care plan for pneumonia

7/31/2019 care plan for pneumonia

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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 admission & time: 13-10-2010; 4.00 PM

Diagnosis : Pneumonia

CHIEF COMPLAINTS

Mr. Nagesh was admitted 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 : Decreases after taking medications prescribed from the Govt.

hospital.

Associated phenomenon: Anxiety

PAST HEALTH HISTORY

Past illness : he has been admitted twice in hospital with same complaint

Childhood illness : Nothing significant


2/16

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 members in his family including his wife, three sons and, one daughter

and himself. All the other family members are healthy. There is no heredity orcommunicable 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


3/16

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 doesnt 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 PATIENTS VALUE NORMAL VALUE

Temperature 98.6 degree Fahrenheit 98.6 degree Fahrenheit

Pulse 78/minute 60-80/ minute

Respiration 18/minute 18-25/ minute

Blood pressure 110/70 mm Hg 120/80mmHg


4/16

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


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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


6/16

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


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GENETALIA AND GROIN

Noting significant

Haemorrhoids present

UPPER AND LOWER EXTREMITIES

Normal ROM possible

NERVOUS SYSTEM

Higher functions : Normal

Speech : Fluent and clear

Sensory and motor functions: Normal

Reflexes: Normal

INVESTIGATIONS

INVESTIGATIONS PATIENTS VALUE NORMAL VALUE

Hb

WBC

Lymphocytes

Eosinophils

S.Urea

ESR

12 gm%

16000/cumm

60%

46%

34 mg/dl

30 cm2/hr

14-18 gm%

4000-11000/cumm.

20-40%

1-6%

10-50mg/dl

< 20 cm2 /hr


8/16

MEDICATIONS

DRUG DOSAG

E

ROUTE FREQUENCY ACTION SIDE-EFFECTS

Tab.

Deriphiline

500 mg Orally BD Relaxation of

smooth

muscles of

the bronchial

wall

Diarrhea, epigastric pain,

palpitation and tachypnoea

Tab.

brufen

400 mg oral BD Inhibits

prostoglandi

n synthesis

by decreasing

enzyme

needed for

bio synthate

analgase

Tachy cardia

Palpitation

Preganancy

Blurred vision

Inj. Rosella

ampicillin

500 mg IV QID Infers with

cell wall

respiration of

microorganis

m the cell

wall rended

osmality

unstable

swell blank

pneumonia

pressure

Rash

Utricaria

Anemia

Bleeding

Depression

Nausea

Vomitting

Lethargy

Tab.

Pantoprazo

l

40 mg Oral Tid Gastro

eosophago

reflux disease

severe

oesophagitis

zoolinger

Ellison

syndrome

Head ache

Insomnia

Diarrhea

Abdominal pain

Flatulence

Hypersensitivity

Hyperglycemia


9/16

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


10/16

ASSESSMENT NURSINGDIAGNOSIS

OBJECTIVES INTERVENTION RATIONALE IMPLEMETION EVALUATION

Subjective

data:

Patient says

that I cant

breathe

properly

Objective data:

Patient ishaving

breathlessness

Ineffective

breathing

pattern related

to pneumonia

anxiety and

pain as

manifested by

rapid

respirationdyspnea and

tachypnea

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 lungsto provide

ongoing patients

response to

therapy3.Administer

oxygen as

inhealed to

maintain

optimal oxygen

level and to

increase patient

comfort4.provide

semifowlers

position for

breathing to

maximize lung

expansion

To determine

effectiveness

of therapy

To reduce

fever

To replace

fluid loss andmaintain

adequate

blood volume

To treat thecausative

agent

To evaluate

patients

response to

treatment

To reduce

fever andprovide

comfort

Assessed the

pattern of

breathing

Checked vital

signs and

auscultate lungs

Administered

oxygen to

patient

Provided semi

fowlers position

for patient

Patient

expressed some

feeling of comfort


11/16

ASSESS

MENT

NURSING

DIAGNOSIS

OBJECTIVE

S

INTERVENTI

ON

RATIONAL

E

IMPLEMENT

ATION

EVALUATION

subjective

data:

patient

says that

he cant

breathe

properly

objective

data:

patient is

having

thick

secretionsin the

airway and

cant

cough

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.Administer

expectorant to

increasebronchial fluid

product and

promote

expectoration

and cough

3.Maintain fluid

intake of 3L

daily to liquefy

secretions

To evaluate

cardiac

response

This may

indicate

impaired

ability of the

heart to

respond

appropriately

to increase

activity

To ensure

that patients

basic needs

are met

To reduce

cardiac work

load

Patient can

an active

participant onthat

Assisted

patient to

cough by

splinting chest

Administered

expectorant to

increasebronchial fluid

production

Maintain fluid

intake of 3L

daily

Patient maintained

clear breath sounds


12/16

ASSESSME

NT

NURSING

DIAGNOS

IS

OBJECTI

VES

INTERVENTION RATIONALE IMPLEMENT

ATION

EVALUAT

ION

Subjective

data: patient

verbalizes

that he is not

having

appetite and

feeling so

weakObjective

data: patient

is looking so

weak

Impaired

nutritional

status lessthan body

requireme

nt relatedto

anorexia,

nauseaand

vomiting

asmanifeste

d by

weakness

Patient

maintains

normal

nutritional

status and

maintain

normal

weight

1.Assess the food

preferences

2.weigh patient

daily and use same

scales and at the

same time of the

day

3.provide caloric

intake as ordered

4.advice to take

high protein high

caloric small

frequent feeding

Preferred foods

will be available

To provide

accurate

evaluation of

weight

To meet body

requirement

To prevent

negative nitrogen

balance and

excessive weightloss

Assessed food

preferences of

the patient

Checked the

weight of the

patient daily

Advised the

patient to take

high protein

and high

caloric diet

Patient

maintained

normal

nutritional

status than

before


13/16

ASSESSME

NT

NURSING

DIAGNOS

IS

OBJECTIV

ES

INTERVENTI

ON

RATIONA

LE

IMPLEMENTATI

ON

EVALUATIO

N

Subjective

data:

patient says

that I am

feeling tired

and weak

Objective

data:Verbal

response of

weakness

Activity

intolerance

related to

fatigue

treatment

regimen

and

weaknessas

manifested

by fatigue

and

dizziness as

exalin

Patient

experiences

increased

tolerance for

activity

1.Assess

response to

activity to

evaluate

patients

hypoxemia and

plan changes

accordingly2.Provide bed

rest and limit

physical

activity to

evaluate

patients

hypoxemia

3.Assist withthe activities as

needed to

ensure that

patients basicneeds are met

4.Place needed

items within

easy reach to

conserve energy

while

facilitating

indepenadance

Assessed response

to activity

Provide bed rest to

patient

Assisted with theactivities of the

patient

Placed needed

items within easy

reach of patient

Patient

experienced

increased

tolerance for

activity than

before


14/16

ASSESSMENT

NURSINGDIAGNOS

IS

OBJECTIVES

INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

Risk for

health

maintenan

ce relatedto lack of

knowledge

regarding

treatment

regimen

afterdischarge

Patient

gains

enough

knowledgeregarding

treatment

regimen

1.Assess the

ability to

continue self

care at home

2.Encouragepatient to

continue on

full course of

antibiotic

therapy

3.Encourage

patient toobtain

adequate rest,

nutrition and

fresh air

To identify

patients

knowledge

about selfcare and

ability to

manage self

care

To preventrelapse of

pneumonia

and

developme

nt

To assist

healingprocess

Assessed the

ability to continue

self care at home

Encouraged thepatient to continue

full course of

antibiotic therapy

Encouraged the

patient to obtainadequate rest and

nutrition

Patient got

knowledge

regarding

treatmentregimen

follow up

and activity

schedule


15/16

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. Itold him to take prescribed medication properly and correct time

PROGRESS NOTE


16/16

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 administered according to Doctors order.

DAY-2

Pain slightly reduced. Still patient is on NPO. 5 pint IV fluids are administered.

Foley catheter removed and patient pass 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 admitted 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 Suddarths 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

care plan for pneumonia

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