Day 01 Care plan

Date & Assessment Time 2013/8/14 -Today is the 4th 7.30 a.m day of hospitalization. -Mr.Luxman admitted to the ward 15 at 11.50a.m on 10/08/2013. - On admission -Tem 98.4F0 -PR 76min-1 -RR 22min-1 -BP 140/80mmHg Nursing Diagnosis Planning Implementation Evaluation -Risk for To prevent dehydration dehydration related to poor fluid intake. -Giving oral fluid. -Maintain fluid balance chart. -Nutritional deficiency related to poor oral To Prevent intake. Nutritional deficiency.

-Offered fluid.

oral

-The temperature -Maintained fluid went down in balance chart. 1C.

-Assissted to the patient to get his meal.

-Mild fever related -Assisst patient -Opened the to inflammatory to get his meal. window. -Patient looks very reaction. ill and weak. -QH temperature -Anxiety related to To reduce fever chart maintained. -Poor fluid intake. hospitalization. -Applied colon

-Patient facial expressions showed that anxiety reduced.

-Disordered sleeping pattern.

-Risk for infections related -Patient restless to poor personal and aggressive. hygiene. -Both legs swelling. -Personal is not good. are -Risk for constipation related to poor hygiene oral intake.

-Bed bath given -Increased with luke warm -Iv canula is placed interstitial fluid To reduce water. -Reduced the right hand. due to disease Anxiety swallowing. process. -Oral fluids were -The canula site has -Give Nursing given. not signs of care in friendly infection. manner. -Administered drugs according -Patients skin is to the B.H.T oedematous. To reduce risk for infections. -Legs were -Patient has elevated.

-Give good ventilation. -Appling cold compress. -Maintaining QH temperature chart. -Administer drugs according to the B.H.T

mixed compress.

cold

-Administered drugs according to the B.H.T -Reduced the risk for infection -Nursing care and patient is given in friendly comfortable. manner.

generalized swelling.

body

-Today patients bowel open. -Maintain intake and output chart.

-Provide a bed bath to the patient with mouth care. To prevent constipation -Giving oral fluid. -Administer drugs according to the B.H.T To Reduce swelling -Elevate the swallowing legs

Day 02 Care plan

Date & Assessment Nursing Planning Time Diagnosis th 2013/8/15 -Today is the 5 day -Poor personal To reduce a.m 8.00 of hospitalization. hygiene related to infections body weakness. -Patient looks weak. -Provide a bed bath to the patient -Poor fluid intake. with mouth care. -Body weakness -Patient aggressive. due to poor To reduce body nutritional intake. weakness. -Poor personal hygiene. -Promoting to -Risk for bed take food. IV canula in sore. -Giving various placed right hand. taste food. -Risk for -Today patients infection. To reduce the risk bowel open. for bed sores. -Risk for -Maintaining intake dehydration -Change the and out put chart. related to poor position 2 hourly. fluid intake. Implementation Evaluation

-Bed bath given -Patient is with luke warm comfortable. water.

-Assissted to the patient to get his meal.

-Health education given to the relatives.

-Changed the position 2 hourly.

-Back

massage
4

To prevent given. dehydration. -Offered a milk. -Giving oral fluid. -Fluid balance -Maintain fluid chart maintained. balance chart. .

Day 03 Care plan

Date & Assessment Nursing Planning Implementation Evaluation Time Diagnosis th 2013/8/16 -Today is the 6 day -Body weakness -Assist patient to -Offered a milk to 7.30a.m of his related to poor get his meal. the patient. -Reduced hospitalization. nutritional intake. the risk for infection -Patient restless. -Bed bath given and patient -Poor personal -Provide a bed with luke warm is -Swelling of the legs hygiene related to bath to the patient. water. comfortable. are reduced. body weakness. -Personal hygiene is -Changing the not good. -Risk for bed cloth. sore. -Iv canula is in place right hand. -Risk for -Changing the dehydration linen. -Today patients related to poor bowel open. fluid intake. -Change position of the patient. -Maintaining fluid -Loose stool due intake and output. to medication. -Provide oral fluids to the -Changed cloths. the -Reduced the risk for the bed sores.

-Changed linen.

-Changed the position of the patient 2 hourly. -Given a perineal care to the patient.
6

-Urine colour yellow.

is

patient.

-Now patient is coming on normal condition.