Sample Care Plan Template Page 3
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51Briefly describe the Medical and Surgical History (Describe the medical diagnoses, surgical procedure(s)
and/or chronic illness that initiate the admission or reason for the continuing condition. Include smoking
history.).
Medical History
Description of each Diagnosis
1) Hypertension
1) Hypertension is described as an elevated
blood pressure reading over 140 systolic and
90 diastolic (McCance & Huether, 2010, p.
1149). The patient is normally hypertensive
when not on the sedation medication and
when the patient is placed on sedation
vacation his BP will spike above 200 systolic
and 100 diastolic.
2) Degenerative disk disease
2) Degenerative disk disease is a common
finding in people over the age of 30 and
results from biochemical/biomechanical
changes to the intervertebral disks (McCance
& Huether, 2010, p. 596). The changes to the
patients disk are visible on CT.
3) GERD
3) GERD is gastroesophageal reflux disease
which is the reflux of chime from the
stomach into the esophagus (McCance &
Huether, 2010, p. 1458). GERD is a common
syndrome for patients with alcoholism.
4) Alcohol Withdrawal Syndrome (AWS)
4) Alcohol Withdrawal Syndrome (AWS) refers
to the serious of life threatening symptoms
(including seizures) that can occur when an
alcoholic dependent person stops drinking
(“Alcohol withdrawal”, 2012). The patient
was admitted for AWS diagnosis.
5) Acute encephalopathy
5) Encephalopathy is a general term that is used
to describe any abnormalities in the brains
function or structure (Wedro, 2012). The
cause of the patient’s encephalopathy is his
alcohol withdrawal syndrome and possibly
liver damage the doctors are looking into the
patient’s ammonia levels.
6) Alcoholic gastritis
6) Alcoholic gastritis is gastritis (inflammation
of the lining of the stomach) caused
exclusively by excessive alcohol
consumption (McCance & Huether, 2010).
The patient has malnutrition from impaired
gastric absorption caused by his excessive
alcohol intake.
7) Hepatitis mild
7) Hepatitis mild is a disease characterized by
inflammation of the liver (McCance &
Huether, 2010). The patient has hepatitis in
addition to transaminitis.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical