Вы находитесь на странице: 1из 5

Demographic Data

My patients name is Jimmy Pulac. 61 y/o and is residing in Km. 12 Shilan, La Trinidad, Benguet. Born on the 15
th
of April 1953 and is a Roman Catholic. He is married and
currently has no work and stays at home.
Working Diagnosis: Chronic Kidney Disease Stage 5 secondary to neuropathy, DM II, insulin-requiring DM, gastropathy cholelithiasis
HISTORY OF PRESENT ILLNESS
Patient is diagnosed to have Diabetes Mellitus type II, and is aware of it. The patient was also diagnosed of having hypertension and Chronic Kidney Disease secondary to
DM. He is taking some maintenance medications like Furosemide, Amlopidine, Trimetazidine and Metoprolol.
Days prior to admission, according to his SO, he experienced some episodes of nausea and vomiting. There was no severe pain in any part of the body. And he was
afebrile.
1 day PTA, patient experienced persistent nausea and complained of epigastric pain. They have seek consultation, and hence admission.
CHIEF COMPLAINT: epigastric pain
HISTORY OF PRESENT ILLNESS
A. Past History
Patients Diabetes medications are not taken regularly. This is not the first time the patient has gone to a hospital. He cannot already recall how many times he has
been gone to hospitals. The recent hospitalization was this year; he went for check-up in Baguio General Hospital and Medical Center for his diabetes. Since childhood, the
patient commonly experiences cough and colds which is relieved by drinking water.
Date of Hospitalization Reason of Confinement/ Condition Name of Institution
Check-up for DM Baguio General Hospital and Medical Center

B. Family History
Patient has no familial history of HPN, Cancer or Diabetes in both maternal and paternal side. He has no allergies. He is married and is residing with his daughter,
considered as his first kin.
C. Social and Environment History
The patient is not working due to health condition. The patient lives in a non-congested house with his daughter. The water is from a water station that is used for
drinking. The water from the water district is used for cleaning and domestic use. The patient is married. The usual dietary pattern is rice and an ulam that may be vegetables or
meat or fish. The patient admits to be an occasional alcohol drinker and is a non-smoker.
PROBLEM IDENTIFICATION AND PRIORITIZATION
Prioritizing problems based on Maslows Hierarchy of Needs
1. Priority 1: Biological/Physiological needs
a. Altered comfort
b. Activity intolerance
2. Priority 2: Physical/Psychological Safety
a. Risk for unstable blood glucose level
3. Priority 3: Love and Belonging - none
4. Priority 4: Self-esteem needs - none
5. Priority 5: Self-actualization none
Priority List of Problems Justification for Prioritization
a. altered comfort A. It is an actual problem since my patient is complaining of discomfort and episodes of pain. We should prioritize this probl em because if
the patient has discomforts and pain, he or she would not participate or listen to any of the instructions or activities that you ask them to
do.
b. activity intolerance This is an actual compromise in the biological needs of the client. Resolution of this problem will help the patient do ADLs without any
complications and may promote homeostasis to the bodys daily biological functions.
c. risk for unstable blood glucose If your blood sugar remains unbalanced too frequently the body starts to ignore the insulin message, a condition called insulin resistance.
We would not want our patient to have this condition, and because my patient has DM, this would likely to happen.
REFERENCES: Elsevier (2014). Nursing Care Plan, 5
th
edition. Retrieved from http://www.us.elsevierhealth.com//MERLIN
The National Kidney and Urologic Diseases Information Clearinghouse, 1987.
Elsevier Heatlh, 2014.







NCP PROPER
CUES EXPLANATION OF THE
PROBLEM
OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
S: paggising ko masakit
na yung puson ko. parang
mabibitak na. kahapon pa
ako hindi makaihi.

O: claims to have
distended bladder and
feeling uncomfortable.
Grimacing and guarding
behavior noted. Irritable.

Nsg. Dx: Altered comfort r/t
urinary retention
Urinary retention is the
inability to empty the
bladder. Urinary
retention can be acute or
chronic. Acute urinary
retention is a medical
emergency. People with
acute urinary retention
cannot urinate at all, even
though they have a full
bladder. Acute urinary
retention, a potentially life-
threatening medical
condition, requires
immediate emergency
treatment. Acute urinary
retention can cause great
discomfort or pain.

The National Kidney and
Urologic Diseases
Information Clearinghouse,
1987.

Altered comfort is
perceived to be lack of
ease, relief and
transcendence in physical,
psychospiritual,
environmental and social
dimensions.

Elsevier Heatlh, 2014.
LTO: The client will feel
absence of discomfort
after 32 hours of nursing
intervention

STO: After 4hours of nursing
interventions, the client will
experience diminished
discomfort as evidenced
by:
a. verbalization of no
discomfort
b. relaxed facial expression
and body positioning
c. increased participation
in activities and given
instructions
d. stable vital signs
Tx:
INDEPENDENT:
asses for non verbal signs
of discomfort




assure client that the need
for relief of discomfort is
understood.




provided rest periods by
clustering nursing
interventions.



ask clients mode used to
manage discomforts




DEPENDENT/COLLABORATIVE:
IFC insertion as ordered

Provides a baseline to
measure changes in
discomfort pattern. May
indicate worsening
condition of
nephropathies.

These actions promote
relaxation and
subsequently increase
clients threshold and
tolerance for discomfort.

Rest may alleviate the
discomforts felt by the
patient and help him
restore his energy.

Patient would likely
participate in this because
it is his own way to
manage his discomforts
and he knows that this will
alleviate his discomforts.

Since my patient cannot
void resulting to distended
bladder, it would help
ease the pain and
discomfort by draining the
urine through IFC.
GOAL FULLY MET IF:
Patient will experience
diminished discomfort as
evidenced by:
a. verbalization of no
discomfort
b. relaxed facial expression
and body positioning
c. increased participation
in activities and given
instructions
d. stable vital signs

GOAL PARTIALLY MET IF:
Only 2 of the evidences in
the STOs are achieved.

GOAL NOT MET IF:
None or only one of the
evidences in the STOs is
achieved.

ACTUAL EVALUATION:
Goal fully met
Patient experienced
diminished discomfort as
evidenced by:
a. . verbalization of no
discomfort
b. relaxed facial expression
and body positioning
c. increased participation
in activities and given
instructions
d. stable vital signs



TEACHING PLAN FOR DIABETIC DIET
Description of the Learner: Jimmy Pulac, 61 y/o. A diabetic patient who malpractices his eating diet and regular intake of medications.
Learning Need: What are the appropriate and right foods should be taken?
Learning Diagnosis: Knowledge Deficit: Proper Diabetic diet related to lack of information
Goal: The client will be able to know what foods to eat and avoid to prevent further complications.

BLOS TOPIC OUTLINE TEACHING STRATEGY TIME ALLOTMENT AND
RESOURCES NEEDED
METHOD EVALUATION

After 15 minutes of discussion,
the client will be able to:

1. Discuss what foods to
eat and avoid.



2. Discuss the steps on
how to do prepare
some dishes with these
foods.





3. Discuss the importance
of proper diet.




Diabetic Diet




How to prepare Diabetic
Diet







importance of Diabetic Diet






One-on-one lecture
discussion with pamphlet.




One-on-one lecture
discussion with pamphlet.






One-on-one lecture
discussion with pamphlet.





5 minutes
- Pamphlet
containing
information about
Diabetic diet.

5 minutes
- Pamphlet
containing
information about
Diabetic diet.

5 minutes
- Pamphlet
containing
information about
Diabetic diet.





Instant Feedback: The client
will be able to answer
question about the topic.



Instant Feedback: The client
will be able to answer
question about the topic.





Instant Feedback: The client
will be able to answer
question about the topic.


REFERENCE: www. healthnavigator.org