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Care Plan Pneumonia Compress
Care Plan Pneumonia Compress
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 College of Nursing,
banglore
INTRODUCTION
IDENTIFICATION DATA
Name of the patient : Mrs. Kannikamma
Age : 37 yrs
Sex : Female
Religion : Hindu
Marital Status : Married
Education : Polytechnique
Occupation : House Wife
Income : Nill
I P No. : 16731
Unit : Female Medical ward
Date of Admission : 11/03/2012 at 4.34 p.m
Medical diagnosis : Pneumonia
Address : Puthanahalli,7th cross
Date of care started : 12/03/2012
Date of care ended : 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 doesn’t 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 - normal
Posture - no deformity
Personal appearance - well groomed and hygenic
Emotional status - depressed
Co-operativeness - co-operative
Vital signs
Temperature - 101 °F
Pulse - 70 beats per min
Respiration - 26 breaths per min
Blood pressure - 130/80 mmHg
Skin
Colour - no cyanosis, no jaundice
Edema - no edema
Moisture - warm and normal
Lesions - 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 - normal
Eyelids - normally close and open
Eye balls - normal, globes clear and firm
Conjunctiva - dark pink and clear
Sclera - pink and clear
Iris - brown
Visual acuity - normal 6/6
PERRLA - pupils round symmetrical, reacting to light and
accommodation, 3mm, constrict to light.
Eye movements - move in conjugate fashion and normal
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 - no nasal flaring, mucous membranes pink and moist
Sense of smell - normal
No DNS or running nose
Mouth and throat
Lips - symmetric, moist, no lesions, no cyanosis
Tongue - moist, pink, no glossitis, no coating
Teeth - stained teeth, equally distributed
Gum - no gingivitis
Buccal mucosa - no lesions
Palate - intact, symmetrical, pink
Sense of Taste - normal
No glossitis, no stomatitis
Neck
Appearance - no deformity, spondilitis, tenderness, stiffness, swelling
Trachea - no deviation, no tenderness
Lymph nodes - not palpable
Thyroid glands - symmetric
No distended neck veins
Palpation
Expansion - unequal, inflammation of lining of lungs
Vocal tactile fremitus - fremitus present
Presence of local swelling, and tenderness in the right thorax
Percussion
Basal - resonance
Apical - dull percussion
Auscultation
Bronchial - sound is loud and harsh heard on trachea
Bronchovesicular - sounds are moderatly heard at 2nd intercostal space on both
sides
Vesicular - heard all over the lung field both front and back
Friction rub - 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 - no fluid thrill
Auscultation
Apical rate - 70 beats/min & S1, S2 heard
Blood pressure - 130/80 mmHg
ABDOMEN
Inspection
Shape - Scaphoid shape
Movements - abdominal wall bulges in inspiration, falls during expiration
Skin texture - no discoloration, no cyanosis, no distension
Contour - normal, flat, no mass, normal bowel, no organomegaly
Auscultation
Bowel sounds heard
Percussion
organ borders - gaseous distention found
Palpation
Mass - no organomegaly, soft abdomen
Back
Spinal curvature - no deformity
- Concavity in the cervical region
- Concavity in the lumbar region
- Convexity in the thoracic region
Symmetry - normal
Movement - normal ROM
UPPER EXTREMITIES
Normal ROM possible
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 - normal
Speech - fluent and clear
Motor function - normally muscle tone, gait normal
Sensory functions - normally responds to pain and light touch
Cranial nerves and reflexes - normal
Reflexes - normal functions (superficial and deep reflexes)
Vital Signs
Investigations
Tab. Deriphiline 500 mg Orally BD Relaxation of smooth muscles Diarrhea, epigastric pain,
of the bronchial wall palpitation and tachypnoea
Tachy cardia
Tab. brufen 400 mg Oral BD Inhibits prostoglandin Palpitation
synthesis by decreasing Preganancy
enzyme needed for bio Blurred vision
synthate analgase
Inj. Rosella 500 mg IV QID Infers with cell wall respiration Rash
ampicillin of microorganism the cell wall Utricaria
rended osmality unstable swell Anemia
blank pneumonia pressure Bleeding
Depression
Nausea
Vomitting
Lethargy
2. Ineffective airway clearance related to pain, fatigue and thick secretions as manifested
3. Impaired nutritional status less than body requirement related to anorexia, nausea and
5. Risk for health maintenance deficit related to lack of knowledge regarding treatment
Advised about the follow up measures and to take medications at correct time.
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
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 Suddarth’s, “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.