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 Bed Diagnosis Doctor name IPNO

patient no
 PATIENT PROFILE

Name of the patient: Mr. V.Nookaraju

Age: 59years

Sex: Male

Marital status: Married

Religion: Hindu

Education: Degree (B.COM)

Occupation: Employee, Dept. ESR

Spoken language: Telugu, English

Income: 45,000/month

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

I.p.no: 1305

Bed no: 18

Ward: I C U

Date of admission: 10/4/13.

 HEALTH ASSESSMENT
Name of the patient: Mr. V.Nookaraju

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.

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

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 200gm 690k.cal 6.9 74.5 5.2
dhal 100gm 372k.cal 20.8 58.9 0.2
4pm tea 200ml 110 k.cal 3.0 4.0 3.8
8pm rice and 200gm 690k.cal 6.9 74.5 5.2
dhal 100gm 372k.cal 20.8 58.9 0.2

Socio – economic history:

Housing: building house

Ventilation: well ventilated

Electricity: present

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

0 0
temperature 98.6 f 98.6 f 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

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

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

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

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

Varicose veins: present

INVESTIGATIONS

Date Specimen/ Type of Result Normal Significance

investigation values
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 abnormal

g/L

 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 2.4-7.0 mg/dL abnormal
mg/dL
Creatinine  2.7 0.5-1.7 mg/dL abnormal
mg/dL
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
vomiting, general
2 Inj. Amkacin 500mg BD antibiotic anorexia, condition of
tachycardia, patient
3 Inj.Dopamine,150mg,BD analgesic subsided - Observes for the
4 T. Pantop, 400mg, BD fluid drug side effects
5 oxygen administration antacid retention, - Immediate
4l/m continuous insomnia, etc nursing
administration intervention are
6 inhalation duodline and to be done
sarbutrate BD - Administration
of alternative
agonist 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
 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.
 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
-monitor the disease process
 name
vital signs
 age, Adequate
 sex, -Administer knowledge in
 education, continuous disease process
oxygen &
 occupation Rehabilitation &
medication
 income follow up
- health
education
about disease
condition

feed back
 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 observation:
chutney 10/4/13 Patient is very thin & less activity
830 water 50ml  Inj. Monocef 1gm BD and weakness; cough; fever;
800 coconut breathlessness.
 Inj. Amkacin 500mg BD
water  Monitored vital signs
100ml  Inj.Dopamine,150mg,BD  Temp:98.60 F
 T. Pantop, 400mg, BD
1030 rice porage  oxygen administration  Pluse:82b/min
1 cup 4l/m continuous  Resp:24b/min
administration
 inhalation duodline and  Blood pressure:150/100mmhg
sarbutrate BD  SpO2: 93%
1045  Provide position changing
frequently
1055  Provide complete bed rest
 Provide calm environment
 Administer medication as per
physician prescribed
30
9  Administered O2
 Provide nebulisation
00
11
 History collection and
30
11
performed physical examination
1145  Provide psychological support
1215  Provided health education about
 Diet
 Exercises
 Personal hygiene
 Relaxation therapy.
lakshmi/St.N
 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 Bed Diagnosis Doctor name IPNO

patient no
 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

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

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 - -

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 200gm 690k.cal 6.9 74.5 5.2
dhal 100gm 372k.cal 20.8 58.9 0.2
4pm tea 200ml 110 k.cal 3.0 4.0 3.8
8pm rice and 200gm 690k.cal 6.9 74.5 5.2
dhal 100gm 372k.cal 20.8 58.9 0.2

Socio – economic history:

Housing: building house

Ventilation: well ventilated

Electricity: present

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.

Healso 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

0 0
temperature 98.6 f 98.6 f 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

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

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

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:
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 Significance

investigation values
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 abnormal

g/L

 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 2.4-7.0 mg/dL abnormal
mg/dL
Creatinine  2.7 0.5-1.7 mg/dL abnormal
mg/dL
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
vomiting, general
2 Inj. Amkacin 500mg BD antibiotic anorexia, condition of
tachycardia, patient
3 Inj.Dopamine,150mg,BD analgesic subsided - Observes for the
4 T. Floxen, 150mg, TID analgesic fluid drug side effects
5 T. Pantop, 400mg, BD antacid retention, - Immediate
insomnia, etc nursing
intervention are
to be done
- Administration
of alternative
agonist 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 observation:
chutney 10/4/13 Patient is very thin & less activity
830 water 50ml Inj. Monocef 1gm BD and weakness; cough; fever;
800 coconut breathlessness.
Inj. Amkacin 500mg BD
water  Monitored vital signs
Inj.Dopamine,150mg,BD
100ml  Temp:98.60 F
T. Floxen, 150mg, TID
1030 rice porage T. Pantop, 400mg, BD  Pluse:82b/min
1 cup  Resp:24b/min
 Blood pressure:150/100mmhg
 SpO2: 93%
1045  Provide position changing
frequently
1055  Provide complete bed rest
 Provide calm environment
 Administer medication as per
physician prescribed
30
9  Administered O2
 Provide nebulisation
00
11
 History collection and performed
30
11
physical examination
1145  Provide psychological support
1215  Provided health education about
 Diet
 Exercises
 Personal hygiene
 Relaxation therapy.
lakshmi/St.N
 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 Bed Diagnosis Doctor name IPNO

patient no
 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

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

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 age sex relation occupation remark

members ship
1 Abhayanathi Manjhi 62y M husband General CAD, DM,
manager HTN
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
5 DruKumar Manjhi 6y M Son -
 Nutritional history:

Sl Time Diet Amount Caloric Protein Carbohydrate Fat

no
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 200 grms
curry 15.0k.cal 3.0 4.0 3.8
4. 4:00pm tea 150ml
5. 8:30pm rice with
curry 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

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

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

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
 INVESTIGATIONS

Slink Name of the Pt value Normal value Remarks

investigation
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

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

3. T. Ivas 750mg oral BD client

4. T.Flavidon MR. 20mg oral BD  observe the client for

5. oxygen inhalation side effects

 immediate nursing

intervention are to be

done

 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.
 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.
 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
-monitor the disease process
 name
vital signs
 age, Adequate
 sex, -Administer knowledge in
 education, continuous disease process
oxygen &
 occupation Rehabilitation &
medication
 income follow up
- health
education
about disease
condition

Feed back
 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

730 Idly with observation:
chutney 17/4/13 Patient is very thin & less activity
830 water 50ml Inj. Mixtard 18 IU and weakness; cough; fever;
800 coconut subcutaneous BD breathlessness.
water Inj. PNZ 40mg IV OD  Monitored vital signs
100ml T.Ivas 10mg oral BD  Temp:98.60 F
1030 rice porage T. Flavidon M.R20mg  Pluse:86b/min
1 cup Oral OD  Resp:22b/min
o2 inhalation  Blood pressure:100/70mmhg
 SpO2: 93%
1045  Provide position changing
frequently
1055  Provide complete bed rest
 Provide calm environment
 Administer medication as per
physician prescribed
30
9  Administered O2
 Provide nebulisation
00
11
 History collection and performed
30
11
physical examination
1145  Provide psychological support
1215  Provided health education about
 Diet
 Exercises

 Personal hygiene
 Relaxation therapy.
lakshmi/St.N