NURSING CARE PLAN

Patient: Hospital no.:

Age: Room no.:
Impression: Physician:
Diagnosis: Nurse’s signature:

Clinical Portrait Pertinent Data

During my first contact with the patient, he was seen lying A case of Mr. Benito Sotto, 55 yrs. old recently residing at
on bed, awake conscious, and afebrile with an IVF of PNSS 1L Consolacion, Cebu. Patient has no history of hypertension, and is
at 30 gtts/min infusing well. Surgical dressing present at the non-asthmatic. Patient is occasional drinker and smoker. His chief
right knee area. He was cooperative and attentive during nursing complaint is severe pain in his right knee and therefore admitted at
care activities made to him. VCMC.
Twenty days prior to admission, patient noted onset of bullae at
Vital signs taken: left foot dorsum about the size of one peso coin. A days prior to
BP = 130/90 mmhg admission, spontaneously ruptured, applied Betadine one a day
RR = 25 cpm with no relief. Wound spread to proximal tibia.
PR = 96 bpm One day prior to admission, admitted at VCMC for managed
Temp = 35.9 C accordingly.

Physical Assessment: LABORATORY RESULTS:

Lower Extremities: HEMATOLOGY – November 15, 2006
Both legs were both amputated. WBC 25.8
RBC 3.99
Raw Nursing Diagnosis: HGB 11.7
Acute Pain Hematocrit 29.1
Impaired Physical Mobility Platelet 612.0
Activity Intolerance Neutrophil 26.0
Impaired Skin Integrity Lymphocyte 1.87
Risk for Infection Monocyte 0.562
Risk for Injury Eosinophil 0.046
Risk for Delayed Surgery Recovery Basophil 0.081
Body Image Disturbance
Self Care Deficit URINALYSIS – November 12, 2006
Altered Role Performance Color: Amber
pH: 6.0
Appearance: Cloudy
Specific Gravity: 1.020
Protein: +1
Glucose: +2