KARDEX Date Medications Dose Time Date Nursing care plan Time

Date

Treatment

Dose

Time

Age Religion

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 Marital status: Married Religion: Hindu Education: Degree (B.COM) Occupation: Employee, Dept. ESR Spoken language: Telugu, English Address: V. Nookaraju, sector-6, 302, steel plant Date of admission: 26/3/13. 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 1 2 3 4 5 6 name of the family member V.Nokkaraju V. Pydithalli V.Ravi V.Rajlakshmi V. Prasad V. Ratnam age 59 50 45 30 24 20 sex M F M F M F R/ship husband wife son occupation income

employee 45,000/m house wife employee 15000/m daughter in house wife law son employee 10,000/m daughter in house wife law

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 8am 10am 12pm 4pm 8pm Diet tea idly with chutney rice and dhal tea rice and dhal Amount 200ml 3 nos 200gm 100gm 200ml 200gm 100gm Calorie 110.kcal 372k.cal 690k.cal 372k.cal 110 k.cal 690k.cal 372k.cal Protein 3.0 6.9 6.9 20.8 3.0 6.9 20.8 CHO 4.0 58.9 74.5 58.9 4.0 74.5 58.9 Fat 3.8 0.2 5.2 0.2 3.8 5.2 0.2

Socio economic history: Housing: building house Ventilation: well ventilated Electricity: present Water supply: municipality

My Patient is a hardworking person thats 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

temperature pulse respiration blood pressure

patient value normal value

98.6 f 82b/m 24b/m 150/100mmhg
0

remarks
normal abnormal abnormal abnormal

98.6 f 72b/m 16-20b/m 120-90mmhg

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 Pain: no history of pain 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 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 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:
Lesions: absence of lesion Scars: absence of scars Discharge: no discharges 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 ROM: normal range of motion

Gait: abnormal Varicose veins: present

INVESTIGATIONS

Date

Specimen/ Type of investigation

Result
162.0

Normal values
120-160 g/L 4.5-5.0 x 1012 g/L

Significance
abnormal

27-3-13 hematological Hgb Total Red Cell Total WBC Segmenters Lymphocytes Monocytes Eosinophiles Basophiles 27-3-13 blood chemistry Glucose FBS Uric acid Creatinine BUN Cholesterol Triglycerides chest x-ray

10.2 0.80 0.12 0.80 98.0 mg/dL 5.44 mg/dL 8.4 mg/dL 2.7 mg/dL 159.2 mg/dL 80.0 mg/dL

5-10 x 10-19 g/L 0.40-0.600. 20-0.400. 02-0.080. 01-0.03 0-0.01 75-115 mg/dL 4.2-6.4 mg/dL 2.4-7.0 mg/dL 0.5-1.7 mg/dL 10.1-50.0 mg/dL suspect >220mg/dL suspect >150mg/dL normal

abnormal

normal abnormal

abnormal normal normal abnormal abnormal

normal normal normal

MEDICATIONS

slink
1 2 3 4 5

drug
Inj. Monocef 1gm BD Inj. Amkacin 500mg BD

action
antibiotic antibiotic

side effects

nurses responsibility

Inj.Dopamine,150mg,BD analgesic T. Pantop, 400mg, BD oxygen administration antacid 4l/m continuous administration inhalation duodline and sarbutrate BD

nausea, - Assess the vomiting, general anorexia, condition of tachycardia, patient subsided - Observes for the fluid drug side effects retention, - Immediate insomnia, etc 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,

energy, broncho pulmonary infection.

increased sputum production, ineffective cough, fatigue / lack of

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 Roys 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 Roys 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 persons 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 persons 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 persons effort to creativity use his or her coping mechanism. INPUT THROUGH PUT OUT PUT

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 feed back

-The client will have knowledge regarding disease process Adequate knowledge in disease process Rehabilitation & follow up

NURSES NOTES

Name of the patient: V. Nooka raju Age: 59years Sex: male I.p no: 1305 Time 730 830 800 Diet Idly with chutney 10/4/13 water 50ml Inj. Monocef 1gm BD coconut water 100ml 1030 Medication

Ward: ICU Diagnosis: COPD Dr. Name: Dr. Venkata challam Bed. no: 18 Nurses Care Plan observation: Patient is very thin & less activity and weakness; cough; fever;

Inj. Amkacin 500mg BD

breathlessness. Monitored vital signs

Inj.Dopamine,150mg,BD Temp:98.60 F T. Pantop, 400mg, BD rice porage oxygen administration Pluse:82b/min 4l/m continuous Resp:24b/min 1 cup administration Blood pressure:150/100mmhg inhalation duodline and sarbutrate BD SpO2: 93% Provide frequently position changing

1045 1055

Provide complete bed rest Provide calm environment Administer medication as per physician prescribed

30

Administered O2 Provide nebulisation History

11 11

00 30

collection

and

performed physical examination

1145 1215

Provide psychological support Provided health education about Diet Exercises Personal hygiene Relaxation therapy. lakshmi/St.N

KARDEX Date Medications Dose Time Date Nursing care plan Time

Date

Treatment

Dose

Time

Age Religion

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. G. Sannibabu Age: 54years Sex: male Marital status: Married Religion: Hindu Education: Degree Occupation: Foremen Spoken language: Telugu Income: 40,000/month Address: G. Sannibabu; Yunaparthi; pervade; vsp. I.p.no: 6829 Bed no: 4 Ward: I C U Date of admission: 10/4/13.

HEALTH ASSESSMENT
Name of the patient: Mr. G. Sannibabu Age: 54years Sex: male Marital status: Married Religion: Hindu Education: Degree Occupation: Foremen Spoken language: Telugu Address: G. Sannibabu; Yunaparthi; pervade; vsp. Date of admission: 10/4/13. Medical diagnosis: Ischemic cardio myopathy Physician: Dr.Naveen 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. 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 Past medical history: 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. 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 1 2 3 4 5 6 name of the family member G.Sannibabu G. Pydithalli G. Ravi G. Rajlakshmi G. prasad G. Ramesh age 54 50 35 30 24 20 sex M F M F M M R/ship occupation income 10,000/m 4,000/m -

husband farmer wife farmer son farmer daughter in house wife law son cooli 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. Nutritional history: Time 8am 10am 12pm 4pm 8pm Diet tea idly with chutney rice and dhal tea rice and dhal Amount 200ml 3 nos 200gm 100gm 200ml 200gm 100gm Calorie 110.kcal 372k.cal 690k.cal 372k.cal 110 k.cal 690k.cal 372k.cal Protein 3.0 6.9 6.9 20.8 3.0 6.9 20.8 CHO 4.0 58.9 74.5 58.9 4.0 74.5 58.9 Fat 3.8 0.2 5.2 0.2 3.8 5.2 0.2

Socio economic history: Housing: building house Ventilation: well ventilated Electricity: present Water supply: municipality My Patient is a hardworking person thats 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

temperature pulse respiration blood pressure

patient value normal value

98.6 f 82b/m 24b/m 150/100mmhg
0

remarks
normal abnormal abnormal abnormal

98.6 f 72b/m 16-20b/m 120-90mmhg

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 Pain: no history of pain 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 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.

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:
Lesions: absence of lesion Scars: absence of scars Discharge: no discharges 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 ROM: normal range of motion Gait: abnormal Varicose veins: present

INVESTIGATIONS

Date

Specimen/ Type of investigation

Result
162.0

Normal values
120-160 g/L 4.5-5.0 x 1012 g/L

Significance
abnormal

10-7-12 hematological Hgb Total Red Cell Total WBC

10.2 0.49

5-10 x 10-19 g/L 0.38-0.50 2-5 min 1-3 min 0.40-0.600. 20-0.400. 02-0.080. 01-0.03 0-0.01 75-115 mg/dL 4.2-6.4 mg/dL 2.4-7.0 mg/dL 0.5-1.7 mg/dL 10.1-50.0 mg/dL up to 37 u/L 37C up to 42 u/L 37C suspect >220mg/dL

abnormal

Hct Clottingtime Bleedingtime Segmenters

normal

0.80 0.12 0.80 98.0 mg/dL 5.44 mg/dL 8.4 mg/dL 2.7 mg/dL 55.7 u/L 52.7 u/L 159.2 mg/dL

normal abnormal

Lymphocytes Monocytes Eosinophiles Basophiles 10-7-12 blood chemistry Glucose FBS Uric acid Creatinine BUN SGOT SGPT Cholesterol

abnormal normal normal abnormal abnormal

abnormal abnormal normal

Triglycerides HDL-P LDL

80.0 mg/dL 35.2 mg/dL 168.0 mg/dL

suspect >150mg/dL > 35 mg/dL < 150 mg/dL

normal normal abnormal

MEDICATIONS

slink
1 2 3 4 5

drug
Inj. Monocef 1gm BD Inj. Amkacin 500mg BD

action
antibiotic antibiotic

side effects

nurses responsibility

Inj.Dopamine,150mg,BD analgesic T. Floxen, 150mg, TID analgesic T. Pantop, 400mg, BD antacid

nausea, - Assess the vomiting, general anorexia, condition of tachycardia, patient subsided - Observes for the fluid drug side effects retention, - Immediate insomnia, etc 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 ow (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 uid 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 Sex: male I.p no: 6829 Time 730 830 800 Diet Idly with chutney 10/4/13 Medication Diagnosis: Ischemic cardiomyopathy Dr. Name: Dr. Naveen Bed. no: 5 Nurses Care Plan observation: Patient is very thin & less activity and weakness; cough; fever;

water 50ml Inj. Monocef 1gm BD coconut water Inj. Amkacin 500mg BD

breathlessness. Monitored vital signs Temp:98.60 F Pluse:82b/min Resp:24b/min Blood pressure:150/100mmhg SpO2: 93%

1030

Inj.Dopamine,150mg,BD 100ml T. Floxen, 150mg, TID rice porage T. Pantop, 400mg, BD 1 cup

1045 1055

Provide frequently

position

changing

Provide complete bed rest Provide calm environment Administer medication as per physician prescribed

30

Administered O2 Provide nebulisation History collection and performed physical examination

11 11

00 30

1145 1215

Provide psychological support Provided health education about Diet Exercises Personal hygiene Relaxation therapy. lakshmi/St.N

KARDEX Date Medications Dose Time Date Nursing care plan Time

Date

Treatment

Dose

Time

Age Religion

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. Abhayanathi Manjhi Age: 63years Sex: Male Marital status: Married Religion: Hindu Education: Degree (B.COM) Occupation: General Manger Spoken language: Telugu, English Income: 65,000/month 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 Marital status: Married Religion: Hindu Education: Degree (B.COM) Occupation: General Manger Spoken language: Telugu, English Address: flat no:9, sri nagar Date of admission: 15/04/13 at 4:30pm Medical diagnosis: coronary heart disease Physician: Dr. Naveen. Date and duration of nursing care: 5 days of nursing care plan 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 Past medical history: He was admitted in hospital due to breathlessness, oedema in lower extremities, fever and cough, diabetes mellitus, hypertension. Present surgical history: Not significant of any surgical history Past medical 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: There is a history of diabetes and hypertension and there is no hereditary of congenital abnormalities.

Family tree:

Family profile: Sl no 1 2 3 4 name of the family members Abhayanathi Manjhi Devjani Devi Pankaj kumar Punam Devi age 62y 55y 32y 28y sex M F M F relation ship husband Wife Son occupation General manager 10th class B.Tech Daughter B. Sc in law Computers 4th class Son remark CAD, DM, HTN -

DruKumar Manjhi

6y

Nutritional history: Sl no 1. 2. 3. Time 8am 9am Diet Amount 150ml 2nos Caloric 110k.cal 372k.cal Protein Carbohydrate 3.0 6.9 6.9 3.0 4.0 58.9 74.5 4.0 Fat 3.8 0.2 5.2 3.8

4. 5.

milk idly -2 with chutney 12:30pm rotti-2 rice with curry 4:00pm tea 8:30pm rice with curry Personal history:

150 grms 690k.cal 200 grms 15.0k.cal 150ml 150 grms 372k.cal

20.8

58.9

0.2

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 Electricity: present Water supply: Visakha steel plant water supply

Physical examination: vitals signs Temperature Pulse Respiration Blood pressure Spo2 patient value 98.60F 86b/min 22b/min 100/70mmhg 93% normal value 98.60F 72b/min 16-18b/min 120/80mmhg 100% remarks normal abnormal abnormal abnormal normal

General appearance: Consciousness: conscious Orientation: oriented time, place, and date Nourishment: moderate nourished Health: un healthy Body build: moderate 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 beds: pale in colour Nail plates: flat, absence of clubbing Cyanosis: no central and peripheral cyanosis 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 1. 2. 3. Name of the investigation Hb% TWBC DC Pt value 14gms 9900cells/cumm 85% 13% 0.2% 1.7 laks/cumm 100mg/dl 1.3mg% -ve 570Mg 104mg Extreme tachycardia lt.ant. hemi block invented T wave ST-T abnormality excessive overload of lt. atrium, lt. ventricular hypertrophy Normal value Remarks

P L E

14-16gms abnormal 1,500000cells/cumm abnormal 4,5000c/cumm abnormal

4. 5. 6. 7. 8. 9. 10.

platelet count bil.urea sr. creatine urine for ketone bodies RBS FBS ECG

10-40mg/dl 0.5-1.4mg/dl normal

abnormal normal normal

normal

abnormal

MEDICATIONS Slink 1. 2. 3. 4. 5. Medications Inj. Mixtand Inj. PNZ T. Ivas T.Flavidon MR. oxygen inhalation Dose 18IU 40mg Route Time Nursing responsibility assess the patient

subcutaneous BD IV OD BD BD

general condition of client observe the client for side effects immediate nursing

750mg oral 20mg oral

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 Roys 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 Roys 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 persons 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 persons 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 persons effort to creativity use his or her coping mechanism. INPUT THROUGH PUT OUT PUT

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 Feed back

-The client will have knowledge regarding disease process Adequate knowledge in disease process Rehabilitation & follow up

NURSES NOTES

Name of the patient: Abhayanathimanjhi Ward: ICU Age: 62years Sex: male E.p no: 12016303 Time 730 830 800 Diet Idly with chutney water 50ml Inj. coconut water 100ml 1030 17/4/13 Mixtard 18 Medication Diagnosis: coronary heart disease Dr. Name: Dr. Naveen Bed. no: 5 Nurses Care Plan observation: Patient is very thin & less activity IU and weakness; cough; fever;

subcutaneous BD Inj. PNZ 40mg IV OD T.Ivas 10mg oral BD Flavidon

breathlessness. Monitored vital signs Temp:98.60 F Resp:22b/min Blood pressure:100/70mmhg SpO2: 93% Provide frequently

rice porage T. 1 cup

M.R20mg Pluse:86b/min

Oral OD o2 inhalation

1045 1055

position

changing

Provide complete bed rest Provide calm environment Administer medication as per physician prescribed

30

Administered O2 Provide nebulisation History collection and performed physical examination

11 11

00 30

1145 1215

Provide psychological support Provided health education about Diet Exercises Personal hygiene Relaxation therapy. lakshmi/St.N