Bronchitis
Bronchitis
college, bardoli
Submitted on:
HISTORY OF THE PATIENT
IDENTIFICATION DATA :-
Age : 55 years
Sex : Male
Bed No. : 24
Occupation : Inoccupation
Religion : Hindu
Diagnosis : Bronchitis
PRESENT MEDICAL HISTORY : My patient was admitted to Dhiraj General Hospital With the
complains of dry cough, haemoptysis, reduced weight, laboured breathing, loss of appetite and sleep
pattern disturbances.
PAST MEDICAL HISTORY : My patient was previously 3 months before admitted to Dhiraj
general Hospital with the complains of malaria and No any other significant history of HTN, DM,
COPD, Cancer, Asthma and Arthritis etc.
PAST SURGICAL HISTORY :-
. No any other significant history of any past surgical history. .
FAMILY HISTORY :
Family tree :- Patient
Family Information :
Sr. Name of the family Relati. Age Educa- Occupa- Marital Health
no. members with Pt. (yrs.) tion tion status status
1. Mr. Manish Shankarlal Wife 65 Illiterate House wife Married Healthy
navib
2. Mr. Kaushikl M. navib Son 40 5th std. Worker Married Healthy
3. Mrs. Akashi M. navib Daughter 35 Illiterate House wife Married Healthy
in low
4. Ms. Bhavika M. navib Grand 18 11th std. Student Unmarried Healthy
daughter
5. Mr. Dev M. Navib Grand son 15 8th std. Student Unmarried Healthy
Sr. No. Current Medication Dose / Frequency Route Last Dose Given
1. Inj. Ceftiaxone 1gm. / BD IV 8am.
2. Tab. Tangold BD Orally 8am.
3. Cap. Shelkal 500mg. / BD Orally 8am.
4. Tab. Wysolon 20mg. / OD Orally 8am.
5. Inj. Hydrocort 200mg. /SOS IV 8am.
6. Cap. Anti TB 1800mg. / 1day Orally 10am.
7. Budocort Nebulizer / TDS Orally 8am.
C) Personal hygiene practices :- They are maintaining personal hygiene, taking bathe
daily, washing hands, cutting nails, brush daily etc.
D) Community resources :- Resources like bus and train are available for transportation
educational resources are available up to 12th std. there is lack of lack of
health resources.
E) Religious practices :-
Client and his family members strong are believed in god and
they worship everyday. They go to temple everyday.
DEVELOPMENTAL HISTORY
Inter Personal Relationship :- Patient maintain good IPR with every hospital staff.
He is very calm and co-operative.
Activity / Exercises :- He can able to do active and passive exercise from the both
upper and lower extremities.
Rest / Sleep :- He cannot take proper sleep in night because of hospitalization and
anxiety about disease condition.
Elimination Pattern :- The bowel and bladder elimination patterns are normal.
Self perception / self concept pattern :- Patient has insight and he is having general
sense of emotions.
Values and Beliefs :- patient is hindu and he celebrates all the festival. He knows
about his diseases.
DIETARY HISTORY :
o General appearance : Thin / Average / Obese
o Appetite : Good / Fair / Poor
o Diet : Veg. / Non veg.
o Meal pattern : Two times in day and breakfast in the morning
o Need assistant / Feed self : No need to assistant.
o Any other method of feeding : Nil
PHYSICAL ASSESSMENT
General Appearance :
Level of Consciousness : Conscious / Unconscious / Semiconscious / Coma
Orientation : To Place / Person / Time
Activity : Active / Dull / Lethargy
Body Built : Mild / Moderate / Thin / Obese
Anthropometric Measurement :
1.Height – 5’4” 2. Weight – 68 Kgs. 3. Mid Upper Arm Circumference – 16cms
Vital Signs :
Temperature – 98.5’ F 2. Pulse – 86 b/m. 3. Respiration – 28 b/m.
Blood Pressure – 130/90 mm of hg.
Head :
Hair - Equally Distributed / Baldhead
Colour of Hair - Gray / White / Black
Scalp - Clean / Dandruff present – Yes / No
Pediculosis - Present / Absent
Face :
Face - Symmetrical/Asymmetrical
Facial Puffiness - Present /Absent
Eyes
Eye Brows - Symmetrical / Asymmetrical / Scaling / Lesions
Eye Lid/Lashes - Redness / Swelling / Discharge / Lesions
Eye Ball - Sunken / Protrusion / Normal
Conjunctiva - Colour / Swelling / Lesions
Sclera - White / Pink / Yellow / Tenderness / Discharge / Lesions
Puncta - Red / Swollen / Tender To Pressure
Cornea - Regular / Irregular Ridges
Iris - Flat / Irregular Shape
Eye discharge - Present /Absent
Use of glasses - Present /Absent
Pupils - Equally Reacting To Light – Yes / No
Size – 6 mm
Dilated And Fixed, Unequal - Equal
Visual Acuity – Normal
Nose :
Nasal Septum – Deviated / Central
Nasal Polyps – Present / Absent
Nasal Discharge – Present / Absent
Mouth :
Number of Teeth - 26
Dentures – Present / Absent
Dental Carries - Present / Absent
Odour of Mouth - Foul Smell / Acetone Smell / Others : Nil
Gums – Weak / Swollen / Pale Colour / Healthy
SINUSES :
Maxillary sinus infection : Yes / No
Frontal sinus infection : Yes / No
SYSTEMATIC EXAMINATION
RESPIRATORY SYSTEM :
Respiratory Rate - 30 b/m.
Inspect the Chest : Thoracic Cage - Shape - Barrel Chest / Scoliosis / Kyphosis
Configuration – Pectus Excavatum / Pectus Carinatum/ Normal
Skin Colour and Condition – Normal / Cyanosis / Pallor
Chest Expansion – Symmetric / Asymmetric
DIGESTIVE SYSTEM :
Abdominal Girth : 98 cms.
Diarrhoea / Constipation : Nil
Inspection : Size - Scaphoid / Protuberant Flat / Rounded
Symmetry – Bulges / Masses / Hernia : Normal
Scar - Bilateral Surgical scar in inguinal region
Lesions - No
Redness - No
Palpation : Tenderness - Abscent.
Fluid Collection - No
Mass / Soft - No
Percussion : Ascitis/Peritonitis - No
Gas / Fluid collection / Normal in size - No
No Gas / Fluid Collection : No
Auscultation : Bowel Sounds - Normal / Borborygmus / Absent
GENITO URINARY :
Frequency of Urination - Nil
Urine Last Voided - Nil
Colour - Pale yellow
Normal / Anuria / Hematuria / Dysuria / Incontinence / Any Other : Poliuria
Catheter Present : Yes / No
Urethral Discharge : Nil
INTEGUMENTORY SYSTEM :
Skin Colour - Normal Brown
Dermatitis - No
Allergies - No
Cause : Nil
Reaction : Nil
Lesions / Abrasions - No
Tenderness / Redness - No
Surgical scar - Bilateral Surgical scar in inguinal region
Secretion - No
MENTAL STATUS :
Memory : Good
Knowledge : Good
Thinking : Good
Judgement : Good
Insight : Yes
Tab. Lasix 40 mg. Inhibits the re- Pulmonary Hypersensitivity Circulatory - Assess the signs of metabolic
absorption of oedema in to sulphonamide, collapse, loss alkalosis, drowsiness,
Pharmacolo- Available sodium and chronic heart enuresis, of bearing, restlessness
-gical name : forms : chloride at failure, hepatic hypovolemia, renal failure,
Frusemide Tabs – 20, proximal and disease, electrolyte thrombocytop - In IM to avoid interference
40 ,80 mg distal tubules and nephritic depletion, and enia, with sleep if using drug as a
in the loop of syndrome, lactation. leucopenia. diuretic.
Oral henle. ascites and
solurion hypertension. - Potassium replacement if
potassium < 3 mg. / dl.
IV route : it should be
undiluted.
Tab. Domstal Tab. Preventing nausea Prevention of Should not be Headache After dilution of single dose
4,8mg and vomiting by nausea and used in patients Bronchospasmn in 50ml NS or D5W 0.45%
Pharmacologi blocking serotonin vomiting as with This drugs Nacl.
cal Name : Inj. peripherally, associated with phenylketonuria, altering the
2mg/ml, centrally and in the cancer with liver activity of liver Give over 15 minute.
Ondensetrone 32mg/50 small intestine. chemotherapy, impairment enzymes,
ml radiotherapy (daily dose not to headache, To report diarrhoea,
Therapeutic class : and prevention exceed 8 mgs) fatigue, constipation, rash, or changes
Antiemetic of post diarrhoea. in respiration or discomfort at
operative insertion site.
Chemical class : nausea and
5HT3 receptor vomiting. Direct IV – administer
antagonist undiluted (2mg/ml)
immediately before induction
of anaesthesia or
postoperatively if nausea and
vomiting occurs shortly after
surgery.
Tab. PCM Tab. 160mg Inhibit the Mild pain Previous Hepatic failure Assess overall health status and
325mg synthesis of Fever hypersensitivity, Hepatotoxicity alcohol usage before administering
Pharmacolo 500mg prostaglandin that products (over dose) PCM.
gical class: 650mg may serve as containing alcohol, renal failure ,
Acetaminoph mediators of pain aspartame, neutropenia, Patient who are malnourished or
en Solution : and fever, saccharine, sugar pancytopenia , chronically abuse alcohol are at
primarily in the or tartarazine. rash. higher risk of developing
Therapeutic CNS. Has no Hepatotoxicity with chronic use f
class : significant anti Use cautiously in usual doses of this drug.
Antipyretic, inflammatory hepatic disease,
Nonopioid property or GI renal disease, Do not administered with the history
analgesics. toxicity. chronic use or of self medicated, prolonged use of
abuse, PCM, it will increased risk of
malnutrition. adverse renal effects.
This four modes are inter related. Responses to in any one mode may have an effect on or act as a stimuli’s
in one or all of the other modes. Response in each modes are judged as either adaptive or ineffective.
The adaptation level is determined by the combined effect of the focal, contextual and residual
stimuli. Adaptation occur when the person respond positively to environmental changes. This adaptive
response promote the integrity of the person which lead to health.
Application :- My patient Mr. Geta bhai M. Parmar was suffering from Tuberculosis than the surgery
was perform. He having limitation like immobilization and difficulty in walking. It is difficult for him to
adopt to this new environment.
Cognator Regulator
Because of changes in his daily routine & decreased working capacity due to
hospitalization, immobility, difficulty in walking and medication and treatment.
Maladaptation process
Stimulate three stimuli
Environmental hygiene
Feeling anxious Food hygiene and practices Sleep pattern disturbance
Unknown to situation
Increased respiration
Dry cough
- Assessment of client - Assess the fluid volume & - Provide psychological support
- Lab investigation electrolyte imbalance - Provide knowledge about
disease condition
- Input and output chart - Explain about dietary pattern.
- Avoid complication - Explain about follow up
- Monitor vital signs
- Medication & maintain nutritional status
Provide calm and quite environment
Subjective data: Excess fluid Patient will Assess for sign of fluid Assessed the sing of fluid Expected outcome
Patient says volume related to experiences optimal volume excess elevated BP, volume excess BP – 140/86 is partially met as
that he is having disease process. fluid balance as tachycardia, oedema and mm of hg., oedema is present evidenced by
oedema on the evidenced by weight gain. periorbital oedema. Weight reducing weight,
both the legs and normal BP and gain 3 kg./ week. reducing oedema,
face. He is feeling weight gain is less. decreased BP and
restlessness and Assess the patient Assess the patient verbalization.
fatigue. compliance with dietary and compliance because it can
fluid restriction at home. lead fluid volume excess.
Objective data :
Oedema on Assess weight at every visit Assessed the patient weight
the face and legs. before and after dialysis. before and after
BP is administration of the
elevated 140/88 diuretics.
mm of hg.
Weight gain. Advise the patient to Advised the patient to
Restlessness. elevated his feet when sitting elevated his feet when sitting
down. down to reduce the pedal
oedema. .
Subjective data: Imbalanced Patient is optional Assess the possible cause of Assessed the possible cause Expected outcome
Patient says that nutrition less than status is mentioned poor appetite. patient is having anorexia is partially met as
he is not able to body requirement as evidenced by and nausea. evidenced by
take proper related to stable body weight increase appetite
amount of food. anorexia, and and adequate Assess the laboratory value Assessed the value of and verbalization.
He is feeling restricted diet. calorie intake. like haemoglobin. haemoglobin decreased value
fatigue and may indicate poor nutritional
nausea. status. His haemoglobin is
10.2 gm%
Subjective data: Impaired skin Patient will Assess the skin integrity for Assessed the skin integrity Expected outcome
Patient says integrity related maintain skin pitting oedema on the legs. because chronic fluid excess is partially met as
that he is having to uremic frost integrity as can result can skin break evidenced by
itching on the feet and changes in oil evidenced by relief down. reducing itching.
and all over the and sweat glands. from itching.
body. Instruct the patient to wear Instruct the patient to wear
the loose cloths when the loose cloths when
oedema is present. oedema is present.
Objective data :
- bed rest. To keep skin clean while kept skin clean while
- fluid volume relieving itching and dryness relieving itching and dryness
excess -Basis soap applied oil on the skin.
- Oedema -Sodium bicarbonate
- Itching added to bath water.
- Numbness. -Apply oil on the skin.
Subjective data: Activity Patient will have to Assess the patient to Assessed the patient that he Expected outcome
Patient says that intolerance demonstrate response on activity. is not perform the any is partially met as
he is not able to related to fatigue, activity on activity. evidenced by
perform his daily anaemia and evidenced by verbalization.
activity. He is dietary restriction. verbalization. Assess the factors Assessed the factors
feeling fatigue. contributing to activity contributing patient is having
intolerance , fatigue, fatigue and anaemia.
anaemia, and fluid and
Objective data : electrolyte imbalances.
-Looks fatigue.
- Inability to Encourage alternating Encourage the patient to
perform daily activating with rest. promote activity and
activity. excessive with in limit and
- weakness. adequate rest.
- Hb – 10.2mg%
- Oedema Encourage patient for self Encouraged patient for self
care. care.
Subjective data: Anxiety related to Client will exhibit To assess the cause of Assessed cause of anxiety. Client exhibit
Client lack of calm behaviour by anxiety. positive attitude as
complains of knowledge positive attitude, evidenced by
restlessness regarding disease optimistic thoughts To provide safe and calm Provided safe and calm verbalization of
and feeling of condition. and verbalization in environment. environment. optimistic thoughts
helplessness and reduction of level and reduction in
discomfort and of anxiety. To provide psychological Client was explained all level of anxiety.
about support and build hope in treatment regimen about
hospitalization. treatment. disease and hospitalization.
Subjective data ; Knowledge Patient will have Assess the level of the Assessed the level of the Expected out come
Patient says that deficit related to increase his knowledge of the patient. knowledge of the patient by is partially met as
he is not known treatment regimen knowledge as asking question about evidenced by
about his medical and prognosis of evidenced by disease condition. verbalization.
treatment and disease. asking question and
about disease follow the To Explain about the surgery Explained about the surgery
condition and instruction. and disease condition. and disease condition.
surgery.
To explain about the Explained about the
Objective data : importance of medication importance of medication
- Asking and side effects. and side effects.
questioning
regarding his To encourage the patient to Encouraged the patient to ask
disease condition. ask the question and clear his the question and clear his
- lack of doubts. doubts.
knowledge.
- Misconception To explain about the diet. Explained about the diet like
- he is asking his high fibre, high protein
about his surgery. and high calorie diet.
NURSES NOTES - 1
Name of the Patient - Mr. Manish Shankarlal Navib Diagnosis - Bronchitis
Age / Sex - 55 years / Male Name of Surgery - Nil
Date of Admission - 15/02/2018 Date of Surgery - Nil
Ward / Bed No. - Male Medical ward Dr. Incharge - Dr. pareek
Nursing Observation,
Date Diet Medication Time Sign.
Intervention and Remark
16/02 Break fast : Tab. Rantac 150mg BD 8.00am Patient is sleeping in supine position. He had intracath on
Upma -1 plate Tab. Lasix 40mg BD right hand. He is talking with his relatives.
Banana - 1 Tab. Deriphylline
Water – 150cc 100mg TDS 8.30am Bed was looks unclean and untidy. So bed making was
Tab. Domstal 20mg BD done.
Lunch :
Roti – 3 9.00am Patient had a Break fast.
Boil egg - 1
Dal – 1wati 9.30am Patients vital sings are checked and this are following :
Mix veg. -1 wati Temperature : 98.6’F
Water – 150cc Pulse : 88b/m.
Respiration : 24b/m.
Blood pressure : 140/90 mm of hg.
17/02 Break fast : Tab. Rantac 150mg BD 8.00am Patient was came from the bathroom after taking bath.
Poha -1 plate Tab. Lasix 40mg BD
Banana - 1 Tab. Deriphylline 8.30am Bed was looks unclean and untidy. So bed making was
Water – 150cc 100mg TDS done.
Tab. Domstal 20mg BD
Lunch : 9.00am Patient had a Break fast.
Roti – 3
Boil egg – 1 9.30am Patients vital sings are checked and this are following :
Dal – 1wati Temperature : 98.6’F
Ladies finger. -1 wati Pulse ;86b/m.
Water – 150cc Respiration : 26b/m.
Blood pressure : 146/98 mm of hg.
CONCLUSION :-
As per my medical surgical nursing requirement I selected care plan on Bronchitis from Civil
hospital, surat. I selected Mr. Manish from malemadial ward who diagnosed Bronchitis. I
provided him 3 days care and from that learnt about the head injury and I am able to provide
care to other patients who have same diagnosis.
BIBLIOGRAPHY :-
(1) Lippincott , Manual of Nursing Practice, 8th Edition, Lippincott –New
York, Page no. – 674 - 678
(4)Davis, Drug Guide for Nuses, 20th Edition, F.A. Davis Company,
Philadelphia, Page no. – 100-102, 340-342, 667-668
(5) Hollowry Nancy, Medical Surgical Care Planning, 8th Edition, Spring
house Publication, Page no. – 420 -425