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Maniba bhula nursing

college, bardoli

Subject: Medical surgical nursing


Topic: Care plan on “Bronchitis”

Submitted To: Submitted By:


Mr. Manjunath Beth Mrs. Meghana Goswami
Asst. Professor. 2nd year M.Sc Nursing
M.B.N.C M.B.N.C

Submitted on:
HISTORY OF THE PATIENT

IDENTIFICATION DATA :-

Name of the Patient : Mr. Manish Shankarlal navib

Age : 55 years

Sex : Male

Address Piparia, Teh. Wagodia, Dist.Baroda.

Bed No. : 24

Doctor’s Unit : Dr. Pareek

Ward : Male Medical ward

I.P.D. No. : I1702150121

Date of Admission : 15/02/2017

Educational Status : 3rd std.

Occupation : Inoccupation

Monthly Income : 5500/-

Religion : Hindu

Mother Tongue : Gujrathi

Marital Status : Married

Diagnosis : Bronchitis

Dare of the Surgery : Nil

Name of the Surgery : Nil

Date of data collection : 16/02/2018

Present Complaints : A patient Mr. Manjunath Shankarlal nathbar came to Dhiraj


General Hospital with the complains of difficulty in breathing, blood in sputum, loss of weight, dry
cough, sleep disturbance and decreased appetite from the last 1 month.

PRESENT MEDICAL HISTORY : My patient was admitted to Dhiraj General Hospital With the
complains of dry cough, haemoptysis, reduced weight, laboured breathing, loss of appetite and sleep
pattern disturbances.

PAST MEDICAL HISTORY : My patient was previously 3 months before admitted to Dhiraj
general Hospital with the complains of malaria and No any other significant history of HTN, DM,
COPD, Cancer, Asthma and Arthritis etc.
PAST SURGICAL HISTORY :-
. No any other significant history of any past surgical history. .
FAMILY HISTORY :
Family tree :- Patient

Family Information :

Sr. Name of the family Relati. Age Educa- Occupa- Marital Health
no. members with Pt. (yrs.) tion tion status status
1. Mr. Manish Shankarlal Wife 65 Illiterate House wife Married Healthy
navib
2. Mr. Kaushikl M. navib Son 40 5th std. Worker Married Healthy
3. Mrs. Akashi M. navib Daughter 35 Illiterate House wife Married Healthy
in low
4. Ms. Bhavika M. navib Grand 18 11th std. Student Unmarried Healthy
daughter
5. Mr. Dev M. Navib Grand son 15 8th std. Student Unmarried Healthy

Family income per year:- 80,000/-

Family interpersonal relationship / Any family disharmony :-


Patient and family members are maintained good interpersonal
relationship with all family members and society.

Family history of illness :-


No any past and present family history of illness like Hypertension,
DM, Cancer, Arthritis, Renal disease etc.

PRESENT MEDICATION HISTORY :-

Sr. No. Current Medication Dose / Frequency Route Last Dose Given
1. Inj. Ceftiaxone 1gm. / BD IV 8am.
2. Tab. Tangold BD Orally 8am.
3. Cap. Shelkal 500mg. / BD Orally 8am.
4. Tab. Wysolon 20mg. / OD Orally 8am.
5. Inj. Hydrocort 200mg. /SOS IV 8am.
6. Cap. Anti TB 1800mg. / 1day Orally 10am.
7. Budocort Nebulizer / TDS Orally 8am.

SOCIO ECONOMIC STATUS :-


A) Housing : –
 Type of house : Small house of three rooms made up of bricks.
 Lighting : Proper lighting facilities are available.
 Ventilation : Eight windows and door, good ventilation facility are available.
 Water facility : Everyday.
 Sanitation : Lack of sanitation and hygiene.
B) Food hygiene practices :- They wash vegetables & cooking food in hygienic condition.

C) Personal hygiene practices :- They are maintaining personal hygiene, taking bathe
daily, washing hands, cutting nails, brush daily etc.

D) Community resources :- Resources like bus and train are available for transportation
educational resources are available up to 12th std. there is lack of lack of
health resources.

E) Religious practices :-
Client and his family members strong are believed in god and
they worship everyday. They go to temple everyday.

F) Family income and expenditure :-


 Food – 2000/-py -750 2
 Clothing – 500/- eth- 600 2
 Education – 1000/- isonia -2
 Health – 1000/- rifam-450 -1
 Others – 1000/-

ALLERGIES AND MEDICATION :-


 Drugs / Foods / Dyes / Others : Client doesn’t have any kind of allergies from
drug, food and dyes.
 Sings and symptoms : Nil
 Blood reaction : Nil
VICES :-
 Alcohol / Tobacco / Cigarette / Drug abuse : Biddi smoking
 Amount of intake/day : 1½ bundle / day
 Duration of intake (since when) : 25 years.

DEVELOPMENTAL HISTORY

MENSTRUAL HISTORY : Not applicable

OBSTRETIC HISTORY :- Not applicable

FUNCTIONAL HEALTH PATTERN -

Inter Personal Relationship :- Patient maintain good IPR with every hospital staff.
He is very calm and co-operative.

Hygiene :- Patient is able to do his daily routine activities.

Activity / Exercises :- He can able to do active and passive exercise from the both
upper and lower extremities.

Rest / Sleep :- He cannot take proper sleep in night because of hospitalization and
anxiety about disease condition.

Elimination Pattern :- The bowel and bladder elimination patterns are normal.

Cognitive / Perceptual :- Cognitive function are normal.

Self perception / self concept pattern :- Patient has insight and he is having general
sense of emotions.

Coping Stress Tolerance :- Patient is able to tolerate the stress.

Values and Beliefs :- patient is hindu and he celebrates all the festival. He knows
about his diseases.

Personal Habits :- He use to take rest and sleep.

DIETARY HISTORY :
o General appearance : Thin / Average / Obese
o Appetite : Good / Fair / Poor
o Diet : Veg. / Non veg.
o Meal pattern : Two times in day and breakfast in the morning
o Need assistant / Feed self : No need to assistant.
o Any other method of feeding : Nil

PHYSICAL ASSESSMENT

General Appearance :
Level of Consciousness : Conscious / Unconscious / Semiconscious / Coma
Orientation : To Place / Person / Time
Activity : Active / Dull / Lethargy
Body Built : Mild / Moderate / Thin / Obese

Anthropometric Measurement :
1.Height – 5’4” 2. Weight – 68 Kgs. 3. Mid Upper Arm Circumference – 16cms

Vital Signs :
Temperature – 98.5’ F 2. Pulse – 86 b/m. 3. Respiration – 28 b/m.
Blood Pressure – 130/90 mm of hg.

Head :
Hair - Equally Distributed / Baldhead
Colour of Hair - Gray / White / Black
Scalp - Clean / Dandruff present – Yes / No
Pediculosis - Present / Absent

Face :
Face - Symmetrical/Asymmetrical
Facial Puffiness - Present /Absent

Eyes
Eye Brows - Symmetrical / Asymmetrical / Scaling / Lesions
Eye Lid/Lashes - Redness / Swelling / Discharge / Lesions
Eye Ball - Sunken / Protrusion / Normal
Conjunctiva - Colour / Swelling / Lesions
Sclera - White / Pink / Yellow / Tenderness / Discharge / Lesions
Puncta - Red / Swollen / Tender To Pressure
Cornea - Regular / Irregular Ridges
Iris - Flat / Irregular Shape
Eye discharge - Present /Absent
Use of glasses - Present /Absent
Pupils - Equally Reacting To Light – Yes / No
Size – 6 mm
Dilated And Fixed, Unequal - Equal
Visual Acuity – Normal
Nose :
Nasal Septum – Deviated / Central
Nasal Polyps – Present / Absent
Nasal Discharge – Present / Absent

Mouth :
Number of Teeth - 26
Dentures – Present / Absent
Dental Carries - Present / Absent
Odour of Mouth - Foul Smell / Acetone Smell / Others : Nil
Gums – Weak / Swollen / Pale Colour / Healthy

Lips : Crack / Healthy


Cleft Lips – Unilateral / Bilateral
Stomatitis - Present / Absent

Ears : Size - Normal


Shape - Normal
Position And Alignment - Normal
Redness – Present / Absent
Discharge – Present / Absent
Cerumen – Present / Absent
Lesions - Present / Absent
Foreign Body – Present / Absent
Hearing Acuity – Normal in both ear
Use of Hearing Aids – Yes / No
Tuning Fork Test - Negative
Weber test - Negative
Rinne test – Negative

SINUSES :
Maxillary sinus infection : Yes / No
Frontal sinus infection : Yes / No

SYSTEMATIC EXAMINATION

RESPIRATORY SYSTEM :
Respiratory Rate - 30 b/m.
Inspect the Chest : Thoracic Cage - Shape - Barrel Chest / Scoliosis / Kyphosis
Configuration – Pectus Excavatum / Pectus Carinatum/ Normal
Skin Colour and Condition – Normal / Cyanosis / Pallor
Chest Expansion – Symmetric / Asymmetric

Percussion Lung Field – Clear : Yes / No


Resonance - Hyper resonance / Dull
Diaphragmatic Excursion - Dull / Normal

Auscultation :Breathing Sound - Broncho / Broncho Vesicular/ Vesicular


Adventitious Sound - Crackles / Wheeze : No
Respiratory Pattern – Normal / Tachypnea / Bradypnea / Cheyne
Stokes / Hypo / Hyper Ventilation / Bitot’s
CARDIO VASCULAR SYSTEM :
Pulse : 82 b/m.
Carotid Pulse Rate : 86 b/m.
Blood Pressure : 130/90mm of hg.
Heart Sound (S1, S2 Heard) : Yes / No
Abnormal Heart Sound (S3 or S4 ) : Present / Absent
Murmurs : Present / Absent

PERIPHERAL LYMPHATIC SYSTEM :


Inspect and Palpate The Leg – Cyanosis / Uni / Bilateral Edema : Nil
Posterior Tibial Pulse – Rt. – 76 b/m. Lt. – 76 b/m.
Dorsalis Pedis Pulse – Rt. - 74 b/m. Lt. – 74 b/m.
Edema – Present / Absent
Type of Edema – Pitting / Pretibial / Generalized
Lymph Edema – Present / Absent
Varicose Veins – Present / Absent
Venous Ulcer - Present / Absent

DIGESTIVE SYSTEM :
Abdominal Girth : 98 cms.
Diarrhoea / Constipation : Nil
Inspection : Size - Scaphoid / Protuberant Flat / Rounded
Symmetry – Bulges / Masses / Hernia : Normal
Scar - Bilateral Surgical scar in inguinal region
Lesions - No
Redness - No
Palpation : Tenderness - Abscent.
Fluid Collection - No
Mass / Soft - No
Percussion : Ascitis/Peritonitis - No
Gas / Fluid collection / Normal in size - No
No Gas / Fluid Collection : No
Auscultation : Bowel Sounds - Normal / Borborygmus / Absent

GENITO URINARY :
Frequency of Urination - Nil
Urine Last Voided - Nil
Colour - Pale yellow
Normal / Anuria / Hematuria / Dysuria / Incontinence / Any Other : Poliuria
Catheter Present : Yes / No
Urethral Discharge : Nil

INTEGUMENTORY SYSTEM :
Skin Colour - Normal Brown
Dermatitis - No
Allergies - No
Cause : Nil
Reaction : Nil
Lesions / Abrasions - No
Tenderness / Redness - No
Surgical scar - Bilateral Surgical scar in inguinal region
Secretion - No

MUSCULO SKELETAL SYSTEM :


Range of Motion - Normal
Joint Swelling / Pain / Others : - Normal
Weakness / Paralysis / Contracture : - No
Extremities strength – Equal / Unequal : - Equal

SPINE :- Lordosis / Kyphosis / Scoliosis : Nil

MENTAL STATUS :
 Memory : Good
 Knowledge : Good
 Thinking : Good
 Judgement : Good
 Insight : Yes

MOTOR FUNCTION : Reflexes

Sr. No. NAME OF THE REFLEX REMARK


1. Biceps Normal
2. Triceps Normal
3. Patellar Normal
4. Achilles Normal
5. Plantar Normal
6. Gluteal Normal

FINAL IMPRESSION :- All the cranial nerves function are normal.

LABORATORY / OTHER INVESTIGATION :

Date Investigations Name Normal Findings Patient’s Findings Remarks


28/07/10 Haemoglobin 13-17 mg% 9.2 mg% Decreased
Leucocytes 4000-11000 /cuum 16000/ cumm Increased
Neutrophils 60-70 % 70 % Normal
Urea 11-45 mg% 25 mg% Normal
Creatinine 0.6-1.3 mg% 0.8 mg% Normal
Albumin Absent Absent Normal
Pus cells Absent Absent Normal
RBC’S Absent Absent Normal
29/07/10 Sputum for AFB Absent Present Affected
05/08/10 Sputum for AFB Absent Present Affected

X-ray :- Chest X-ray are shows patient with a bronchitis.

ECG :- ECG is with in the normal limit.

ECHO :- Not done.

USG :- Not done.


MEDICATION
Pharmacolo- Dose / Mechanism of Indications Contra- Side-Effects Nurses Responsibilities
gical Name/ Route Action Indications
Trade Name

Tab. Lasix 40 mg. Inhibits the re- Pulmonary Hypersensitivity Circulatory - Assess the signs of metabolic
absorption of oedema in to sulphonamide, collapse, loss alkalosis, drowsiness,
Pharmacolo- Available sodium and chronic heart enuresis, of bearing, restlessness
-gical name : forms : chloride at failure, hepatic hypovolemia, renal failure,
Frusemide Tabs – 20, proximal and disease, electrolyte thrombocytop - In IM to avoid interference
40 ,80 mg distal tubules and nephritic depletion, and enia, with sleep if using drug as a
in the loop of syndrome, lactation. leucopenia. diuretic.
Oral henle. ascites and
solurion hypertension. - Potassium replacement if
potassium < 3 mg. / dl.

- PO with food if nausea occurs,


absorption may be decreased
slightly, tabs may be crushed.

IV route : it should be
undiluted.

Assess fluid status. Monitor


daily weight , intake and output
ratios, skin turgor and mucous
membrane.

If administering twice daily ,


give last dose no later than 5pm
to minimize disruption of sleep
cycle.
Pharmacolo- Dose / Mechanism of Indications Contra- Side-Effects Nurses Responsibilities
gical Name / Route Action Indications
Trade Name

Tab. Domstal Tab. Preventing nausea Prevention of Should not be Headache After dilution of single dose
4,8mg and vomiting by nausea and used in patients Bronchospasmn in 50ml NS or D5W 0.45%
Pharmacologi blocking serotonin vomiting as with This drugs Nacl.
cal Name : Inj. peripherally, associated with phenylketonuria, altering the
2mg/ml, centrally and in the cancer with liver activity of liver Give over 15 minute.
Ondensetrone 32mg/50 small intestine. chemotherapy, impairment enzymes,
ml radiotherapy (daily dose not to headache, To report diarrhoea,
Therapeutic class : and prevention exceed 8 mgs) fatigue, constipation, rash, or changes
Antiemetic of post diarrhoea. in respiration or discomfort at
operative insertion site.
Chemical class : nausea and
5HT3 receptor vomiting. Direct IV – administer
antagonist undiluted (2mg/ml)
immediately before induction
of anaesthesia or
postoperatively if nausea and
vomiting occurs shortly after
surgery.

Advice patient to notify health


care professional immediately
if involuntary movement of
eyes, face or limbs occurs.
Pharmacolo- Dose / Mechanism of Indicatio Contra- Side-Effects Nurses Responsibilities
gical Name/ Route Action ns Indications
Trade Name

Tab. PCM Tab. 160mg Inhibit the Mild pain Previous Hepatic failure Assess overall health status and
325mg synthesis of Fever hypersensitivity, Hepatotoxicity alcohol usage before administering
Pharmacolo 500mg prostaglandin that products (over dose) PCM.
gical class: 650mg may serve as containing alcohol, renal failure ,
Acetaminoph mediators of pain aspartame, neutropenia, Patient who are malnourished or
en Solution : and fever, saccharine, sugar pancytopenia , chronically abuse alcohol are at
primarily in the or tartarazine. rash. higher risk of developing
Therapeutic CNS. Has no Hepatotoxicity with chronic use f
class : significant anti Use cautiously in usual doses of this drug.
Antipyretic, inflammatory hepatic disease,
Nonopioid property or GI renal disease, Do not administered with the history
analgesics. toxicity. chronic use or of self medicated, prolonged use of
abuse, PCM, it will increased risk of
malnutrition. adverse renal effects.

When combined with opioids do not


exceed the maximum recommended
daily dose PCM.

Administer with a full glass of water

Advice patient to take medication


exactly as directed and not to take
more than the recommended amount.

Advice patient to avoid alcohol (3 or


more glasses per day increase the
risk of liver damage).
APPLICATION OF THE NURSING THEORY

CALISTA ROYS ADAPTATION MODEL :-

Adaptation is the control feature of this model.


Adaptation occurs through two types of innate or acquired, copping mechanism used to
responded to changing environmental stimuli.
1. Regular coping subsystem.
2. Cognator coping subsystem.
3. Stabilizer subsystem control process.
4. Innovator subsystem control process.

Response takes place in four modes for individual and group –


(1) Physiological / physical mode
(2) self concept mode
(3) role function mode.
(4) interdependence mode.

This four modes are inter related. Responses to in any one mode may have an effect on or act as a stimuli’s
in one or all of the other modes. Response in each modes are judged as either adaptive or ineffective.

Implication For Nursing Practise :-


Roy’s practise methodology is the roy adaptation model nursing
process, which encompasses
Six steps - 1) Assessment of behaviour.
2) Assessment of stimuli.
3) Nursing diagnosis – nurse may link the roy adaptation model based nursing
diagnosis with a relevant diagnosis from the taxonomy of NANDA.
4) Goal setting
5) Nursing intervention
6) Evaluation.

The adaptation level is determined by the combined effect of the focal, contextual and residual
stimuli. Adaptation occur when the person respond positively to environmental changes. This adaptive
response promote the integrity of the person which lead to health.

Application :- My patient Mr. Geta bhai M. Parmar was suffering from Tuberculosis than the surgery
was perform. He having limitation like immobilization and difficulty in walking. It is difficult for him to
adopt to this new environment.

According to concept of theory :-


Person is client – Health is his adaptation to changes in his body.
Environmental – Internal and external changes.
Nursing – In with help of my client to adapt to environment of also with disease
condition.
Altered coping mechanism

Cognator Regulator
Because of changes in his daily routine & decreased working capacity due to
hospitalization, immobility, difficulty in walking and medication and treatment.

Maladaptation process
Stimulate three stimuli

Focal stimuli Contextual stimuli Residual stimuli

Environmental hygiene
Feeling anxious Food hygiene and practices Sleep pattern disturbance
Unknown to situation
Increased respiration
Dry cough

Nursing intervention for manipulation of stimuli

- Assessment of client - Assess the fluid volume & - Provide psychological support
- Lab investigation electrolyte imbalance - Provide knowledge about
disease condition
- Input and output chart - Explain about dietary pattern.
- Avoid complication - Explain about follow up
- Monitor vital signs
- Medication & maintain nutritional status
Provide calm and quite environment

Outcomes – client feels comfortable, relax, adjust with


situation, minimize anxiety, have the knowledge
regarding disease condition and reduce oedema.

Adapted to new situation

LIST OF NURSING DIAGNOSIS :-

(1) Excess fluid volume related to disease process.


(2) Imbalanced nutrition : les than body requirement related to anorexia, vomiting and restricted diet.
(3) Impaired skin integrity related to uremic frost and changes in oil and sweat glands.
(4) Activity intolerance related to fatigue, anaemia and dietary restriction.
(6) Anxiety r/t lack of knowledge regarding disease condition, treatment regimen & reoccurrence.
(7) Knowledge deficit related to treatment regimen, prognosis and diet of disease.
(8) Sleep pattern disturbance related to pain, immobilization, surgery and hospitalization.
(9) Ineffective therapeutic regimen management related to restrictions imposed by CRF and its treatment.
(10) Risk for injury while ambulating related to potential fractures and muscle cramps due to calcium
deficiency.
NURSING CARE PLAN
Nursing Nursing Expected Out Planning Interventions Evaluation
Assessment Diagnosis Come

Subjective data: Excess fluid Patient will Assess for sign of fluid Assessed the sing of fluid Expected outcome
Patient says volume related to experiences optimal volume excess elevated BP, volume excess BP – 140/86 is partially met as
that he is having disease process. fluid balance as tachycardia, oedema and mm of hg., oedema is present evidenced by
oedema on the evidenced by weight gain. periorbital oedema. Weight reducing weight,
both the legs and normal BP and gain 3 kg./ week. reducing oedema,
face. He is feeling weight gain is less. decreased BP and
restlessness and Assess the patient Assess the patient verbalization.
fatigue. compliance with dietary and compliance because it can
fluid restriction at home. lead fluid volume excess.
Objective data :
Oedema on Assess weight at every visit Assessed the patient weight
the face and legs. before and after dialysis. before and after
BP is administration of the
elevated 140/88 diuretics.
mm of hg.
Weight gain. Advise the patient to Advised the patient to
Restlessness. elevated his feet when sitting elevated his feet when sitting
down. down to reduce the pedal
oedema. .

To administer the diuretics. Administered the diuretics


tab. Lasix 40mg. BD Orally

To advice the patient Advised the patient


regarding restriction fluid regarding restriction of fluid
intake as required by the intake.
patient condition.

To instruct the patient Instruct the patient regarding


regarding restricting dietary restricting dietary sodium to
sodium. prevent thirst.
Nursing Nursing Expected Out Planning Interventions Evaluation
Assessment Diagnosis Come

Subjective data: Imbalanced Patient is optional Assess the possible cause of Assessed the possible cause Expected outcome
Patient says that nutrition less than status is mentioned poor appetite. patient is having anorexia is partially met as
he is not able to body requirement as evidenced by and nausea. evidenced by
take proper related to stable body weight increase appetite
amount of food. anorexia, and and adequate Assess the laboratory value Assessed the value of and verbalization.
He is feeling restricted diet. calorie intake. like haemoglobin. haemoglobin decreased value
fatigue and may indicate poor nutritional
nausea. status. His haemoglobin is
10.2 gm%

To give health education Health education given


Objective data : regarding low protein and regarding low protein and
- Anorexia low sodium diet. low sodium diet.
- Nausea
- looks fatigue Assess the nutritional status. Assessed the nutritional
of weakness. - weight change status – weight gain
- dietary - laboratory value (s. - urea and creatinine
restriction. electrolyte, BUN, creatinine, level is increased.
and iron) -

Explain rational for dietary provided patient food


restriction and relationship to preferences because increase
kidney. dietary intake.

Weight the patient daily. Explained rational for dietary


restriction to promotes
patient understanding.
Nursing Nursing Expected Out Planning Interventions Evaluation
Assessment Diagnosis Come

Subjective data: Impaired skin Patient will Assess the skin integrity for Assessed the skin integrity Expected outcome
Patient says integrity related maintain skin pitting oedema on the legs. because chronic fluid excess is partially met as
that he is having to uremic frost integrity as can result can skin break evidenced by
itching on the feet and changes in oil evidenced by relief down. reducing itching.
and all over the and sweat glands. from itching.
body. Instruct the patient to wear Instruct the patient to wear
the loose cloths when the loose cloths when
oedema is present. oedema is present.
Objective data :
- bed rest. To keep skin clean while kept skin clean while
- fluid volume relieving itching and dryness relieving itching and dryness
excess -Basis soap applied oil on the skin.
- Oedema -Sodium bicarbonate
- Itching added to bath water.
- Numbness. -Apply oil on the skin.

To apply ointment or creams Applied ointment for


for comfort and to relieve comfort and to relieve
itching. itching.

To keep nails short and Cut short the nails.


trimmed to prevent
excoriation.

To keep hair clean and kept hair clean and


moisturised. moisturised.
Nursing Nursing Expected Out Planning Interventions Evaluation
Assessment Diagnosis Come

Subjective data: Activity Patient will have to Assess the patient to Assessed the patient that he Expected outcome
Patient says that intolerance demonstrate response on activity. is not perform the any is partially met as
he is not able to related to fatigue, activity on activity. evidenced by
perform his daily anaemia and evidenced by verbalization.
activity. He is dietary restriction. verbalization. Assess the factors Assessed the factors
feeling fatigue. contributing to activity contributing patient is having
intolerance , fatigue, fatigue and anaemia.
anaemia, and fluid and
Objective data : electrolyte imbalances.
-Looks fatigue.
- Inability to Encourage alternating Encourage the patient to
perform daily activating with rest. promote activity and
activity. excessive with in limit and
- weakness. adequate rest.
- Hb – 10.2mg%
- Oedema Encourage patient for self Encouraged patient for self
care. care.

Tell patient to take proper Told patient to take proper


rest and perform the small- rest and perform the small-
small work. small work.

Provide emotional support Provide emotional support


while increasing activity. while increasing activity.
Nursing Nursing Expected Out Planning Interventions Evaluation
Assessment Diagnosis Come

Subjective data: Anxiety related to Client will exhibit To assess the cause of Assessed cause of anxiety. Client exhibit
Client lack of calm behaviour by anxiety. positive attitude as
complains of knowledge positive attitude, evidenced by
restlessness regarding disease optimistic thoughts To provide safe and calm Provided safe and calm verbalization of
and feeling of condition. and verbalization in environment. environment. optimistic thoughts
helplessness and reduction of level and reduction in
discomfort and of anxiety. To provide psychological Client was explained all level of anxiety.
about support and build hope in treatment regimen about
hospitalization. treatment. disease and hospitalization.

To encourage patient to He was asked to verbalize all


express the feelings of the feelings and question/
Objective data : anxiety and fear. doubts.
Lack of
confidence To use reassurance and Using reassurance and
expression of therapeutic conversation to therapeutic conversation to
helplessness and relieve feat and anxiety. relieve feat and anxiety.
discomfort
To provide divisional Provided the divisional
therapy. therapy like listening music,
reading news papers, jokes
etc.

To prepare to coping the Explained all about the


patient and family for long disease condition, treatment
time bed rest of the patient regimen, bed rest,
and giving care to him reoccurrence of disease and
during hospitalization. hospitalization.
Nursing Nursing Expected Out Planning Interventions Evaluation
Assessment Diagnosis Come

Subjective data ; Knowledge Patient will have Assess the level of the Assessed the level of the Expected out come
Patient says that deficit related to increase his knowledge of the patient. knowledge of the patient by is partially met as
he is not known treatment regimen knowledge as asking question about evidenced by
about his medical and prognosis of evidenced by disease condition. verbalization.
treatment and disease. asking question and
about disease follow the To Explain about the surgery Explained about the surgery
condition and instruction. and disease condition. and disease condition.
surgery.
To explain about the Explained about the
Objective data : importance of medication importance of medication
- Asking and side effects. and side effects.
questioning
regarding his To encourage the patient to Encouraged the patient to ask
disease condition. ask the question and clear his the question and clear his
- lack of doubts. doubts.
knowledge.
- Misconception To explain about the diet. Explained about the diet like
- he is asking his high fibre, high protein
about his surgery. and high calorie diet.
NURSES NOTES - 1
Name of the Patient - Mr. Manish Shankarlal Navib Diagnosis - Bronchitis
Age / Sex - 55 years / Male Name of Surgery - Nil
Date of Admission - 15/02/2018 Date of Surgery - Nil
Ward / Bed No. - Male Medical ward Dr. Incharge - Dr. pareek
Nursing Observation,
Date Diet Medication Time Sign.
Intervention and Remark

16/02 Break fast : Tab. Rantac 150mg BD 8.00am Patient is sleeping in supine position. He had intracath on
Upma -1 plate Tab. Lasix 40mg BD right hand. He is talking with his relatives.
Banana - 1 Tab. Deriphylline
Water – 150cc 100mg TDS 8.30am Bed was looks unclean and untidy. So bed making was
Tab. Domstal 20mg BD done.
Lunch :
Roti – 3 9.00am Patient had a Break fast.
Boil egg - 1
Dal – 1wati 9.30am Patients vital sings are checked and this are following :
Mix veg. -1 wati Temperature : 98.6’F
Water – 150cc Pulse : 88b/m.
Respiration : 24b/m.
Blood pressure : 140/90 mm of hg.

9.45am Medication was given.

10.00am Dressing was done. Its look healthy.

11.00am Patient history was taken in all the aspects of history


taking format.

Patient is talking with his relatives.


12.30am
NURSES NOTES – 2
Name of the Patient - Mr. Manish Shankarlal navib Diagnosis - Bronchitis
Age / Sex - 55 years / Male Name of Surgery - Nil
Date of Admission - 15/02/2018 Date of Surgery - Nil
Ward / Bed No. - Male Medical ward
Nursing Observation,
Date Diet Medication Time Sign.
Intervention and Remark

17/02 Break fast : Tab. Rantac 150mg BD 8.00am Patient was came from the bathroom after taking bath.
Poha -1 plate Tab. Lasix 40mg BD
Banana - 1 Tab. Deriphylline 8.30am Bed was looks unclean and untidy. So bed making was
Water – 150cc 100mg TDS done.
Tab. Domstal 20mg BD
Lunch : 9.00am Patient had a Break fast.
Roti – 3
Boil egg – 1 9.30am Patients vital sings are checked and this are following :
Dal – 1wati Temperature : 98.6’F
Ladies finger. -1 wati Pulse ;86b/m.
Water – 150cc Respiration : 26b/m.
Blood pressure : 146/98 mm of hg.

9.45am Medication was given.

10.15am Dressing on the incision was done. The incision site is


looks healthy.

11.00am Patient history was taken in all the aspects of history


taking format.

12.30am Patient is sleeping.


NURSES NOTES – 3
Name of the Patient - Mr. Manish Shankarlal navib Diagnosis - Bronchitis
Age / Sex - 55 years / Male Name of Surgery - Nil
Date of Admission - 15/02/2018 Date of Surgery - Nil
Ward / Bed No. - Male Medical ward
Nursing Observation,
Date Diet Medication Time Sign.
Intervention and Remark
18/02
Break fast : Tab. Rantac 150mg BD 8.00am Patient is sleeping in supine position. He had intracath on
Idali -1 plate Tab. Lasix 40mg BD left hand. He is talking with his relatives.
Banana - 1 Tab. Deriphylline
Water – 150cc 100mg TDS 8.30am Bed was looks unclean and untidy. So bed making was
Tab. Domstal 20mg BD done.
Lunch :
Roti – 3 9.00am Patient had a Break fast.
Boil egg – 1
Dal – 1wati 9.30am Patients vital sings are checked and this are following :
Mix veg. -1 wati Temperature : 98.6’F
Water – 150cc Pulse ;82b/m.
Respiration : 26b/m.
Blood pressure : 150/100 mm of hg.

9.45am Medication was given.

10.15am Dressing on the incision was done. The incision site is


looks healthy.

11.00am Patient history was taken in all the aspects of history


taking format.

Patient is talking with his relatives.


12.30am
HEALTH EDUCATION :-
1. To promote adherence to the therapeutic program, teach the following :
- Weight self every morning to avoid fluid over load.
- Drink limited amount f fluid only when thirst.
- Measure allotted fluids and save some for ice cubes , sucking on ice is
thirst quenching.
- Eat food before drinking fluids to alleviate dry mouth.
- Use hard candy or chewing gum to moisten mouth.
2. Encourage reporting for routine urinalysis and follow up examinations.
3. Avoid avoidance of any medication unless specifically prescribed.
4. recommended resuming activity gradually because muscle weakness will
be present from excessive catabolism.

CONCLUSION :-
As per my medical surgical nursing requirement I selected care plan on Bronchitis from Civil
hospital, surat. I selected Mr. Manish from malemadial ward who diagnosed Bronchitis. I
provided him 3 days care and from that learnt about the head injury and I am able to provide
care to other patients who have same diagnosis.

BIBLIOGRAPHY :-
(1) Lippincott , Manual of Nursing Practice, 8th Edition, Lippincott –New
York, Page no. – 674 - 678

(2) Brunner and Sugharths, Text book of Medical Surgical Nursing,


10th Edition, Lippincott Williams and Wilkins, Page no. – 988 - 993

(3)Gulanick / Myers, Nusing Care Plan, 6th Edition, Mosby Elsevier


Publication, Page no. – 541 -544

(4)Davis, Drug Guide for Nuses, 20th Edition, F.A. Davis Company,
Philadelphia, Page no. – 100-102, 340-342, 667-668

(5) Hollowry Nancy, Medical Surgical Care Planning, 8th Edition, Spring
house Publication, Page no. – 420 -425

(6) Internet Resourses –


www.Google.com
www.wikipedia.org.
www.emedicine.medcape.com