Nursing

MEDICAL WARD

CASE STUDY YEAR 2.2

TAN TOCK SENG HOSPITAL

WARD 9D

Nur Suliah Binte Nordin

JR1104B

TTSH Group 2

Patient Profile

Mr Steve J.K, 88 year old, Chinese, Male

Drug Allergy: NKDA

Date of Admission: 4th February 2013

Walking Aid: Wheelchair, Walking Frame

Diet: Ensure Plus 150 mls + H20 20 mls

Precaution: Fall Precaution

Level of Assistance: A2

Diagnosis:

Right Frontal Contusion, Personality Disorder, AMS

Past Medical History

NIL

Nursing Care Plan

|Nursing Diagnosis |Goal |Intervention |Evaluation |

| | |Action |Rationale | |

|Risk of violence to self or others related|Patient will not endanger|Assist patient to identify |Knowledge of the |The patient has not |

|to mental illness |themselves and others at |precipitating factors to |precipitating factor |demonstrated any progress |

| |the ward within two |dysfunctional mood |helps patient and |due to his severe |

|As evidence by; |weeks. | |nurse to develop |confusion and altered |

| | | |strategies to prevent |mental status, Hence, goal|

|Subjective Data: | | |mood changes. |not met. |

|Patient complain of doctors cannot be | | | | |

|trusted, nurses are all mistreating him | | | | |...