KARDEX

Date Medications Dose Time Date Nursing care plan Time

Date Treatment Dose Time

Age Sex Bath T.P.R B.P Diet

Religion

Name of the patient Bed Diagnosis Doctor name IPNO

no

1
 ARCHANA COLLEGE OF NURSING, PANDALAM

NURSING FOUNDATION

Proforma For Health Assessment

Name of the patient:

Age:

Sex:

Marital status:

Religion:

Education:

Occupation:

Spoken language:

Income:

Address:

I.p.no:

Bed no:

Ward:

Date of admission: 10/4/13.

HEALTH ASSESSMENT

Name of the patient: Mr. V.Nookaraju

2
Age: 59years

Sex: Male

Marital status: Married

Religion: Hindu

Education: Degree (B.COM)

Occupation: Employee, Dept. ESR

Spoken language: Telugu, English

Address: V. Nookaraju, sector-6, 302, steel plant

Date of admission: 26/3/13.

Medical diagnosis: Chronic Obstructive Pulmonary Disease

Physician: Dr. Venkata Challam, M.B.BS (Medical physician)

Date and duration of nursing care: 5 days of nursing care plan

Date of discharge: 14-4-13.

HISTORY COLLECTION

Chief complaints:

My patient Mr. V. Nookaraju, age 59years, admitted in ICU ward in Visakha steel
general hospital complains of breathlessness, severe cough weakness, chest tightness from
last 2days onwards

History Present illness:

My patient Mr. V. Nookaraju, age 59years, admitted in ICU ward in Visakha steel
general hospital complains of breathlessness, severe cough weakness, and chest tightness
from last 2days onwards and it was diagnosed as chronic obstructive pulmonary disease.

3
Past medical history:

My patient not having any previous Injuries/ accidents and any communicable
diseases. My patient is hypertensive. He is taking medication last 4 years on wards.

Present surgical history:

There is no significant or evident present surgical history.

Past surgical history:

Previous hospitalization – 2006 appendectomy; and there is no other surgical

histories.

Family history:

Any hereditary:

There is a history of diabetes and hypertension and there is no hereditary of congenital

abnormalities.

Family tree:

Family profile:

sl.no name of the family age sex R/ship occupation income

member
1 V.Nokkaraju 59 M husband employee 45,000/m
2 V. Pydithalli 50 F wife house wife -
3 V.Ravi 45 M son employee
15000/m
4 V.Rajlakshmi 30 F daughter in house wife -
law
5 V. Prasad 24 M son employee 10,000/m
6 V. Ratnam 20 F daughter in house wife -
law

4
 Personal history:

Diet:

Patient diet includes vegetarian and non-vegetarian 3 times / day. Non –vegetarian is
the favorite food habit.

Rest and sleep: Disturbed sleep pattern.

Nutrition: mixed diet

Elimination:

Pattern of Elimination: Before illness present

BOWEL ELIMINATION

Frequency – normally passing the stools

Character of stool Problems encountered such as constipation, diarrhoea, etc.

Every other day Yellowish brown, solid Constipation.

URINARY ELIMINATION

Frequency- 4-6 times

Quantity- 900ml

Character of urine Problems encountered such as pain, burning. Yellow to reddish in colour.

Nutritional history:

Time Diet Amount Calorie Protein CHO Fat

8am Tea 200ml 110.kcal 3.0 4.0 3.8
10am idly with 3 nos 372k.cal 6.9 58.9 0.2
chutney
12pm rice and dhal 200gm 690k.cal 6.9 74.5 5.2
tea 100gm 372k.cal 20.8 58.9 0.2
4pm rice and dhal 200ml 110 k.cal 3.0 4.0 3.8
8pm 200gm 690k.cal 6.9 74.5 5.2
100gm 372k.cal 20.8 58.9 0.2

Socio – economic history:

Housing: building house

Ventilation: well ventilated

Electricity: present

5
Water supply: municipality

My Patient is a hardworking person that’s why he was able to give what his family
needs. In their community hazard, patient was living in visakha steel plant quarters.

Environmental history:

My patient is unaware of problems he may encounter as a cook. He also

does overtime work. In their home and community hazard, patient said that their stairs in
house have several flights. He was always having difficulty in going up and down stairs. He
said that he have to move slowly for him to be safe.

PHYSICAL EXAMINATION

Vital signs:

vital signs patient value normal value remarks

temperature 98.60 f 98.60f normal
pulse 82b/m 72b/m abnormal
respiration 24b/m 16-20b/m abnormal
blood pressure 150/100mmhg 120-90mmhg abnormal

General examination:

Conscious: conscious

Orientation: oriented to time, place and date

Nourishment: moderate nourished

Health: un healthy

Body build: moderate

Activity: dull

Look: anxious

Hygiene: moderate hygiene

Speech: clear

REVIEW OF SYSTEM

Skin / integumentary system:

Colour: black/ dark colour

Texture: dry skin texture is smooth

6
Skin turgor: bad skin present

Hydration: well hydrations and Cold to touch

Discoloration: lower extremities discolouration of skin oedematous; redness and breaking

down of skin.

Head:

Distribution: The hair is distributed well

Color: The color of the hair is brown and some white hair, Dry hair
Head, dandruff: No head lice, dandruff or any infection
Size: Round head
Scalp: Scalp is smooth, No nodules or masses

Eyes:

Vision: normal vision, no visual disturbances

Glasses: not evident

Discharge: no discharges

Pain: no history of pain

Itching: no history of pain

 Proportion the size

 Eyebrows are black in color and symmetrical
 Conjunctiva is pale in color – due to decrease in RBC, Hgb and Hct. count
 Sclera are white in color and cornea are shiny
 No abnormal involuntary movements
 Can able to move in all direction
Ears:

Hearing: Poor hearing, Proportion to the size of the head

Pain: No pain, No presence of discharge
Itching: No itching

Ringing: no ringing sensation

Vertigo: no history of vertigo

Nails:

Nail beds: pale in colour

Nail plates: flat; absence of clubbing

7
Cyanosis: no central and peripheral cyanosis

Colour: black

Texture: dry

Nose& sinuses:

Deviated nasal septum: no deviation septum found

Discharge: no history of nasal discharge

Allergies: no history of allergies

Frequent cold: no history of any colds

Obstruction: no evident of obstruction

Pain: no history of pain

Epistaxis: no history of Epistaxis

 No tenderness, masses and displacement of the bone

 Maxillary and Frontal sinus is normal and not inflamed
Mouth and throat:

Tongue: The tongue is negative in lesions and tenderness

Lesions: Absent of any swelling, lesions and ulcerations

Lips: Lips are pale in color

Bleeding: no history of bleeding

Tooth decay: no history of tooth decay

Dental caries: No teeth in upper and lower incisors the pt. used dentures

Neck:

Stiffness: no history of stiffness

Limited motions: normal range of motion

Swelling: no history of swelling

Pain: no history pain

Thyroid disease: history of thyroid disease ( type –II DM)

 Symmetrical and freely movable without difficulty

 presence of jugular vein distension

8
Thorax:
 Crackles present
 Tachypnea- inadequate blood supply/decrease blood flow resulting to decrease
oxygen, the lungs need to compensate
 Cheynestokes breathing
CARDIO- VASCULAR SYSTEM:

Heart:
 murmur – abnormal heart sound present
 Tachycardia – 105bpm

History of hypertension: hypertensive

Varicose veins: no history of varicose veins

Dyspnoea: dyspnoea present

Chest pain: evident

palpitation: present

Heart sounds: present s1 &s2 sounds

Pulse: tachycardia

Heart beat: normal rate, rhythm

Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected.

Palpations: on palpations masses are detected

Percussion: no percussion done

Auscultations: on auscultation at 5 areas, pulmonic, aortic, erbs point, mitral and apical area,
s1 & s2sounds are heard, no abnormal gallop sounds.

Respiratory system:

Lesions: absence of lesion

Scars: absence of scars

Dysnea: present

Cough: present

Sputum: thick secretions are present

Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected.

Palpations: on palpations masses are detected

9
Percussion: no percussion done

Auscultations: on auscultation at wheezing sounds & murmurs sounds are heard.

Gastro-intestinal system:

Auscultation: bowel sounds present; peristalsis movement are present.

Inspection: no scars; lesions; hernia are not evident

Palpations: no tenderness/ hardness.

Percussion: abnormal sounds are present.

Genitor-urinary system:

Lesions: absence of lesion

Scars: absence of scars

Discharge: no discharges

Infections: no infections

Voiding: passing urine 6 to 7 times a day

Colour of urine: dark yellowish colour.

Muscular skeletal system:

Postural curve: kyposis, lordosis are absent

Muscle tone: no depth

Muscle strength: weakness than normal

Upper extremities:

Symmetry: symmetrical

ROM: normal range of motion

Reflexes: present

Joints: oedematous & swelling and tenderness is present

Lower extremities:

Symmetry: symmetric

ROM: normal range of motion

Gait: abnormal

10
 Varicose veins: present

INVESTIGATIONS

Date Specimen/ Type of Result Normal values Significance

investigation
27-3-13 hematological 120-160 g/L abnormal
 Hgb  162.0
 Total Red Cell 4.5-5.0 x 10-12
g/L

 Total WBC  10.2 5-10 x 10-19 g/L abnormal

 Segmenters  0.80 0.40-0.600. normal

 Lymphocytes  0.12 20-0.400. abnormal

 Monocytes 02-0.080.
 Eosinophiles  0.80 01-0.03 abnormal
 Basophiles 0-0.01
27-3-13 blood chemistry  98.0 75-115 mg/dL normal
Glucose mg/dL
FBS  5.44 4.2-6.4 mg/dL normal
mg/dL
Uric acid  8.4 mg/dL 2.4-7.0 mg/dL abnormal
Creatinine  2.7 mg/dL 0.5-1.7 mg/dL abnormal
BUN 10.1-50.0 mg/dL
Cholesterol  159.2 suspect normal
mg/dL >220mg/dL
Triglycerides  80.0 suspect normal
mg/dL >150mg/dL
chest x-ray normal normal

MEDICATIONS

slink drug action side effects nurses responsibility

1 Inj. Monocef 1gm BD antibiotic nausea, - Assess the general
vomiting, condition of patient
2 Inj. Amkacin 500mg BD antibiotic anorexia, - Observes for the
tachycardia, drug side effects
3 Inj.Dopamine,150mg,BD analgesic subsided fluid - Immediate nursing
4 T. Pantop, 400mg, BD retention, intervention are to

11
5 oxygen administration 4l/m antacid insomnia, etc be done
continuous administration - Administration of
inhalation duodline and alternative agonist
6 sarbutrate BD to prevent the side
effects.

NURSING DIAGNOSIS:

Based on the assessment data, major nursing diagnoses for the patient may include:
 Ineffective airway clearance related to: bronchoconstriction, increased sputum
production, ineffective cough, fatigue / lack of energy, broncho pulmonary infection.
 Ineffective breathing pattern related to: shortness of breath, mucus, bronchoconstriction,
airway irritants.
 Impaired gas exchange related to: ventilation perfusion inequality
 Activity intolerance related to: imbalance between oxygen supply with demand.
 Imbalanced Nutrition: less than body requirements related to: anorexia.
 Disturbed sleep pattern related to: discomfort, sleeping position.
 Bathing / Hygiene Self-care deficit related to: fatigue secondary to increased respiratory
effort and ventilation and oxygenation insufficiency.
 Anxiety related to: threat to self-concept, threat of death, purposes that are not being met.
 Ineffective individual coping related to: lack of socialization,anxiety,depression,'low
activity levels and an inability to work.
 Deficient Knowledge related to: lack of information, do not know the source of
information

12
 Theory application Roy’s adaptation model

Introduction:

 Sister callista Roy began her nursing career in 1963. After receiving B.Sc(N) noting from
moult saint marry college.
 1960receives Ms in nursing
 1977 her doctorate in sociology
 Roy’s model is characterised as a system theory with a strong analogies of intervention.

General system:

Due to set of organized components released to form a whole employee feedback

cycle of input, through put, output.

 INPUT: Input includes tensions adaption level (the range of stimuli to which persons
adaptation early)
 THROUGH PUT: through put makes use of a person processes and effect ions. Process
refers to control mechanism that a person uses as a adaptive system. Effectors refers to
the physiologic function, self concept and role function involved in adaptation.
 OUTPUT: output is the outcome of the system when system is a person. Output refers to
person’s behaviour.

Metaparadigm and RAM:

 Human being:Person is a bio psychological being in constant interaction with changing

environment and recipient the nursing care as living system
 Environment: Environment and surrounding and effect the development and behaviour
of the persons group. The internal and external are the part of the person’s environment.
For ex: elderly person admitted to hospital all the conditions of influence on him/her.
 Health: heath is a process whereby individual are striving to achieve their maximum
potential. It can be seen in healthy people, exercises regularly, not smoking pay attention
dietary pattern. It is a process to relieve acute and chronic illness and terminal stages of
diseases & to control the sign and symptoms, to promote health of the persons by
promoting adaptive responses.

13
 Nurses: the nurses to reduce the ineffective responses as output behaviour of the person.
The nurse promotes the health in all life processes. The nurses suggested by the model
include approaches aimed at maintaining adaptive responses that support the person’s
effort to creativity use his or her coping mechanism.
INPUT THROUGH PUT OUT PUT

- Early
Demoraghpical detection and -The client will
variables of the screening have knowledge
patient programs regarding
disease process
 name -monitor the
 age, vital signs Adequate
 sex, -Administer knowledge in
 education, continuous disease process
 occupation oxygen &
medication Rehabilitation &
 income follow up
- health
education
about disease
condition

feed back

14
 NURSES NOTES

Name of the patient: V. Nooka raju Ward: ICU

Age: 59years Diagnosis: COPD
Sex: male Dr. Name: Dr. Venkata challam
I.p no: 1305 Bed. no: 18

Time Diet Medication Nurses Care Plan

730 Idly with 10/4/13 observation:
chutney  Inj. Monocef 1gm BD Patient is very thin & less activity and
830 water 50ml weakness; cough; fever; breathlessness.
 Inj. Amkacin 500mg BD
800 coconut  Monitored vital signs
water 100ml  Inj.Dopamine,150mg,BD  Temp:98.60 F
 T. Pantop, 400mg, BD
rice porage  oxygen administration 4l/m  Pluse:82b/min
1030 1 cup continuous administration  Resp:24b/min
 inhalation duodline and
sarbutrate BD  Blood pressure:150/100mmhg
 SpO2: 93%
 Provide position changing frequently
45
10  Provide complete bed rest
 Provide calm environment
1055  Administer medication as per
physician prescribed
 Administered O2
 Provide nebulisation
30
9
 History collection and performed
physical examination
00
11
 Provide psychological support
1130
 Provided health education about
 Diet
1145
 Exercises
1215
 Personal hygiene
 Relaxation therapy.
lakshmi/St.N

15
16
 KARDEX

Date Medications Dose Time Date Nursing care plan Time

Date Treatment Dose Time

Age Sex Bath T.P.R B.P Diet

Religion

Name of the patient Bed Diagnosis Doctor name IPNO

no

17
 PATIENT PROFILE

Name of the patient: Mr. G. Sannibabu

Age: 54years

Sex: male

Marital status: Married

Religion: Hindu

Education: Degree

Occupation: Foremen

Spoken language: Telugu

Income: 40,000/month

Address: G. Sannibabu; Yunaparthi; pervade; vsp.

I.p.no: 6829

Bed no: 4

Ward: I C U

Date of admission: 10/4/13.

HEALTH ASSESSMENT

Name of the patient: Mr. G. Sannibabu

Age: 54years

18
Sex: male

Marital status: Married

Religion: Hindu

Education: Degree

Occupation: Foremen

Spoken language: Telugu

Address: G. Sannibabu; Yunaparthi; pervade; vsp.

Date of admission: 10/4/13.

Medical diagnosis: Ischemic cardio myopathy

Physician: Dr.Naveen

Date and duration of nursing care: 5 days of nursing care plan

Date of discharge: 14/4/13.

HISTORY COLLECTION

Chief complaints:

My patient Mr. G. Sannibabu, age 54years, admitted in ICU ward in VIsakha steel
general hospital complains of fever, weakness, swelling; pain; Oedema of both legs and feet;
Ischemic Cardiomyopathy

Present medical history:

My patient Mr. G. Sannibabu, age 54years, admitted in ICU ward in Visakha steel
general hospital complains of fever, weakness, swelling; pain; Oedema of both legs and feet;
at present diagnosed with Ischemic Cardiomyopathy

19
Past medical history:

My patient not having any previous Injuries/ accidents and any communicable
diseases. My patient is hypertensive and type –II diabetes mellitus. He is taking medication
last 4 years on wards.

Present surgical history:

There is no significant or evident present surgical history.

Past surgical history:

Previous hospitalization – 2006 appendectomy; and there is no other surgical

histories.

Family history:

Any hereditary:

There is a history of diabetes and hypertension and there is no hereditary of congenital

abnormalities.

Family tree:

Family profile:

sl.no name of the family age sex R/ship occupation income

member
1 G.Sannibabu 54 M husband farmer 10,000/m
2 G. Pydithalli 50 F wife farmer -
3 G. Ravi 35 M son farmer -
4 G. Rajlakshmi 30 F daughter in house wife -
law
5 G. prasad 24 M son cooli 4,000/m
6 G. Ramesh 20 M son - -

20
 Personal history:

Diet:

Patient diet includes vegetarian and non-vegetarian 3 times / day. Non –vegetarian is
the favorite food habit.

Rest and sleep: Disturbed sleep pattern.

Nutrition: mixed diet

Elimination:

Pattern of Elimination: Before illness present

BOWEL ELIMINATION

Frequency – frequently passing

Character of stool Problems encountered such as constipation, diarrhea, etc.

Every other day Yellowish brown, solid Constipation.

URINARY ELIMINATION

Frequency- 4-6 times

Quantity- 900ml

Character of urine Problems encountered such as pain, burning. Yellow to reddish in color.

Nutritional history:

Time Diet Amount Calorie Protein CHO Fat

8am tea 200ml 110.kcal 3.0 4.0 3.8
10am idly with 3 nos 372k.cal 6.9 58.9 0.2
chutney
12pm rice and dhal 200gm 690k.cal 6.9 74.5 5.2
tea 100gm 372k.cal 20.8 58.9 0.2
4pm rice and dhal 200ml 110 k.cal 3.0 4.0 3.8
8pm 200gm 690k.cal 6.9 74.5 5.2
100gm 372k.cal 20.8 58.9 0.2

Socio – economic history:

Housing: building house

Ventilation: well ventilated

Electricity: present

21
Water supply: municipality

My Patient is a hardworking person that’s why he was able to give what his family
needs. In their community hazard, patient was living near the main road, air and noise
pollution affects them but the patient interpreted that their place is safe.

Environmental history:

My patient is unaware of problems he may encounter as a cook. He also

does overtime work. In their home and community hazard, patient said that their stairs in
house have several flights. He was always having difficulty in goingup and down stairs. He
said that he have to move slowly for him to be safe.

PHYSICAL EXAMINATION

Vital signs:

vital signs patient value normal value remarks

temperature 98.60 f 98.60f normal
pulse 82b/m 72b/m abnormal
respiration 24b/m 16-20b/m abnormal
blood pressure 150/100mmhg 120-90mmhg abnormal

General examination:

Conscious: conscious

Orientation: oriented to time, place and date

Nourishment: moderate nourished

Health: un healthy

Body build: moderate

Activity: dull

Look: anxious

Hygiene: moderate hygiene

Speech: clear

REVIEW OF SYSTEM

Skin / integumentary system:

Colour: black/ dark colour

Texture: dry skin texture is smooth

22
Skin turgor: bad skin present

Hydration: well hydrations and Cold to touch

Discoloration: lower extremities discolouration of skin oedematous; redness and breaking

down of skin.

Head:

Distribution: The hair is distributed well

Color: The color of the hair is brown and some white hair, Dry hair
Head, dandruff: No head lice, dandruff or any infection
Size: Round head
Scalp: Scalp is smooth, No nodules or masses

Eyes:

Vision: normal vision, no visual disturbances

Glasses: not evident

Discharge: no discharges

Pain: no history of pain

Itching: no history of pain

 Proportion the size

 Eyebrows are black in color and symmetrical
 Conjunctiva is pale in color – due to decrease in RBC, Hgb and Hct. count
 Sclera are white in color and cornea are shiny
 No abnormal involuntary movements
 Can able to move in all direction
Ears:

Hearing: Poor hearing, Proportion to the size of the head

Pain: No pain, No presence of discharge
Itching: No itching

Ringing: no ringing sensation

Vertigo: no history of vertigo

Nails:

Nail beds: pale in colour

Nail plates: flat; absence of clubbing

23
Cyanosis: no central and peripheral cyanosis

Colour: black

Texture: dry

Nose& sinuses:

Deviated nasal septum: no deviation septum found

Discharge: no history of nasal discharge

Allergies: no history of allergies

Frequent cold: no history of any colds

Obstruction: no evident of obstruction

Pain: no history of pain

Epistaxis: no history of Epistaxis

 No tenderness, masses and displacement of the bone

 Maxillary and Frontal sinus is normal and not inflamed
Mouth and throat:

Tongue: The tongue is negative in lesions and tenderness

Lesions: Absent of any swelling, lesions and ulcerations

Lips: Lips are pale in color

Bleeding: no history of bleeding

Tooth decay: no history of tooth decay

Dental caries: No teeth in upper and lower incisors the pt. used dentures

Neck:

Stiffness: no history of stiffness

Limited motions: normal range of motion

Swelling: no history of swelling

Pain: no history pain

Thyroid disease: history of thyroid disease ( type –II DM)

 Symmetrical and freely movable without difficulty

 presence of jugular vein distension

24
Thorax:
 Crackles present
 Tachypnea- inadequate blood supply/decrease blood flow resulting to decrease
oxygen, the lungs need to compensate
 Cheynestokes breathing
CARDIO- VASCULAR SYSTEM:

Heart:
 murmur – abnormal heart sound present
 Tachycardia – 105bpm

History of hypertension: hypertensive

Varicose veins: no history of varicose veins

Dyspnoea: dyspnoea present

Orthopnea: not evident

Chest pain: evident

palpitation: present

Claudication: not evident

Heart sounds: present s1 &s2 sounds

Pulse: tachycardia

Heart beat: normal rate, rhythm

Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected.

Palpations: on palpations masses are detected

Percussion: no percussion done

Auscultations: on auscultation at 5 areas, pulmonic, aortic, erbs point, mitral and apical area,
s1 & s2sounds are heard, no abnormal gallop sounds.

Gastro-intestinal system:

Auscultation: bowel sounds present; peristalsis movement are present.

Inspection: no scars; lesions; hernia are not evident

Palpations: no tenderness/ hardness.

Percussion: abnormal sounds are present.

Genitor-urinary system:

25
 Lesions: absence of lesion

Scars: absence of scars

Discharge: no discharges

Infections: no infections

Voiding: passing urine 6 to 7 times a day

Colour of urine: dark yellowish colour.

Muscular skeletal system:

Postural curve: kyposis, lordosis are absent

Muscle tone: no depth

Muscle strength: weakness than normal

Upper extremities:

Symmetry: symmetrical

ROM: normal range of motion

Reflexes: present

Joints: oedematous & swelling and tenderness is present

Lower extremities:

Symmetry: symmetric

ROM: normal range of motion

Gait: abnormal

Varicose veins: present

INVESTIGATIONS

Date Specimen/ Type of Result Normal values Significance

investigation
10-7-12 hematological 120-160 g/L abnormal
 Hgb  162.0
 Total Red Cell 4.5-5.0 x 10-12
g/L

 Total WBC  10.2 5-10 x 10-19 g/L abnormal

26
  Hct  0.49 0.38-0.50 normal
 Clottingtime 2-5 min
1-3 min
 Bleedingtime

 Segmenters  0.80 0.40-0.600. normal

 Lymphocytes  0.12 20-0.400. abnormal

 Monocytes 02-0.080.
 Eosinophiles  0.80 01-0.03 abnormal
 Basophiles 0-0.01
10-7-12 blood chemistry  98.0 75-115 mg/dL normal
Glucose mg/dL
FBS  5.44 4.2-6.4 mg/dL normal
mg/dL
Uric acid  8.4 mg/dL 2.4-7.0 mg/dL abnormal
Creatinine  2.7 mg/dL 0.5-1.7 mg/dL abnormal
BUN 10.1-50.0 mg/dL
SGOT  55.7 u/L up to 37 u/L abnormal
37C
SGPT  52.7 u/L up to 42 u/L abnormal
37C
Cholesterol  159.2 suspect normal
mg/dL >220mg/dL
Triglycerides  80.0 suspect normal
mg/dL >150mg/dL
HDL-P  35.2 > 35 mg/dL normal
mg/dL
LDL  168.0 < 150 mg/dL abnormal
mg/dL

MEDICATIONS

slink drug action side effects nurses responsibility

1 Inj. Monocef 1gm BD antibiotic nausea, - Assess the general
vomiting, condition of patient
2 Inj. Amkacin 500mg BD antibiotic anorexia, - Observes for the
tachycardia, drug side effects
3 Inj.Dopamine,150mg,BD analgesic subsided fluid - Immediate nursing
4 T. Floxen, 150mg, TID analgesic retention, intervention are to
5 T. Pantop, 400mg, BD antacid insomnia, etc be done
- Administration of
alternative agonist

27
 to prevent the side
effects.

NURSING DIAGNOSIS:

Based on the assessment data, major nursing diagnoses for the patient may include:
 Decreased cardiac output related to structural disorders caused by cardiomyopathy or to

dysrhythmia from the dis-ease process and medical treatments

 Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion related to
decreased peripheral blood flow (resulting from decreased cardiac output)
 Impaired gas exchange related to pulmonary congestion caused by myocardial failure
(decreased cardiac output)
 Activity intolerance related to decreased cardiac output or excessive fluid volume, or both
 Anxiety related to the change in health status and in role functioning Powerlessness
related to disease process Noncompliance with medication and diet therapies
NURSES NOTES

Name of the patient: Mr. G. Sannibabu Ward: ICU

Age: 54years Diagnosis: Ischemic cardiomyopathy
Sex: male Dr. Name: Dr. Naveen
I.p no: 6829 Bed. no: 5

Time Diet Medication Nurses Care Plan

730 Idly with 10/4/13 observation:
chutney Inj. Monocef 1gm BD Patient is very thin & less activity and
830 water 50ml weakness; cough; fever; breathlessness.
Inj. Amkacin 500mg BD
800 coconut  Monitored vital signs
Inj.Dopamine,150mg,BD
water 100ml  Temp:98.60 F
T. Floxen, 150mg, TID
rice porage T. Pantop, 400mg, BD  Pluse:82b/min
1030 1 cup  Resp:24b/min
 Blood pressure:150/100mmhg
 SpO2: 93%
 Provide position changing frequently
45
10  Provide complete bed rest
 Provide calm environment

28
1055  Administer medication as per physician
prescribed
 Administered O2
 Provide nebulisation
30
9  History collection and performed
physical examination
00
11  Provide psychological support
30
11  Provided health education about
 Diet
45
11  Exercises
15
12  Personal hygiene
 Relaxation therapy.
lakshmi/St.N

29
 KARDEX

Date Medications Dose Time Date Nursing care plan Time

Date Treatment Dose Time

Age Sex Bath T.P.R B.P Diet

Religion

Name of the patient Bed Diagnosis Doctor name IPNO

no

30
 PATIENT PROFILE

Name of the patient: Mr. Abhayanathi Manjhi

Age: 63years

Sex: Male

Marital status: Married

Religion: Hindu

Education: Degree (B.COM)

Occupation: General Manger

Spoken language: Telugu, English

Income: 65,000/month

Address: flat no:9, sri nagar

I.p.no: 1305

Bed no: 5

Ward: I C U

Date of admission: 15/04/13 at 4:30pm

Doctor name: Dr. Naveen.

HEALTH ASSESSMENT

Name of the patient: Mr. Abhayanathi Manjhi

Age: 63years

31
Sex: Male

Marital status: Married

Religion: Hindu

Education: Degree (B.COM)

Occupation: General Manger

Spoken language: Telugu, English

Address: flat no:9, sri nagar

Date of admission: 15/04/13 at 4:30pm

Medical diagnosis: coronary heart disease

Physician: Dr. Naveen.

Date and duration of nursing care: 5 days of nursing care plan

Date of discharge: 20-4-13.

HISTORY COLLECTION

Chief complains:

My patient Mr. Abhayanthi Manjhi,62years,male admitted in Visakha Steel Plant

General Hospital complains breathlessness, constipation, vomiting, appetite, oedema last 4
days.

Present medical history:

He admitted in ICU due to breathlessness, vomiting, appetite, oedema last 4 days on

wards with complain of coronary heart disease as diagnosed by physician

32
 Past medical history:

He was admitted in hospital due to breathlessness, oedema in lower extremities, fever

and cough, diabetes mellitus, hypertension.

Present surgical history:

Not significant of any surgical history

Past medical history:

He was undergone for PTCA with DES (severe acute NSTEMI with LV dysfunction)
operated in the Apollo hospital in Visakhapatnam last 6 months

Family history:

Any hereditary:

There is a history of diabetes and hypertension and there is no hereditary of congenital

abnormalities.

Family tree:

Family profile:

Sl no name of the family members age sex relation occupation remark

ship
1 Abhayanathi Manjhi 62y M husband General CAD, DM, HTN
manager -
2 Devjani Devi 55y F Wife 10th class -

3 Pankaj kumar 32y M Son B.Tech -

4 Punam Devi 28y F Daughter B. Sc

in law Computers
4th class -

33
5 DruKumar Manjhi 6y M Son

Nutritional history:

Sl no Time Diet Amount Caloric Protein Carbohydrate Fat

1. 8am milk 150ml 110k.cal 3.0 4.0 3.8
2. 9am idly -2 2nos 372k.cal 6.9 58.9 0.2
with chutney
3. 12:30pm rotti-2 150 grms 690k.cal 6.9 74.5 5.2
rice with curry 200 grms
tea 15.0k.cal 3.0 4.0 3.8
4. 4:00pm rice with curry 150ml
5. 8:30pm
150 grms 372k.cal 20.8 58.9 0.2

Personal history:

Diet: patient diet includes vegetarian and non vegetarian. He takes food in per day 3 times &
non veg-2 times/week. Non veg is the his favourite food for him.

Rest & sleep: disturbed sleep pattern

Elimination: abnormal bowel & bladder (bowel – constipation & urination is frequently &
small amount of urine is passing)

Socio economic history: socio-economic status monthly income is 95000/-

Environmental history:-

Housing: building and quarters

Ventilation: adequate ventilation

Electricity: present

Water supply: Visakha steel plant water supply

PHYSICAL EXAMINATION:

vitals signs patient value normal value remarks

Temperature 98.60F 98.60F normal
Pulse 86b/min 72b/min abnormal
Respiration 22b/min 16-18b/min abnormal
Blood pressure 100/70mmhg 120/80mmhg abnormal
Spo2 93% 100% normal

34
General appearance:

Consciousness: conscious

Orientation: oriented time, place, and date

Nourishment: moderate nourished

Health: un healthy

Body build: moderate

Activity: dull

Look: anxious

Hygiene: moderately hygiene

Speech: clear

REVIEW OF SYSTEMS

Skin /integumentary system:

Colour: black

Texture: wrinkles skin/dry skin

Skin turgor: present

Hydration: well hydrated

Discolouration: no discolouration of skin

Subjective symptoms: dry skin is present

Nails:

Nail beds: pale in colour

Nail plates: flat, absence of clubbing

Cyanosis: no central and peripheral cyanosis

Colour: black

Texture: dry

Eyes:

eye brows: symmetric

Eyelashes: equally distributed

35
Papillary reflex: normal

Conjunctiva: normal

Vision: normal vision

Ears:

Pinna: normally placed

Cerumen: no defect

Otarrhea: no discharges from ear

Hearing: no defect in hearing process

Nose:

Nasal septum: no deviation of nasal septum

Nasal pathway: clear nasal pathway

Smell: no defect

Mouth & pharynx:

Lips: absence of cracks and pale in colour

Tongue: coated tongue

Bleeding : no history of bleeding

Tooth decay: history of tooth decay

Dental care: no history of dental caries

Neck:

ROM: possible

Lymph nodes: not palpable

Trachea: present in midline

Thyroid gland: not enlarged

Jugular vein: not distended.

SYSTEMIC EXAMINATION

Respiratory system:

History of smoking: smoking habit is evident but at present he is stopped

36
Sputum: sputum with thick expectoration

Asthma: no h/o asthma

Wheezing: present

Haemoptysis: no H/o of haemoptysis

Cough: present

Shortness of breath: present

Inspection: on inspection the thoracic cavity is normal, no deviations, no lesions are found

Palpation: no palpable masses detected on palpation

Percussion: on percussion wheezing sounds and adventious breath sounds are evident

Auscultation: on auscultation rounchi, wheezing sounds are evident. Abnormal bronchial

vesicular sounds are evident.

Cardiovascular system:

H/O hypertension: hypertensive

Varicose veins: no H/o varicose veins

Dysponea: present

Orthopnea: not evident

Chest pain: evident

Palpitation: present

Heart sounds: present S1 S2 sounds

Pluse: 86 b/min

Heart beat: abnormal rate and rhythm

Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected, sutured
mark presented

Palpation: no palpable masses detected

Percussion: no percussion performed

Auscultation: on auscultation at 5 areas , pulmonic, aortic, erbs point, mitral, apical area. S1
S2 sounds are clear and gallop& murmurs sounds present

37
 INVESTIGATIONS

Slink Name of the investigation Pt value Normal value Remarks

1. Hb% 14gms 14-16gms abnormal
2. TWBC 9900cells/cumm 1,500000cells/cumm abnormal
3. DC P 85% 4,5000c/cumm abnormal
L 13%
E 0.2%
4. platelet count 1.7 laks/cumm
5. bil.urea 100mg/dl 10-40mg/dl abnormal
6. sr. creatine 1.3mg% 0.5-1.4mg/dl normal
7. urine for ketone bodies -ve normal normal
8. RBS 570Mg
9. FBS 104mg
10. ECG  Extreme normal abnormal
tachycardia
 lt.ant. hemi
block
 invented T
wave
 ST-T
abnormality
 excessive
overload of
lt. atrium, lt.
ventricular
hypertrophy

MEDICATIONS

Slink Medications Dose Route Time Nursing responsibility

1. Inj. Mixtand 18IU subcutaneous BD  assess the patient general

2. Inj. PNZ 40mg IV OD condition of client

3. T. Ivas 750mg oral BD  observe the client for side

4. T.Flavidon MR. 20mg oral BD effects

5. oxygen inhalation  immediate nursing

intervention are to be done

38
  administration of

alternatives agonist to

prevent the side effects

 administer continuous

oxygen inhalation

NURSING DIAGNOSIS:

 Decreased cardiac output related to alteration in preload/after load/ contractility/ heart

rate.
 Impaired gas exchanges related to ventilation/perfusion mis match or intra pulmonary
shunting
 In effective airway clearance related to retained secretions and excess secretions
 Risk of haemorrhage related to inadequate haemostasis, disruption of suture lines or
coagulation
 Acute pain related to tissue trauma secondary to sternotomy and leg incision
 Risk of post cardiotomy delirium or stroke
 Activity intolerance related to fatigue secondary to cardiac insufficiency and pulmonary
congestion as evidenced by dyspnoea, shortness of breath, weakness
 Anxiety related to dyspnoea as evidenced by restlessness, irritability
 Deficient knowledge related to disease process as evidenced by questions about the
disease and patients statement.

NURSES NOTES

Name of the patient: Abhayanathimanjhi Ward: ICU

Age: 62years Diagnosis: coronary heart disease

Sex: male Dr. Name: Dr. Naveen
E.p no: 12016303 Bed. no: 5

Time Diet Medication Nurses Care Plan

39
730 Idly with 17/4/13 observation:
chutney Inj. Mixtard 18 IU Patient is very thin & less activity and
830 water 50ml subcutaneous BD weakness; cough; fever; breathlessness.
800 coconut Inj. PNZ 40mg IV OD  Monitored vital signs
water 100ml T.Ivas 10mg oral BD  Temp:98.60 F
rice porage T. Flavidon M.R20mg Oral  Pluse:86b/min
1030 1 cup OD  Resp:22b/min
o2 inhalation  Blood pressure:100/70mmhg
 SpO2: 93%
 Provide position changing frequently
1045  Provide complete bed rest
 Provide calm environment
55
10  Administer medication as per physician
prescribed
 Administered O2
 Provide nebulisation
930
 History collection and performed
physical examination
00
11
 Provide psychological support
30
11
 Provided health education about
 Diet
1145
 Exercises
1215

 Personal hygiene
 Relaxation therapy.
lakshmi/St.N

40
41