Care Plannursing Care Plan
Care Plannursing Care Plan
Care Plannursing Care Plan
Date & Assessment Time 2013/8/14 -Today is the 4th 7.30 a.m day of hospitalization. -Mr.Luxman admitted to the ward 15 at 11.50a.m on 10/08/2013. - On admission -Tem 98.4F0 -PR 76min-1 -RR 22min-1 -BP 140/80mmHg Nursing Diagnosis Planning Implementation Evaluation -Risk for To prevent dehydration dehydration related to poor fluid intake. -Giving oral fluid. -Maintain fluid balance chart. -Nutritional deficiency related to poor oral To Prevent intake. Nutritional deficiency.
-Offered fluid.
oral
-Mild fever related -Assisst patient -Opened the to inflammatory to get his meal. window. -Patient looks very reaction. ill and weak. -QH temperature -Anxiety related to To reduce fever chart maintained. -Poor fluid intake. hospitalization. -Applied colon
-Risk for infections related -Patient restless to poor personal and aggressive. hygiene. -Both legs swelling. -Personal is not good. are -Risk for constipation related to poor hygiene oral intake.
-Bed bath given -Increased with luke warm -Iv canula is placed interstitial fluid To reduce water. -Reduced the right hand. due to disease Anxiety swallowing. process. -Oral fluids were -The canula site has -Give Nursing given. not signs of care in friendly infection. manner. -Administered drugs according -Patients skin is to the B.H.T oedematous. To reduce risk for infections. -Legs were -Patient has elevated.
-Give good ventilation. -Appling cold compress. -Maintaining QH temperature chart. -Administer drugs according to the B.H.T
mixed compress.
cold
-Administered drugs according to the B.H.T -Reduced the risk for infection -Nursing care and patient is given in friendly comfortable. manner.
generalized swelling.
body
-Provide a bed bath to the patient with mouth care. To prevent constipation -Giving oral fluid. -Administer drugs according to the B.H.T To Reduce swelling -Elevate the swallowing legs
-Back
massage
4
To prevent given. dehydration. -Offered a milk. -Giving oral fluid. -Fluid balance -Maintain fluid chart maintained. balance chart. .
-Changed linen.
-Changed the position of the patient 2 hourly. -Given a perineal care to the patient.
6
is
patient.