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DEMOGRAPHIC DATA OF THE PATIENT :
Name : Mr. kailesh
Father’s /husband’s name : S/O Mr. dyanand
Age : 31 years
Sex : Male
Occupation : auto drive
Religion : Hindu
Address : 196, shyam nagar, amritsar
marital status : Married
Diagnosis provisional : tuberculosis
Final diagnosis : pulmonary tuberculosis
Surgery if any :No surgical intervention is done .
HISTORY TAKING :-
Present complain :The patient is having present complain of ;
Severe dyspnoea on exertion even at rest also .
Cough with sputum
Chest pain due to excessive cough
Cold
Upper respiratory tract infection
Weakness , restlessness, weight loss
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This all symptoms are persisting since 6yr but from last night it is in peak .
History of present illness : Since 3 month the patient is having problem of
breathlessness , cough, intermittent chest pain , he took treatment from dr. in the
hospital .the medications brought symptomatic relieve and he used to come for follow
–up but since last 8days he developed severe dyspnoea due to congesion as well as
during sleep and he used to get up and sit for long time than it used to be relieved but
last night the symptoms were on peak and he was so uncomfortable because of that
the relative brought him in hospital and after consultation with doctor he was being
got admit.
Past history : he has no have any complaint of chronoc disease
Family history : In his family no one is suffering from any major disease
condition neither any person died due to any disease .
Socio-economc status : He is from lower middle class family ,he has his own ‘pakka
‘ house which is having 3 rooms only and well ventilated , he disposes garbage
outside the house there is no particular place for disposing the garbage .he is very
friendly and all like to talk with him , he participate in all religious functions .
Family composition :
S.No Name of the Age Sex Relation Health
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member with the status
patient
1. Mr .kailesh 30 years Male Patient Poor
2. Mrs. Parwati 25 years Female Wife Having
joint pain
3. Pooja 2 years Female Daughter Healthy
4. munna 7 years male son healthy
Personal history :
Eating habits :He is pure vegetarian , he usually takes light diet since he
developed this disease .He takes Roti, Dal, rice , any type of vegetable whatever is
available. Sometimes he take fruits , he does not keep fast .
Elimination pattern : He was having good bowel and bladder elimination pattern but
since the problem is more severe now the renal perfusion is also decreased and it is
affecting the bladder elimination .
Any abuse : He used to smoke and sometimes he used to take alcohol but
since last 3 year he stopped taking all these things .
Life style :He lives very simple lifestyles , he does not do any extra
activity like walking or any other exercise.
PHYSICAL EXAMINATION :
Height : 160 cm
Weight : 63 kg
VITAL SIGNS :
Temperature : 99.8®F
Pulse : 42/mt.
Respiration : 44/mt.
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Blood pressure : 130/70 mmhg per arterial blood pressure .
HEAD :
Scalp : No scar was seen but the scalp seems to be dry & having
dandruff.
Face : Normal in shape , size and alignment ,a black mole was present
on chin .
Sinus area : No tenderness present.
Nodes : No nodes are enlarged .
Cranium : Normal
EYES :
Visual acuity : Normal
Visual field : Clear,6/6
Ocular movement : Normal , moves to both sides as well as towards the up and
down .
Lids : Eye Lides are normal no edema or inflammation is being
detected .
Lacrimal glands : The Lacrimal Glands are normal and secretes normally
Sclera : pale
Cornea : No Abnormality detected
Lens and media : Normal , the image forms normally.
Fundus : Normal
EARS :
External structure : Normal in alignment ,
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Canal: Normal , no discharge is seen
Tympanic membrane : Normal.
Hearing : Normal , checked by tunic fork.
NOSE :
External structure : normal in alignment ,
septum : No deviation seen
Mucus membrane : Moist , no inflammation seen .
Patency : Good
Olfactory sense : This was normal , checked by using some flavour
ORAL CAVITY :
Lips : Mildly cyanosed , cracked , dry .
Buccal mucosa : Cyanosed and dry
Gums : Pale
Teeth : Unhygienic , yellow stain was present .
Palates and uvula : Normal
Tonsillar areas : No enlargement detected
Tongue : Cyanosed , dry ,
Floor : Normal .
Voice : No hoarseness was present .
Breath : Dyspnoea present , the patient was on oxygen .
NECK :
General structure : Normal in shape and size .
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Trachea : Present in central
Thyroid : Normal , no enlargement seen
CHEST AND RESPIRATORY SYSTEM :
Chest shape: Slightly heavy
Type of respiration : Thoraco- abdominal respiration was present .
Expansion : It was fast .
General palpation : On palpation chest movement was present as well as apex
impulse was felt on 5th intercostals space.
Percussion : on percussion no air or fluid detected .
Breath sound : B/L +
CARDIOVASCULAR SYSTEM :
History :
1)Cardinal symptoms :
Dyspnoea : There was presence of marked dyspnoea on exertion ,even
with mild exertion .
Chest pain : It was not that evident but sometimes the client used to be
irritated due pleuritic chest pain
Cough : He was having vigorous cough .\
Expectoration : yes,expectoration was present .
Haemoptysis :There was no presence of haemoptysis ,
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Palpitation :There was presence of slightly palpitation .
Syncopal attack : 1 times he had Syncopal attack .
Build and nutrition : He was averagely nourished .
Nails and conjunctiva : Nails were cyanosed . .
Thyroid : No enlargement detected .
Oedema : There was no presence of oedema .
Skin : The skin was pallor & brittle .
ABDOMEN AND INGUINAL AREAS :
Contour and tone : Good contour and good muscle tone .
Scars marks : There is no scar marks detected .
Liver :
Spleen : Normal
Kidneys :
Bladder : Normal
Hernias : There is no hardness or swelling over the groin .
Masses : No masses are felt on abdomen
Palpation : On palpation no mass or any kind of hardness is felt , abdomen
was soft to touch .
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Percussion : On percussion no fluid or gas collection detected .
Auscultation : On auscultation normal peristaltic movement heard .
GENITALIA AND AREA NODE :No such kind of nodes, abrasion or lesions seen.
RECTAL EXAMINATION :No rashes or any kind of abnormality detected.
MUSCULOSKELETAL SYSTEM :
Gait : Normal
Upper extremities : Both are in normal alignment no extra digits are present and
cyanosis were present on fingers .
Lower extremities: Both are in normal alignment .
Deformities : No such deformities detected .
Range of motion : He was so tired that could not perform the full range of
motion . .
NERVOUS SYSTEM :
Mental status : He was well oriented to date , place and time , even he was
knowing the reasons for admission in hospital . .
Language : He has no problem in language , no sludge speech .
Motor co-ordination : Motor co-ordination was good .
Lower extremities : Good tone of muscles , no rigidity detected and well co-
ordination present , there is presence of cyanosis .
s. no Investigations Normal value Patients value EVALUATION
1. Haemoglobin 11.5-15.5 gm. 15.2 gm
2. W.B.C 4000-10000/cmm 22,100/cmm More
3. Packed cell vol. 37-45% 45 %
4. Platelet count 1.5-4.0lacs/cmm 2.34 lacs /cmm
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5. Blood group - B positive
6. R.B.S 70-140mg/dl 87 mg/dl
7. SGOT 5-40 IU/L 32IU/L
SGPT 3-40 IU/L 47IU/L more
8.
9. S. Bilirubin 0.2-1.2 mg/dl 0.46mg/dl
10. Direct Upto 0.3 mg/dl 0.30mg/dl
11. Indirect 0.2-1.0 mg/dl 0.16mg/dl
12. S. Creatinine 0.5-1.5mg/dl 0.9mg/dl
13. S.na+ 135-145meq/l 137 Meq/L
14. S.K+ 3.5-5 Meq/L 5.1Meq/L more
15. CL- 96-107 Meq/L 95 Meq/L
16. S. Protein 6-8 gm/dl 5.8gm/dl
17. S. Albumin 3.5-5 gm/dl 3.2gm/dl
18. S.Globulin 2.5-3.5 gm/dl 2.6 gm/dl
19. Bld. Urea 15-40 mg/dl 43mg /dl more
20. Hbsag Negative Negative
21. HIV Non-reactive NR.
22. Blood group - B positive
23. PT –test - 15 sec.
24. Control - 13 sec.
25. INR - 1.11
URINE
ROUTINE
26. Albumin Nil Trace
27. Sugar Nil Nil
CHEST X-RAY :-The chest x- ray shows patchy, inflamed bronchioles,
consolidation in the lungs due to thick sputum. clouding appearance was observed.
Medial treatment : The patient was admitted in ICU and he was on oxygen therapy,
the medications which were being prescribed for him are listed below ;
INJ. Clavum I.V 1.2gm 8hourly
INJ. Aciloc 50mg I.V BD
INJ. Deriphyllin I.V 1 amp 8 hourly
INJ. Prednisone I.V 1 amp OD
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INJ. Ibrufen 1apm I.M. BD
Tab Metagard CR 60mg 1 OD
Tab. Alupent 10mg 1 QID
Nebulise with Asthalin & Budecort 6 hourly
Syrup Mucinex 2t
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Nursing outcome Implementation Rationale Evaluation
Assessment diagnosis
Subjective data Impaired gas Patient breathing Give comfortable To extent lung Now patient is feel
patient have complaint exchange pattern will be position to the surface. better he have no
of breathing difficulty related to normal patient. complaint of breathing
objective data- decrease lung difficulty.
I observe patient surface Promote bed rest Reducing 0xygen
breathing pattern and I /limit activity & assist consumption
observe that patient with self care demands during
have breathing activities as periods of
difficulty and its come necessary. respiratory
under the first compromise may
component of virgenia reduce severity of
herson theory symptoms.
Give the inhalation to
the patient. It clean the airway
obstruction.
Instruct & encourage
patient to take deep Deep breathing &
breathing & cough coughing exercise
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every hour promote normal
breathing pattern.
Nursing diagnosis outcome Implementation Rationale Evaluation
Assessment
Subjective data- my Chest pain related to Patient chest pain Give comfortable To proper lung Expected outcome
patient have disease condition will be reduce position to the extension is completely meet
complain of chest patient here
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pain To provide comfort
Give continous bed and rest to the
Objective data- rest to the patient patient.
I observe my
patient expression Explain the Proper coughing
coughing exercise. pattern will reduce
the pain
Apply the chest To remove
physiotherapy coughing
Give the medicine
as by ordered
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Nursing diagnosis outcome Implementation Rationale Evaluation
Assessment
Subjective data-my Vomiting related to Patient vomiting Give the To provide Patient feel good
patient have drug induct will be reduce comfortable comfortable and now he have no
complaint of position to patient. maintain sence of complaint of
vomiting Vomiting related to well being vomiting
Objective data- disease process. Instruct the patient
observe that patient to avoid crowd of Some time crowd
doing vomiting relatives may cause vomiting
infront of me sensation
Give the antiemetic
as by ordered Antiemetic to
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prevent the
vomiting p
Subjective data – Alteration in Patient sleep pattern Discourage large This often change
my patient have sleeping pattern will be maintained period of sleep the client ususl
complaint about related to prolonged during day time sleeping pattern
lack of sleep or counghing
heavy ness in eyes. Provide column and Its induct to sleep
Objective data- I quit environment to
observed by patient the patient
condition and
consult with night Remove the cause To provide sleep
staff. with is disturb to pattern
sleeping pattern
Give the medicine To induct sleep
asprescribed by
physician.
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Nursing diagnosis outcome Implementation Rationale Evaluation
Assessment
Subjective data-my Imbalanced Patient nutritional Check the body Note to changes in Patient nutritional
patient have nutrition less then status will be weight regularly body weight status is maintained
complaint of weight body requirement maintain and he take interest
loss and lack of related to frequent Document clients Useful in defining intake of food.
hunger anorexia. nutritional status degree/extent of
from admission and problem &
Objective data- I history of vomiting/ appropriate choice
observed that Weight loss related nausea of intervention
patient have lack of to lack of interest to
interest of food he food intake. Assess client Helpful in
refused to take food usually dietary identifying and
pattern like /dislike specific need
consideration of
Monitor input and individual
out put amount preference may
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improve dietary
Encourage to intake
patient to take more
vitamins protein To improve
diet nutritional status &
promote weight loss
Nursing diagnosis outcome Implementation Rationale Evaluation
Assessment
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Subjective data- my Knowledge Patient knowledge Assess client ability Learning depends
patient have deficiency related to will be improved to learn on emotional and
complaint me about misinterpretion of regarding disease physical readiness
his condition information of lack condition Provide interection & is achieved at an
He asked me of information specific written individual pace
question regarding regarding disease. information for
his condition client Written information
relieves client of the
Objective data – I Encourage client to burden of having to
listen the patient verbalize fear/ remember large
question concerns amount of
information.
Teach about disease
process and Provides
medication opportunity to
correct
misconceptions
inadequate finances
may affect coping
Teach about T.B. with maintaining
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transmission. health.
To provide
knowledge about
transmission of
infection of T.B.
