Nursing care plan
Student name: مؤمن الهزايمة ID#:0501001210 Instructor: Ahmad tubaishat date: 11/3/2007
Patient name: محمد غازي ابو خاطر Age: 41 years Gender: male Hospital: Prince Basma hospital Ward: Medical Male. Room No.: 3 Bed No.: 2 Admission date: 1/3/2007 Medical diagnosis: renal failure (RF) Data of Surgical: @@@@@
Diet: high-calorie, low-protein, low- sodium, and low-potassium. Physical Limitations: no Physical Limitations Allergies: no allergies. Safety precaution: no Safety precaution I.V Therapy: GS 045% Religion: Islam communication: no communication
1. health perception/ Health Management patterns:
Perception of Quality: the health is very important to any person & it the most important in the person life.
Perceived control & management of health: If I ill or sense pain I will go to the doctor and I will take my drug in it time.
2. Current Health Status ( chief complaint & History of present Illness) -Past History: the patent complains of Hypertension from 5yaers& he was noncompliance to medication. -Chief complains on admission:
The patient said" I have sever headache , edema in lower limb, difficulty of breathing, coughing, decreased urine output, loss of appetite , nausea, & vomiting last 3days" -Present illness: the patent complains headache, pitting edema in the (feet, tibia, and sacrum), & hypertension (BP=160/110mmHg), anorexia, nausea, vomiting (3 times), & fatigue. The pain increased with activates & decreased with medication and semi-setting. Pain radiated to lower abdomen & both side. Pt reports the pain 7 degree at vas scale. -Vital signs:
BP = 160/110 mmHg. (Hypertension) Temperature = 37C. Pulse =80 \mint. Respirations = 22\mint.
dead male dead female 33 years pt 41 years
alive male alive female
Review of Body System:
- No any significant with general appearance .
Skin, hair, and nails:
Lesions, dryness and brawn color.
Headache, seizure and dizziness.
-No any significant with eyes.
-No any significant with ears.
Nose and sinuses:
-No any significant with Nose and sinuses.
Mouth, pharynx and neck:
Oral infection. & No any significant with pharynx and neck. Thorax and lung:
- the pain in the Thorax region , asthma ,cough.& sputum (color yellow , frequency in morning , quantity smell amount.)
-No any significant with Heart.
Edema and cramps.
Nausea, vomiting, abdomen pain and diarrhea.
Infection & oliguria.
-No any significant with Endocrine.
Type of blood A- & No any significant with Hematopietic.
Spin & extremities:
No any significant with Spin & extremities.
Physical Examination of the affected system:
By inspect the abdomen: color of the skin brawn, no scars, no hernia & inflammation. Contours for shape asymmetry. By auscultation: Bowel sound 35/mint.& no friction rubs.
By percussion both side asymmetry & enlargement of kidney
By palpation tenderness in both side (more in RUQ), enlargement of kidney .
Special diagnostic procedure:
|Test |Normal value |Result |interpretation | |WBCs |3000-10000ml |7000 ml |normal | |Hb |11-16g\dl |6.2 g\dl |normal...
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