NURSING CARE PLAN

IDENTIFICATION DATA:-

Patient profile:-

 Name :- Mrs. Kanchan rajput

 Age:- 48 years
 Sex Female
 Hospital name:- Medanta the Medicity Gurgaon
 Registration no./I.P. no.:- MM00800617
 Unit/ ward :- ICU -3
 Bed no.:- 59
 Address:- Flat no.32, noida , Newdelhi.
 Medical diagnosis:- Subarachnoid Hemorrhage,
 Date of admission:- 02– 12 – 15
 Date of discharge:- not yet planned
 Date of care started:- 4- 12 -15
 Date of care ended:- 6-12-15

2. SOCIO ECONOMIC DATA:-

 Religion:- Hindu
 Education:- M.Sc.
 Occupation housewife
 Marital status:- Married
 Spiritual belief Patient is belief spiritual.
 Income (per month/annual):- 35,000/months
 Language known
Able to understand: - yes
Able to speak: - yes
Able to read and write:-yes
Family composition:-

S.No. Name Age Sex Relationship Education Occupation Health Remark

status

1 Mr. K.G. rajput 52yr M Head M.E Civil healthy good

engineer

2 Mrs.Kanchan 48yr F wife M.Sc. housewife unhealthy Poor

3 Mr. Partik 19yr M Son HSSC Student good good

4 Ms,Priya 16yr F Daughter HSC Student good good

Family degree:-

53 Y 48

19Y 16Y

-3. HEALTH HISTORY:-

 Reason for hospitalization:- subarachnoid hemorrhage

 Mode of coming to hospitalization/ward:- Ambulance
 Present illness Medical:-.Patient is complaint sudden onset headache followed by
vomiting and loss of conscious and patient came to Medanta in Emergency department
for further investigation and management.
 Past illness medical:- unknown
 Present illness history:- patient have subarachnoid hemorrhage
 Past surgical illness:- no significant history of surgeries
 Family history:- there are 4 family member one son and one daughter and husband wife.
She is good attitude in the family and she does not history of any disease of family
member such as diabetes mellitus.
 Allergic history:- unknown
 Dietary patterns:- Diet:- non vegetarian diet
Like: - all vegetarian (paneer)
Dislike:-papaya
Habits:- no bad habits

4. GORDONS FUNCTION HEALTH PATTERN ASSEESSMENT:-

 Health perception – health management pattern: Patient is not aware in own

health care she is tensed and anxious.
 Nutritional metabolic pattern: Patient is vegetarian and suffering from disease
condition & she does not taking proper diet.
 Elimination pattern : patient elimination & bowel pattern is disturbed
 Activity exercise pattern: Patient daily activity is very poor because patient was
admitted in hospital in 1weeks. So now she is restricted.
 Sleep rest pattern: patient is taken 4-5 hours sleep, sleeping pattern is affected and
interrupted.
 Cognitive – perceptual pattern: patient does not taste sensation ,vision & hearing is
normal .
 Self perception / self concept pattern: patient body image is disturbed but she has
positive attitude towards her health.
 Role relationship pattern: patient is living in a small family with her Husband and
son & daughter. she had good relationship is society.
 Sexuality reproductive pattern: patient is married. She has no history of
reproductive tract disease.
  Coping – stress tolerance pattern : patient can cope up with the disease condition
she is aware of her health problem

5. PHSICAL EXAMINATION:-

 General health status:-

 Level of consciousness:- semi - conscious
 Height-cm/inch.:- 150 cm
 Weight:- 72kg
 Appearance:- fatty
 Complexion fair
 Head to toe assessment criteria:-
General appearance
 Age- 45 yrs
 Colour - fair
 Nutritional status-adequate

 Vital sign
S.No. Name of Vital Patient value Normal value Remark
sign
1 Temperature 98.8.f 98.6.f normal

2 Pulse 138 beat /m 70- 80beat/m Tachycardia

3 Respiration 22 breath/m 16- 24breath/m high

4 Blood pressure 110/60mmhg 120/80mmhg Hypotension

 Head and face:-

 Size:-
 Symmetry: symmetrical
 Shape: round
 Colour:- whitish
 Pain:- 2/10
 Tenderness:- present
 Lesion:- absent
 Edema:- absent

 Scalp:-
 Colour:- white
 Texture:- non-hydrated
 Scale:- present
 Lumps:- palpable
 Lesion:- absent
 Inflammation:- absent
 Hair:-
 Colour:- brown
 Face:-
 Shape:- round
 Colour:- whitish
 Movement:- restricted
 Expression :- anxious
 Acne:- absent
 Tics:- absent
 Tremors:- absent
 Scars:- present
 Eye:-
 Acuity:-

 Visual loss:- normal

 Glasses:- absent
 Diplopia:- absent
 Photophobia:- absent
 Pain burning:- absent
 Eyelids:-
 Colour:- black
 Ptosis:- present
 Edema:- present
 Exophthalmoses:- absent
 Extra colour movement:-
 Position and alignment of eye:- symmetrical
 Strabismus: present
 Nystagmus:- no abnormal movement present
 Conjunctiva:-
 Colour :- pale
 Discharge:- absent
 Vascular changes:- normal
 Iris:-
 Colour :- white
 Vascularity: - normal
 Jaundice:- absent
 Pupils:-
 Size: 2mm
 Shape: round
 Equality: appropriate
 Reaction to light: reacted to light
 Ear:-
 Acuity:-
 Hearing loss :- able to hear
 Hearing Aid:- absent
 Pain:- intensity
  Tinnitus:- ringing
 External ear:-
 Lobe:- symmetrical
 Auricle:- normal
 Ear canal:- no discharge
 Inner ear:-
 Vertigo: present
 Nose:-
 Smell:- present
 Symmetry:- symmetrical
 Flaring:- absent
 Sneezing:- absent
 Deformities:- absent
 Mucosa:-
 Colour:- white
 Edema:- non-pitting
 Exudates:- present
 Pain tendencies:- present
 Sinus tenderness:- present
 Mouth and throat:-
 Odor: - foul smell
 Pain:- neuronal
 Ability:- clear
 Chew:- less movement
 Swallow dysphasia
 Lips:-
 Colour:- black
 Symmetry:- symmetrical
 Hydration:- dry lips
 Lesions:- absent
 Blister: absent
 Swelling:- absent
 Numbness:- absent
 Gums:-
 Colour:- pink
 Edema:- non-pitting
 Bleeding:- absent
 Teeth:-
 Number:- 30
 Missing:- 2
 Caries:-:- absent
 Sensitivity to heat and cold:- cold sensitivity

Tongue –
 Symmetry:- symmetrical
 Color- coated tongue
 Hydration:- moist
  Protrusion:- absent
 Ulcers: - absent
 Swelling:- absent
 Throat:-
 Gag reflex:- present
 Soreness:- present
 Cough:- dry
 Sputum:- thin
 Hemoptysis:- present
 Voice:-
 Hoarseness:- absent
 Loss:- dysphonia
 Neck:-
 Symmetry:- symmetrical
 Movement :- present
 Range of motion:-present
 Masses:- absent
 Scar:- absent
 Pain:- present
 Stiffness:- absent

 Trachea:-
 Deviation:- no deviation
 Thyroid:-
 Size shape:- normal
 Symmetry:- symmetrical
 Tenderness:- absent
 Enlargement:- No enlargement
 Nodules:- palpable
 Scar:- absent

 Vessel’s (carotid, jugular) –

 Quality strength and symmetry of pulsation bruits: distension of
carotid
 Venous distention: present
 Lymph nodes -
 Size:- pea size
 Shape:- round
 Mobility:- absent
 Tenderness:- absent
 Enlargement:- enlargement
 Chest:-
 Size:- normal
 Shape:- normal
 Symmetry:- symmetrical
 Deformity:- absent
 Pain:-- present
 Tenderness:- present
 Skin:-
 Colour:- whitish
 Rashes:- absent
 Scar:- present
 Hair distribution:- distributed regular
 Turgor:- poor
 Temperature:- 99.8.f
 Edema crepitating:-absent
 Breast:-
 Contour:- normal
 Symmetry:- symmetrical
 Colour:- wheatish
 Size:- normal
 Inflammation:- no inflammation
 Scars:- absent
 Masses:- absent
 Pain:- absent
 Dimpling swelling:- absent
 Nipples:-
 Colour:- black
 Discharge:- absent
 Ulceration:- absent
 Bleeding:- absent
 Inversion:- absent
 Pain:- absent

 Axillae:-
 Nodes:- palpable
 Tenderness:- no enlargement
 Rashes:- absent
 Inflammation:- no inflammation

 Lungs:-
 Breathing pattern:- abnormal
 Rate:- 22breath/minutes
 Regularity:- irregularity
 Depth:- normal
 Sound:- present
 Pitch:- high pitch
 Duration:- normal
 Vocal resonance:- normal
 Heart:-
 Cardiac pattern:-
 Rate: 138 beat/minutes
 Rhythm:- normal
 Regularity:- regular
  Skipped or extra beats: absent- normal
 Implanted pacemaker:- absent
 Abdomen:-
 Size:- normal
 Symmetry:- asymmetrical
 Colour:- wheatish
 Muscles tone:- rigid
 Turgor:- poor
 Hair distribution:- properly distributed
 Scar:- present
 Umbilicus:- protuded
 Distention :- absent
 Sound:- bowel sound present
 Liver:- enlarged
 Kidney:-
 Urinary output:- 1800ml/days
 Amount:- 600 ml/day
 Colour:- yellow
 Odor:- present
 Dribbling:- absent
 Incontinence:- absent
 Hematuria:- absent
 Nocturia:- absent
 Oliguria - absent
 Genitalia:-
 Labia majora:- edema present
 Labia minora:- edema present
 Urethral and vaginal orifice:- present
 Discharge:- present
 Swelling:- present
 Ulceration:- absent
 Nodules:- palpable
 Masses:- present
 Tenderness:- present
 Pain:- absent
 Rectum:-
 Pigmentation:- No pigment
 Hemorrhoids:- absent
 Masses:- absent
 Lesion:- absent
 Tenderness: present
 Pain:- absent
 Itching:- absent
 Back:-
 Scar:- absent
 Edema:- absent
  Spiral abnormalities:-absent
 Pain:- present
 Tenderness:- absent
 Extremities:-
 Upper extremities-
 Symmetry:- symmetrical
 Joint:- pain present
 Muscles:- diminished
 Edema:- absent
 Lower extremities:-
 Symmetry:- symmetrical
 Joint:- pain present
 Muscles:- weak
 Edema:- present
 Reflexes:-
 Biceps and triceps reflexes:- present
 Patellar reflexes:- present
 Planter reflexes:- present

INVESTIGASTIONS:
DATE NAME OF PATIENT VALUE NORMAL REMARKS
INVESTIGATION VALUE

3/12/15 Total leukocyte count 6000/cumm 4000- Normal

11000/cumm

3/12/15 Urea 33mg/dl 10-50mg/dl Normal

3/12/15 Potassium 3.9mmol/l 3.5-5.5mmol/l Normal

3/12/15 WBC basophiles 0.1% 0-1% Normal

3/12/15 WBC eosinophils 0.8% 1-6% Normal

3/12/15 WBC lymphocytes 10% 20-45% Decreased

3/12/15 WBC monocytes 8.1% 2-10% Normal

3/12/15 WBC neutrophils 80.9% 40-75% Increased

3/12/15 Platelet count 1.20lakh/cu 1.5-4.5lakh/cu Normal

3/12/15 Glucose blood 145mg/dl 70-140mg/dl Increased

3/12/15 Sodium 141mmol/l 130-150 mmol/l Normal

3/12/15 Antibodies to HIV Non-reactive Negative Normal

3/12/15 Creatinine 0.80mg/dl 0.6-1.4mg/dl Normal

3/12/15 E.S.R 36mm/fhr 0-10mm/f Increased

3/12/15 Bleeding time 2.15 sec 2-5sec Normal

3/12/15 Clotting time 5.40 sec 4-5 sec Increased

3/12/15 Alkaline phosphate 71U/L 15-47U/L Increased

3/12/15 Hb 8.1 gm/% [13-18]gm% low

CRITICAL PATHWAY

SL.NO NAME OF TEST DAY 1 DAY 2 DAY 3 DAY 4

1 URIC ACID 36mg/dl 3.5mg/dl 3.6mg/dl 3.2mg/dl

2. SODIUM 142mmol/L 146mmol/L 148mmol/L 142mmol/L

 Drug study

S. Trade name Chemical name Dose Frequency Route Action Contra- Side Effect Nursing
No. indications Responsibility
Mineral
-hyper- - hypotension -Monitor renal function.
1. Corticoid
INJ.INSPRA EPLERENONE 80MG BD I/V kalaemia. -dizziness. -Monitor serum
receptor
electrolytes level
antagonist

-Monitor Vital signs.

Proton pump Hypersen- -dry mouth
2. INJ.PANTOCID PANTAPRAZOLE 40MG OD I/V -Observe any abnormal
Inhibitor’s sitivity -Nausea
sign.

Myopathy -Advice patient to do

-pregnancy Hypotension
Lowering not
3. INJ. ATORVA ROSUVASTATINE 40MG BD I/V -breast Dizziness
high Drive or perform unsafe
Feeding. Fainting
cholesterol task.
-Rash -Take family history
Thrombolytic Blood -itching. Of bleeding disorder.
4. INJ.ACTILYSE ALTEPLASE 50MG BD I/V Agent. Clotting -shortness of -Assess sign of
Defect breath. dyspnoea.

-GI ulcer. -Monitor blood pressure

Viral
5. TAB.ECOSPIRION ASPIRIN 300MG BD ORAL NSAID’S -stomach -Monitor cardiac
infection
bleeding. pattern.
1. INPUT OUTPUT RECORD:

INTAKE OUTPUT
DATE URINE
TIME BY MOUTH TUBE PARENTRAL EMESIS SUCTION
VOIDED CATHETER
7am-
3pm
29/11/2015 350ml _ 500ml _ 350ml _ _

TOTAL 350ml 500ml 350ml

3pm-
11pm
250ml _ _ _ 320ml _ _

TOTAL 250ml 320ml _

3pm-
7am
300ml _ 200ml _ 350ml _ _

TOTAL 300ml 200ml 350ml _

24 HOUR TOTAL 900ml _ 700ml _ 1020ml _ _

24 HOUR GRAND TOTAL INTAKE= 1600ML 24 HOUR GRAND TOTAL OUTPUT=1020 ML

NURSING THEORY APPLICATION

DOROTHEA E. OREM’S SELF CARE THEORY:

Dorothea Elizabeth Orem, one of America’s foremost Nursing Theorists, was born in
Baltimore, Maryland. In the early 1930s she received her diploma certificate of
nursing from Providence Hospital School of Nursing, In 1939, BSN and 1945 Master
in Nursing Education, In 1976 Doctorate in Nursing.

A conceptual framework for nursing:

PATIENT Self-care

R
R

Therapeutic
Self-care
self-care
capabilities
demand
V

R
R
NURSE Nursing
capabilities

R=relationship

V= deficit relationship, current or projected

 WHOLLY COMPENSATORY SYSTEM

Accomplishes patient’s therapeutic self-care

Nurse
action Patient
Compensates for patient’s inability to engage in self-care action
limited

Supports and protect patient

Nurse plan care of personal hygiene like oral hygiene and bed
Nurse
bath. Administer medication, and maintain fluid and electrolyte
action
balance

Implemented personal hygiene care, administered medication

and maintaining fluid and electrolyte balance. Patient
action
limited
Protection from infection to change bed linen regularly and
support patient and family emotional needs and also spiritual
needs.

Nursing Management

Assessment

 A complete neurologic assessment is performed initially which includes :-

 Altered level of consciousness
 Sluggish pupillary action
 Motor and sensory dysfunction
 Speech difficulties and visual disturbance
 Headache or other neurologic deficits
 Neurologic assessment findings are documented and reported as indicated.
 Any changes in patient’s condition require assessment and through documentation,
changes should be reported immediately.
 Assessment data must be analyzed and if the client is deteriorating, the physician should
be notified.
 Volume of fluids ingested or administered and volume of urine exerted per 24hrs. is
monitored.
 Maintain the neurologic flow sheet which includes colour of face and extremities,
temperature and moisture of skin, quality and rate of pulse and respiration.
Nursing Diagnosis

1. Pain related to sudden bleeding in brain evidenced by severe headache.

2. Impaired communication related to impaired cerebral circulation as evidenced
by impaired articulation.
3. Nutrition altered related to inability to swallowing as evidence by loss of
muscles coordination.
4. Risk for aspiration related to loss of swallowing reflex as evidence by
impaired muscles coordination.
5. Knowledge deficit related to unfamiliarity with information resources as
evidence by incorporate follow through interaction..
S. Assessment Nursing Planning Implementation Rationale Evaluation
No Diagnosis
. Goal intervention

1. Subjective data Pain related to Short term  Assess the  patient is suffering from To assess the
sudden goal:- condition of pain. intensity.
Patient is bleeding in patients.
complaining for brain To provide
pain. evidenced by comfort.  Provide
severe comfortable  Comfortable supine position To relive from
headache. position to the should be provided. pain.
client.

 Administer  Tablet. Aspirin 150 Mg To reduce pain The client will

Long term medication if given. relive from
goal:- Prescribed.
pain.
To reduce  Provide cool and  Patient’s environment cool To prevent from
Objective pain. anxiety.
calm and calm.
data:-
environment.
I observe that
patients is  Support patients  Personal hygiene is
in performing maintained and patients is To provide
suffering from activity. feeling relax comfort.
severe pain
S. Assessment Nursing Planning Implementation Rationale Evaluation
No Diagnosis
. Goal Intervention

2. Subjective data Impaired Short term  Assess type and  Type and degree of dysfunction Helps to Client’s will
communication goal:- degree of assessed. determine area established
Patient is unable related to dysfunction. and degree of method of
to speak clearly. impaired To understand brain communication
cerebral the client’s  Listen for errors  Listen error in conversation and
circulation as involvement. in which needs
needs. in conversation. feedback provided.
evidence by can be
impaired expressed.
articulation.  Ask the patients  Asked for “shut your eyes,” Test for
Objective Long term to follow simple “point to the door,” receptive
data:- commands.
goal:- aphasia.
I observe that To improve
patients is communicatio  Provide  Alternative method such as Provides for
unable to n. alternative writing or pictures. communicatio
communicate methods of n of needs
properly. communication. based on
client’s
situation.
 Speak in normal  Given patients ample time to
Raising voice
tones and avoid respond. may irritate
talking too fast. patients.
S. Assessment Nursing Planning Implementation Rationale Evaluation
No Diagnosis
. Goal Intervention

3. Subjective data Nutrition altered Short term  Assess the  Nutritional pattern is assessed. To fulfil Patient will
related to goal:- nutritional status nutrition needs demonstrate
Patient is unable inability to of patients. signs of
to speak clearly. swallowing as Provide  Administer small  Small feed is given to the patient adequate
adequate & frequent such as mashed banana.
evidence by loss nutrition.
nutrition. feeding.
of muscles
coordination.  Provide adequate  Diet is given according to patient’s
caloric protein. requirements.
Objective
data:-
Long term  Plan meals when  Ensured that suction equipment is
I observe that Fatigue can
goal:- client’s is well On hand during meals.
patients is increase the risk
rested.
unable to To provide of aspiration.
swallowing . appropriate
 Offer viscous Viscous food
food.  Mashed banana is given to the increase
liquids such as patients
mashed banana, peristalsis.
potatoes.
S. Assessment Nursing Planning Implementation Rationale Evaluation
No Diagnosis
. Goal intervention

1. Subjective data Risk for Short term  Assess the  Client’s ability should be assessed. To assessing Demonstrate
aspiration related goal:- client’s ability in actual condition feeding method
Patient is unable to loss of swallowing and of clients. appropriate to
to swallow swallowing Provide clarity of speech. individual
properly. reflex evidence adequate situation with
by impaired support to the  Ensured that  Suction equipment available at Untoward
muscles suction bedside. effect of aspiration
client’s. prevented.
coordination. equipment is aspiration.
On hand during
meals.
Objective
data:-
Long term
I observe that
goal:-  Provide pleasant  Pleasant environment is provided. Promotes
patients is environment free relaxation
unable to To prevent from distraction.
swallowing and from
having risk for aspiration. To promotes
 Stimulate lips to  Manually open mouth by light muscular
aspiration. close. pressure on lips. control.

To provide
 Provide food in  Place food of appropriate sensory
small quantity. consistency in affected side of stimulation.
mouth.
To prevent from
 Avoid straw for
 Straw is avoided for drinking Aspiration.
liquids.
juices.
S. Assessment Nursing Planning Implementation Rationale Evaluation
No Diagnosis
. Goal intervention

1. Subjective data Knowledge Short term  Assess the  Assess the degree of sensory To help in Patient will
deficit related to goal:- condition of involvement. choosing demonstrate
Patient is unable unfamiliarity client’s. teaching signs of
to understand with information Provide method. adequate
properly. resources as adequate To providing nutrition.
information.  Include family in  Family is included in discussion.
evidence by discussion and support.
incorporate teaching.
follow through
interaction.  Refer to home  Referred to home care supervisor Home
Objective care supervisor or visiting nurse.
data:- Long term environment
goal:- needs
I observe that  Identify  Community resources such as modification to
patients having To provide community American heart association and meet client’s
less knowledge knowledge resources. national stroke association. needs.
regarding regarding
condition. patient’s
 Review Importance review given on
condition. To improve
importance of balance diet.
balance diet. general health
HEALTH EDUCATION:

 SPECIFIC HEALTH EDUCATION: I explained about ill status and alteration

and variation in vital sign, its reason and ongoing management of the patient to
her caregivers.
 MEDICATION: I taught to patient and her caregivers about ongoing medication.
 EXERCISE: I advised to do regular exercise on bed and taught about some light
ROM exercise to the patient.
 NUTRITION: I taught to Mrs. Kanchan about ongoing diet schedule and it’s
important and role in maintain health.
 FOLLOW UP: I advised him to co-operate with all health care team members.

PROGNOSIS:
Mrs. Kanchan health status is improved. And she and her family very much assured about
the management and hospital care. Variation in vital signs especially in blood pressure is
controlled.
SUMMARY:
Mrs.Kanchan is admitted in the Medanta the Medicity, Gurgaon with complaint of severe
Headache. And got shifted in ICU -3 with altered vital signs. The health care team is
providing comprehensive care to the patient.

CONCLUSION:
Mrs. Kanchan vital sign is stable during the care, and nursing care mainly focused to
maintain his self care and improvement of her health status. Patient is now much more
assured about her ill status and management.