IDENTIFICATION DATA

Name: Mr vishal walia

Age: 24 years
I.P No.: - 70742-5
Address: v.p.o makroli teh indoora district kangra
D.O. A:-21-02-2019
Marital status: Unmarried
Occupation: - private job
Education: - graduate
Religion: - Hindu
Ward: - Male medicine ward
Bed No.: - 26
Diagnosis: - scrub typhus fever

CHIEF COMPLAINTS:
Mr vishal walia was admitted in male medicine ward center at Dr. RPMC Tanda on 21/01/2019 with the chief complaint of:

 Multiple episodes of nausea and vomiting X 4days

 Fever X 4days

1
 Generalized weakness X 4days
 loss of appetite X 3 days
 diarrhea X 4days
 cough X5days

PRESENT MEDICAL HISTORY: The patient was suffering from fever, vomiting and nausea . From 3days he was suffering
from anorexia, weakness, headache and diarrhea, muscle pain. He was also suffering from cough
PAST MEDICAL HISTORY
 History of any past illness & treatment:
no history of any severe illness, DM, hypertension.
 H/o allergy/medications/ infection: Not significant
 Allergies: No history of any other allergy.
 Immunization: done
 Hospitalization: not significant.
 Habits: non-vegetarian.
 Sleeping pattern: disturbed due to hospital environment and disease.

PRESENT SURGICAL HISTORY: not significant.

PAST SURGICAL HISTORY: not significant
FAMILY HISTORY
Type of family: joint

a) Composition of family members- 5

S.No Name of Age Sex Education Occupation Marital Health Condition

2
 family Status
members
1. Suresh 56 Male Graduate Private job Married Healthy
years

2. Sumana devi 54 year FA Graduate House wife Married healthy

3. Vishal walia 24 MA Graduate private unmarried patient

employee
Year

b) Family tree:
KEY POINTS:
Male=

Female =

c) Family Medical History: not significant. Patient=

PERSONAL HISTORY
 Diet- soft diet
 Number of meals per day: loss of appetite
 Food allergies, food preferences: soft diet. No food allergies.
 Bowel & Bladder habit- regular
 Frequency of Micturition: 5-6 time per day

3
  Frequency of defecation: diarrhea
 Sleep pattern: disturbed due to hospitalization and disease.
 Smoking: non-smoker
 Alcohol Consumption: non-alcoholic
 Tobacco chewing: not significant

Psychosocial history:
 Languages spoken: Hindi
 Social support systems present.
 Any psychological stressors present: anxiety related to associated disease.
PHYSICAL EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR
 Body build-
 Hygiene & grooming – well groomed
 Mobility status- mobile
 Activity level- dull
 Pallor: yes
 Jaundice: absent
 Consciousness-oriented to person, place, time

ANTROPOMENTRIC MEASUREMENT
 Height: 160 cm
 Weight:60kg
 BMI= WEIGHT IN KG/ (height in meters)2= 20kg/m2

VITAL SIGNS

4
 Date Temperature Pulse Respiration Bp
28/01/2019 102 F 105 bpm 26bpm 140/100 mmHg

SKIN: -
Inspection
 Colour – dark.
 Lesion – no Primary, Skin lesions, secondary skin lesions
 Vascularity: - no Ecchymosis, Petechiae

Palpation
 Moisture: dry
 Texture: - rough
 Turgor: - normal
 Temperature: - warm

HAIR AND SCALP: -

Hair
 Colour: - black
 Texture: - rough
 Distribution: - normal

SCALP
Dryness present. No Lumps, Lesions, Pediculosis and dandruff is present.
HEAD
No head injuries
NAILS
 Nail bed color: - pale
 Shape of nail plate: - flat

5
  Tissues surrounding nails: - intact
 Blanch test of capillary refill: - intact
 Blanch test of capillary refill: - 4 sec

SKULL: normocephalic
FACE
 Color: fair
 Symmetry: symmetrical
 Edema: - not present
 Involuntary movements: -not present
 Examination of Trigeminal nerve: sensory: he was not able to distinguish between sharp and soft touch.
Motor: bilateral equal tension.
 Examination of facial nerve: sensory: corneal reflex present.
Motor: symmetrical facial expressions.
EYES & VISION: -
External structures

 Eye brows: present

 Hair distribution: equal
 Scaling & Flakiness of skin: not present
 Alignment & movement of eyebrows: symmetrical
 Iris/ pupil: normal
 Eye lashes: - no sty and other infection
 Eye lids: - no ptosis/ectropion/entropion.
 Conjunctiva: - pink
 Sclera: - White
 Cornea: soft

6
 Pupils: -

 Reaction to light: pupils constriction to light

 Coronal reflex: - present
 Enophthalmos: not present
 Ptosis: absent
 Examination of optic nerve: Bilateral pupillary constriction to light
 Visual acuity: - 6/6 (both right and left eye).

EARS:
Auricles
 Colour: - normal
 Alignment: - symmetrical
 Elasticity: -pinna recoils after it is folded
 Tenderness: - non-tender

External ears
No redness and discharge. Dry cerumen present
Hearing acuity:

 Weber test: - sound is heard in both ears. Equal laterization of sound.

 Rinne’s test: - AC>BC

NOSE AND SINUS:

 Nasal septum: - deviated

 Facial sinuses (maxillary, frontal): - no tenderness
 Smell (examination of olfactory nerve): - Normal
 Any other problem: no discharge, no tender, no lesions

7
MOUTH AND OROPHARYNX
1. LIPS

 Color: - darkening
 Texture: - dry
 Angular stomatitis: not present

2. BUCCAL MUCOSA

 Color- reddish dark

 Texture-Moist
 Presence of lesions: not present

3. GUM
 Colour- dark complex
 Texture- Moist firm
 Gums bleeding/Gingivitis: not present

4. TEETH: dental carries

5. TONGUE
 Position-Central
 Colour and texture-Pink Colour, moist, smooth lateral margins, no lesions.
 Tongue base- smooth tongue base with prominent veins
 Mobility- Moves freely

6. FLOOR OF MOUTH: Smooth with no nodule

7. TONSIL: not enlarged

8. PALATE

8
  Light Pink & smooth soft palate
 Light pink hard palate,

9. UVULA: Midline in position

10. OROPHARYNX

 Taste: normal
 Odor of mouth: no foul odor
 Gag reflex: present
 Swallowing reflex: present
NECK: -
Muscle
 Size: Equal and Head centered
 Head movement: - Coordinated smooth movements with no discomfort
 ROM: rotation, extension, flexion is possible.
 Lymph node: not enlarged
 Trachea: midline
 Thyroid gland: not enlarged
 Jugular veins: not distended

CHEST
Thorax and lungs
Posterior thorax

 Shape and symmetry: - normal shape

 Movement of chest: equal
 Percussion: -resonant sound
 Auscultation: -– bilateral normal breath sound present

9
Anterior Thorax
Inspection
 Shape &symmetry: - normal
 Movement of chest: Equal
 Any deformity- absent
 Dyspnea on rest- absent
 Dyspnea on expansion- absent
Palpation:
 Symmetrical chest expansion- symmetrical
 Any tenderness- no
 Lump or mass- No
 Skin Temp – warm
 Moisture- dry
Percussion: - resonant sound
Auscultation: - bronchial sound
BREATHING PATTERN-
 Regular
 Respiration rate- 24 breath/min
 Breathing via oxygen mask- no
 Breathing via ET tube- No
 Breathing via F piece- No
 On ventilator- No

CIRCULATORY SYSTEM:

 Pain: not present

 Numbness: not present
 Syncope: absent

10
  Dizziness: absent

HEART:

 Heart sounds: - S1& S2

 Chest pain- not present
 Any other heart disease or any problem- no history of hypertension.
CHEST AND AXILLAE
 Symmetry: symmetrical
 Lymph nodes: not enlarged
 No gynecomastia.

ABDOMEN:

 Position of umbilicus: central

Inspection

 Contour of the abdomen: mild distension.

 Shape of abdomen: flat and symmetrical.
 Umbilical hernia: not present.
 Umbilicus: clean
Percussion: - mass
 Bowel sounds: present,
 Inguinal hernia: not present
 Appetite: decreased
Palpation:
 No Hepatosplenomegaly
BACK
 presence of decubitus ulcer: not present.
NUTRITIONAL:

11
  Appetite: decreased
 Nausea: present
 Vomiting: present
 Pain related to eating: absent
 Dysphagia: absent
NEUROLOGICAL:
 Confusion: absent
 Convulsions: absent
 Loss of strength: yes
 Weakness: present
 Pain: present
 In-coordination: absent
 Changes in sensation: no
 Tingling /pricking: absent
 level of consciousness: conscious, orientated

REFLEXES
Superficial reflexes
 Superficial abdominal reflex: physiological absent.
Deep reflexes
 Biceps reflex: reactive
 Triceps reflex: reactive
 Patellar reflex: reactive
 Achilles reflex: reactive
INTEGUMENTARY SYSTEM:
 Skin color: dark complex
 Texture: dry

12
  Skin turgor: decreased
 Hydration: dehydrated
 Discoloration: not present
 Pigmentation: not present
 Lesions /masses: absent
ENDOCRINE SYSTEM- no goiter, no thyroid tenderness, no tremors and weakness.
hormone therapy: no.
HEMATOLOGIC SYSTEM – Any known abnormalities of blood cells: no
MUSCULOSKELETAL SYSTEM:

 Postural curve: kyphosis

 Muscle tone: normal
 Muscle strength: week
Upper extremities:
 Inspection: - symmetrical, no deformity, and swelling.
 Palpation: - no edema, tenderness, crepitus, nodule
 ROM: adduction, abduction, extension, flexion possible.
 Finger nails: capillary refill 2-3 seconds
 Peripheral pulses: Radial: - 78 beats per minute
 Triceps: reactive
 Edema/swelling: absent
 Cyanosis: absent
 Joint: absent

Lower extremities:
Muscle
 Symmetry: symmetrical
 Contractures/tremors/atrophy/hypertrophy/asymmetry: No

13
  Muscle tone: normal
 Toe nails: capillary refill 3 seconds
 Range of motion: possible
 Reflexes: patellar – reactive
 Edema/swelling: not present
 Cyanosis: absent
 Joint: no pain
 Deformity: absent
 Other signs /symptoms: loss of sensation in lower limb.
GENITOURINARY SYSTEM –

 no history of STD
 incontinence
 Catheterized.

RECTUM&ANUS:

 Perineal skin integrity: intact

 Bowel elimination pattern: diarrhea
 Subjective symptoms: no other subjective complaints

INVESTIGATIONS DONE:

14
 Investigation Patient value Normal value Remarks

Heamoglobin 13.7 mg/dl 13- 17mg/dl Normal

TLC 25.8 7+/ 3.0 Increased
Neutrophil 82 40-80% Increased
LYMPHOCYTES 33 20-40% Normal
Esonophil 1.3 01-06% Normal
Blood urea nitrogen 7 6.0-23.0 mg/dl Normal
Serum urea 11 10-45 mg/dl Normal
Serum creatinine 0.9 0.2-1.2 mg/dl Normal
Serum uric acid 6.6 2.4-7.0 mg/dl Normal
Bilirubin total 0.2 0.2-1.0 mg/dl Increased
Bilirubin direct 0.02 0-0.3 mg/dl Increased
SGOT 83 5.0-40 IU/L Normal
SGPT 84 5.0-40 IU/L Normal
Alkaline phosphate 72 40-129 U/L Increased
Scrub typhs antibodies rapid Detected
Detected
test
ESR 35 10-20 Increased
TREATMENT CHART
Sr. Name of the Drug Dose Route Frequency Action
no.
1) Inj doxicyclin 1 gm IV BD Board spectrum antibiotic
2) Inj Pantocid 40 mg IV BD PPI
3) Inj Emset 4 mg IV SOS Antiemetic
4) Inj Voveron 75 mg IM SOS Analgesics
5) Tab PCM 650mg orally BD Antipyretic
6) Capsule B-complex 400 mg Oral OD Vitamin E supplements

15
 NURSING MANAGEMENT

NURSING ASSESSMENT
 History : Ask for past history of cardiac disorder, liver disorders, Hypertension, Diabetes etc.
 Ask for any family history.
 Ask for history of smoking, alcoholism and occupation.
 Assess for chief complaints.
 Assess the client for the multiple effects of gall bladder on all body systems
 Cardiac monitoring
 Strict intake output monitoring
 Regularly assess the biochemistry profile of the patient

NURSING DIAGNOSIS:

 Alterd body temperature related to infection as evidence by increase body temperature

 Fluid volume deficit related to vomiting as evidence by Intake and output chart and skin turgor.
 Imbalance nutritional status less than body requriment related to loss of appetite as evidence by weight loss.
 Ineffective therapeutic regimen related to knwolegde deficit as evidence by frequent question

Goals:
Short term goal Long term goal

16
 To maintain the body temperature.  To maintain optimal health care.
 To maintain the fluid electrolyte balance .  To provide head to foot care.
 To maintain the skin integrity  To rehabilitate the patient.
 To improve the nutritional status  To maintain aseptic technique.

Nursing Goal Nursing intervention Nursing

diagnosis evaluation
Nursing
Assessment
Subjective data- Altered body To maintain  Assess the general condition of the patient By providing
temperature body all measures
Patient says “ Iam temperature now patients
related to  Monitor vital signs of the patient.
having hot flushes body
infection as temperature is
and feeling restless
evidence by maintained.
 Give cold sponges to patient.
increased

Objective data- body

 Provide comfortable environment to patient.
temperature .
 Body
temperature  Administer medication as prescribed by doctor

17
 increased

Assessment Nursing Expected Implementation Evaluatio

outcome n
diagnosis
Subjective data- Fluid volume To maintain Fluid volume
deficit related fluid volume • Assess the general condition of the patient is maintained .
The patient says I to vomiting
• Monitor vital signs of the patient.
am feeling as evidence
by Intake and • Monitor Intake and output chart
polypepsia .
output chart • Administer IV fluids to patient.
and
• Administer medication as prescribed by doctor
Objective data

Electrolyte
imbalance due to
vomitings

Assessment Diagnosis Goal Planning Evaluation

Subjective data Imbalance To improve Assess the nutritional status of patient The
Patient says “ I am nutrition less the nutritional
not able to eat than body nutritional status was

18
 properly. requirement status improved
related to Provide small and frequent diet to patient
Objective data nausea and
Weight loss vomiting as Administer fluid to patient
Decrease appetite evidence by
Vomiting weight loss Insert NG tube to the patient for feeding
Pallor

Administer drugs to patient

HEALTH EDUCATION:
 Diet- Patient is taught regarding balanced diet, rich in fibers and fluids. Patient is advised to take green vegetables, fruits, juices &
salad in diet and to avoid fat rich diet
 Exercise – Patient is taught some active & passive exercise. Patient is advised to do deep breathing exercise.
 Hygiene – Patient is advised to keep her surroundings clear & perform hand hygiene properly.
 Fluids – Patient is advised to take more fluids & beverages.
 Pain management & Medications - Analgesic medication timing is clearly explained to patient & with that
feedback for medications intake is also taken.
 Follow Up- Follow up dates are given to patient & them should be clearly explained regarding it. The patient was referring to
oncology ward and all its treatment was explained to her.

Conclusion:

19
I was posted in male medicine ward at Dr. RPGHC Tanda, where I took a case of scrub typhus . I took detailed history of
patient & performed physical examination on patient. I provided all the need-based care to my patient. with that I maintained good
IPR with patient & listened her difficulties & problems. I provided health education to my patient. In future, if I will get the similar
case, I will be able to provide holistic care to my patient.

References:

 Brunner and Suddarth’s ‘ Textbook of Medical Surgical Nursing’ 9th edition 2001 page: 1173-1178

 Smeltzer CS, Bare B. Brunner & Suddarth’s Textbook of Medical Surgical Nursing. 10th ed. Philadelphia(PA): Lippincott
Publishers; 2006.

 Chintamani. Lewis’s Medical Surgical Nursing. 7thed. New Delhi: Elsevier limited; 2010.

20