Make an NCP from the given scenario
Aubrey, 19 years old, an incoming college freshman student went to Ateneo De Manila Health Services for physical examination. The nurse gathered the following information: Height: 5 ft Weight: 48 kg Vital signs: Temp 37.2C, Pulse rate: 95 beats per minute, Respiration rate: 12 breaths per minute, and BP: 100/70mmHg. Family History of illness: Father (+) Hypertension (HPN), and Diabetes Mellitus (DM) Present Health History: Aubrey never experienced to get hospitalized as far as she can remember. Her mother ensures that she takes daily supplemental vitamins such as vitamin C and B complex, and every year she gets flu vaccine from their family doctor. During the interview with the nurse, Aubrey mentioned that she has no known allergies. She said “I don’t think I have any problems with my health. I am lacto-ovo vegetarian. Most of the time I hang out with my friends for a tea or coffee. Although I think everything’s okay, I still would like to be active, and do activities that won’t take up so much of my time, but help me lose few pounds to 45 kg. I just live across this university, although I walk to church every Thursday, Friday, and Sunday for 15 minutes, I think it’s not enough. Last month, during the enhanced community quarantine, I gained 2 kg.” CBC and X-ray results were reviewed by the doctor, and noted with normal findings.
WHAT TO DO:
1. Make a list po 5 identified problems then prioritze
2. Make an NCP of the 1st priority problem. (Follow the 7-column format below)
Patient’s Name Age Sex Room/Bed #
Medical Diagnosis Date Shift
Prepared by Supervisor/CI
Cues
|
Nursing Diagnosis
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Analysis
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Plan of Care
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Intervention
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Rationale
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Evaluation
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