NURSING CARE PLAN

Patient’s Name: __________________________________________ Hospital Number: ______________Age : __________ _______________________________ Room Number: ________________Impression/ Diagnosis: ____________________________________ Physician: ____________________Nurse’s Name & Signature: ________________________________

CLINICAL PORTRAIT PERTINENT DATA

I. ASSESSMENT:

A case of patient A.O.G., 59 years old, male, Filipino, Roman Catholic, born on 12/01/53 in Liloan, Cebu. During the first patient-nurse interaction, the patient is seen lying on bed, awake, conscious, afebrile and with ongoing IVF # 1 PNSS at left arm regulated 30 gtts/min infusing well with the following vital signs:

T- 36 CP- 64 bpmR- 22 cpmBP- 100/60 mmHg

II. SIGNIFICANT FINDINGS:

The patient has Diabetes Mellitus Type 2 and experiencing Cholecystitis with Choledocholithiasis and for surgery tomorrow. Patient stayed in S11 Ward 5C in Chong Hua Hospital for 5 days.

III. VITAL SIGNST- 36.1 CP- 74 bpmR- 20 cpmBP- 110/70

I. HISTORY OF PRESENT ILLNESS:

One day prior to admission patient had sudden onset sharp midepigastric abdominal pain occasionally radiating diffusely, constant in duration, not alleviated by changes in position with highest painscore of 10/10. Persistence of pain prompted consult and hence admission. No fever, no chills, no dysuria, no hematuria, no melena

II. CHIEF COMPLAINTS

Epigastric Pain

III. HEALTH HISTORY RELEVANT TO PRESENT ILLNESS:

IV. VITAL SIGNS TAKEN DURING ADMISSIONT- 36 CP- 64 bpmR- 22 cpmBP- 100/60

PARAMETERS RESULTS NORMAL VALUES UNIT

MCH H 31.6 Neutrophil H 82.7

Lymphocyte % L 10.3 0.19- 0.48 % Lymphocyte # L 0.81 0.19- 0.48 # SGPT- ALT H 96 Alkaline Phospahte

H 241 Total Bilirubin H 5.1

Direct BilirubinH

4.8

UTZ Report

Impression:

Thick layer of bile sludge with progression of cholecystitis. Mid to distal choledocholithiasis within the prominent and edematous CBD.