Professional Documents
Culture Documents
Laboratory Examination
Discharge Plan
Problem Health Teaching Level
Hygiene:: Have a cane / crutch Promotive/Preventive
Daily Bed bath Risk for fall/further always when walking
Oral Care injury and avoid walking on
a rough/rocky road.
Wound Care See physical Rehabilitative
therapist for
evaluation and
treatment.
Activity:
Walking with crutch as Someone accompany Preventive
tolerated, everyday you on walking
Rest and Sleep regularly Anemia
Eat more green leafy Promotive
Attending mass every vegetables
Sunday Compliance to
regimen Curative
Avoid sleeping late at Preventive
night
Diet:
Foods Rich in Ca + Vit. D.
Instruct relatives to Promotive
Adequate CHO, Chon and fat assist the patient in
intake Self Care
dependence doing ADLs Preventive
Eat lots of vegetable & Allow patient to
Fruits function Curative
independently if
possible
Compliance to
regimen for fast
recovery
Instruction: Return 3-5days
after discharge for ff. check up.
See physician therapist.
Compliance to bring home
medications.
Ex.FeSO4 Capsule 2x a day for 2
weeks
PROBLEM LIST
Patient’s Initial: JB Chief Complaint:
Gunshot wound L leg Room/Ward: Orthopedic Ward
Diagnosis: Fx open type 111a, complete comminuted p/3-M/3 Fibula Age: 16 y/o
Date of Exposure: Aug. 4-5, 2009 Attending Physician: Dr. Flores
Clinical Instructor: Mr. Alberto Mahinay, RN
Area of exposure: CLMMRH
Physiologic
Behavioral
Cues Problems Actual Potential Actual Potential
Subjective:
The patient Risk for
Pain Pain related to Risk for acute Stress overload
verbalizes “ disorganized
Injuring confusion related related to 4 days
nabudlayan ko behavior related
Agent(Physical) to pain episodes agony of pain.
mag giho-giho, to pain
bisan pagpangihi
ko gapabulig pa
Sleeplessness
ko kay tatay
Sleep deprivation Risk for fall r/t Impaired social
tungod limitado Risk for spiritual
r/t physiological fatigue ability interaction r/t
ang pag hulag ko distress r/t
responses of the need to rest.
kay naga sakit complicated
body toward
daun ang parte health condition.
health condition
sang tiil ko nga
Low hemoglobin
naigo sang bala
& hematocrit Risk for activity Ineffective denial
tungod sini
level Ineffective tissue intolerance r/t r/t personal and
nagakawad an Risk for
perfusion r/t to decrease oxygen family value
nako gana mag situational low
decrease carrying capacity system
giho.” self-esteem r/t
hemoglobin of the blood
“indi man ko unrealistic self
concentration in
maka tulog gid expectation.
blood
mayo kag
makapahuway
tungod sang
sitwasyon ko.
Objective:
Limited
range of
motion
Difficulty
turning
Slowed
movement
Postural
instability
Hematocrit
o.39l/l
Hemoglobin 125g