NURSING CARE PLAN

PATIENT’S PROFILE
I. IDENTIFICATION DATE
Name of the patient :- Mr. Manohar patil
Age / sex :- 32yrs.yrs / male
:-
Date of admission :- 22/07/019
IPD no. :- 1677
Marital status :- Married
Religion :- Hindu
Educational qualification :- M.A B.ed
Occupation :- Employ in motor compeny
Family income :- Rs. 12000 /- per month
Diagnosis :- Fracture of femur
Habits / vices :- no any type of addiction is found in the
patient. habits.

1. PRESENT COMPLAIN : - Mr. Manohar patil admitted in the orthopedic ward on date
22/07/019 with the complaints of fracture of right
femur with Severe Pain and tenderness.

HISTORY OF THE PRESENT ILLNESS : - Mr. Manohar patil admitted in the

orthopedic ward with the complaints of fracture of right femur with Severe Pain and
tenderness

2. History of past illness :- There is no history of any past

illnesses

3. PAST MEDICAL & SURGICAL HISTORY :-There is no past medical and surgical

history except minor illnesses.

4. FAMILY HISTORY OF ANY ILLNESS : - there is no any Family history of illness

5. MENSTRUAL HISTORY :-

a. Age of menarche :- NO
 b. Menstrual cycle :- NO

c.Any complaints :- NO

2. FUNCTION HEALTH PROBLEM :- NAD

3. HYGIENE :- my patient is looking very neat

and tidy. Daily he takes bath by

own and change his clothes.

4. ACTIVITY EXERCISE :- Patient can not perform own

daily routine activities and

exercise due to fracture of

femur.

5. SLEEP / REST :- Patient sleep pattern is disturbed due

to the pain.

6. ELIMINATION PATTERN : - Patient’s elimination pattern is disturbed due to

lack of exercise and activities.

7. COGNITIVE PERCEPTUAL : -Patient is well orientated with

the time, place & person.

8. FAMILY HISTORY:-

SR. NAME OF THE AGE / RELATION EDUCATION REMARK

NO. FAMILY MEMBER SEX WITH THE
 PATIENT
61 YRS
1. MR. SHIVA PATIL FATHER ILLITRATE ----
MALE
56 YRS /
1. MRS. KARUNI PATIL MOTHER ILLITRATE ----
FEMALE
MR. MANOHAR IS
31 YRS
2. MR. MANOHAR PATIL SELF M.A B.ED GOT FRACTURE OF
MALE
FEMUR

27 YRS
3. MRS. ANJALI PATIL WIFE GRADUATE ----
FEMALE
8 YRS
4. MS PINKI PATIL DAUGHTER 3RD STND ----
FEMALE

9. FAMILY TREE:-

10. SOCIO ECONOMIC STATUS: -

a. Monthly income

SR. NO. NAME OF THE FAMILY MEMBER OCCUPATION MONTHLY INCOME

1. MR. MANOHAR PATIL EMPLOY IN MOTOR COMPENY 12,000

 b. Expenditure:

SR. NO. ITEM AMOUNT

1 FOOD 3500
2 CLOTHING 1000
3 ELECTRICITY BILL 500
4 LPG GAS 500

5 SHOPPING / PURCHASING 1500

6 PETROL 2000

7 EXPENDITURE ON HEALTH 500

8 MISCELLANEOUS 1000
9 SAVING 1500
Total 12000

1 of the family member are earning their monthly income is rupees 12,000/- & total expenditure
Rs. 10,500/- & they save Rs. 1500/- per month, so economic status is Poor.
Home assets:-
Shah family has their own assets as listed:-
 Own flat (2 BHK) at budhwar peth, Pune - 1
 four wheeler - NO
 Two wheeler - 1
 Television - 1
 Landline telephone - 1
 Mobiles - 1
 Fridge - 1
 Computer - no
 Laptop - no
 PHYSICAL ASSESMENT

I. BASE LINE DATA-

PHYSICAL EXAMINATION
WEIGHT :- 62 kg.
HEIGHT :- 164 Cm
TEMPERATURE :- 98.5 °f

PULSE :- 82 PULSE/MIN.
RESPIRATION :- 24 / min.
Chest circumference :- 34 cm

I. GENERAL APPEARANCE:-
1. Nourishment :- well nourished
2. Body fluid :- normal
3. Health :- Unhealthy
4. Activity :- restricted
II. MENTAL STATUS
1. Consciousness :- conscious
2. Look
Patient look well nourished with adequate body weight.
But he is looking Anxious and restless due to the illnesses.
III. POSTURE
1. Body curve :- Normal
2. Movement :- not there

IV. SKIN CONDITION

1. colour :- Normal
2. Texture :- Good
 V. HEAD & NECK
1. Scalp :- Clean hair turned,
gray due to old age.
2. Face :- Anxious

VI. EYES
1. Eye brows :- Normal
2. Eye lashes :- Normal
3. Eye lids :- Normal
4. Eye ball :- Normal
5. Eye conjunctiva :- Normal
6. Sclera :- Normal
7. Cornea & iris :- Normal
8. Lens :- Normal
9. fundus :- No congestion, no
Hemorrhage

VII. EARS
1. External ear :- No discharge tenderness
Hearing :- normal

VIII. NOSE
1. External nares :- Normal
2. Nostrils :- Normal
IX. MOUTH & PHARYNX
1. Lips :- Dry due to dehydration
2. Odour of mouth :- No bed odour
3. Teeth :- Normal
4. Palate :- Normal
5. Gums :- Normal
6. Uvula :- Normal

X. NECK
1. Shape :- Normal, symmetrical
 2. Lymph nodes :- Normal, No any abnormality
has been detect
3. Movements :- Normal
4. Thyroid glands :- Normal, Not enlarge.

XI. CHEST
1. Shape :- Normal
2. Inspection :- No abnormal movement
3. Auscultation :- No any abnormal sound has
been found.
4. Percussion :- Normal

XII. ABDOMEN
1. Inspection :- Shape of the abdomen is
symmetrical on both
the sides. No any type of
infection found.
2. Abdominal girths :- 45 cm
3. Palpation :- no abnormality found
4. Auscultation :- Bowel sound found normal
5. Percussion :- No fluid thrill, & no any
presence of gas or
any mass or
swelling of
visceral
XIII. BACK :- Body curve normal.

XIV. EXTREMITIES
Patient is having fracture at the right femur and due to this unable to move out
of bed.
 XV. GENITALIA :- No any deformity found
XVI. RECTUM :- No any deformity found
XVII. NEUROLOGICAL ASSESSMENT
Patient is well oriented to time place and person.

Ciprofloxacin

Drug classes
Antibacterial
Fluoroquinolone

Therapeutic actions
Bactericidal; interferes with DNA replication in susceptible bacteria preventing cell
reproduction.

Indications
 For the treatment of infections caused by susceptible gram-negative bacteria,
including E. coli, P. mirabilis, K. pneumoniae, Enterobacter cloacae, P. vulgaris,
P. rettgeri, M. morganii, P. aeruginosa, Citrobacter freundii, S. aureus, S.
epidermidis, group D streptococci
 Treatment of uncomplicated UTIs caused by E. coli, K. pneumoniae as a one-time
dose in patients at low risk of nausea, diarrhea (Proquin XR)
 Otic: Treatment of acute otitis externa
 Treatment of chronic bacterial prostatitis
 IV: Treatment of nosocomial pneumonia caused by Haemophilus influenzae, K.
pneumoniae
 Oral: Typhoid fever
 Oral: STDs caused by N. gonorrheae
 Prevention of anthrax following exposure to anthrax bacilla (prophylactic use in
regions suspected of using germ warfare)
 Acute sinusitis caused by H. influenzae, Streptococcus pneumoniae, or Moraxella
catarrhalis
 Lower respiratory tract infections caused by E. Coli, Klebsiella, Enterobacter
species, P. mirabilis, P. aeruginosa, H. influenzae, H. parainfluenzae, S.
pneumoniae
 Unlabeled use: Effective in patients with cystic fibrosis who have pulmonary
exacerbations

Contraindications and cautions

 Contraindicated with allergy to ciprofloxacin, norfloxacin or other
fluoroquinolones, pregnancy, lactation.
 Use cautiously with renal dysfunction, seizures, tendinitis or tendon rupture
associated with fluoroquinolone use.

Available forms
Tablets—100, 250, 500, 750 mg; ER tablets—500, 1,000 mg; injection—200, 400 mg;
powder for oral suspension—250, 500 mg/5 mL; ophthalmic ointment—3.33 mg/g;
ophthalmic solution—3.5 mg/mL; otic suspension—2 mg/mL

Dosages
ADULTS
 Uncomplicated UTIs: 100–250 mg PO q 12 hr for 3 days or 500 mg PO daily (ER
tablets) for 3 days. Proquin XR—500 mg PO as a single dose.
 Mild to moderate UTIs: 250 mg PO q 12 hr for 7–14 days or 200 mg IV q 12 hr
for 7–14 days.
  Complicated UTIs: 500 mg PO q 12 hr for 7–14 days or 400 mg IV q 12 hr or
1,000 mg (ER tablets) PO daily for 7–14 days.
 Chronic bacterial prostatitis: 500 mg PO q 12 hr for 28 days or 400 mg IV q 12
hr for 28 days.
 Ophthalmic infections caused by susceptible organisms not responsive to other
therapy: 1 or 2 drops per eye daily or bid or 1/2-inch ribbon of ointment into
conjunctival sac tid on first 2 days, then apply 1/2-inch ribbon bid for next 5 days.
 Acute otitis externa: 4 drops in infected ear, tid–qid.

IV facts

Preparation: Dilute to a final concentration of 1–2 mg/mL with 0.9% NaCl injection
or 5% dextrose injection. Stable up to 14 days refrigerated or at room temperature.
Infusion: Administer slowly over 60 min.
Incompatibilities: Discontinue the administration of any other solutions during
ciprofloxacin infusion. Incompatible with aminophylline, amoxicillin, clindamycin,
floxacillin, heparin in solution.

Adverse effects
 CNS: Headache, dizziness, insomnia, fatigue, somnolence, depression, blurred
vision
 CV: Arrhythmias, hypotension, angina
 EENT: Dry eye, eye pain, keratopathy
 GI: Nausea, vomiting, dry mouth, diarrhea, abdominal pain
 Hematologic: Elevated BUN, AST, ALT, serum creatinine and alkaline
phosphatase; decreased WBC, neutrophil count, Hct
 Other: Fever, rash

Interactions
Drug-drug
 Decreased therapetic effect with iron salts, sucralfate
 Decreased absorption with antacids, didanosine
 Increased serum levels and toxic effects of theophyllines if taken concurrently
with ciprofloxacin
 Increased effects of coumarin or its derivatives
Drug-alternative therapy
 Increased risk of severe photosensitivity reactions if combined with St. John's
wort therapy.

Nursing considerations
Assessment
 History: Allergy to ciprofloxacin, norfloxacin or other quinolones; renal
dysfunction; seizures; lactation
 Physical: Skin color, lesions; T; orientation, reflexes, affect; mucous membranes,
bowel sounds; LFTs, renal function tests
Interventions
 Arrange for culture and sensitivity tests before beginning therapy.
 Continue therapy for 2 days after signs and symptoms of infection are gone.
 Be aware that Proquin XR is not interchangeable with other forms.
 Ensure that the patient swallows ER tablets whole; do not cut, crush, or chew.
 Ensure that patient is well hydrated.
 Give antacids at least 2 hr after dosing.
 Monitor clinical response; if no improvement is seen or a relapse occurs, repeat
culture and sensitivity.
 Encourage patient to complete full course of therapy.

Teaching points
 If an antacid is needed, take it at least 2 hours before or after dose.
 Take Proquin XR with the main meal of the day.
 Do not touch tip of eye ointment or solution for this may contaminate the product.
 Drink plenty of fluids while you are taking this drug.
 You may experience these side effects: Nausea, vomiting, abdominal pain (eat
frequent small meals); diarrhea or constipation; drowsiness, blurring of vision,
dizziness (observe caution if driving or using dangerous equipment).
 Report rash, visual changes, severe GI problems, weakness, tremors.

Ranitidine hydrochloride
Drug class
Histamine2 (H2) antagonist

Therapeutic actions
Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the
parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid
secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and
pentagastrin.

Indications
 Short-term treatment of active duodenal ulcer
 Maintenance therapy for duodenal ulcer at reduced dosage
 Short-term treatment of active, benign gastric ulcer
 Short-term treatment of GERD
 Pathologic hypersecretory conditions (eg, Zollinger-Ellison syndrome)
 Treatment of erosive esophagitis
 Treatment of heartburn, acid indigestion, sour stomach

Contraindications and cautions

 Contraindicated with allergy to ranitidine, lactation.
 Use cautiously with impaired renal or hepatic function, pregnancy.

Available forms
Tablets—75, 150, 300 mg; effervescent tablets and granules—25, 150 mg; syrup—
15 mg/mL; injection—1, 25 mg/mL

Dosages
ADULTS
 Active duodenal ulcer: 150 mg bid PO for 4–8 wk. Alternatively, 300 mg PO
once daily hs or 50 mg IM or IV q 6–8 hr or by intermittent IV infusion, diluted
to 100 mL and infused over 15–20 min. Do not exceed 400 mg/day.
 Maintenance therapy, duodenal ulcer: 150 mg PO hs.
 Active gastric ulcer: 150 mg bid PO or 50 mg IM or IV q 6–8 hr.
 Pathologic hypersecretory syndrome: 150 mg bid PO. Individualize dose with
patient's response. Do not exceed 6 g/day.
 GERD, esophagitis, benign gastric ulcer: 150 mg bid PO.
 Treatment of heartburn, acid indigestion: 75 mg PO as needed.

IV facts
Preparation: For IV injection, dilute 50 mg in 0.9% sodium chloride injection, 5% or
10% dextrose injection, lactated Ringer's solution, 5% sodium bicarbonate injection to a
volume of 20 mL; solution is stable for 48 hr at room temperature. For intermittent IV,
use as follows: Dilute 50 mg in 100 mL of 5% dextrose injection or other compatible
solution
Infusion: Inject over 5 min or more; for intermittent infusion, infuse over 15–20 min;
continuous infusion, 6.25 mg/hr
Incompatibilities: Do not mix with amphotericin B

Adverse effects
 CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo
 CV: Tachycardia, bradycardia, PVCs (rapid IV administration)
 Dermatologic: Rash, alopecia
 GI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis,
increased ALT levels
  GU: Gynecomastia, impotence or decreased libido
 Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia
 Local: Pain at IM site, local burning or itching at IV site
 Other: Arthralgias

Interactions
Drug-drug
 Increased effects of warfarin, TCAs; monitor patient closely and adjust dosage as
needed

Nursing considerations
Assessment
 History: Allergy to ranitidine, impaired renal or hepatic function, lactation,
pregnancy
 Physical: Skin lesions; orientation, affect; pulse, baseline ECG; liver evaluation,
abdominal examination, normal output; CBC, LFTs, renal function tests

Interventions
 Administer oral drug with meals and hs.
 Decrease doses in renal and liver failure.
 Provide concurrent antacid therapy to relieve pain.
 Administer IM dose undiluted, deep into large muscle group.
 Arrange for regular follow-up, including blood tests, to evaluate effects.

Teaching points
 Take drug with meals and at bedtime. Therapy may continue for 4–6 weeks or
longer.
 If you also are on an antacid, take it exactly as prescribed, being careful of the
times of administration.
 Have regular medical follow-up care to evaluate your response.
 You may experience these side effects: Constipation or diarrhea (request aid from
your health care provider); nausea, vomiting (take drug with meals); enlargement
of breasts, impotence or decreased libido (reversible); headache (adjust lights and
temperature and avoid noise).
 Report sore throat, fever, unusual bruising or bleeding, tarry stools, confusion,
hallucinations, dizziness, severe headache, muscle or joint pain.

NURSING MANAGEMENT
DORTHY OREM’S SELF CARE MODEL can be applied in this case. This theory focuses
on meeting universal needs of a person & provision of satisfaction of self care
demand.
There are three approaches in this theory as follows:-
1. Wholly compensatory system
2. Partially compensatory system
3. Supportive educative system.
AS my patient is in semiconscious stage, he is not able to meet his following
universal needs.
1. Maintenance of a sufficient intake of air.
2. Maintenance of a sufficient intake of water
3. Maintenance of a sufficient intake of food
4. Maintenance of a balance between activity & rest.
5. Maintenance of social interaction & attitudes.
6. Prevention of hazards to human life human functioning & human well-
being.
7. Promotion of human functioning & development within Social groups.

As my patient is semiconscious, bedridden, debilitated, he is not able to perform his

daily activities & I have to perform it for my patient.
This is why “Wholly compensatory system” is used for Mr. Shah
 A CONCEPTUAL FRAMEWORK FOR NURSING

SELF-CARE

SELF-CARE SELF-CARE

SELF-CARE
DEFICIT
 WHOLLY COMPENSATORY SYSTEM

ACCOMPLISHES PATIENT’S
THERAPUTIC SELF CARE

NURSES PATIENT
ACTION Compensate for patient inability to ACTION LIMIT
self care

Supports & patient protection

OREM’S NURSING PROCESS & THE NURSING PROCESS FOR MR. SHAH:-

SR. NO. NURSING PROCESS OREM’S NURSING PROCESS

1. Assessment
Step – I - Diagnosis of prescription; determine why nursing care is needed.
2. Nursing diagnosis
Analyze and interpret – Make judgment regarding care.
3. Plans with scientific rational
Step – II- Design for a nursing system & plan for delivery of care.
4. Implementation
Step – I - Production & management of nursing system
5. Evaluation
 DISCHARGE PLANNING

Mr. sumit salunkhe is not yet discharged. but discharge planning is provided

with the health education on following aspects.

 Medication: - They should continue their drug regimen at home.

Should take medication on time.

 Exercises: - Mr. sumit salunkhe should take befits of active & passive

exercises at home.

 Activity: - They can continue his morning walk according to doctors

advice, but they should prevent the extra mental

load, & extra physical activities.

 Dietary modification: - as diet is modifies with high protein, high

caloric, calcium & vitamins. He should follow this

diet at home.

 Follow up: - They supposed to come regular check-up to the hospital

for follow up.

.SUMMARY:-

When. MR. Manohar Ptil 32 YEARS / MALE got admission on 23/03/09 in

Orthopaedic ward with the chief complaints of Fracture at right femur and severe

pain.but with the great effort of the physicians and other team members and nursing

staff patient is improving day by days. and he is in good state.

BIBLIOGRAPHY
1. Drug Today, January-march 2007, Pp 23-25, 88-89, 124-125, 505-509.

2. Edward & smith, sear’s, Anatomy & physiology for nurses, 6 th edition, jaypee

publication, Bangalore, Pp – 834-840

3. Joyce M. Black, medical surgical Nursing, Lippincott Williams & Wilkins

Publication, 10th edition; Pp-1120-1128.

4. Julia George, Nursing theories, 4th edition, library of congress Publication, 1995

USA; Pp – 99-105

5. Lewis etal, medical surgical nursing, 4th edition, 1992; mosby publication,

Philaldelpaia; Pp – 633-644.

6. The Lippincott manual of nursing practice, Lippincott publication, 7 th edition;

2001; Pp – 1232-.1246

7. Ross & Wilson, textbook of anatomy & physiology, 9 th edition 2001, Waugh &

Grant Publication; Pp- 188-195.