history collection and physical examination (kardex & nurses notes)

KARDEX

Date Medications Dose Time Date Nursing care plan Time

Date Treatment Dose Time

ReligionAge Sex Bath T.P.R B.P Diet

Name of the patient Bed no

Diagnosis Doctor name IPNO

PATIENT PROFILE

Name of the patient: Mr. V.Nookaraju

Age: 59years

Sex: Male

Marital status: Married

Religion: Hindu

Education: Degree (B.COM)

Occupation: Employee, Dept. ESR

Spoken language: Telugu, English

Income: 45,000/month

Address: V. Nookaraju, sector-6, 302, steel plant

I.p.no: 1305

Bed no: 18

Ward: I C U

Date of admission: 10/4/13.

HEALTH ASSESSMENT

Name of the patient: Mr. V.Nookaraju

Age: 59years

Sex: Male


Religion: Hindu


Occupation: Employee, Dept. ESR


Address: V. Nookaraju, sector-6, 302, steel plant


Medical diagnosis: Chronic Obstructive Pulmonary Disease

Physician: Dr. Venkata Challam, M.B.BS (Medical physician)

Date and duration of nursing care: 5 days of nursing care plan

Date of discharge: 14-4-13.

HISTORY COLLECTION

Chief complaints:

My patient Mr. V. Nookaraju, age 59years, admitted in ICU ward in Visakha steel general hospital complains of breathlessness, severe cough weakness, chest tightness from last 2days onwards

History Present illness:

My patient Mr. V. Nookaraju, age 59years, admitted in ICU ward in Visakha steel general hospital complains of breathlessness, severe cough weakness, and chest tightness from last 2days onwards and it was diagnosed as chronic obstructive pulmonary disease.

Past medical history:

My patient not having any previous Injuries/ accidents and any communicable diseases. My patient is hypertensive. He is taking medication last 4 years on wards.

Present surgical history:

There is no significant or evident present surgical history.

Past surgical history:

Previous hospitalization – 2006 appendectomy; and there is no other surgical histories.

Family history:

Any hereditary:

There is a history of diabetes and hypertension and there is no hereditary of congenital abnormalities.

Family tree:

Family profile:

sl.no name of the family member

age sex R/ship occupation income

1 V.Nokkaraju 59 M husband employee 45,000/m2 V. Pydithalli 50 F wife house wife -3 V.Ravi 45 M son employee 1500

0/m4 V.Rajlakshmi 30 F daughter in

lawhouse wife -

5 V. Prasad 24 M son employee 10,000/m6 V. Ratnam 20 F daughter in

law house wife -

Personal history:

Diet:

Patient diet includes vegetarian and non-vegetarian 3 times / day. Non –vegetarian is the favorite food habit.

Rest and sleep: Disturbed sleep pattern.

Nutrition: mixed diet

Elimination:

Pattern of Elimination: Before illness present

BOWEL ELIMINATION

Frequency – normally passing the stools

Character of stool Problems encountered such as constipation, diarrhoea, etc.

Every other day Yellowish brown, solid Constipation.

URINARY ELIMINATION

Frequency- 4-6 times

Quantity- 900ml

Character of urine Problems encountered such as pain, burning. Yellow to reddish in colour.

Nutritional history:

Time Diet Amount Calorie Protein CHO Fat8am10am

12pm

4pm8pm

teaidly with chutneyrice and dhaltearice and dhal

200ml3 nos

200gm100gm200ml200gm100gm

110.kcal372k.cal

690k.cal372k.cal110 k.cal690k.cal372k.cal

3.06.9

6.920.83.06.920.8

4.058.9

74.558.94.074.558.9

3.80.2

5.20.23.85.20.2

Socio – economic history:

Housing: building house

Ventilation: well ventilated

Electricity: present

Water supply: municipality

My Patient is a hardworking person that’s why he was able to give what his family needs. In their community hazard, patient was living in visakha steel plant quarters.

Environmental history:

My patient is unaware of problems he may encounter as a cook. He also does overtime work. In their home and community hazard, patient said that their stairs in house have several flights. He was always having difficulty in going up and down stairs. He said that he have to move slowly for him to be safe.

PHYSICAL EXAMINATION

Vital signs:

vital signs patient value normal value remarkstemperaturepulserespirationblood pressure

98.60 f82b/m24b/m150/100mmhg

98.60f72b/m16-20b/m120-90mmhg

normalabnormalabnormalabnormal

General examination:

Conscious: conscious

Orientation: oriented to time, place and date

Nourishment: moderate nourished

Health: un healthy

Body build: moderate

Activity: dull

Look: anxious

Hygiene: moderate hygiene

Speech: clear

REVIEW OF SYSTEM

Skin / integumentary system:

Colour: black/ dark colour

Texture: dry skin texture is smooth

Skin turgor: bad skin present

Hydration: well hydrations and Cold to touch

Discoloration: lower extremities discolouration of skin oedematous; redness and breaking down of skin.

Head:

Distribution: The hair is distributed well

Color: The color of the hair is brown and some white hair, Dry hair

Head, dandruff: No head lice, dandruff or any infection

Size: Round head

Scalp: Scalp is smooth, No nodules or masses

Eyes:

Vision: normal vision, no visual disturbances

Glasses: not evident

Discharge: no discharges

Pain: no history of pain

Itching: no history of pain

Proportion the size Eyebrows are black in color and symmetrical Conjunctiva is pale in color – due to decrease in RBC, Hgb

and Hct. count Sclera are white in color and cornea are shiny No abnormal involuntary movements Can able to move in all direction

Ears:

Hearing: Poor hearing, Proportion to the size of the head

Pain: No pain, No presence of discharge

Itching: No itching

Ringing: no ringing sensation

Vertigo: no history of vertigo

Nails:

Nail beds: pale in colour

Nail plates: flat; absence of clubbing

Cyanosis: no central and peripheral cyanosis

Colour: black

Texture: dry

Nose& sinuses:

Deviated nasal septum: no deviation septum found

Discharge: no history of nasal discharge

Allergies: no history of allergies

Frequent cold: no history of any colds

Obstruction: no evident of obstruction


Epistaxis: no history of Epistaxis

No tenderness, masses and displacement of the bone Maxillary and Frontal sinus is normal and not inflamed

Mouth and throat:

Tongue: The tongue is negative in lesions and tenderness

Lesions: Absent of any swelling, lesions and ulcerations

Lips: Lips are pale in color Bleeding: no history of bleeding

Tooth decay: no history of tooth decay

Dental caries: No teeth in upper and lower incisors the pt. used dentures

Neck:

Stiffness: no history of stiffness

Limited motions: normal range of motion

Swelling: no history of swelling

Pain: no history pain

Thyroid disease: history of thyroid disease ( type –II DM)

Symmetrical and freely movable without difficulty presence of jugular vein distension

Thorax: Crackles present Tachypnea- inadequate blood supply/decrease blood flow resulting to

decrease oxygen, the lungs need to compensate Cheynestokes breathing

CARDIO- VASCULAR SYSTEM:

Heart: murmur – abnormal heart sound present Tachycardia – 105bpm

History of hypertension: hypertensive

Varicose veins: no history of varicose veins

Dyspnoea: dyspnoea present

Chest pain: evident

palpitation: present

Heart sounds: present s1 &s2 sounds

Pulse: tachycardia

Heart beat: normal rate, rhythm

Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected.

Palpations: on palpations masses are detected

Percussion: no percussion done

Auscultations: on auscultation at 5 areas, pulmonic, aortic, erbs point, mitral and apical area, s1 & s2sounds are heard, no abnormal gallop sounds.

Respiratory system:

Lesions: absence of lesion

Scars: absence of scars

Dysnea: present

Cough: present

Sputum: thick secretions are present




Auscultations: on auscultation at wheezing sounds & murmurs sounds are heard.

Gastro-intestinal system:

Auscultation: bowel sounds present; peristalsis movement are present.

Inspection: no scars; lesions; hernia are not evident

Palpations: no tenderness/ hardness.

Percussion: abnormal sounds are present.

Genitor-urinary system:




Infections: no infections

Voiding: passing urine 6 to 7 times a day

Colour of urine: dark yellowish colour.

Muscular skeletal system:

Postural curve: kyposis, lordosis are absent

Muscle tone: no depth

Muscle strength: weakness than normal

Upper extremities:

Symmetry: symmetrical

ROM: normal range of motion

Reflexes: present

Joints: oedematous & swelling and tenderness is present

Lower extremities:

Symmetry: symmetric


Gait: abnormal

Varicose veins: present

INVESTIGATIONS

Date Specimen/ Type of Result Normal Significance

investigation values27-3-13 hematological

Hgb 162.0120-160 g/L abnormal

Total Red Cell 4.5-5.0 x 10-12 g/L

Total WBC 10.2 5-10 x 10-19 g/L

abnormal

Segmenters 0.80 0.40-0.600. normal

Lymphocytes 0.12 20-0.400. abnormal

Monocytes 02-0.080. Eosinophiles 0.80 01-0.03 abnormal

Basophiles 0-0.0127-3-13 blood chemistry

Glucose 98.0

mg/dL75-115 mg/dL

normal

FBS 5.44 mg/dL

4.2-6.4 mg/dL

normal

Uric acid 8.4 mg/dL

2.4-7.0 mg/dL

abnormal

Creatinine 2.7 mg/dL

0.5-1.7 mg/dL

abnormal

BUN 10.1-50.0 mg/dL

Cholesterol 159.2 mg/dL

suspect >220mg/dL

normal

Triglycerides 80.0 mg/dL

suspect >150mg/dL

normal

chest x-ray normal normal

MEDICATIONS

slink drug action side effects nurses responsibility

1

2

345

6

Inj. Monocef 1gm BD

Inj. Amkacin 500mg BD

Inj.Dopamine,150mg,BDT. Pantop, 400mg, BDoxygen administration 4l/m continuous administration inhalation duodline and sarbutrate BD

antibiotic

antibiotic

analgesic

antacid

nausea,vomiting,anorexia,tachycardia,subsided fluid retention,insomnia, etc

- Assess the general condition of patient

- Observes for the drug side effects

- Immediate nursing intervention are to be done

- Administration of alternative agonist to prevent the side effects.

NURSING DIAGNOSIS:

Based on the assessment data, major nursing diagnoses for the patient may include:

Ineffective airway clearance related to: bronchoconstriction,

increased sputum production, ineffective cough, fatigue / lack of

energy, broncho pulmonary infection.

Ineffective breathing pattern related to: shortness of breath, mucus,

bronchoconstriction, airway irritants.

Impaired gas exchange related to: ventilation perfusion inequality

Activity intolerance related to: imbalance between oxygen supply

with demand.

Imbalanced Nutrition: less than body requirements related to:

anorexia.

Disturbed sleep pattern related to: discomfort, sleeping position.

Bathing / Hygiene Self-care deficit related to: fatigue secondary to

increased respiratory effort and ventilation and oxygenation

insufficiency.

Anxiety related to: threat to self-concept, threat of death, purposes

that are not being met.

Ineffective individual coping related to: lack of

socialization,anxiety,depression,'low activity levels and an inability

to work.

Deficient Knowledge related to: lack of information, do not know

the source of information

Theory application Roy’s adaptation model

Introduction:

Sister callista Roy began her nursing career in 1963. After receiving B.Sc(N)

noting from moult saint marry college.

1960receives Ms in nursing

1977 her doctorate in sociology

Roy’s model is characterised as a system theory with a strong analogies of

intervention.

General system:

Due to set of organized components released to form a whole employee

feedback cycle of input, through put, output.

INPUT: Input includes tensions adaption level (the range of stimuli to which

persons adaptation early)

THROUGH PUT: through put makes use of a person processes and effect

ions. Process refers to control mechanism that a person uses as a adaptive

system. Effectors refers to the physiologic function, self concept and role

function involved in adaptation.

OUTPUT: output is the outcome of the system when system is a person.

Output refers to person’s behaviour.

Metaparadigm and RAM:

Human being:Person is a bio psychological being in constant interaction

with changing environment and recipient the nursing care as living system

Environment: Environment and surrounding and effect the development

and behaviour of the persons group. The internal and external are the part of

the person’s environment.

For ex: elderly person admitted to hospital all the conditions of influence on

him/her.

Health: heath is a process whereby individual are striving to achieve their

maximum potential. It can be seen in healthy people, exercises regularly, not

smoking pay attention dietary pattern. It is a process to relieve acute and

chronic illness and terminal stages of diseases & to control the sign and

symptoms, to promote health of the persons by promoting adaptive

responses.

Nurses: the nurses to reduce the ineffective responses as output behaviour

of the person. The nurse promotes the health in all life processes. The nurses

suggested by the model include approaches aimed at maintaining adaptive

responses that support the person’s effort to creativity use his or her coping

mechanism.

INPUT THROUGH PUT OUT PUT

feed backNURSES NOTES

Name of the patient: V. Nooka raju Ward: ICU

Age: 59years Diagnosis: COPD

Demoraghpical variables of the patient

name age, sex, education, occupation income

- Early detection and screening programs

-monitor the vital signs

-Administer continuous oxygen & medication

- health education about disease condition

-The client will have knowledge regarding disease process

Adequate knowledge in disease process

Rehabilitation & follow up

Sex: male Dr. Name: Dr. Venkata challam

I.p no: 1305 Bed. no: 18

Time Diet Medication Nurses Care Plan

730

830

800

1030

1045

1055

930

1100

1130

1145

1215

Idly with

chutney

water 50ml

coconut

water

100ml

rice porage

1 cup

10/4/1

3

Inj. Monocef 1gm BD


Inj.Dopamine,150mg,BD T. Pantop, 400mg, BD oxygen administration

4l/m continuous administration

inhalation duodline and sarbutrate BD

observation:

Patient is very thin & less activity

and weakness; cough; fever;

breathlessness.

Monitored vital signs

Temp:98.60 F

Pluse:82b/min

Resp:24b/min

Blood pressure:150/100mmhg

SpO2: 93%

Provide position changing

frequently

Provide complete bed rest

Provide calm environment

Administer medication as per

physician prescribed

Administered O2

Provide nebulisation

History collection and

performed physical examination

Provide psychological support

Provided health education about

Diet

Exercises

Personal hygiene

Relaxation therapy.

lakshmi/St.N

KARDEX






PATIENT PROFILE

Name of the patient: Mr. G. Sannibabu

Age: 54years

Sex: male


Religion: Hindu

Education: Degree

Occupation: Foremen

Spoken language: Telugu


Address: G. Sannibabu; Yunaparthi; pervade; vsp.

I.p.no: 6829

Bed no: 4

Ward: I C U


HEALTH ASSESSMENT

Name of the patient: Mr. G. Sannibabu

Age: 54years

Sex: male


Religion: Hindu

Education: Degree

Occupation: Foremen

Spoken language: Telugu

Address: G. Sannibabu; Yunaparthi; pervade; vsp.


Medical diagnosis: Ischemic cardio myopathy

Physician: Dr.Naveen


Date of discharge: 14/4/13.

HISTORY COLLECTION

Chief complaints:

My patient Mr. G. Sannibabu, age 54years, admitted in ICU ward in VIsakha steel general hospital complains of fever, weakness, swelling; pain; Oedema of both legs and feet; Ischemic Cardiomyopathy

Present medical history:

My patient Mr. G. Sannibabu, age 54years, admitted in ICU ward in Visakha steel general hospital complains of fever, weakness, swelling; pain; Oedema of both legs and feet; at present diagnosed with Ischemic Cardiomyopathy


My patient not having any previous Injuries/ accidents and any communicable diseases. My patient is hypertensive and type –II diabetes mellitus. He is taking medication last 4 years on wards.


There is no significant or evident present surgical history.

Past surgical history:

Previous hospitalization – 2006 appendectomy; and there is no other surgical histories.

Family history:

Any hereditary:


Family tree:

Family profile:

sl.no name of the family member

age sex R/ship occupation income

1 G.Sannibabu 54 M husband farmer 10,000/m2 G. Pydithalli 50 F wife farmer -3 G. Ravi 35 M son farmer -4 G. Rajlakshmi 30 F daughter in

lawhouse wife -

5 G. prasad 24 M son cooli 4,000/m6 G. Ramesh 20 M son - -

Personal history:

Diet:

Patient diet includes vegetarian and non-vegetarian 3 times / day. Non –vegetarian is the favorite food habit.

Rest and sleep: Disturbed sleep pattern.

Nutrition: mixed diet

Elimination:

Pattern of Elimination: Before illness present

BOWEL ELIMINATION

Frequency – frequently passing

Character of stool Problems encountered such as constipation, diarrhea, etc.

Every other day Yellowish brown, solid Constipation.

URINARY ELIMINATION

Frequency- 4-6 times

Quantity- 900ml

Character of urine Problems encountered such as pain, burning. Yellow to reddish in color.


Time Diet Amount Calorie Protein CHO Fat8am10am

12pm

4pm8pm

teaidly with chutneyrice and dhaltearice and dhal

200ml3 nos

200gm100gm200ml200gm100gm

110.kcal372k.cal

690k.cal372k.cal110 k.cal690k.cal372k.cal

3.06.9

6.920.83.06.920.8

4.058.9

74.558.94.074.558.9

3.80.2

5.20.23.85.20.2

Socio – economic history:

Housing: building house

Ventilation: well ventilated


Water supply: municipality

My Patient is a hardworking person that’s why he was able to give what his family needs. In their community hazard, patient was living near the main road, air and noise pollution affects them but the patient interpreted that their place is safe.

Environmental history:

My patient is unaware of problems he may encounter as a cook. Healso does overtime work. In their home and community hazard, patient said that their stairs in house have several flights. He was always having difficulty in

goingup and down stairs. He said that he have to move slowly for him to be safe.

PHYSICAL EXAMINATION

Vital signs:

vital signs patient value normal value remarkstemperaturepulserespirationblood pressure

98.60 f82b/m24b/m150/100mmhg

98.60f72b/m16-20b/m120-90mmhg

normalabnormalabnormalabnormal

General examination:

Conscious: conscious

Orientation: oriented to time, place and date


Health: un healthy


Activity: dull

Look: anxious

Hygiene: moderate hygiene

Speech: clear

REVIEW OF SYSTEM

Skin / integumentary system:

Colour: black/ dark colour

Texture: dry skin texture is smooth

Skin turgor: bad skin present

Hydration: well hydrations and Cold to touch

Discoloration: lower extremities discolouration of skin oedematous; redness and breaking down of skin.

Head:

Distribution: The hair is distributed well

Color: The color of the hair is brown and some white hair, Dry hair

Head, dandruff: No head lice, dandruff or any infection

Size: Round head

Scalp: Scalp is smooth, No nodules or masses

Eyes:

Vision: normal vision, no visual disturbances

Glasses: not evident



Itching: no history of pain

Proportion the size Eyebrows are black in color and symmetrical Conjunctiva is pale in color – due to decrease in RBC, Hgb

and Hct. count Sclera are white in color and cornea are shiny No abnormal involuntary movements Can able to move in all direction

Ears:

Hearing: Poor hearing, Proportion to the size of the head

Pain: No pain, No presence of discharge

Itching: No itching

Ringing: no ringing sensation

Vertigo: no history of vertigo

Nails:


Nail plates: flat; absence of clubbing


Colour: black

Texture: dry

Nose& sinuses:

Deviated nasal septum: no deviation septum found

Discharge: no history of nasal discharge

Allergies: no history of allergies

Frequent cold: no history of any colds

Obstruction: no evident of obstruction


Epistaxis: no history of Epistaxis

No tenderness, masses and displacement of the bone Maxillary and Frontal sinus is normal and not inflamed

Mouth and throat:

Tongue: The tongue is negative in lesions and tenderness

Lesions: Absent of any swelling, lesions and ulcerations

Lips: Lips are pale in color Bleeding: no history of bleeding

Tooth decay: no history of tooth decay

Dental caries: No teeth in upper and lower incisors the pt. used dentures

Neck:

Stiffness: no history of stiffness

Limited motions: normal range of motion

Swelling: no history of swelling

Pain: no history pain

Thyroid disease: history of thyroid disease ( type –II DM)

Symmetrical and freely movable without difficulty presence of jugular vein distension

Thorax: Crackles present Tachypnea- inadequate blood supply/decrease blood flow resulting to

decrease oxygen, the lungs need to compensate Cheynestokes breathing

CARDIO- VASCULAR SYSTEM:

Heart: murmur – abnormal heart sound present Tachycardia – 105bpm

History of hypertension: hypertensive

Varicose veins: no history of varicose veins

Dyspnoea: dyspnoea present

Orthopnea: not evident

Chest pain: evident

palpitation: present

Claudication: not evident

Heart sounds: present s1 &s2 sounds

Pulse: tachycardia

Heart beat: normal rate, rhythm




Auscultations: on auscultation at 5 areas, pulmonic, aortic, erbs point, mitral and apical area, s1 & s2sounds are heard, no abnormal gallop sounds.

Gastro-intestinal system:

Auscultation: bowel sounds present; peristalsis movement are present.

Inspection: no scars; lesions; hernia are not evident

Palpations: no tenderness/ hardness.

Percussion: abnormal sounds are present.

Genitor-urinary system:




Infections: no infections

Voiding: passing urine 6 to 7 times a day

Colour of urine: dark yellowish colour.

Muscular skeletal system:

Postural curve: kyposis, lordosis are absent

Muscle tone: no depth

Muscle strength: weakness than normal

Upper extremities:

Symmetry: symmetrical


Reflexes: present

Joints: oedematous & swelling and tenderness is present

Lower extremities:

Symmetry: symmetric


Gait: abnormal

Varicose veins: present

INVESTIGATIONS

Date Specimen/ Type of Result Normal Significance

investigation values10-7-12 hematological

Hgb 162.0120-160 g/L abnormal

Total Red Cell 4.5-5.0 x 10-12 g/L

Total WBC 10.2 5-10 x 10-19 g/L

abnormal

Hct Clottingtime Bleedingtime

0.49 0.38-0.502-5 min1-3 min

normal

Segmenters 0.80 0.40-0.600. normal

Lymphocytes 0.12 20-0.400. abnormal

Monocytes 02-0.080. Eosinophiles 0.80 01-0.03 abnormal

Basophiles 0-0.0110-7-12 blood chemistry

Glucose 98.0

mg/dL75-115 mg/dL

normal

FBS 5.44 mg/dL

4.2-6.4 mg/dL

normal

Uric acid 8.4 mg/dL

2.4-7.0 mg/dL

abnormal

Creatinine 2.7 mg/dL

0.5-1.7 mg/dL

abnormal

BUN 10.1-50.0 mg/dL

SGOT 55.7 u/L

up to 37 u/L 37C

abnormal

SGPT 52.7 u/L

up to 42 u/L 37C

abnormal

Cholesterol 159.2 mg/dL

suspect >220mg/dL

normal

Triglycerides 80.0 mg/dL

suspect >150mg/dL

normal

HDL-P 35.2 mg/dL

> 35 mg/dL

normal

LDL 168.0 mg/dL

< 150 mg/dL

abnormal

MEDICATIONS

slink drug action side effects nurses responsibility

1

2

345

Inj. Monocef 1gm BD


Inj.Dopamine,150mg,BDT. Floxen, 150mg, TIDT. Pantop, 400mg, BD

antibiotic

antibiotic

analgesicanalgesicantacid

nausea,vomiting,anorexia,tachycardia,subsided fluid retention,insomnia, etc

- Assess the general condition of patient

- Observes for the drug side effects

- Immediate nursing intervention are to be done

- Administration of alternative agonist to prevent the side effects.

NURSING DIAGNOSIS:

Based on the assessment data, major nursing diagnoses for the patient may include:

Decreased cardiac output related to structural disorders caused by

cardiomyopathy or to dysrhythmia from the dis-ease process and medical

treatments

Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion

related to decreased peripheral blood flow (resulting from decreased cardiac

output)

Impaired gas exchange related to pulmonary congestion caused by

myocardial failure (decreased cardiac output)

Activity intolerance related to decreased cardiac output or excessive fluid

volume, or both

Anxiety related to the change in health status and in role functioning

Powerlessness related to disease process Noncompliance with medication

and diet therapies

NURSES NOTES

Name of the patient: Mr. G. Sannibabu Ward: ICU

Age: 54years Diagnosis: Ischemic cardiomyopathy

Sex: male Dr. Name: Dr. Naveen

I.p no: 6829 Bed. no: 5


730

830

800

1030

1045

1055

930

1100

1130

1145

1215

Idly with

chutney

water 50ml

coconut

water

100ml

rice porage

1 cup

10/4/

13

Inj. Monocef 1gm BD


Inj.Dopamine,150mg,BDT. Floxen, 150mg, TIDT. Pantop, 400mg, BD

observation:



breathlessness.


Temp:98.60 F

Pluse:82b/min

Resp:24b/min


SpO2: 93%


frequently





Administered O2


History collection and performed

physical examination



Diet

Exercises

Personal hygiene

Relaxation therapy.

lakshmi/St.N

KARDEX






PATIENT PROFILE

Name of the patient: Mr. Abhayanathi Manjhi

Age: 63years

Sex: Male


Religion: Hindu


Occupation: General Manger



Address: flat no:9, sri nagar

I.p.no: 1305

Bed no: 5

Ward: I C U

Date of admission: 15/04/13 at 4:30pm

Doctor name: Dr. Naveen.

HEALTH ASSESSMENT

Name of the patient: Mr. Abhayanathi Manjhi

Age: 63years

Sex: Male


Religion: Hindu


Occupation: General Manger


Address: flat no:9, sri nagar

Date of admission: 15/04/13 at 4:30pm

Medical diagnosis: coronary heart disease

Physician: Dr. Naveen.


Date of discharge: 20-4-13.

HISTORY COLLECTION

Chief complains:

My patient Mr. Abhayanthi Manjhi,62years,male admitted in Visakha Steel Plant General Hospital complains breathlessness, constipation, vomiting, appetite, oedema last 4 days.

Present medical history:

He admitted in ICU due to breathlessness, vomiting, appetite, oedema last 4 days on wards with complain of coronary heart disease as diagnosed by physician


He was admitted in hospital due to breathlessness, oedema in lower extremities, fever and cough, diabetes mellitus, hypertension.


Not significant of any surgical history


He was undergone for PTCA with DES (severe acute NSTEMI with LV dysfunction) operated in the Apollo hospital in Visakhapatnam last 6 months

Family history:

Any hereditary:


Family tree:

Family profile:

Sl no name of the family members

age sex relation ship

occupation remark

1

2

3

4

5

Abhayanathi Manjhi

Devjani Devi

Pankaj kumar

Punam Devi

DruKumar Manjhi

62y

55y

32y

28y

6y

M

F

M

F

M

husband

Wife

Son

Daughter in law

Son

General manager10th class

B.Tech

B. ScComputers4th class

CAD, DM, HTN

- -

-

-


Sl no

Time Diet Amount Caloric Protein Carbohydrate Fat

1.2.

3.

4.5.

8am9am

12:30pm

4:00pm8:30pm

milkidly -2with chutneyrotti-2rice with currytearice with curry

150ml2nos

150 grms200 grms

150ml

150 grms

110k.cal372k.cal

690k.cal

15.0k.cal

372k.cal

3.06.9

6.9

3.0

20.8

4.058.9

74.5

4.0

58.9

3.80.2

5.2

3.8

0.2

Personal history:

Diet: patient diet includes vegetarian and non vegetarian. He takes food in per day 3 times & non veg-2 times/week. Non veg is the his favourite food for him.

Rest & sleep: disturbed sleep pattern

Elimination: abnormal bowel & bladder (bowel – constipation & urination is frequently & small amount of urine is passing)

Socio economic history: socio-economic status monthly income is 95000/-

Environmental history:-

Housing: building and quarters

Ventilation: adequate ventilation


Water supply: Visakha steel plant water supply

Physical examination:

vitals signs patient value normal value remarks

TemperaturePulseRespirationBlood pressureSpo2

98.60F86b/min22b/min

100/70mmhg93%

98.60F72b/min

16-18b/min120/80mmhg

100%

normalabnormalabnormalabnormalnormal

General appearance:

Consciousness: conscious

Orientation: oriented time, place, and date


Health: un healthy


Activity: dull

Look: anxious

Hygiene: moderately hygiene

Speech: clear

REVIEW OF SYSTEMS

Skin /integumentary system:

Colour: black

Texture: wrinkles skin/dry skin

Skin turgor: present

Hydration: well hydrated

Discolouration: no discolouration of skin

Subjective symptoms: dry skin is present

Nails:


Nail plates: flat, absence of clubbing


Colour: black

Texture: dry

Eyes:

eye brows: symmetric

Eyelashes: equally distributed

Papillary reflex: normal

Conjunctiva: normal

Vision: normal vision

Ears:

Pinna: normally placed

Cerumen: no defect

Otarrhea: no discharges from ear

Hearing: no defect in hearing process

Nose:

Nasal septum: no deviation of nasal septum

Nasal pathway: clear nasal pathway

Smell: no defect

Mouth & pharynx:

Lips: absence of cracks and pale in colour

Tongue: coated tongue

Bleeding : no history of bleeding

Tooth decay: history of tooth decay

Dental care: no history of dental caries

Neck:

ROM: possible

Lymph nodes: not palpable

Trachea: present in midline

Thyroid gland: not enlarged

Jugular vein: not distended.

SYSTEMIC EXAMINATION

Respiratory system:

History of smoking: smoking habit is evident but at present he is stopped

Sputum: sputum with thick expectoration

Asthma: no h/o asthma

Wheezing: present

Haemoptysis: no H/o of haemoptysis

Cough: present

Shortness of breath: present

Inspection: on inspection the thoracic cavity is normal, no deviations, no lesions are found

Palpation: no palpable masses detected on palpation

Percussion: on percussion wheezing sounds and adventious breath sounds are evident

Auscultation: on auscultation rounchi, wheezing sounds are evident. Abnormal bronchial vesicular sounds are evident.

Cardiovascular system:

H/O hypertension: hypertensive

Varicose veins: no H/o varicose veins

Dysponea: present

Orthopnea: not evident

Chest pain: evident

Palpitation: present

Heart sounds: present S1 S2 sounds

Pluse: 86 b/min

Heart beat: abnormal rate and rhythm

Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected, sutured mark presented

Palpation: no palpable masses detected

Percussion: no percussion performed

Auscultation: on auscultation at 5 areas , pulmonic, aortic, erbs point, mitral, apical area. S1 S2 sounds are clear and gallop& murmurs sounds present

INVESTIGATIONS

Slink Name of the investigation

Pt value Normal value Remarks

1.2.3.

Hb%TWBCDC P L E

14gms9900cells/cumm85%13%

14-16gms1,500000cells/cumm4,5000c/cumm

abnormalabnormalabnormal

4.5.6.7. 8.9. 10.

platelet countbil.ureasr. creatineurine for ketone bodiesRBSFBSECG

0.2%1.7 laks/cumm100mg/dl1.3mg%-ve570Mg104mg Extreme

tachycardia lt.ant. hemi

block invented T

wave ST-T

abnormality excessive

overload of lt. atrium, lt. ventricular hypertrophy

10-40mg/dl0.5-1.4mg/dlnormal

normal

abnormalnormalnormal

abnormal

MEDICATIONS

Slink Medications Dose Route Time Nursing responsibility

1. Inj. Mixtand 18IU subcutaneous BD assess the patient

2.

3.

4.

5.

Inj. PNZ

T. Ivas

T.Flavidon MR.

oxygen inhalation

40mg

750mg

20mg

IV

oral

oral

OD

BD

BD

general condition of

client

observe the client for

side effects

immediate nursing

intervention are to be

done

administration of

alternatives agonist to

prevent the side effects

administer continuous

oxygen inhalation

NURSING DIAGNOSIS:

Decreased cardiac output related to alteration in preload/after load/

contractility/ heart rate.

Impaired gas exchanges related to ventilation/perfusion mis match or intra

pulmonary shunting

In effective airway clearance related to retained secretions and excess

secretions

Risk of haemorrhage related to inadequate haemostasis, disruption of suture

lines or coagulation

Acute pain related to tissue trauma secondary to sternotomy and leg incision

Risk of post cardiotomy delirium or stroke

Activity intolerance related to fatigue secondary to cardiac insufficiency

and pulmonary congestion as evidenced by dyspnoea, shortness of breath,

weakness

Anxiety related to dyspnoea as evidenced by restlessness, irritability

Deficient knowledge related to disease process as evidenced by questions

about the disease and patients statement.

Theory application Roy’s adaptation model

Introduction:

Sister callista Roy began her nursing career in 1963. After receiving B.Sc(N)

noting from moult saint marry college.

1960receives Ms in nursing

1977 her doctorate in sociology

Roy’s model is characterised as a system theory with a strong analogies of

intervention.

General system:

Due to set of organized components released to form a whole employee

feedback cycle of input, through put, output.

INPUT: Input includes tensions adaption level (the range of stimuli to which

persons adaptation early)

THROUGH PUT: through put makes use of a person processes and effect

ions. Process refers to control mechanism that a person uses as a adaptive

system. Effectors refers to the physiologic function, self concept and role

function involved in adaptation.

OUTPUT: output is the outcome of the system when system is a person.

Output refers to person’s behaviour.

Metaparadigm and RAM:

Human being:Person is a bio psychological being in constant interaction

with changing environment and recipient the nursing care as living system

Environment: Environment and surrounding and effect the development

and behaviour of the persons group. The internal and external are the part of

the person’s environment.

For ex: elderly person admitted to hospital all the conditions of influence on

him/her.

Health: heath is a process whereby individual are striving to achieve their

maximum potential. It can be seen in healthy people, exercises regularly, not

smoking pay attention dietary pattern. It is a process to relieve acute and

chronic illness and terminal stages of diseases & to control the sign and

symptoms, to promote health of the persons by promoting adaptive

responses.

Nurses: the nurses to reduce the ineffective responses as output behaviour

of the person. The nurse promotes the health in all life processes. The nurses

suggested by the model include approaches aimed at maintaining adaptive

responses that support the person’s effort to creativity use his or her coping

mechanism.

INPUT THROUGH PUT OUT PUT

Feed back

NURSES NOTES

Name of the patient: Abhayanathimanjhi Ward: ICU

Age: 62years Diagnosis: coronary heart disease

Sex: male Dr. Name: Dr. Naveen

Demoraghpical variables of the patient

name age, sex, education, occupation income

- Early detection and screening programs

-monitor the vital signs

-Administer continuous oxygen & medication

- health education about disease condition

-The client will have knowledge regarding disease process

Adequate knowledge in disease process

Rehabilitation & follow up

E.p no: 12016303 Bed. no: 5


730

830

800

1030

1045

1055

930

1100

1130

1145

1215

Idly with

chutney

water 50ml

coconut

water

100ml

rice porage

1 cup

17/4/

13

Inj. Mixtard 18 IU

subcutaneous BD

Inj. PNZ 40mg IV OD

T.Ivas 10mg oral BD

T. Flavidon M.R20mg

Oral OD

o2 inhalation

observation:



breathlessness.


Temp:98.60 F

Pluse:86b/min

Resp:22b/min


SpO2: 93%


frequently





Administered O2


History collection and performed

physical examination



Diet

Exercises

Personal hygiene

Relaxation therapy.

lakshmi/St.N

history collection and physical examination (kardex & nurses notes)

Documents

family history

patient diet

nutritional history

history of diabetes

past surgical history

past medical history

socio economic history

degree b