Introduction: As a part of our clinical experience in advanced concept of nursing we

were posted to Jayanagar General Hospital D/ /12/07 to D/ /12/07 for 7 days. Each one

us had taken 5 clients for providing a nursing care on the basis of nursing theories. When

I posted to male surgical ward I came across a patient name Mrs Fathima diagnosed as

acute Cholethiasis.

I.Biographic data:

Name: Mrs Fathima

Age : 65 yrs.

Gender: Female.

Marital status: Married.

IP No: 185568

Ward : Male surgical.

Address: No 123.

2nd Cross,

Lakkasandra Nagar.

Bangalore.

Religion: Muslim.

Education : nil.

Occupation: Housewife.

Monthly Family Income: 4,000/month

Date of admission: 08/07/07

Diagnosis: Cholelithiasis.

Operation:
Date of operation:

NURSING ALLERT: ALLERGIC TO TAXIM

Socioeconomic Status:

Type of house: Semipucca house.

Biohazards: Sullage water disposed by open drainage.

Water facility: Tap water.

II.Reasons for seeking care/Chief complaints:

 Pain in epigastric region since 1 month.

 Pain in left hypochondria regions since one month.

 Pain aggrevates on bending down.

 Passage if stools 3 to 4 times a day.

III.Present health status:

Health management:

Symptom analysis:

 Location: Epigastric region.

 Pain is generalised.

 Squeeaing pain.

 Associated with nausea.

 Pain agrevates in bending down.

IV.Past health history:

 Patient suffered from malaria. Had appendectomy about 30 years ago.No history

of any childhood illness and accidents.

  Acoording to national immunization schedule Mr Sridhar was immmunized.

 Mr Sridhar is allergic to parthenium plant.

V.Family History:

 Type of family: Nuclear family.

 Number of members: 5

 Any illness: No heriditary disease found in a family.

 Genogram:

 Health facilities available near their house and its distance and transportaion

available: They go to private clinic near to their house, which is walkable

distance.

VI.Personal History:

1. Personal Hygiene:
 Oral Hygiene: Tooth paste id used to brush teeth once in a day.

 Baths: Once in a day with soap.

 Diet: Mixed, 3 meals /day.

 Fluid: Drinks 1 ltrs of water per day,Drinks tea thrice a day.

 Sleep: Interrupted sleep since one week.

 Elimination: Passes stools 3 to 4 times / day since 2 days. urine elimination is

normal.

 Mobility and Exercise: No walking habits.

 Activity : Moderate activity.

 Joints: No pain and discomfort reported.

 Sexual / Marital history: Spouse is healthy, his wife is working for garments,

There is a harmonious relationship between husband and wife.They have one

child of 5 years it is healthy.

VII.Cognitive perceptual history:

 Sensory perception is normal and does not use any of the external aids.

 No general pain other than abdomen pain.

 Memory is good and sharp.

 Mr Sridar likes to learn things by seeing.

VIII. Psycho-Social history:

 Significant relationship: He has the most affectionate bond with his wife.

 Hobbies: He spends time with painting.

 Habits & Smoking: Mr Sridhar is alcoholic.

  Occupation: Satisfied with occupation but not with the payment.

 No stress faced by th epatient recently.

 Social Support: Mr Sridhar has social support from his family.

 They adopt meditation as coping strategies.

 Patient bites his nail when he is in anxiety.

Physical examination:

1. Vital signs:

 Temperature: 98.6· F

 Pulse:88 beats/ min

 Respiration: 25 Breaths/ minute

2. Anthropometric measurement:

 Height: 158cm

 Weight : 57kg

 BMI: 22.833(acceptable)

3. General appearance:

 Mental alertness: Mr Sridhar is alert.

 Body built: Average

 Hygiene: personal hygiene is not maintained.

4. Head:

 Symmetry: symmetrical

 Hair color: Black.

 Hair distribution: Baldness in middle and front.

  Pediculosis: No

 Swelling or tenderness: No

 Previous injuries: No

5. Eyes:

 Globes: no protrusions

 Lid margins: No secretions present and no erthema

 Conjunctive: Pale congectiva

 Sclera: White in color

 Pupils: Both pupil 3 mm in size and equally reacting to light

 Pupils:

 PERELA: Present

 Eye movements: Upward, downward and lateral and rotation movements

are normal.

 Visual fields:

 Visual acuity:

6. Ears

 Pinna: normal in size and shape and no lesions present

 External canal: discharge present in outer ear no masses and foreign

bodies present.

 Tympanic membrane:

 Hearing acuity: both air and bone conductions are normal.

7. Nose
  Nasal symmetry: symmetrical and nasal patency present

 Nasal septal deviation: No septal deviation

 Discharge: Absent

 Color of mucous membrane:

 Nasal obstruction:Nasal patency present and no signs of nasal obstruction.

 Sinuses: both frontal and maxillary sinuses are normal.

 Sense of smell: normal

8. Mouth:

 Lip color: dried cracked and dark in color, no pigmentation ulceration and

fissures present.

 Teeth :26, unequally arranged, creamish color, no carries present.

 Gums:pink in color no discharge of swelling present.

 Buccal mucosa: pink in color

 Tongue: coated tongue

 Pharynx: normal

 Salivary glands normal no inflammation

 Uvula: Normal

 Tonsil: No tonsillitis.

 Voice:Normal with low pitch.

9. Neck:

 Symmetry: Symmetrical at both the sides.

 Masses:no signs of inflammation or any lesion.

  Range of motion:normal

 Thyroid:no thyroid enlargement.

 Muscular strength; adequate muscular strength.

 External jugular veins: are palpable at both the sides.

 Carotid pulse:Palpable

 Lymph nodes: no enlargement.

 Trachea: No tracheal rings, no inflammation, and are palpable.

10. Nervous system:

a. Level of consciousness:

 Orientation:well oriented to time, place and person

 Appearance: Personal hygiene is not maintained

 Mood and affect:

 Attention: Attention span is good and normal.

 Memory skills; immediate, remote and recent memory is good.

 Judgments: Good

 Thought: All forms of thought process is good.

 Communication and language skills; communication is good and

languages known are Kannada, Hindi

b. Sensory function:

 Pain: Complaining a pain at lower abdomen.

 Touch: sensation is good

 Vibration:
  Position:

 Discrimination: Discrimination capacity is good.

 Temperature: Able to differentiate hot and cold.

c. Motor function:

 Muscle tone: is good.

 Muscle power: rated 4 on 5 point scale.

d. Reflex:

 Deep tendon reflexes: it is normal and quick.

 Superficial tendon: Normal and quick.

e. Cranial nerve assessment

f. Cerebellar function:

 Gait: is normal

 Romeberg’s test:

 Nose to finger test: able to touch nose and finger normally with eye closed.

 Coordination: Good co ordination is shown.

g. Spine:

 Muscle power – 5 point: 4 on 5 point scale.

 Muscle tone scale:

 Range of motion: Normal

 Abnormal curvature: No

 Tuft of hair: No tuft hairs.

 Sciatica:
11. Respiratory system:

a. Inspection:

 Respiratory rate: 25 breaths/min

 Respiratory depth: Deep respiration

 Type of respiration:

 Symmetry: Symmetrical

 Structural deformity: No structural deformity found

 Chest movements: normal

 AP diameter:

 Lateral diameter;

b. Palpation:

 Tenderness: no lesion, masses or inflammation present tenderness was

absent.

 Respiratory excursion: no excursion while breathing

 Tactile Fremitus:

c. Palpation

 Symmetry: Chest is symmetrical and no abnormal sound heard.

d. Auscultation

 Breath sounds( Broncho Vesicular): Normal

 Adventitious sounds:

12. Gastro Intestinal System

Inspection:

 Contour of the abdomen;

  Symmetry: Symmetrical

 Visible peristalsis: Not visible

 Aortic pulsation:

 Hernia: no protrusion of abdominal organs through abdominal wall, no

history of hernia.

 No rashes central single striae found.

 Previous scar: No

 Abdominal girth:

Auscultation

 Bowel sounds: 6 – 7 times bowel sounds are heard in 15 minutes.

 Bruits: Not palpable.

Percussion:

 Abnormal sounds: No abnormal sounds are heard.

Palpation:

13. Reproductive system:

Male:

 No discharges from penis:

 Inguinal testis is normal

Rectum:

 Anal canal: is clean and normal

 Peri anal region: Is clean and normal

 No hemorrhoids, inflammation, scars, lesions, ulcerations found.

14. Musculo skeletan system:

  Size:

 Symmetry:

 Gait and posture:

 Range of motion:

15. Integumentary system:

 Appearance:: skin is dried wrinkled.

 Temperature: is normal

 Lesion masses, ulceration, inflammation: no evidences

 Hygiene: Not maintained

 Capillary refilling: Normal

 Clubbing nails: No

 Color of the nail: Pale

16. Cardiovascular system:

 Heart beat: 82

 S1 and s2 sounds are heard.

 BP: 120/80 mm of hg

 Apical pulse is palpable.

 No abnormal sounds are heard.

Assessment Nursing Diagnosis Objective Intervention Evaluation
Subjective: I Abdominal pain To -Assess the intensity of .
am having related to reduce pain.
severe pain cholelithiasis pain -Provide bed rest.
at lower -Administer Analgesic
abdomen, injection.
Objective: -With hold oral feeding.
On
observation
patient is
dull and
holding her
hands at
abdomen
and showing
some non
verbal
gestures..
Subjective: I Nausea and vomiting To relieve -No fluids orally. No vomiting.
am having related to nausea - Start intravenous fluid
nausea. cholelithiasis and 5% dextrose 500ml and
Objective: avoid Ringer lactate 200ml in
On vomiting. 24 hours.
observation - Give antieemetic inj.
patient is Reglan 1 amp .
dull and was TDS(10mg0
not able to - Give regular
take full mouthwash.
meals due
to nausea.
Subjective: I Chronic back pain To relieve -Provide hard bed and Pain relieved to
am having pain comfortable position. certain extend.
back pain - Advice to take bed
since 3 rest.
years. - Apply hot water bag.
Objective: - Apply Volin gel
On - Avoid sitting for long
observation time
patient is - Advice to maintain
leaning good posture.
forward and
backward
and keeping
his hands on
his back
often
Subjective: I Anxiety related to To -Explain the Less anxious
am scared investigation( gastros reduce gastroscopy procedure. and co
to go for copy) anxiety. -Explain how the operated with
gasrtoscopy; investigation help in procedure.
Objective : diagnosis.
on - Introduce patient who
observation experienced
patient is gastroscopy.
biting his - Provide psychological
nails often support.

Subjective: Deficient knowledge To impart Educate the following Condition

Patient asks on disease condition knowled - Maintain regular meal improved and
so many and follow up care. ge and to timings. patient
questions on minimize - take diet which are discharged on
procedures recurrenc tolerable preferable 09/07/08
and disease e of bland diet.
conditions. gastric - Avoid smoking
Oservation: pain - Avoid anxiousness.
On - Continue with
observation medication.
patient is - Attend clinic regularly
restless and
showing
blank face
on few of
the
conversatio
ns.