Scribd
Upload
121 views4 pages

Contoh NCP

This document contains an assessment of a 55-year-old female patient named L.P. She has a history of COPD, hypertension, IBS, celiac disease, depression and other conditions. Her key assessment findings include severe muscle weakness, limited mobility, impaired hearing, mood changes and a knowledge deficit regarding nutrition. Her admitting diagnosis is a left hip fracture and her current diagnosis is a hip dynamic screw. Priority nursing diagnoses identified are imbalanced nutrition related to decreased oral intake and hopelessness related to long-term stress. The evaluation section notes improvements in her mood, weight gain, and increased oral intake and physical appearance over time.

Uploaded by

salsa bila
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
121 views4 pages

Contoh NCP

This document contains an assessment of a 55-year-old female patient named L.P. She has a history of COPD, hypertension, IBS, celiac disease, depression and other conditions. Her key assessment findings include severe muscle weakness, limited mobility, impaired hearing, mood changes and a knowledge deficit regarding nutrition. Her admitting diagnosis is a left hip fracture and her current diagnosis is a hip dynamic screw. Priority nursing diagnoses identified are imbalanced nutrition related to decreased oral intake and hopelessness related to long-term stress. The evaluation section notes improvements in her mood, weight gain, and increased oral intake and physical appearance over time.

Uploaded by

salsa bila
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

1.

Assessment

General Information.

Patient Initials: L.P

Gender: Female

Age: 55

Allergies

Food: Shellfish, Seafood, Gluten

Medications: Levofloxacin, Anafranil, ASA-aspirin(Stomach ulcer).

IYM Status: 1PA

Diet: High Protein, High Calorie, Minced Diet, Ensure +235ml Daily Calorie Counts

Health History & Current Medical Diagnosis.

 COPD
 HTN
 IBS **
 Depression
 Deaf-Left ear (Cochlear implant)
 Celiac **
 Right Hip Replacement
 Small bowel obstruction
 Aspiration Pneumonia
 Malnutrition

Key Assessment Findings.

Subjective Data

• “I have alway been skinny but I have lost a lot of weight in the past few years”
• “There’s no point anyway...it won’t change anything.”

Objective Data.

• Severe muscle weakness (lower extremities only)


• Limited mobility (most likely a result of muscle weakness)
• Impaired hearing
• Vital Signs constantly stable
• Severe pain (only during transfers)
• Mood changes
• Knowledge deficit regarding necessary nutrients
• Eats only about ¼ of meals

Lab Values.

• Low RBC count **


• Low potassium leels
• Low sodium levels

2. Diagnosing

Admitting Diagnosis.

Left Hip Fracture

Current Diagnosis.

Hip Dynamic Screw

Priority Nursing Diagnosis.

 Imbalanced nutrition related to decreased oral intake as evidenced by physical appearance.


 Hopelessness related to long-term stress, as evidenced by negative statements of current
situation.

3. Planning & Implementating

Planning (for diagnosis #1).

Imbalanced nutrition related to decreased oral intake as evidenced by physical appearance.

Implementation (for diagnosis #1).


Planning (for diagnosis #2.

Hopelessness related to long-term stress, as evidenced by negative statements of current situation.

Implementation (for diagnosis #2).

4. Evaluation.

• Nursing Actions.

Occasionally ask L.P about feelings.

Patient Response and Finding.

She states that she is feeling energetic and is willing to attend group activity.

• Nursing Actions.

Weigh L.P

Patient Response and Finding.

L.P gains over 2 pounds in a month


• Nursing Actions.

Observe L.P’s daily oral intake.

Patient Response and Finding.

She consumes up to ½ of meals and finishes high protein and high caloric food items.

• Nursing Actions.

Observe L.P’s physical appearance.

Patient Response and Finding.

Patient appears to have more subcutaneous fat

You might also like