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.