care plan pneumonia
TRANSCRIPT
Care Plan
On
Pneumonia
Submitted to
Prof. Mrs.Vanjeenathammal
H.O.D Medical-Surgical Nursing
The Capitol College of Nursing, banglore
Submitted by
Ms.Sruthy Mohan M J
1st Year M.Sc Nursing
Dept. of Medical Surgical Nursing
The Capitol College of Nursing, banglore
INTRODUCTION
As a part of my clinical experience in Medical Surgical Nursing I was posted in Female Medical ward of Sanjaygandhi general hospital,banglore. There were 31 patients and I selected Mrs. Kannikamma as my patient. I am supposed to investigate present problems based on observations and signs and symptoms of the disease.
IDENTIFICATION DATA
Name of the patient : Mrs. Kannikamma
Age : 37 yrs
Sex : Female
Religion : Hindu
Marital Status : Married
Education : Polytechnique
Occupation : House Wife
Income : Nill
I P No. : 16731
Unit : Female Medical ward
Date of Admission : 11/03/2012 at 4.34 p.m
Medical diagnosis : Pneumonia
Address : Puthanahalli,7th cross
Date of care started : 12/03/2012
Date of care ended : 15/03/2012
Medical History
Present Medical History
Mrs. Kannikamma was admitted to Sanjaygandhi general hospital,banglore.on 11/03/12 at 4.34 p.m with complaints of fever, chills, persistent cough and chest pain since 3 months. The doctor diagnosed the case as Pneumonia.
Past Medical History
Nothing Significant
Surgical History
Present and Past Surgical History
Nothing Significant
Personal History
Mrs. Kannikamma has no bad like smoking and alcoholism but she has a habit of chewing on betal nuts. She takes mixed diet. She is maintaining good relationship with her family members and neighbours.
FAMILY HISTORY
There are 3 members in her family including her husband and a 10 year old daughter. Theirs is a nuclear family. All the other family members are healthy. There is no heredity or communicable diseases in his family.
KEY
Patient
Male
Female
SOCIO-ECONOMIC HISTORY
Mr. Nagesh is the husband of Mrs. Kannikamma. He is the bread winner of the family. He is having an income of Rs. 5000/month. He is a businessman. They are living in their own house.
ENVIRONMENTAL HISTORY
Mrs. Kannikamma 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 lavatory facility.
NUTRITIONAL HISTORY
She is taking mixed diet with 2 meals per day. She doesn’t have allergy with food items. She is taking white rice and vegetable salad very much.
ELIMINATION HISTORY
Her bowel and bladder functions were normal.
PHYSICAL EXAMINATIONGeneral observation Stature - normalPosture - no deformityPersonal appearance - well groomed and hygenicEmotional status - depressed Co-operativeness - co-operative Vital signs Temperature - 101 °F Pulse - 70 beats per min Respiration - 26 breaths per min Blood pressure - 130/80 mmHg
Height and weight Height - 154 cms Weight - 61 kg
Skin Colour - no cyanosis, no jaundiceEdema - no edema Moisture - warm and normal Lesions - Absence of macules, papules, and vesicals Head Normal cephalic, no lesions, normal distribution of hair and color of hair is normal, no pediculosis, normal range of motion possible, Eyes Expressions - normal Eyelids - normally close and open Eye balls - normal, globes clear and firm Conjunctiva - dark pink and clear
Sclera - pink and clearIris - brownVisual acuity - normal 6/6PERRLA - pupils round symmetrical, reacting to light and
accommodation, 3mm, constrict to light. Eye movements - move in conjugate fashion and normal Ears Appearance - auricles are normal and symmetrical Hearing - normal hearingNormal shape, no discharge, no tinnitus, no vertigo, no infection, Cerumen is present NoseAppearance - no nasal flaring, mucous membranes pink and moist Sense of smell - normalNo DNS or running nose
Mouth and throat Lips - symmetric, moist, no lesions, no cyanosis Tongue - moist, pink, no glossitis, no coatingTeeth - stained teeth, equally distributed Gum - no gingivitis Buccal mucosa - no lesionsPalate - intact, symmetrical, pinkSense of Taste - normalNo glossitis, no stomatitis NeckAppearance - no deformity, spondilitis, tenderness, stiffness, swellingTrachea - no deviation, no tendernessLymph nodes - not palpableThyroid glands - symmetric No distended neck veins CHEST AND RESPIRATORY SYSTEMInspection Symmetry - bilaterally symmetrical Expansion - thoracic expansion is abnormalEquality of movements - unequal in the right lungsType of respiration - Abdomino-thorasic Rate - 26 breaths/min Rhythm - irregular Palpation Expansion - unequal, inflammation of lining of lungsVocal tactile fremitus - fremitus present
Presence of local swelling, and tenderness in the right thorax PercussionBasal - resonanceApical - dull percussion Auscultation Bronchial - sound is loud and harsh heard on trachea Bronchovesicular - sounds are moderatly heard at 2nd intercostal space on both
sides Vesicular - heard all over the lung field both front and back Friction rub - nothing significant CARDIOVASCULAR SYSTEM Inspection Chest contour - abnormal, sternal depression presentNeck - no jugular venous distention PercussionCardiac outline - difficult to find out the cardiac borders
Palpation Supra sternal notch - no fluid thrill Auscultation Apical rate - 70 beats/min & S1, S2 heard Blood pressure - 130/80 mmHg ABDOMENInspection Shape - Scaphoid shapeMovements - abdominal wall bulges in inspiration, falls during expirationSkin texture - no discoloration, no cyanosis, no distension Contour - normal, flat, no mass, normal bowel, no organomegaly AuscultationBowel sounds heard Percussionorgan borders - gaseous distention found PalpationMass - no organomegaly, soft abdomen Back Spinal curvature - no deformity - Concavity in the cervical region - Concavity in the lumbar region - Convexity in the thoracic regionSymmetry - normalMovement - normal ROM Genitalia and groin Nothing significant UPPER EXTREMITIES Normal ROM possible LOWER EXTREMITIESAppearance - Normal in both the extremitiesTemperature - warm to touch and moistPulses in the periphery - dorsalis pedis artery felt 70 beats /min
NERVOUS SYSTEM Higher functions - normalSpeech - fluent and clear Motor function - normally muscle tone, gait normal Sensory functions - normally responds to pain and light touch Cranial nerves and reflexes - normalReflexes - normal functions (superficial and deep reflexes)
Vital Signs
Sl. No. Procedure Normal Value Patients value Remarks
1.
2.
3.
4.
Temperature
Pulse
Respiration
Blood Pressure
98.6 °F
60 – 70 beats/min
18 – 20 beats/min
120/80 mm of Hg
101 °F
70 beats/min
26 beats/min
130/80 mm of Hg
Increased
Normal
Increased
Normal
Sl. No.
Name of the Investigation
Normal Value Patients value Remarks
1.
2.
3.
4.
5.
6.
Hb
WBC
Lymphocytes
Eosinophils
S.Urea
ESR
14-18 gm%
4000-11000/cumm.
20-40%
1-6%
10-50mg/dl
< 20 cm2 /hr
12 gm%
16000/cumm
60%
46%
34 mg/dl
30 cm2/hr
Decreased
Increased
Increased
Increased
Normal
Increased
Investigations
MEDICATIONS
DRUG DOSAGE 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 prostoglandin synthesis by decreasing enzyme needed for bio synthate analgase
Tachy cardiaPalpitationPreganancyBlurred vision
Inj. Rosella ampicillin
500 mg IV QID Infers with cell wall respiration of microorganism the cell wall rended osmality unstable swell blank pneumonia pressure
Rash UtricariaAnemiaBleedingDepressionNauseaVomittingLethargy
Tab. Pantoprazol 40 mg Oral Tid Gastro eosophago reflux disease severe oesophagitis zoolinger Ellison syndrome
Head ache Insomnia Diarrhea Abdominal painFlatulence HypersensitivityHyperglycemia
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 explained.
5. Risk for health maintenance deficit related to lack of knowledge regarding treatment
regimen after discharge.
Care plan
Assessment Nursing Diagnosis
Objective Planning Implementation Evaluation
Subjective Data: Patient says that I can’t breathe properly
Objective data: On observation Patient is having breathlessness
Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by rapid respiration dyspnea and tachypnea
Patient maintains normal respiratory rate and express feeling of comfort
Assess the pattern of breathing to provide guidance for intervention.
Take vital signs and auscultate lungs to provide ongoing patients response to therapy to identify the response to treatment.
Administer oxygen as inhaled to maintain optimal oxygen level and to increase patient comfort to increase patient comfort
Provide semi fowlers position for breathing to maximize lung expansion to maximize lung expansion
Assessed the pattern of breathing.
Checked vital signs and auscultate lungs.
Administered oxygen to patien.
Provided semi fowlers position for patient.
Patient expressed some feeling of comfort.
Assessment Nursing Diagnosis
Objective Planning Implementation Evaluation
Subjective Data: patient says that he can’t breathe properly
Objective data: patient is having thick secretions in the airway and can’t 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
Assist the patient to cough by splinting chest, and teach patient how to cough effectively to clear airway by bringing secretion to the mouth to bring out secretion
Administer expectorant to increase bronchial fluid product and promote expectoration and cough to remove secretions
Maintain fluid intake of 3L daily to liquefy secretions to liquefy secretions
Assisted the patient to cough by splinting chest, and teach patient how to cough effectively to clear airway by bringing secretion to the mouth
Administered expectorant to increase bronchial fluid product and promote expectoration and cough
Maintained fluid intake of 3L daily to liquefy secretions
Patient maintained clear breath sounds
Assessment Nursing Diagnosis
Objective Planning Implementation Evaluation
Subjective Data: patient verbalizes that he is not having appetite and feeling so weak.
Objective data: On observation patient is looking so weak .
Impaired nutritional status less than body requirement related to anorexia, nausea and vomiting as manifested by weakness.
Patient maintains normal nutritional status and maintain normal weight.
Assess the food preferences so the preferred foods will be available.
Weigh patient daily and use same scales and at the same time of the day to provide accurate evaluation of weight.
Provide caloric intake as ordered to meet body requirement.
Advice to take high protein high caloric small frequent feeding to prevent negative nitrogen balance and excessive weight loss.
Assessed food preferences of the patient.
Checked the weight of the patient daily.
Provided caloric intake as ordered to meet body requirement.
Advised the patient to take high protein and high caloric diet.
Patient maintained normal nutritional status than before.
Assessment Nursing Diagnosis
Objective Planning Implementation Evaluation
Subjective Data: patient says that I am feeling tired and weak
Objective data: On observation patient is giving Verbal response of weakness
Activity intolerance related to fatigue treatment regimen and weakness as manifested by fatigue and dizziness as explained.
Patient experiences increased tolerance for activity
Assess response to activity To evaluate patients hypoxemia and plan changes accordingly
Provide bed rest and limit physical activity to evaluate patients hypoxemia
Assist with the activities as needed to ensure that patients basic needs are met to ensure that patients basic needs are met
Place needed items within easy reach to conserve energy while facilitating independence to conserve energy while facilitating independence
Assessed response to activity
Provided bed rest and limit physical activity
Assisted with the activities of the patient
Placed needed items within easy reach of patient
Patient experienced increased tolerance for activity than before
Assessment Nursing Diagnosis
Objective Planning Implementation Evaluation
Subjective Data: Patient is asking doubts regarding to treatment.
Objective data: On observation patient is unaware of her disease condition.
Risk for health maintenance related to lack of knowledge regarding treatment regimen after discharge.
Patient gains enough knowledge regarding treatment regimen.
Assess the ability to continue self care at home to identify patients knowledge about self care and ability to manage self care.
Encourage patient to continue on full course of antibiotic therapy to prevent relapse of pneumonia and development.
Encourage patient to obtain adequate rest, nutrition and fresh air to assist healing process.
Assessed the ability to continue self care at home.
Encouraged the patient to continue full course of antibiotic therapy.
Encouraged the patient to obtain adequate rest and nutrition.
Patient got knowledge regarding treatment regimen follow up and activity schedule.
DIET PLAN
Time Food Amount
8.00 a.m Breakfast
Tea
Dosai
Bengal gram Curry
1 Glass
2 Piece
1 servings
12.30 p.m Lunch
Rice
Fish Curry
Cabbage side dish
2 servings
1Servings
4.00 p.m Tea time
Tea
Biscuit
1 Cup
2 Numbers
8.00 p.m Dinner
Chappthi
Green piece curry
4 Numbers
1 Servings
10.30 p.m Bedtime
Hot Milk 1 Cup
HEALTH EDUCATION
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
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
Advised the patient to take bath daily and to wear clean clothes
Advised the patient to take high protein containing diet and include diet containing
vegetables and fruits etc.
Conclusion
Mrs. Kannikamma was admitted to Sanjaygandhi general hospital,banglore on
11/03/12 at 4.34 p.m with complaints of fever, chills, persistent cough and chest pain since 3
months. The doctor diagnosed the case as Pneumonia.
I started the care on 12/03/2012 and I ended my care on 15/033/2012. During my
care I gave care to my client like mouth care, nail care, and provided nebulization, fowlers
position.
The patient was health educated on various aspects of her disease condition such
as, the diet or nutrition required for his disease, the personal hygiene necessary, and the need
for exercise during the recovery stage.
Mrs. Kannikamma received three days of nursing care from me. And the patient
recovered well from her disease condition.
From this case, I had gained immense knowledge regarding Pneumonia and its
Medical intervention.
Bibliography
1. Suzanne c. Smelzer and Brenda Bare, Brunner and Suddarth’s, “Text book of medical
surgical Nursing”, 10th Edition, Philadelphia, Lippincott Publishers.
2. Joyce M. Black, “Medical Surgical Nursing”, 6th Edition, New Delhi, Harcous Publishers.
3. B. T. Basavanthappa, “Medial Surgical Nursing”, 1st Edition, Jaypee Publishers (P) Ltd.,
Bangalore.
4. Anne Waugh and Allison Grant, “Ross and Wilson, Anatomy and Physiology in Health
and Illness”, 9th edition, Churchill Livingstone Publication, Philadelphia.