NURSING HISTORY

 IDENTIFICATION DATA
 Name- Mr. Suraj dubey
 Age- 60 year
 Sex- male
 Hospital name- Medanta the Medicity
 Registration no/ I.P. no- 664898
 Unit/ ward- HDU 8TH floor A wing
 Bed no- 22
 Address- Kanpur
 Medical diagnosis- Chronic kidney disease
 Date of admission- 19/11/2015
 Date of discharge- not yet planned
 Date of care started- 19/11/2015
 Date of care ended- 20/11/2015

 SOCIO ECONOMIC DATA

 Religion- Hindu
 Caste- Brahmin
 Education- 12th
 Occupation- Businessman
 Marital status- Married
 Spiritual belief- He has belief in lord Shiva
 Income (per month/ annual)- 40,000/ month
 Language known
 Able to understand- Hindi, English
 Able to speak- Hindi
 Able to read and write- Hindi, English

 Family composition

S. no Name Age Sex Relationship Education Occupation Health Remark

status
1 Mr. 60 M Patient 12th Businessm Sick
Suraj year an

2 Mrs. 54 F Wife 10th House wife Healthy

Pooja year

3 Mr. 26 M Son M.B.A. Job Healthy

Aayush year
Family pedigree

60 year 54 year

26 year

 HEALTH HISTORY
 Reason for hospitalization- Patient has complaints of difficulty to pass the urine and
breathing difficulty and edema in lower extremities.

 Mode of coming to hospital/ward- By own car

 Present illness
 Medical- Mr. Suraj was admitted with the complain of heaviness in chest with
breathlessness difficulty to pass the urine and edema in legs.
 Surgical- Mr. Suraj does not under gone any surgical procedure. But he has done the
dialysis 4- 5 times.

 Past illness:
 Medical- Mr. Suraj has history of hypertension since 2 years.
 Surgical- Mr. Suraj does not gone any past surgical procedure.

 Family history- Mr. Suraj living in small family. He is having good relationship with his
family member.

 Allergic history- Mr. Suraj has no history of any allergy with food and medicine.

 Dietary pattern
 Diet: Vegetarian
 Likes: Rice
 Dislikes: Pumpkin
 Habits: Mr. Suraj has a habit of smoking since 10 years.

 GORDONS FUNCTIONAL HEALTH PATTERN ASSESSMENT:

 Health perception:
Health management pattern: Mr. Suraj maintained his health. At present his health is
improved and he is conscious about his health.

 Nutrition:
 Metabolic health pattern: Mr. Suraj used to have food twice a day daily. He is both
vegetarian..

 Elimination pattern: Mr. Suraj has abnormal elimination pattern. He has having urination
of 4-5 times.

 Activity pattern:
Exercise pattern: Mr. Suraj is able to perform range of motion exercise but for short
period.

 Sleep:
Rest pattern: Mr. Suraj used to sleep 8 hours of a day. He sleeps regularly.

 Cognitive:
Perceptual pattern: Mr. Suraj has good sensory function of hearing, touch, smell and
pains are normal. Patient has god recent, immediate and remote memory.

 Self perception pattern: The voice pattern of client is dull.

 Role:
Relationship pattern: Mr. Suraj having good relationship with family and society.

 Sexuality:
Reproductive pattern: Mr. Suraj is married and he is having no disease related to
reproductive system.

 Coping:
Stress tolerance pattern: Mr. Suraj can cope up with the disease condition. He is aware of
his health problem.

 PHYSICAL EXAMINATION
 General health status:
 Level of consciousness- Conscious
 Height 162cm
 Weight 72 kg
 Appearance- Thin
 Complexion- Whitish
 Head to toe assessment
 General appearance-
Observations: Patient is thinand inactive
 Color: Whitish
Skin: Dry

 Vital signs

Vital signs Patient value Normal value (oral/axilla Remark

Temperature In Celsius In In Celsius In
Fahrenheit Fahrenheit
37 C 98 F 37.2 98.7 F
pulse 90b/min 72-80b/min
Respiration 18-20b/min 16-20b/min
Blood pressure 140/100 mm hg 120/100 mm hg

Head and face

 Size-
 Symmetry: Symmetrical
 Shape: Oval
 Color: Whitish
 Pain: Absent
 Tenderness: Absent
 Lesion: Absent
 Edema: Absent
 Scalp-
 Colour: White
 Texture: Hydrated
 Scales: Absent
 Lumps: Absent
 Lesions: Absent
 Inflammation: Absent
 Hair
 Colour: Black
 Face:
 Shape: Round
 Colour: whitish
 Movement: Normal
 Expression: Anxious
 Pigmentation: Absent
 Acne: Absent
 Tics: Absent
 Tremors: Absent
 Scars: Absent

Eyes:
 Acuity:
 Glasses: Absent
 Visual loss: Normal
 Diplopia: Absent
 Photophobia: Absent
 Pain burning: Absent
 Eyelids-
 Color: Black
 Potosi’s: Absent
 Edema: Absent
 Sty: Absent
 Extra ocular movement-
 Position and alignment of eyes: Symmetrical
 Strabismus: Absent
 Nystagmus: Absent
 Conjunctiva-
 Colour: Pale
 Discharge: Absent
 Vascular changes: Absent
 Iris-
 Colour: Ambiguous
 Vascularity: Present
 Jaundice: Absent
 Pupils-
 Size: 2 mm
 Shape: Normal
 Equality: Normal
 Reaction to light: Reactive

Ears-

 Acuity
 Hearing loss: Able to hear
 Hearing aid: Absent
 Pain: Absent
 Tinnitus: Absent
 External ear-
 Lobe: Normal
 Auricle: Present
 Ear canal: Present
o Inner ear
 Vertigo: Absent

Nose-
  Smell: Present
 Symmetry: Symmetrical
 Flaring: Absent
 Sneezing: Present
 Deformities: Absent

Mucosa

 Color: Red
 Edema: Absent
 Exudates: Absent
 Pain tendencies: Absent
 Sinus tenderness: Absent

Mouth and Throat

 Odor: Foul smelling

 Pain: Inflammatory
 Ability to speak: Clear
 Chew: Not
 Swallow: No problem
 Lips-
 Hydration: dry lips
 Lesions: Absent
 Blister: Absent
 Swelling: Absent
 Numbness: Absent
 Gums-
 Colour: Pink
 Edema: Non pitting edema
 Bleeding: Absent
 Teeth-
 Number: 32
 Missing: No
 Caries: Absent
 Tongue-
 Symmetry: Symmetrical
 Color: Coated tongue
 Hydration: Dry
 Protrusion: Absent
 Ulcers: Absent
 Swelling: Absent
 Throat-
 Gag reflex: Present
 Soreness: Non sensitive
  Cough: Dry
 Sputum: Thin
 Hemoptysis: Absent
 Voice-
 Hoarseness: Absent
 Loss: Dysphonic
 Neck
 Symmetry: Symmetrical
 Movement: Passive
 Range of motion: Present
 Masses: Absent
 Scars: Absent
 Pain: Absent
 Stiffness: Absent
 Trachea-
 Deviation: Absent
 Thyroid-
 Symmetry: Symmetrical
 Tenderness: Absent
 Enlargement: Absent
 Nodules: Non palpable
 Scares: Absent
 Lymph nodes-
 Size: Normal
 Shape: Round
 Mobility: Absent
 Tenderness: Absent
 Enlargement: Absent

Chest

 Size: Normal
 Symmetry: Symmetrical
 Deformities: Absent
 Pain: Absent
 Tenderness: Absent
 Skin-
 Color: Whitish
 Rashes: Absent
 Scars: Absent
 Hair distribution: Regular
 Turgor: Poor
 Temperature: Normal

Lungs
  Breathing pattern: Irregular
 Rate: 14 breath/ min
 Regularity: Irregular
 Depth: Short
 Use of accessory muscles: Passive
 Sound: Whizzing
 Cardiac patterns-
 Rate: 85b/min
 Regularity: Irregular
 Implanted pacemaker: Absent

Abdomen

 Symmetry: Symmetrical
 Muscle tone: Good
 Turgor: Good
 Hair distribution: Regular
 Scars: Surgical
 Umbilicus: Inverted
 Distention: Absent
 Sound: Normal
 Liver border: Palpitation

Kidney

 Urinary output: Decreased

 Amount: 450ml/ day
 Colour: Yellow
 Frequency: Slow
 Dribbling: Absent
 Incontinence: Absent
 Hematuria: Absent
 Nocturia: Absent

Genitalia

 Male- Penis
 Discharge: Absent
 Ulceration: Absent
 Pain: Absent
 Scrotum: Present
 Swelling: Absent
 Tenderness: Absent
 Testis:
 Size: Normal
 Shape: Normal
  Swelling: Absent
 Masses: Absent

Rectum

 Pigmentation: Absent
 Hemorrhoid: Absent
 Rashes: Absent
 Masses: Absent
 Lesions: Absent
 Tenderness: Absent
 Pain: Absent
 Itching: Absent
 Burning sensation: Absent
 Back-
 Scars: Absent
 Edema: Absent
 Spiral abnormalities: Absent
 Pain: Absent
 Tenderness: Absent

Extremities

 Upper extremities-
 Symmetry: Symmetrical
 Joint: Normal
 Muscle: Normal
 Edema: Absent
 Other symptoms: Absent
 Lower extremities-
 Symmetry: Symmetrical
 Joint: Normal
 Muscle: Absent
 Edema: Present
 Other symptoms: Absent

Reflexes

 Biceps and triceps reflexes: Present

 Patellar reflex: Present
 Plantar reflex: Present

Focal assessment: Mr. Suraj dubey diagnose a chronic kidney disease.

Inspection: He is having chest pain.

Palpitation: Abdominal distended

 Auscultation: Wheezing sound present

Percussion: No gas present

INVESTIGATION:

S. no Date Name of the investigation Patient value Normal value Inference

1 20/11/15 CBC- HB 7gm/dl 13-18 gm/ dl Decreased
2 20/11/15 Total count 12,500 4000-10,000 Increased
3 20/11/15 CPK 1454U/L 24-1950/L Increased
4 20/11/15 Urea 60 mg/dl 10 – 50 mg/dl Increased
5 20/11/15 Prothrombin time 11 sec 12 – 20 sec Normal
6 20/11/15 Serum sodium 120 Meq/l 135-147meq/l Decreased
7 20/11/15 Serum potasium 4.5Meq/l 4.5-5.5 Meq/l Normal

 X ray chest done

 USG KUB done
 MEDICAL TREATMENT:

S. Name of Pharma- Dose Route Freque Action Contra Side effects Nurses
n the cological ncy indication responsiblit
o medication name y
1 Inj. lasix Furosemide 2ml IV BD Diuretic Diabetes, increased Tablet
Gout, Low urination, should be
Amount of thirst, stored in
Magnesium muscle room
in the Blood, cramps, temperatur
Low Amount itching or e.
of Calcium rash,
in the Blood. weakness,
dizziness,
spinning
sensation
2 Tab. pantaprazole 40 orally BD Antacid Clostridium Rashes, Advice to
pantocid mg Bacteria itching avoid drink
Related alcohols
Colitis,
Osteoporosis,
Broken
Bone, .
3 Tab. Lorazepam 1mg orally HS Sedative Allergy or Drowsiness, Always
Ativan hypersensitiv confusion follow
ity rights
4 inj. Tazar Tazobectum 4.5 IV BD Antibioti Pregnancy Diarrhea, Always
pipracilin gm c joint pain, administer
back pain as per
doctor
order.
 CRITICAL PATHWAY

S.no Name of the investigation and Day one Day two Day three Day four
value
1 Serum sodium 125meq/l 129meq/l 133meq/l 136meq/l

INTAKE AND OUT PUT CHART

DATE INTAKE OUTPUT

TIME BY TUBE PARENT URINE EMESIS SUCTI-
MOUTH RAL VOIDED CATHET ON
ER
7am Tea- 50ml - NS 100 ml - 250 ml - -

9am Poha 150ml - - - -

Milk- 100ml
2 pm Lunch and - - - -
water- 300
ml
TOTAL 650 ml 100 ml 250 ml
3pm- - NS 100 ml - 150 ml - -
11pm
5pm Tea- 50 ml - - 200ml - -

8pm Dinner and - - - - -

water- 250
ml

TOTAL 400 ml 350 ml

11pm-
7am 150 ml
Water-100 -
11pm ml

100 ml 250 ml

24 1350 ml 200 ml 850 ml

HOUR
Total

NURSING THEORY APPLICATION:

Virginia Henderson theory: she develops her definition based on sciences of philosophy
medicine, psychology and physics. In this she emphasizes the care of sick and week individuals.
According to her she assists the patient with essential activities to maintain health, recover from
illness or peaceful death.
Assessment:

 Asses the urine output.

 Assess the breathlessness and breathing pattern.
 Assess for level of pain, chest comfort.
 Assess for nutrition pattern and anorexia.
 Assess for anxiety and fear.

Nursing intervention:

 Catheterize the patient

 Provide Comfortable position
 Provide oxygen therapy
 Provide small and frequent diet

Henderson theory:

 Easily measure the urine output.

 Breath normally
 Move and maintain desirable positions.
 Eat and drink adequately.
 Eliminate body waste.

Need of the patient:

 Need to manage for the chest pain.

 Need for normal breathing.
 Need for the maintenance of nutritional status.

Nursing diagnosis:

 Disturbed Thought Process related to Physiological changes.

 Ineffective breathing pattern related to inadequate oxygenation as evidenced
breathlessness..
 Activity intolerance related to decreased cardiac output as evidenced by inability to
perform activities.
 Disturbed sleep pattern related to shortness of breath and physical discomfort as
evidenced by verbalization.
 Anxiety and stress related to its prognosis and discomfort as evidenced by queries done
by the patient.
 Planning

Assessment Nursing Goals Intervention Implementation Rationale Evaluation

diagnosis
Ineffective Patient Check the vital Checked the To see the signs Patient got
Subjective breathing will sign. vital sign. of breathlessness relived
data: pattern maintain from
patient says related to the Check the Checked the To detect the breathless
that he is inadequate normal oxygen level oxygen level changes in ness as
having oxygenatio breathing with pulse with pulse oxygen level. manifeste
shortness n as pattern. oximetre. oximetre. d by
of breath. evidenced respiratory
Objective by Provide rate.
data: I shortness fowler’s Provided Fowlers position
observed of breath. position to the fowler’s descends the
that patient patient. position to the diaphragm and
having patient. gives more space
difficulty Provide to lungs for
oxygen supply. expansion.

Provided Oxygen helps to

oxygen supply. maintain the
saturation level.

Planning

Assessment Nursing Goals Intervention Implementati Rationale Evaluation

diagnosis on

Subjective data: Activity Patient Monitor the Monitored To know about Patient
patient says that intolerance will patient level the patient the activity of maintained
he is having related to improve of activity. level of patient. the normal
weakness and breathlessness the activity. activities as
fatigue. as evidenced activity. manifested
by fatigue, Provide Provided Good sleep by
Objective data: weakness and comfortable comfortable induces the performed
he cannot do inability to position to position to energy level. his daily
the activity he perform the patient. the patient. activities.
needs ability.
assistance. Teach about Taught about To achieve
energy energy maximum
conservation conservation independence
technique. technique. for self care.
 Planning

Assessment Nursing Goals Intervention Implementation Rationale Evaluation

diagnosis

Subjective data: Anxiety To Assess the Assessed the To know Anxiety

patient says that related to relieve level of level of anxiety. how much levels
I am feeling very disease the anxiety. anxious he reduced as
fear about the condition as anxiety. is. manifested
disease. evidenced by by
restlessness Verbalize Verbalized with It helps to verbalize.
Objective data: and verbalize. with the the patient. reduce the
patient was very patient. anxiety.
anxious and
depressed. Given the It helps to
Give the patient relieve her
patient psychological anxiety to
psychologic support. some extent.
al support. .
.

Nursing management:

In book In patient

Advice the patient to stop smoking. Advice the patient to stop smoking.

Advice him to do daily exercise regularly. Advice him to do daily exercise regularly.

Advice to keep weight. Advice to keep weight

Advice to eat a low fat diet. Advice to eat a low fat diet.

.Health education:

 Nutrition
To eat more vegetables
To increase the intake of water.
Avoid fried and spicy food.
 Medication:
Advice to take medicine as per doctor order.
Advice to take medicine after meals.
 Exercise:
Educate the patient to avoid exercise which makes him more tired and steneous.
 Follow up:
Advice him to do as follow up.