Care Plan On Pneumonia

Submitted to
Prof. Mrs.Vanjeenathammal H.O.D Medical-Surgical Nursing The Capitol College of Nursing, banglore

Submitted by
Ms.Sruthy Mohan M J 1st Year M.Sc Nursing Dept. of Medical Surgical Nursing The Capitol banglore College of Nursing,

INTRODUCTION As a part of my clinical experience in Medical Surgical Nursing I was posted in Female Medical ward of Sanjaygandhi general hospital,banglore. There were 31 patients and I selected Mrs. Kannikamma as my patient. I am supposed to investigate present problems based on observations and signs and symptoms of the disease.

IDENTIFICATION DATA
Name of the patient Age Sex Religion Marital Status Education Occupation Income I P No. Unit Date of Admission Medical diagnosis Address Date of care started Date of care ended : Mrs. Kannikamma : 37 yrs : Female : Hindu : Married : Polytechnique : House Wife : Nill : 16731 : Female Medical ward : 11/03/2012 at 4.34 p.m : Pneumonia : Puthanahalli,7th cross : 12/03/2012 : 15/03/2012

Medical History
Present Medical History Mrs. Kannikamma was admitted to Sanjaygandhi general hospital,banglore.on 11/03/12 at 4.34 p.m with complaints of fever, chills, persistent cough and chest pain since 3 months. The doctor diagnosed the case as Pneumonia. Past Medical History Nothing Significant

Surgical History
Present and Past Surgical History Nothing Significant

Personal History
Mrs. Kannikamma has no bad like smoking and alcoholism but she has a habit of chewing on betal nuts. She takes mixed diet. She is maintaining good relationship with her family members and neighbours.

FAMILY HISTORY There are 3 members in her family including her husband and a 10 year old daughter. Theirs is a nuclear family. All the other family members are healthy. There is no heredity or communicable diseases in his family. KEY Patient Male Female

SOCIO-ECONOMIC HISTORY Mr. Nagesh is the husband of Mrs. Kannikamma. He is the bread winner of the family. He is having an income of Rs. 5000/month. He is a businessman. They are living in their own house.

ENVIRONMENTAL HISTORY Mrs. Kannikamma is living in a pacca type of house with three rooms. House is electrified and proper water facility. House is having open drainage system and separate lavatory facility.

NUTRITIONAL HISTORY She is taking mixed diet with 2 meals per day. She doesnt have allergy with food items. She is taking white rice and vegetable salad very much.

ELIMINATION HISTORY Her bowel and bladder functions were normal.

PHYSICAL EXAMINATION
General observation Stature Posture Personal appearance Emotional status Co-operativeness Vital signs Temperature Pulse Respiration Blood pressure Height and weight Height Weight Skin Colour Edema Moisture Lesions - normal - no deformity - well groomed and hygenic - depressed - co-operative

- 101 F - 70 beats per min - 26 breaths per min - 130/80 mmHg

- 154 cms - 61 kg

- no cyanosis, no jaundice - no edema - warm and normal - Absence of macules, papules, and vesicals

Head Normal cephalic, no lesions, normal distribution of hair and color of hair is normal, no pediculosis, normal range of motion possible, Eyes Expressions Eyelids Eye balls Conjunctiva Sclera Iris Visual acuity PERRLA Eye movements

- normal - normally close and open - normal, globes clear and firm - dark pink and clear - pink and clear - brown - normal 6/6 - pupils round symmetrical, reacting accommodation, 3mm, constrict to light. - move in conjugate fashion and normal

to

light

and

Ears Appearance - auricles are normal and symmetrical Hearing - normal hearing Normal shape, no discharge, no tinnitus, no vertigo, no infection, Cerumen is present Nose Appearance Sense of smell No DNS or running nose

- no nasal flaring, mucous membranes pink and moist - normal

Mouth and throat Lips Tongue Teeth Gum Buccal mucosa Palate Sense of Taste No glossitis, no stomatitis Neck Appearance Trachea Lymph nodes Thyroid glands No distended neck veins

- symmetric, moist, no lesions, no cyanosis - moist, pink, no glossitis, no coating - stained teeth, equally distributed - no gingivitis - no lesions - intact, symmetrical, pink - normal

- no deformity, spondilitis, tenderness, stiffness, swelling - no deviation, no tenderness - not palpable - symmetric

CHEST AND RESPIRATORY SYSTEM Inspection Symmetry - bilaterally symmetrical Expansion - thoracic expansion is abnormal Equality of movements - unequal in the right lungs Type of respiration - Abdomino-thorasic Rate - 26 breaths/min Rhythm - irregular Palpation Expansion Vocal tactile fremitus

- unequal, inflammation of lining of lungs - fremitus present Presence of local swelling, and tenderness in the right thorax

Percussion Basal Apical Auscultation Bronchial Bronchovesicular Vesicular Friction rub

- resonance - dull percussion

- sound is loud and harsh heard on trachea - sounds are moderatly heard at 2nd intercostal space on both sides - heard all over the lung field both front and back - nothing significant

CARDIOVASCULAR SYSTEM Inspection Chest contour - abnormal, sternal depression present Neck - no jugular venous distention Percussion Cardiac outline

- difficult to find out the cardiac borders

Palpation Supra sternal notch Auscultation Apical rate Blood pressure ABDOMEN Inspection Shape Movements Skin texture Contour Auscultation Bowel sounds heard Percussion organ borders Palpation Mass Back Spinal curvature

- no fluid thrill

- 70 beats/min & S1, S2 heard - 130/80 mmHg

- Scaphoid shape - abdominal wall bulges in inspiration, falls during expiration - no discoloration, no cyanosis, no distension - normal, flat, no mass, normal bowel, no organomegaly

- gaseous distention found

- no organomegaly, soft abdomen

Symmetry Movement Genitalia and groin Nothing significant UPPER EXTREMITIES Normal ROM possible

- no deformity - Concavity in the cervical region - Concavity in the lumbar region - Convexity in the thoracic region - normal - normal ROM

LOWER EXTREMITIES Appearance - Normal in both the extremities Temperature - warm to touch and moist Pulses in the periphery - dorsalis pedis artery felt 70 beats /min NERVOUS SYSTEM Higher functions Speech Motor function Sensory functions Cranial nerves and reflexes Reflexes

- normal - fluent and clear - normally muscle tone, gait normal - normally responds to pain and light touch - normal - normal functions (superficial and deep reflexes)

Vital Signs
Sl. No. 1. 2. 3. 4. Procedure Temperature Pulse Respiration Blood Pressure Normal Value 98.6 F 60 70 beats/min 18 20 beats/min 120/80 mm of Hg Patients value 101 F 70 beats/min 26 beats/min 130/80 mm of Hg Remarks Increased Normal Increased Normal

Investigations
Sl. No. 1. 2. 3. 4. 5. 6. Hb WBC Lymphocytes Eosinophils S.Urea ESR Name of the Investigation Normal Value Patients value Remarks

14-18 gm% 4000-11000/cumm. 20-40% 1-6% 10-50mg/dl < 20 cm2 /hr

12 gm% 16000/cumm 60% 46% 34 mg/dl 30 cm2/hr

Decreased Increased Increased Increased Normal Increased

MEDICATIONS
DRUG Tab. Deriphiline DOSAGE 500 mg ROUTE Orally FREQUENCY BD ACTION Relaxation of smooth muscles of the bronchial wall Inhibits prostoglandin synthesis by decreasing enzyme needed for bio synthate analgase Infers with cell wall respiration of microorganism the cell wall rended osmality unstable swell blank pneumonia pressure SIDE-EFFECTS Diarrhea, epigastric pain, palpitation and tachypnoea Tachy cardia Palpitation Preganancy Blurred vision Rash Utricaria Anemia Bleeding Depression Nausea Vomitting Lethargy Head ache Insomnia Diarrhea Abdominal pain Flatulence Hypersensitivity Hyperglycemia

Tab. brufen

400 mg

Oral

BD

Inj. Rosella ampicillin

500 mg

IV

QID

Tab. Pantoprazol

40 mg

Oral

Tid

Gastro eosophago reflux disease severe oesophagitis zoolinger Ellison syndrome

NURSING DIAGNOSIS

1. Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by rapid respiration, dyspnea and tachycardia.

2. Ineffective airway clearance related to pain, fatigue and thick secretions as manifested by ineffective cough or thick abnormal breath sound.

3. Impaired nutritional status less than body requirement related to anorexia, nausea and vomiting as manifested by weakness.

4. Activity intolerance related to fatigue treatment regimen and weakness as manifested by fatigue dizziness as explained.

5. Risk for health maintenance deficit related to lack of knowledge regarding treatment regimen after discharge.

Care plan
Assessment Nursing Diagnosis
Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by rapid respiration dyspnea and tachypnea

Objective

Planning

Implementation

Evaluation

Subjective Data: Patient says that I cant breathe properly

Patient maintains normal respiratory rate and express feeling of comfort

Assess the pattern of breathing to provide guidance for intervention. Take vital signs and auscultate lungs to provide ongoing patients response to therapy to identify the response to treatment. Administer oxygen as inhaled to maintain optimal oxygen level and to increase patient comfort to increase patient comfort

Assessed the pattern of breathing.

Patient expressed some feeling of comfort.

Checked vital signs and auscultate lungs.

Objective data: On observation Patient is having breathlessness

Administered oxygen to patien.

Provide semi fowlers position for breathing to maximize lung expansion to maximize lung expansion

Provided semi fowlers position for patient.

Assessment

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

Objective

Planning

Implementation

Evaluation

Subjective Data: patient says that he cant breathe properly

Patient will have breath sounds effective cough with exploration of sputum

Assist the patient to cough by splinting chest, and teach patient how to cough effectively to clear airway by bringing secretion to the mouth to bring out secretion

Assisted the patient to cough by splinting chest, and teach patient how to cough effectively to clear airway by bringing secretion to the mouth

Patient maintained clear breath sounds

Objective data: patient is having thick secretions in the airway and cant cough properly

Administer expectorant to increase bronchial fluid product and promote expectoration and cough to remove secretions

Administered expectorant to increase bronchial fluid product and promote expectoration and cough

Maintain fluid intake of 3L daily to liquefy secretions to liquefy secretions

Maintained fluid intake of 3L daily to liquefy secretions

Assessment

Nursing Diagnosis
Impaired nutritional status less than body requirement related to anorexia, nausea and vomiting as manifested by weakness.

Objective

Planning

Implementation

Evaluation

Subjective Data: patient verbalizes that he is not having appetite and feeling so weak.

Patient maintains normal nutritional status and maintain normal weight.

Assess the food preferences so the preferred foods will be available.

Assessed food preferences of the patient.

Patient maintained normal nutritional status than before.

Weigh patient daily and use same scales and at the same time of the day to provide accurate evaluation of weight.

Checked the weight of the patient daily.

Objective data: On observation patient is looking so weak .

Provide caloric intake as ordered to meet body requirement.

Provided caloric intake as ordered to meet body requirement.

Advice to take high protein high caloric small frequent feeding to prevent negative nitrogen balance and excessive weight loss.

Advised the patient to take high protein and high caloric diet.

Assessment

Nursing Diagnosis

Objective

Planning

Implementation

Evaluation

Subjective Data: patient says that I am feeling tired and weak

Activity Patient experiences intolerance related increased tolerance to fatigue for activity treatment regimen and weakness as manifested by fatigue and Objective data: dizziness as On observation explained. patient is giving Verbal response of weakness

Assess response to activity To evaluate patients hypoxemia and plan changes accordingly

Assessed response to activity

Patient experienced increased tolerance for activity than before

Provide bed rest and limit physical activity to evaluate patients hypoxemia

Provided bed rest and limit physical activity

Assist with the activities as needed to ensure that patients basic needs are met to ensure that patients basic needs are met

Assisted with the activities of the patient

Place needed items within easy reach to conserve energy while facilitating independence to conserve energy while facilitating independence

Placed needed items within easy reach of patient

Assessment

Nursing Diagnosis
Risk for health maintenance related to lack of knowledge regarding treatment regimen after discharge.

Objective

Planning

Implementation

Evaluation

Subjective Data: Patient is asking doubts regarding to treatment.

Patient gains enough knowledge regarding treatment regimen.

Assess the ability to continue self care at home to identify patients knowledge about self care and ability to manage self care.

Assessed the ability to continue self care at home.

Patient got knowledge regarding treatment regimen follow up and activity schedule.

Objective data: On observation patient is unaware of her disease condition.

Encourage patient to continue on full course of antibiotic therapy to prevent relapse of pneumonia and development.

Encouraged the patient to continue full course of antibiotic therapy.

Encourage patient to obtain adequate rest, nutrition and fresh air to assist healing process.

Encouraged the patient to obtain adequate rest and nutrition.

DIET PLAN

Time
8.00 a.m Breakfast Tea Dosai Bengal gram Curry 12.30 p.m Lunch Rice Fish Curry Cabbage side dish 4.00 p.m Tea time 8.00 p.m Dinner 10.30 p.m Bedtime Tea Biscuit Chappthi Green piece curry Hot Milk

Food

Amount
1 Glass 2 Piece 1 servings

2 servings 1Servings 1 Cup 2 Numbers 4 Numbers 1 Servings 1 Cup

HEALTH EDUCATION

Avoid cigarettes smoking. Avoid alcohol ingestion. To take all medications as prescribed. This includes both anti-inflammatory and antibiotic drugs. Failure to take these medications as prescribed can result in relapse. Advised about the follow up measures and to take medications at correct time. Explain the relationship between symptoms and stress. Stress-reducing activities or relaxation strategies are encouraged. Explain about the importance of rest and sleep and to take at least 6-8bhrs. Adequate rest and sleep keep the mind and body fresh Explain the importance of nutrition and told him to take high protein containing diet and to include diet containing vegetables and fruits Advised the patient to do exercises like walking, flexion, extension, abduction and adduction of extremities Explained to the patient regarding follow up measures and its importance. I told him to take prescribed medication properly and correct time Advised the patient to take bath daily and to wear clean clothes Advised the patient to take high protein containing diet and include diet containing vegetables and fruits etc.

Conclusion

Mrs. Kannikamma was admitted to Sanjaygandhi general hospital,banglore

on

11/03/12 at 4.34 p.m with complaints of fever, chills, persistent cough and chest pain since 3 months. The doctor diagnosed the case as Pneumonia.

I started the care on 12/03/2012 and I ended my care on 15/033/2012. During my care I gave care to my client like mouth care, nail care, and provided nebulization, fowlers position.

The patient was health educated on various aspects of her disease condition such as, the diet or nutrition required for his disease, the personal hygiene necessary, and the need for exercise during the recovery stage.

Mrs. Kannikamma received three days of nursing care from me. And the patient recovered well from her disease condition.

From this case, I had gained immense knowledge regarding Pneumonia and its Medical intervention.

Bibliography

1. Suzanne c. Smelzer and Brenda Bare, Brunner and Suddarths, Text book of medical surgical Nursing, 10th Edition, Philadelphia, Lippincott Publishers. 2. Joyce M. Black, Medical Surgical Nursing, 6th Edition, New Delhi, Harcous Publishers. 3. B. T. Basavanthappa, Medial Surgical Nursing, 1st Edition, Jaypee Publishers (P) Ltd., Bangalore.

4. Anne Waugh and Allison Grant, Ross and Wilson, Anatomy and Physiology in Health and Illness, 9th edition, Churchill Livingstone Publication, Philadelphia.