BIOGRAPHICAL INFORMATION Name Age Sex Address Religion : Mr.

Nagesh : 36 years : Male : leela villa, gorur, hassan : Hindu

Marital status: Married Education Occupation Income : 8th standard : business : 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 Onset Duration : Fever, chills, persistent cough and chest pain : chronic onset : 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 Childhood illness : he has been admitted twice in hospital with same complaint : Nothing significant

Surgeries Immunization Medications

: Nothing significant : Completed primary immunizations : Last three month he takes medications from Govt. hospital.

PERSONAL HISTORY Habits Diet : Smoking, alcoholic and tobacco chewing : 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 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 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 Stature Posture : Normal : Normal : Kyphosis

Personal appearance: hygienic. Emotional status Co-operativeness : Depressed : Co-operative

VITAL SIGNS VITAL SIGNS Temperature Pulse Respiration Blood pressure PATIENTS 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 Eye balls : Normal : Normal. Globes clear

Conjunctiva : Pale and clear Sclera Iris :White and clear :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 NOSE No DNS and running nose. Rhyles tube present in the right naris. Appearance : No nasal flaring. Sense of smell: Normal : 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 Expansion : Symmetrical : Normal

Equality of movement: Normal Type of respiration: Normal Rate Rhythm PALPATION Vocal tactile fremitus: Normal No local swelling. PERCUSSION : 26/ minute : Regular

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 Movement : Symmetrical : 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 PATIENTS 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 Tab. Deriphiline DOSAG E 500 mg ROUTE Orally FREQUENCY BD ACTION 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 SIDE-EFFECTS Diarrhea, epigastric pain, palpitation and tachypnoea

Tab. brufen

400 mg

oral

BD

Tachy cardia Palpitation Preganancy Blurred vision

Inj. Rosella 500 mg ampicillin

IV

QID

Rash Utricaria Anemia Bleeding Depression Nausea Vomitting Lethargy

Tab. Pantoprazo l

40 mg

Oral

Tid

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

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

IMPLEMETION the of

EVALUATION Patient expressed some feeling of comfort

Subjective data: Patient says that I cant breathe properly

Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by Objective data: rapid Patient is respiration having dyspnea and breathlessness 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 lungs to provide ongoing patients response to therapy 3.Administer 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 To reduce fever To replace fluid loss and maintain adequate blood volume To treat the causative agent To evaluate patients response to treatment To reduce fever and provide comfort

Checked vital signs and auscultate lungs

Administered oxygen to patient

Provided semi fowlers position for patient

ASSESS MENT subjective data: patient says that he cant breathe properly objective data: patient is having thick secretions in the airway and cant cough properly

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

OBJECTIVE S Patient will have breath sounds effective cough with exploration of sputum

INTERVENTI ON 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 increase bronchial fluid product and promote expectoration and cough 3.Maintain fluid intake of 3L daily to liquefy secretions

RATIONAL E

IMPLEMENT ATION

EVALUATION

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 Administered activity expectorant to increase To ensure bronchial fluid that patients production basic needs are met To reduce Maintain fluid cardiac work intake of 3L load daily Patient can an active participant on that

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

NURSING DIAGNOS IS

OBJECTI VES Patient maintains normal nutritional status and maintain normal weight

INTERVENTION

RATIONALE

IMPLEMENT ATION

EVALUAT ION Patient maintained normal nutritional status than before

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

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

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 Patient experiences increased tolerance for activity

INTERVENTI ON 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 Assessed response to activity

EVALUATIO N

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 Patient gains enough knowledge regarding treatment regimen

INTERVENTI ON 1.Assess the ability to continue self care at home

RATIONA LE

IMPLEMENTATI ON

EVALUATI ON

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 To prevent relapse of pneumonia and developme nt Encouraged the patient to continue full course of antibiotic therapy

2.Encourage patient to continue on 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 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