SENIOR HIGH SCHOOL

UNIVERSITY OF BOHOL
City of Tagbilaran 6300, Bohol, Philippines

UNIVERSITY SENIOR HIGH SCHOOL: A vibrant University High School nurturing lives for a great future. Fulfilling pre-university experiences. SY 2020-2021

HEALTH CARE PLAN (HCP)

Name: M.K Age: 42 years old Status: Married

Address: Tagbilaran City

Impression: Stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns of his anterior neck. Patient is in respiratory distress.

WEEK 3 ASSESSMENT PLANNING INTERVENTIONS

PROBLEM RATIONALE OF BEHAVIOURAL DESIRED HEALTH RATIONALE EVALUATION
(Sample) CUES/DIAGNOSIS THE PROBLEM OUTCOME OUTCOME/S INTERVENTIONS
After 2 days the
CASE: Ineffective Inhalation injury is an After 3 hours the After 2 days the patient Independent a. Suggestive of patient did not
April 12- airway clearance due exposure to patient would be would be able to: a. Assess inhalation injury. met the desired
16 to full thickness burn asphyxiants is the able to: gag/swallow b. Tachypnea, use of goal, evidenced
(on the anterior neck most common cause a. Demonstrate reflexes; note accessory muscles, by:
and chest) and CO2 of early mortality a. Improved clear breath drooling, inability presence of cyanosis,
inhalation due to from inhalation gas sounds, to swallow, and changes in sputum a. Stridor was
exposure of injury. Carbon exchange respiratory rate hoarseness, suggest developing still heard
asphyxiants evidenced dioxide is a common b. The client within normal wheeze cough respiratory distress/ bilateral
compromised asphyxiant, which is will improve range and free b. Monitor pulmonary edema and during
breathing. when organic fluid of respiratory rate, need for medical auscultation,
substances burn. With balance dyspnea/cyanos rhythm, depth and intervention tachypnic
Subjective Data: inhalation of CO2, (circulation is. note presence of c. Although often related b. The patient
the oxygen molecules related to b. The client will pallor/cyanosis and to pain, changes in was still in
- Patient states are displaced, and O2 have an carbonaceous or consciousness may pain and in
that he felt CO2 binds to distribution) acceptable level pink-tinged reflect developing/ respiratory
dizzy and haemoglobin to form . of comfort sputum worsening hypoxia distress
very weak. carboxyhemoglobin. c. Client will c. Investigate d. Anterior neck burn
Tissue hypoxia verbalize a changes in should executive After 2 hours the
Objective Data: occurs from an level of behaviour/mentati extension therapeutic patient partially
V/S: overall decrease in acceptable on, restlessness, position without pillow met the
BP= 90/50 mmHg the blood’s oxygen pain control agitation, and small towel roll behavioural
Hypovolemic, patient delivering capability. (Oxygen confusion and beneath shoulders to goals, evidence
experiences shock related to anxiety. promote neck by:
Pulmonary response pain). d. Anticontracture extension. Burn in the
HR= 112 bpm includes a localized d. The client positioning for the trunk should execute a. Patient
RR= Ambu bag inflammatory will client with the straight postural improved
Temp= 36.4 degree reaction, a decrease in verbalize a burn injury. alignment. gas
celcius bronchial ciliary level of e. Fluid shifts or excess exchange
Weight= 75 kg action, and a decrease acceptable Dependent fluid replacement with the help
Height= 5’6” in alveolar surfactant. anxiety increase fluid demnads of ambu bag
O2 Sat = 87% room After several hours, control a. Monitor 24 hour as much as 35% or for oxygen
O2 sloughing of the (Anxiety fluid balance, more because of support
tracheobronchial related to noting obligatory edema b. Patient
Assessment: epithelium may oxygen) variations/changes. f. Baseline is essential for improved
occur, and b. Monitor/graph further assessment of fluid balance
 Airway hemorrhagic serial ABGs or respiratory status and evidence of
compromised tracheobronchitis pulse oximetry as a guide to treatment. increasing
 Breathing: may develop. Adult g. Maximizes circulating output and
stridor were acute respiratory volume and tissue improved
heard bilateral distress syndrome perfusion consistency
upon may follow. h. Generally, fluid c. Patient was
auscultation replacement should be still in pain
 Circulation: titrated to ensure answering
thread pulses average output of 30- the question
in all four 50 mL/hr. by raising
extremities i. 02 corrects/acidosis. his eyebrows
 Rules of 9: Humidity decreases
27% of body drying of the
was burned respiratory tract and
 Stage 3 burn reduces viscosity of
wounds on his sputum.
anterior and j. Changes reflecting
posterior torso atelectasis/ pulmonary
and entire arm edema may not occur
with stage 2 for 2-3 days after burn
burns on his k. Intubation/mechanical
anterior neck. support is required
when airway edema or
Initial Lab tests: circumferential burn
injury interferes with
 Low, may respiratory function/
oxygenation
 indicate
anemia
 Platelets: 149
slightly low
 Na: 133
(mEq/L)
slightly low,
causes
weakness

SENIOR HIGH SCHOOL

UNIVERSITY OF BOHOL
City of Tagbilaran 6300, Bohol, Philippines

UNIVERSITY SENIOR HIGH SCHOOL: A vibrant University High School nurturing lives for a great future. Fulfilling pre-university experiences. SY 2020-2021

HEALTH CARE PLAN (HCP)

Name: Baby X Age: 3 years old Status: Child

Address: Loay, Bohol

Impression:

WEEK 4 ASSESSMENT PLANNING INTERVENTIONS

PROBLEM RATIONALE BEHAVIOUR DESIRED HEALTH RATIONALE EVALUATION
CUES/DIAGNOSIS OF THE AL OUTCOME/S INTERVENTIO
PROBLEM OUTCOME NS
 CASE 1: Altered electrolyte
April 19-23 imbalance related to active
fluid loss secondary to
vomiting.

Subjective data:
 Patient was
experiencing severe
muscle weakness,
abdominal pain with
severe vomiting.
 Pain scale: 7 (0-10
rate)

Objective data:
 BP:
 Temperature: 38.5
degrees Celsius
 Pulse rate:
 Respiratory rate:
 Poor skin turgor
 Frequent watery
stools (greenish)

History: Baby X is a 3 years

old with a history of G6PD
upon new born screening. He
developed diarrhea and
described by his parents as
loose, somewhat watery
occurring two to three times a
day. The volume of the stool
was not more than normal.
He also had vomiting and
was able to eat and drink
normally.

Allergies: No known drug

 allergies

SENIOR HIGH SCHOOL

UNIVERSITY OF BOHOL
City of Tagbilaran 6300, Bohol, Philippines

UNIVERSITY SENIOR HIGH SCHOOL: A vibrant University High School nurturing lives for a great future. Fulfilling pre-university experiences. SY 2020-2021

HEALTH CARE PLAN (HCP)

Name: Patient A Age: 41 years old Status: Married

Address: Loon, Bohol

Impression: Preeclampsia with deep venous thrombosis.

WEEK 5 ASSESSMENT PLANNING INTERVENTIONS

PROBLEM RATIONALE BEHAVIOUR DESIRED HEALTH RATIONALE EVALUATION
CUES/DIAGNOSIS OF THE AL OUTCOME/S INTERVENTIO
PROBLEM OUTCOME NS

April 26-30 CASE 2: Increased blood

pressure, dizziness and
presence of edema.

Subjective data:
Objective data:
 BP: 110/100 mmhg
 Temperature:
 Pulse rate: 62 bpm
 Respiratory rate: 22
Creatinine: 64mol/L
(reference range: 35-62
mol/l)

History:

A 41 year old woman gravida

6, para 0 at 22 weeks of
gestational weeks because of
progressive edema in the legs
and shortness of breath. The
medical history is
autoimmune hepatitis,
diagnosed at 15 years of age.
The obstetric history is
complicate as her medical
history.

Physical examination saw a

moderately ill woman with
severe edema of the lower
extremities and vulva slightly
elevated central venous
pressure.
 SENIOR HIGH SCHOOL
UNIVERSITY OF BOHOL
City of Tagbilaran 6300, Bohol, Philippines

UNIVERSITY SENIOR HIGH SCHOOL: A vibrant University High School nurturing lives for a great future. Fulfilling pre-university experiences. SY 2020-2021

HEALTH CARE PLAN (HCP)

Name: Patient B Age: 65 years old Status: Married

Address: Baclayon, Bohol

Impression: Diabetes mellitus

WEEK 6 ASSESSMENT PLANNING INTERVENTIONS

PROBLEM RATIONALE BEHAVIOUR DESIRED HEALTH RATIONALE EVALUATION
CUES/DIAGNOSIS OF THE AL OUTCOME/S INTERVENTIO
PROBLEM OUTCOME NS

May 3-7 CASE 3:

Subjective data:

Objective data:
 BP:
 Temperature:
 Pulse rate:
 Respiratory rate:

History: Patient has history

of HTN for 6 months, under
medication of (Amlodipine 5
mg OD). Diabetes under
insulin therapy, feeling of
weakness, difficult to walk
for 3 days. Patient was known
case of hypertension for 6
months, No history of COPD,
No history of any surgical
illness. No history of food
and drugs allergy.