Patient Care Plan Patient : Mr.

Jason Age:74-Year-Old Form of Address : Occupation: Retired Military Marital Status: Married Reason for admission: Client complains of shortness of breath, coughing up phlegm, and chest pain. Then the family takes him to Dr. Soedono Hospital on February 23, 2012 and treated in the Wijaya Kusuma C Dr. Soedono hospital for intensive care. Symptoms : Cough, coughing up phlegm, chest pain, and shortness of breath. Communication: Client is able to interact with other people or nurse (medical team) and work together well, the people who closest to the client is a wife and family. Safety: Changes in mental function, Pairs of restrain to protect the patient. Eating and Drinking: At Home: Client eats 3 times a day,menu : rice, vegetables, and side dishes. His appetite is good, no eating restrictions. Client takes 1500 cc / day. In hospital: Client eats 3 times a day with menu of rice, vegetables, side dishes and fruit. Client cant eat all meals are provided at the hospital (he only ate portion is provided), his appetite isnt good enough, no food restrictions. Client takes 1000 cc / day. Eliminating: At Home: Client said that he was urinating 4-5 times a day, with the number of 1400-1500 cc / day, liquid consistency, clear color, no complaints when urinate and defecate 1-2 times a day, soft consistency , characteristic odor of feces, no melena, no complaints during defecation. In the hospital: Client said that he was urinating 3-4 times a day, using the potty with a number of 1400-1500 cc / day, liquid consistency, clear color, no complaints during urination, and defecation 1-2 times a day, soft consistency, a characteristic odor, no complaints duringdefecation. Mobility: intolerance activity. Medical History: At the time of the assessment date of March 1, 2012 client complained of shortness of breath, coughing up phlegm, and chest pain. 4 months ago a client complained productive cough. The family took the initiative to bring him for treatment to a doctor. 3 days before entering hospital, client was complaining of shortness of breath, coughing and chest pain increasingly felt on the left (Region), tingling pain (qualitative), feeling pain when breathing (Time), pain scale: 3 (Serverity). Then the family brought him to Dr.

Soedono Hospital on February 23, 2012 and treated in the Wijaya Kusuma C Dr. Soedono hospital for intensive care. Past medical history: About 3 months ago, Client had 2 times treated in the RSUP Dr. Soedono with the same complaint. Client said that he never had hereditary diseases such as hypertension, diabetes mellitus, asthma. Never suffered from infectious diseases such as hepatitis. Family History: Client's family said that their family did not have diseases such as those experienced by the client now. Client's family also never had a hereditary disease such as hypertension, diabetes mellitus, asthma. Never suffered from infectious diseases such as hepatitis. Diagnosed: Lung Cancer