NURSING CARE PLAN

Patients Name: __________________________________________

Age
: __________ _______________________________
Impression/ Diagnosis: ____________________________________
Nurses Name & Signature: ________________________________

Hospital Number: ______________

Room Number: ________________
Physician: ____________________

CLINICAL PORTRAIT
I.

ASSESSMENT:

A case of patient A.O.G., 59 years old, male, Filipino, Roman

Catholic, born on 12/01/53 in Liloan, Cebu. During the first
patient-nurse interaction, the patient is seen lying on bed, awake,
conscious, afebrile and with ongoing IVF # 1 PNSS at left arm
regulated 30 gtts/min infusing well with the following vital signs:
T- 36 C
P- 64 bpm
R- 22 cpm
BP- 100/60 mmHg
II.

SIGNIFICANT FINDINGS:

PERTINENT DATA
I.

HISTORY OF PRESENT ILLNESS:

One day prior to admission patient had sudden onset sharp

midepigastric abdominal pain occasionally radiating diffusely,
constant in duration, not alleviated by changes in position with
highest painscore of 10/10. Persistence of pain prompted consult
and hence admission.
No fever, no chills, no dysuria, no hematuria, no melena
II.

CHIEF COMPLAINTS

Epigastric Pain
III.

HEALTH HISTORY RELEVANT TO PRESENT

ILLNESS:

The patient has Diabetes Mellitus Type 2 and experiencing

Cholecystitis with Choledocholithiasis and for surgery tomorrow.
Patient stayed in S11 Ward 5C in Chong Hua Hospital for 5 days.
III.
VITAL SIGNS
T- 36.1 C
P- 74 bpm
R- 20 cpm
BP- 110/70

IV.
VITAL SIGNS TAKEN DURING ADMISSION
T- 36 C
P- 64 bpm
R- 22 cpm
BP- 100/60

PARAMETERS

RESULTS

MCH
Neutrophil

H
H

31.6
82.7

Lymphocyte %
Lymphocyte #
SGPT- ALT
Alkaline Phospahte

L
L
H

10.3
0.81
96

Total Bilirubin

241
5.1

H
H
H

Direct Bilirubin

NORMAL VALUES

UNIT

0.19- 0.48
0.19- 0.48

%
#

4.8

UTZ Report
Impression:
Thick layer of bile sludge with progression of cholecystitis. Mid to distal
choledocholithiasis within the prominent and edematous CBD.