TYPHOID,IGG ,IGM POSITIVE

INDUS COLLEGE OF NURSING (ICON)

History of Patient

Patient’s name:shazia salim Sex: Female

Patient information: Typhoid

Age: 30 years Marital status: Married

Religion: Islam Culture:Punjabi

language:Punjabi. Occupation;no

Education: NILL Diagnosis:TYPHOID,IGG,IGM

POSITIVE

Surgeries: None.

Allergies:tab brufin. Physician:dr naseem BED # 40

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TYPHOID,IGG ,IGM POSITIVE

WEEKLY CLINICAL OBJECTIVES

Student Name: ASIA VICTORIA

Objectives:
At the end of my clinical 1st week, I will be able to:
OBJECTIVES STRATEGY

 Select a patient from assign ward  Random

 Introduce myself to the patient  Communication skills

 Develop repot in front of the patient.  Communication skills

 History Taking
 Take history of the patient

 Nursing Diagnosis
 Identify Patient’s health problems

 Health education
 Provide Problem Based Learning (PBL)

 Prepare a concept map according patient  Cognitive skills

disease

 Make an article according to disease  Summarization

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TYPHOID,IGG ,IGM POSITIVE

Assessment Tool: Functional Health Pattern

1. HEALTH PERCEPTION AND HEALTH MANAGEMENT:

General state of health (client description): NILL

Health practices: (responsibility for health restoration and maintenance): Appropriate.

Medication (at home): Prescribed.

Immunization status: None.

Knowledge of disease and preventive behavior: Appropriate.

General appearance: Lethargic.Weak.Pale.

Current health problem for seeking health care: C/o HEADACHE,VOMITING,FEVER,

WEAKNESS.ANUREXIA.

Previous childhood/adult illnesses, accidents, injuries, hospitalization:yes 5 yrs back

2. NUTRITION-METABOLIC PATTERN:

Weight: 78kg. Height: 176cm. Skin: Normal Turgor Color: Pale

Fluid intake: 2-3 glasses of water a day.

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TYPHOID,IGG ,IGM POSITIVE

3. ELIMINATION PATTERN:

Gastrointestinal:

Diet: Normal routine as usually take. Preferences: Soft Diet..

Dislikes: Cold diet.

Abdomen; Soft in palpation.

Bowel sounds: Normal.

Bowel function: Normal assess out stool twice a day.

Genitourinary:

Bladder: voided about 6 to 8 times a day. Out put: 800-1000 ml/day.

4. ACTIVITY EXERCISE PATTERN:

Respiration:

Respiratory rate: 30/min. Rhythm: Normal

Breath sounds: ---------------------------------------------------------------------------------------

Cough:no Sputum:no Color:none

Temperature: Normal B.P: 120/80 mmHg Pulse rate: 100/min

Capillary refill: 2-3 seconds

Color of extremities: Normal Edema: No

chest pain: Mild.

ACTIVITY:

Typical day activity: daily routine

ROM: full

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TYPHOID,IGG ,IGM POSITIVE

Side rails: prevent from fall.

5. SLEEP REST- PATTERN:

Usual sleep pattern:

Night hours: Slept for about 5 to 7 hours

Quality: Generally rested and ready for activity after sleep.

In hospital: normal

Use of sleep aids: nill

6. COGNITIVE PERCEPTUAL PATTERN:

LOC: Appropriate. Orientation: Fully

Memory: Appropriate Recent: Appropriate Past: Appropriate

Speech/voice: NOT CLEARED

language barrier:no Sensory status: Appropriate

7. SELF PERCEPTION/SELF CONCEPT PATTERN:

Feeling about self/self esteem: Good self steam he is a decision maker of family.

Body image: Good positive self steam.

Emotional state/affect: No

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TYPHOID,IGG ,IGM POSITIVE

8. ROLE- RELATIONSHIP PATTERN FAMILY:

Family:middle.

Family system: Nuclear.

Family significant others:

Communication pattern (decision making): Yes.

Roles and responsibilities in family/problems: As a Decision maker of all.

Socialization: Good. Financial situation: Poor.

9. SEXUALITY/REPRODUCTION PATTERN:

Reproductive history: Appropriate age and situation and sexual relationships satisfying.

10. COPING-STRESS TOLERANCE PATTERN:

Stressors/major life changes: None.

Coping mechanisms/problem management: Well.

Use of alcohol/tobacco/pan/cigarette/prescribed drug: none

11. VALUE BELIEF PATTERN:

Satisfaction with life: Yes satisfied with life.

Spirituality/religious beliefs:

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TYPHOID,IGG ,IGM POSITIVE

NURSING CARE PLAN (NCP)

TYPHOID

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective data: Decrease Short term  Check BP every 15 Short term goal:
pt having severe cardiac out goal:after 6 mints and after .within 6hrs
headache put related to hrs of 1/2hrly during after the nursing
associated with malignant nrsg/intr the drugs. intervention
vomiting.and hypertention client have client,s had no
 Monitor ECG for
feeling RT sided as manifested no raises in elevation in
weakness.pt by decrease blood dysrrythmias, blood
Verbalized. strok volume. pressure  Conduction pressureand will
above normal defects and for maintain blood
limits heart rate. pressure in
.  Sagest frequent normal
Long term position change. limits.goal
Objective data: goal: after 5 acchived.
 Encourage pt to
Lethargic days client
Decrease cardiac will maintain decrease intake Long term goal:
out put. adequate of coffein ,cola After 5 days of
Decrease stroke cardiac and chocolate. nursing
volume. output and  Observe skin intervention
Increase peripheral cardiac color client will
vascular resistance index. ,temperature,capi maintain
llary refills and adequate
Vital signs cardiac output
diaphorasis.
Temp:38C and cardiac
P:88 index.goal met.
R:30
BP:16O/110mmHg

Faculty Signature :____________________

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TYPHOID,IGG ,IGM POSITIVE

Disease Concept Map (DCM)

HYPERTENTION
Causes. Symptoms.
DEFINITION.
The cause of  Sweating.
hypertension is  Anxiety
often not known.  Sleeping
Hypertension is problems
another name for
 Blushing
Around 1 in high blood pressure. It
can lead to severe  Headache
every 20
complications and  Blurried
cases of increases the risk of vision
hypertension is heart disease, stroke,
death.Blood  Neck pain
and death.
the effect of an pressure
Blood pressure
is the force
is the  Nausea
underlying exerted
force exerted
by thebyblood
the  Vomiting
against
blood against
the walls
the ofwalls
the of  Teeth pain.
condition or blood
the blood
vessels.
vessels.
... ...
medication. Unmanagedhypertensio
Unmanaged
n can lead to acan
hypertension heartlead
attack,
to a heart
stroke,
attack,
andstroke,
other
Chronic kidney problems.
and other Nov
problems.
21, 2018
disease (CKD) is
a common
cause of high
blood pressure
because the
kidneys do not Treatmen
filter out fluid.
 diuretics,
This fluid excess
thiazides,
leads to
chlorthalidone,
hypertension.
indapamide.be
Tests.
eta-
Cbc
blockers ,alpha-
Sr na,k ,ca,urea blockers
,cretinin,Rbs.
 calcium-channel
urinalysis blockers.central
agonist.

 central agonists 8

 peripheral
adrenergic
 TYPHOID,IGG ,IGM POSITIVE

DRUG CARD

Injection lasix:

Trade Name Indications:Lasix

Genric name:furosemide.

Dose available: inj lasix 20mg/ml,tab lasix 20mg,40mg.

Dose:20 to 80 mg as a single dose.

Drug classification: Loop diuretic.

Indications: edema,pulmonary edema,hypertention,heart diseases,renal diseases ,liver cirrhosis.

: CONTRAINDICATIONS / PRECAUTIONS

 Sulfonamide hypersensitivity, thiazide diuretic hypersensitivity. ...

 Acid/base imbalance, electrolyte imbalance, hypocalcemia, hypochloremia, hypokalemia,
hypomagnesemia, hyponatremia, metabolic alkalosis. ...
 Diabetes mellitus, hyperglycemia. ...
 Diarrhea, heart failure, ventricular arrhythmias.

Nursing considerations
CLINICAL ALERT! Name confusion has occurred between furosemide and
torsemide; use extreme caution.

 Adverse Effects:

 Nursing Considerations:

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TYPHOID,IGG ,IGM POSITIVE

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