Care Plan For Pneumonia 116rd

BIOGRAPHICAL INFORMATION Name

: Mr. Nagesh

Age

: 36 years

Sex

: Male

Address

: leela villa, gorur, hassan

Religion

: Hindu

Marital status: Married Education

: 8th standard

Occupation

: business

Income

: 5000/ month

Date of ission & time: 13-10-2010; 4.00 PM Diagnosis

: Pneumonia

CHIEF COMPLAINTS Mr. Nagesh was itted with the complaints of fever, chills, persistent cough and chest pain PRESENT ILLNESS Symptom

: Fever, chills, persistent cough and chest pain

Onset

: chronic onset

Duration

: Three month

Aggravating factors: No specific aggravating factors. Alleviating factors hospital.

: Decreases after taking medications prescribed from the Govt.

Associated phenomenon: Anxiety

PAST HEALTH HISTORY Past illness

: he has been itted twice in hospital with same complaint

Childhood illness

: Nothing significant

Surgeries

: Nothing significant

Immunization

: Completed primary immunizations

Medications

: Last three month he takes medications from Govt. hospital.

PERSONAL HISTORY Habits

: Smoking, alcoholic and tobacco chewing

Diet

: Mixed diet with 2 meals per day

Social interaction: Good relationship with neighbors and relatives.

FAMILY HISTORY There are 6 in his family including his wife, three sons and, one daughter and himself. All the other family are healthy. There is no heredity or communicable diseases in his family. KEY Patient Male Female

SOCIO-ECONOMIC HISTORY Mr. Nagesh is the bread winner of the family. He is having an income of Rs. 5000/month. He is a businessman in living in his own house. Mr. Nagesh having good relationship with family, relatives and friends

ENVIRONMENTAL HISTORY Mr. Nagesh is living in a pacca type of house with three rooms. House is electrified and proper water facility. House is having open drainage system and separate lavatoy facility NUTRITIONAL HISTORY He was taking mixed diet with 2 meals per day. He doesn’t have allergy with food items. He is taking white rice and vegetable salad very much.

ELIMINATION HISTORY His bowel and bladder functions were normal.

PHYSICAL EXAMINATION GENERAL OBSERVATION Constitution

: Normal

Stature

: Normal

Posture

: Kyphosis

Personal appearance: hygienic. Emotional status

: Depressed

Co-operativeness

: Co-operative

VITAL SIGNS VITAL SIGNS Temperature Pulse Respiration Blood pressure

PATIENT’S VALUE 98.6 degree Fahrenheit 78/minute 18/minute 110/70 mm Hg

NORMAL VALUE 98.6 degree Fahrenheit 60-80/ minute 18-25/ minute 120/80mmHg

HEIGHT & WEIGHT Height: 162cm Weight: 60kg SKIN Color: Brown Edema: no edema Moisture/turgor: Dry and Poor skin turgor HEAD Normal cephalic, no lesions, normal distribution, normal range of motion possible. EYES Expressions : Anxious Eyelids

: Normal

Eye balls

: Normal. Globes clear

Conjunctiva : Pale and clear Sclera

:White and clear

Iris

:Black

Visual acuity : Normal PERRLA

: Pupils equally round and reactive to light and acccomodation

Eye movements: Normal EARS Normal size and shape. No discharges and infections. Appearance : Auricles are normal and symmetrical Hearing

: normal

NOSE No DNS and running nose. Rhyles’ tube present in the right naris. Appearance : No nasal flaring. Sense of smell: Normal

MOUTH AND THROAT No glossitis, no stomatitis Lips

: Symmetric, moist and no lesions

Tongue: Moist, pink, no coatings Teeth : Dental caries and discoloration absent Gum : No gingivitis Buccal mucosa: No lesions Palate

: Intact, symmetrical, pink

Sense of taste : Normal NECK Appearance : No deformity, tenderness, swelling. Trachea

: No deviation, and tenderness

Lymph nodes : Not palpable Thyroid gland

: Symmetric. Not enlarged

No distended neck veins. CHEST AND RESPIRATORY SYSTEM INSPECTION Symmetry

: Symmetrical

Expansion

: Normal

Equality of movement: Normal Type of respiration: Normal Rate

: 26/ minute

Rhythm

: Regular

PALPATION Vocal tactile fremitus: Normal No local swelling. PERCUSSION

Resonance: normal AUSCULTASTION Bronchial

: Normal

Bronchovescular: Normal Vescular

: Normal

Friction rub : Nothing significant CARDIOVASCULAR SYSTEM INSPECTION Chest countour: Normal Neck

: No jugular vein distention

PERCUSSION Normal AUSCULTATION S1 and S2 normal Apical heart rate is 78/ minute. ABDOMEN INSPECTION Skin rashes, scar and hernia are absent Movement: No movement AUSCULTATION No bowel sounds PERCUSSION AND PALPATION Absence of gas and fluids BACK Spinal curvature: No deformity Symmetry

: Symmetrical

Movement

: Normal ROM

GENETALIA AND GROIN Noting significant Haemorrhoids present UPPER AND LOWER EXTREMITIES Normal ROM possible NERVOUS SYSTEM Higher functions Speech

: Normal : Fluent and clear

Sensory and motor functions: Normal Reflexes: Normal

INVESTIGATIONS INVESTIGATIONS Hb WBC Lymphocytes Eosinophils S.Urea ESR

PATIENT’S VALUE 12 gm% 16000/cumm 60% 46% 34 mg/dl 30 cm2/hr

NORMAL VALUE 14-18 gm% 4000-11000/cumm. 20-40% 1-6% 10-50mg/dl < 20 cm2 /hr

MEDICATIONS DRUG

DOSAG E 500 mg

ROUTE

FREQUENCY

ACTION

SIDE-EFFECTS

Orally

BD

Diarrhea, epigastric pain, palpitation and tachypnoea

400 mg

oral

BD

Inj. Rosella 500 mg ampicillin

IV

QID

Tab. Pantoprazo l

Oral

Tid

Relaxation of smooth muscles of the bronchial wall Inhibits prostoglandi n synthesis by decreasing enzyme needed for bio synthate analgase Infers with cell wall respiration of microorganis m the cell wall rended osmality unstable swell blank pneumonia pressure Gastro eosophago reflux disease severe oesophagitis zoolinger Ellison syndrome

Tab. Deriphiline

Tab. brufen

40 mg

Tachy cardia Palpitation Preganancy Blurred vision

Rash Utricaria Anemia Bleeding Depression Nausea Vomitting Lethargy

Head ache Insomnia Diarrhea Abdominal pain Flatulence Hypersensitivity Hyperglycemia

NURSING DIAGNOSIS 1. Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by rapid respiration, dyspnea and tachycardia 2. Ineffective airway clearance related to pain, fatigue and thick secretions as manifested by ineffective cough or thick abnormal breath sound 3. Impaired nutritional status less than body requirement related to anorexia,

nausea and vomiting as manifested by weakness 4. Activity intolerance related to fatigue treatment regimen and weakness as manifested by fatigue dizziness as exalin 5. Risk for health maintenance deficit related to lack of knowledge regarding

treatment regimen after discharge

ASSESSMENT

Subjective data: Patient says that I can’t breathe properly

NURSING DIAGNOSIS

Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by Objective data: rapid Patient is respiration having dyspnea and breathlessness tachypnea

OBJECTIVES

INTERVENTION

RATIONALE

IMPLEMETION

Patient maintains normal respiratory rate and express feeling of comfort

1.Assess the pattern of breathing to provide guidance for intervention 2.Take vital signs and auscultate lungs to provide ongoing patients response to therapy 3.ister oxygen as inhealed to maintain optimal oxygen level and to increase patient comfort 4.provide semifowlers position for breathing to maximize lung expansion

To determine Assessed effectiveness pattern breathing of therapy

the of

To reduce fever To replace fluid loss and maintain adequate blood volume To treat the causative agent To evaluate patient’s response to treatment To reduce fever and provide comfort

Checked vital signs and auscultate lungs

istered oxygen to patient

Provided semi fowlers position for patient

EVALUATION Patient expressed some feeling of comfort

ASSESS MENT

NURSING DIAGNOSIS

OBJECTIVE S

INTERVENTI ON

RATIONAL E

subjective data: patient says that he can’t breathe properly

Ineffective airway clearance related to pain, fatigue and thick secretions as manifested by cough or thick abnormal breath sounds

Patient will have breath sounds effective cough with exploration of sputum

1.Assist the patient to cough by splinting chest, and teach patient how to cough effectively to clear airway by bringing secretion to the mouth 2.ister expectorant to increase bronchial fluid product and promote expectoration and cough 3.Maintain fluid intake of 3L daily to liquefy secretions

To evaluate Assisted cardiac patient to response cough by Patient maintained splinting chest clear breath sounds This may indicate impaired ability of the heart to respond appropriately to increase istered activity expectorant to increase To ensure bronchial fluid that patients production basic needs are met

objective data: patient is having thick secretions in the airway and can’t cough properly

IMPLEMENT ATION

To reduce Maintain fluid cardiac work intake of 3L load daily Patient can an active participant on that

EVALUATION

ASSESSME NT

NURSING DIAGNOS IS

OBJECTI VES

INTERVENTION

RATIONALE

IMPLEMENT ATION

Subjective data: patient verbalizes that he is not having appetite and feeling so weak Objective data: patient is looking so weak

Impaired nutritional status less than body requireme nt related to anorexia, nausea and vomiting as manifeste d by weakness

Patient maintains normal nutritional status and maintain normal weight

1.Assess the food Preferred foods Assessed food preferences will be available preferences of the patient 2.weigh patient To provide Checked the daily and use same accurate weight of the scales and at the evaluation of patient daily same time of the weight day 3.provide caloric To meet body Advised the intake as ordered requirement patient to take high protein 4.advice to take To prevent and high high protein high negative nitrogen caloric diet caloric small balance and frequent feeding excessive weight loss

EVALUAT ION Patient maintained normal nutritional status than before

ASSESSME NT

NURSING DIAGNOS IS Subjective Activity data: intolerance patient says related to that I am fatigue feeling tired treatment and weak regimen Objective and data: weakness Verbal as response of manifested weakness by fatigue and dizziness as exalin

OBJECTIV ES

INTERVENTI ON

Patient experiences increased tolerance for activity

1.Assess response to activity to evaluate patients hypoxemia and plan changes accordingly 2.Provide bed rest and limit physical activity to evaluate patients hypoxemia 3.Assist with the activities as needed to ensure that patients basic needs are met 4.Place needed items within easy reach to conserve energy while facilitating indepenadance

RATIONA LE

IMPLEMENTATI ON

EVALUATIO N

Assessed response to activity Patient experienced increased tolerance for activity than before Provide bed rest to patient

Assisted with the activities of the patient

Placed needed items within easy reach of patient

ASSESSME NT

NURSING DIAGNOS IS Risk for health maintenan ce related to lack of knowledge regarding treatment regimen after discharge

OBJECTIV ES

INTERVENTI ON

RATIONA LE

IMPLEMENTATI ON

EVALUATI ON

Patient gains enough knowledge regarding treatment regimen

1.Assess the ability to continue self care at home

To identify Assessed the Patient got patients ability to continue knowledge knowledge self care at home regarding about self treatment care and regimen ability to follow up manage self and activity care schedule

2.Encourage patient to continue on full course of antibiotic therapy

To prevent relapse of pneumonia and developme nt

Encouraged the patient to continue full course of antibiotic therapy

3.Encourage To assist patient to healing obtain process adequate rest, nutrition and fresh air

Encouraged the patient to obtain adequate rest and nutrition

HEALTH EDUCATION  Explain dietary modifications, including avoidance of high fat containing diet

like mutton, beef, pork and fried food items and advice to include vegetables and fruits. Small frequent meals are better tolerated than large meals.  Avoid cigarettes smoking. Avoid alcohol ingestion.  To take all medications as prescribed. This includes both anti-inflammatory

and antibiotic drugs. Failure to take these medications as prescribed can result in relapse.  Advised about the follow up measures and to take medications at correct

time.  Explain the relationship between symptoms and stress. Stress-reducing activities or relaxation strategies are encouraged.  Explain about the importance of rest and sleep and to take at least 6-8bhrs. Adequate rest and sleep keep the mind and body fresh  Advised the patient to do exercises like walking, flexion, extension, adduction

and abduction of extremities. Exercise is an important aspect of health  Explain the importance of nutrition and told him to take high protein containing diet and to include diet containing vegetables and fruits  Advised the patient to do exercises like walking, flexion, extension, abduction and adduction of extremities  Explained to the patient regarding follow up measures and its importance. I told him to take prescribed medication properly and correct time

PROGRESS NOTE

DAY-1 Patient had severe pain on the surgical wound. Drainage bag and Foley’ catheter present. Drain is red in color. Amount is normal. Patient is on NPO. Bowel movement is not established. Complaint of sleep disturbance in night also. Vital signs are normal. IV fluids are istered according to Doctors’ order. DAY-2 Pain slightly reduced. Still patient is on NPO. 5 pint IV fluids are istered. Foley’ catheter removed and patient urine. Vital signs are normal. DAY-3 Patient got moderate sleep during night. Antibiotics and other IV fluids are continued. Pain reduced and patient is comfortable. Vital signs are normal. DAY-4 30 ml plain water given. Patient can tolerate. Then fluid diet started. He has slight throat disturbances due to Rhyles’ tube. Vital signs are normal. Bowel function is not normal. DAY-5 Patient slept well during night. Vital signs are normal. Rhyles’ tube removed. Soft diet started. Antibiotics are continued. CONCLUSION Mr. Nagesh was itted to government hospital with the complaints of fever, chills, persistent cough and diagnosed as pneumonia. Now his condition is improving. After taking Mr. Nagesh as my patient for case study. I came to know about pneumonia and its treatment. REFERENCES  Lewis Sharon Mantik et al. “Medical Surgical Nursing- Assessment and

management of clinical problems”; 4th edition; Mosby publication, Newdelhi.  Brunner and Suddarth’s “Textbook of Medical-surgical Nursing”; 10th edition; Vol.1; Lippincot Williams and Willkins publishers, Newdelhi.  Black. M. Joyce “Medical-surgical Nursing-clinical management for positive outcomes”; 6th edition; Vol.2; Elsaevier publication, Newdelhi.  Rekha Sharma, Diet management, 2nd edition, Churchill living stone