edition
Kluwer, Wolters Nursing 2008 Drug Handbook. Philippines: Lippincott Williams and
Wilkins
Peckenpaugh, Nancy J. Nutrition Essentials and Diet Therapy. Singapore: W.b

Sauders Company, 2007
Doenges, Marilynn E, et al. Nurses Pocket Guide. Philadelphia: F.A Davis Company
Brunner and suddarths medical surgical nursing 12th edition. Vol.1

www.medlineplus.com
I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

Subjective
Objective
General
Ito nangangayat na dahil sa sakit ko as
verbalized by the patient.
Weight: 35 kg. (July 10, 2009)

87 kg. (December 2003)
(+) wt. loss 48kg.
(+) numbness at times(lower extremities)
(+)excessive sweats, axilla
(+)weakness
(-)malaise
(-)chills
(-)fever
BP- 130/80
Temp. 36.5 C
Integument
Skin:
Hindi makati sa binti, pero ang braso,
nangangati as verbalized by the patient.
(+)itchiness (upper extremities)

(+)scaly skin
(-)history of skin disease
Dati malago ang buhok ko as verbalized by

the patient.
Thinning of hair, evenly distributed

(+)itchy scalp (scratching)
(+)Oily hair
Ito matigas na ang kuko ko kumpara dati

as verbalized by the patient.
(+)clubbing of nails (long nails)

(+)Yellowish nail beds
Hair:
Nails:
Amount of sun exposure: Exposure to sunlight every morning

Head:
Sumasakit ang ulo ko na parang tinutusok
(+)frequent headache
(+)dizziness
(-) lumps
Eyes:
Malabo na ang paningin ko as verbalized
by the patient.
(+)blurry vision
(+)PERRLA
(+)Anicteric sclera
(+)Pale conjunctiva
(+)itchiness
(-)discharge
Malinaw pa naman ang pandinig ko, pero

may sumasakit minsan as verbalized by the
patient.
Both ears hears well when the examiner is 3 feet

away
(-)cerumen
(-)discharge
Ears:
Mouth and Throat:

Medyo hirap akong lumunok as verbalized
by the patient.
(+)difficulty in swallowing
(+)lesions on tongue
(+)dental carries
(+)hoarseness of voice
Pink tonsils
(-)bleeding gums
(+) gag reflex
Wala naming problema sa leeg ko as

(-)stiffness
(-)pain
(+)palpable bilateral lymphs
Neck:
Breasts and Axillae:

Pawisin ang kilikili ko as verbalized by the
patient.
(+)excessive sweating, axilla

(-)lump
(-)pain
(-)rash
(-)nipple discharge
Medyo nahihirapan akong huminga as

RR 28 bpm
(+)difficulty of breathing
(+)barrel chest
Productive cough
History of lung disease: pneumonia, PTB, 2006
Last chest x-ray: 2007
Paminsan- minsan sumasakit ang dibdib ko

(+)chest pain
(+)dyspnea on exertion (bed to chair)
(+)nocturia
Respiratory:
Cardiovascular
Central:
Peripheral:
(+)coldness(general)
(+)pallor in hands
(+)clubbing of nails
(+)tingling (sole of feet)
(-)numbness
(-)varicose veins
(-)ulcers
0-1 second, capillary refill
Gastrointestinal:
Eto madalas magan ako
kumain
as
(+)good appetite
Food intake tolerated
(+)minimal dysphagia
(-)hematemesis
Frequency of BM: 3x a week
Characteristic of stool: yellowish- brown in color,
formed in consistency
(+)constipation (arch and formed stool)
(-)hemorrhoids
Urinary:
Ihi ako ng ihi as verbalized by the patient.
(+)polyuria
(+)dysuria
(+)nocturia
Dark Yellow in color
History of urinary disease: UTI(2006)
Genitalia:
Refused
Musculoskeletal:
Kumikirot ang kasukasuan at buto-buto ko
(+)minimal pain, knee area and ankle

(+)pain, calf area
(+)lower back pain, radiating
(+)weakness, leg muscles
Alam ko pa naman ang mga sinasabi ko

ngayon as verbalized by the patient.
(-)history of seizure, stroke, fainting

Mental:
(-)nervousness
(+)depression
Self-pity and crying
Motor function:
(-)tremors
(-)paralysis
Sensory function:
Oriented to time, person and place
Pagkakaalam ko,wala naman akong sakit

sa dugo as verbalized by the patient.
(-)bruises
(+)palpable lymph nodes
(+)bleeding tendency of skin (scaly skin)
(-)history of Blood Transfusion
Sa pamilya naming may Diabetes, kaya ako

merong Diabetes as verbalized by the
patient.
(+)DM, type II
(+)polydypsia
(+)polyuria
(+)polyphagia
(+)weight loss
(+)change in skin texture, scaly skin
(+)excessive sweating, axilla
(-)nervousness
(-)tremors
Neurologic:
Hematologic:
Endocrine:

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A Nursing Care Plan

3. History of Past Illness

C.Social and Environmental History

3. Impaired skin integrity related to presence of rashes

1.Ineffective tissue perfusion (Peripheral)

According to Maslows Hierarchy of needs,

According to Maslows Hierarchy of needs,

.As evidence by verbalization of the client

5. Disturbed sleep pattern related to prolonged

6. Risk for infection related to high glucose

As evidence by verbalization of the client

There is a potential problem that had been

The result is slightly

The result is above

The result is within the

The result is below the

The result is below the

The result is below

the normal level

The result is within

Peckenpaugh, Nancy J. Nutrition Essentials and Diet Therapy. Singapore: W.b

Brunner and suddarths medical surgical nursing 12th edition. Vol.1

I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

Weight: 35 kg. (July 10, 2009)

(+)itchiness (upper extremities)

Dati malago ang buhok ko as verbalized by

Thinning of hair, evenly distributed

Ito matigas na ang kuko ko kumpara dati

(+)clubbing of nails (long nails)

Amount of sun exposure: Exposure to sunlight every morning

Malinaw pa naman ang pandinig ko, pero

Both ears hears well when the examiner is 3 feet

Mouth and Throat:

Wala naming problema sa leeg ko as

Breasts and Axillae:

(+)excessive sweating, axilla

Medyo nahihirapan akong huminga as

Paminsan- minsan sumasakit ang dibdib ko

(+)minimal pain, knee area and ankle

Alam ko pa naman ang mga sinasabi ko

(-)history of seizure, stroke, fainting

Pagkakaalam ko,wala naman akong sakit

Sa pamilya naming may Diabetes, kaya ako

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