NURSING CARE PLAN

Patient : Mrs.P.E.M Hospital No.:100022609018

Age: : 87 years old Room No. : A-602
Impression: : CAP Physician : Dr. Lerma Noval
CLINICAL PORTRAIT PERTINENT DATA
I. Assessment: I. History of present Illness:
Patient was received lying on bed, appears weak, unresponsive, and
incoherent. Persistent coughing was noted, has the desire to sleep. With an 2 weeks PTA, pt. started to have a productive cough of
IVF of PNSS @ 10 cc/hr infusing well at Left arm, with O2 saturation @2 whitish yellowish sputum (-) fever. Consult done with local physician,
LPM via rebreathing mask and has NGT for feeding. amoxicillin given (+) difficulty in expectorating.
5 days PTA, pt. has body malaise and difficulty in
Vital signs taken upon first contact: standing. Multivitamins is given.
Temperature : 36.9°C Hours PTA, cough persisted with worsening of dyspnea
Pulse Rate : 89 beats per minute has brought to cough, PNSS started; Hgt:204 pt was transferred due to
Respiratory Rate : 24 cycles per minute unavailability of room
Blood Pressure : 110/60 mmHg II. Chief Complaint:

II. Significant finding: Patient complain shortness of breath

- Increased respiration noted – 24cpm III. Past History of Patient Illness:

- dyspneic, rapid and shallow respiration Patient undergone surgical procedure about 40 years ago (post
- crackles heard upon auscultation cholecyctectomy). Patient has no allergy and has hypertension
- use of accessory muscles during respiration noted
- Productive cough IV. Vital signs upon admission:
- Decubitus ulcer noted at left sacral area
Temperature :37.1°C
Pulse Rate :84beats per minute
Respiratory Rate :24cycles per minute
Blood pressure :152/54 mmHg