INTRODUCTION

As a part of my clinical experience in Medical Surgical Nursing I was posted in

Female Medical ward of Sanjaygandhi general hospital,banglore. There were 31 patients and
I selected Mrs. Kannikamma as my patient. I am supposed to investigate present problems
based on observations and signs and symptoms of the disease.

IDENTIFICATION DATA
Name of the patient : Mrs. Kannikamma
Age : 37 yrs
Sex : Female
Religion : Hindu
Marital Status : Married
Education : Polytechnique
Occupation : House Wife
Income : Nill
I P No. : 16731
Unit : Female Medical ward
Date of Admission : 11/03/2024
11/03/2012 at 4.34 p.m
Medical diagnosis : Pneumonia
Address : Puthanahalli,7th cross
Date of care started : 12/03/2024
12/03/2012
Date of care ended : 15/03/2024
15/03/2012

Medical History
Present Medical History
Mrs. Kannikamma was admitted to Sanjaygandhi general hospital,banglore.on
11/03/24
11/03/12 at 4.34
4.34 p.m
p.m with
with complaints
complaints of
of fever, chills, persistent cough and chest pain since 3
months. The doctor diagnosed the case as Pneumonia.
Past Medical History
Nothing Significant
Surgical History
Present and Past Surgical History
Nothing Significant
Personal History
Mrs. Kannikamma has no bad like smoking and alcoholism but she has a habit of
chewing on betal nuts. She takes mixed diet. She is maintaining good relationship with her
family members and neighbours.

FAMILY HISTORY

There are 3 members in her family including her husband and a 10 year old
daughter. Theirs is a nuclear family. All the other family members are healthy. There is no
heredity or communicable diseases in his family.

KEY
Patient
Male
Female

SOCIO-ECONOMIC HISTORY
Mr. Nagesh is the husband of Mrs. Kannikamma. He is the bread winner of the family.
He is having an income of Rs. 5000/month. He is a businessman. They are living in their
own house.

ENVIRONMENTAL HISTORY
Mrs. Kannikamma is living in a pacca type of house with three rooms. House is
electrified and proper water facility. House is having open drainage system and separate
lavatory facility.

NUTRITIONAL HISTORY
She is taking mixed diet with 2 meals per day. She doesn’t have allergy with food
items. She is taking white rice and vegetable salad very much.

ELIMINATION HISTORY
Her bowel and bladder functions were normal.
 PHYSICAL EXAMINATION
General observation
Stature - normal
Posture - no deformity
Personal appearance - well groomed and hygenic
Emotional status - depressed
Co-operativeness - co-operative

Vital signs
Temperature - 101 °F
Pulse - 70 beats per min
Respiration - 26 breaths per min
Blood pressure - 130/80 mmHg

Height and weight

Height - 154 cms
Weight - 61 kg

Skin
Colour - no cyanosis, no jaundice
Edema - no edema
Moisture - warm and normal
Lesions - Absence of macules, papules, and vesicals

Head
Normal cephalic, no lesions, normal distribution of hair and color of hair is normal, no
pediculosis, normal range of motion possible,

Eyes
Expressions - normal
Eyelids - normally close and open
Eye balls - normal, globes clear and firm
Conjunctiva - dark pink and clear
Sclera - pink and clear
Iris - brown
Visual acuity - normal 6/6
PERRLA - pupils round symmetrical, reacting to light and
accommodation, 3mm, constrict to light.
Eye movements - move in conjugate fashion and normal

Ears
Appearance - auricles are normal and symmetrical
Hearing - normal hearing
Normal shape, no discharge, no tinnitus, no vertigo, no infection, Cerumen is present

Nose
Appearance - no nasal flaring, mucous membranes pink and moist
Sense of smell - normal
No DNS or running nose
Mouth and throat
Lips - symmetric, moist, no lesions, no cyanosis
Tongue - moist, pink, no glossitis, no coating
Teeth - stained teeth, equally distributed
Gum - no gingivitis
Buccal mucosa - no lesions
Palate - intact, symmetrical, pink
Sense of Taste - normal
No glossitis, no stomatitis

Neck
Appearance - no deformity, spondilitis, tenderness, stiffness, swelling
Trachea - no deviation, no tenderness
Lymph nodes - not palpable
Thyroid glands - symmetric
No distended neck veins

CHEST AND RESPIRATORY SYSTEM

Inspection
Symmetry - bilaterally symmetrical
Expansion - thoracic expansion is abnormal
Equality of movements - unequal in the right lungs
Type of respiration - Abdomino-thorasic
Rate - 26 breaths/min
Rhythm - irregular

Palpation
Expansion - unequal, inflammation of lining of lungs
Vocal tactile fremitus - fremitus present
Presence of local swelling, and tenderness in the right thorax

Percussion
Basal - resonance
Apical - dull percussion

Auscultation
Bronchial - sound is loud and harsh heard on trachea
Bronchovesicular - sounds are moderatly heard at 2nd intercostal space on both
sides
Vesicular - heard all over the lung field both front and back
Friction rub - nothing significant

CARDIOVASCULAR SYSTEM
Inspection
Chest contour - abnormal, sternal depression present
Neck - no jugular venous distention

Percussion
Cardiac outline - difficult to find out the cardiac borders
Palpation
Supra sternal notch - no fluid thrill

Auscultation
Apical rate - 70 beats/min & S1, S2 heard
Blood pressure - 130/80 mmHg

ABDOMEN
Inspection
Shape - Scaphoid shape
Movements - abdominal wall bulges in inspiration, falls during expiration
Skin texture - no discoloration, no cyanosis, no distension
Contour - normal, flat, no mass, normal bowel, no organomegaly

Auscultation
Bowel sounds heard

Percussion
organ borders - gaseous distention found

Palpation
Mass - no organomegaly, soft abdomen

Back
Spinal curvature - no deformity
- Concavity in the cervical region
- Concavity in the lumbar region
- Convexity in the thoracic region
Symmetry - normal
Movement - normal ROM

Genitalia and groin

Nothing significant

UPPER EXTREMITIES
Normal ROM possible

LOWER EXTREMITIES
Appearance - Normal in both the extremities
Temperature - warm to touch and moist
Pulses in the periphery - dorsalis pedis artery felt 70 beats /min

NERVOUS SYSTEM
Higher functions - normal
Speech - fluent and clear
Motor function - normally muscle tone, gait normal
Sensory functions - normally responds to pain and light touch
Cranial nerves and reflexes - normal
Reflexes - normal functions (superficial and deep reflexes)
Vital Signs

Sl. No. Procedure Normal Value Patients value Remarks

1. Temperature 98.6 °F 101 °F Increased

2. Pulse 60 – 70 beats/min 70 beats/min Normal

3. Respiration 18 – 20 beats/min 26 beats/min Increased

4. Blood Pressure 120/80 mm of Hg 130/80 mm of Hg Normal

Investigations

Sl. Name of the Normal Value Patients value Remarks

No. Investigation

1. Hb 14-18 gm% 12 gm% Decreased

2. WBC 4000-11000/cumm. 16000/cumm Increased

3. Lymphocytes 20-40% 60% Increased

4. Eosinophils 1-6% 46% Increased

5. S.Urea 10-50mg/dl 34 mg/dl Normal

6. ESR < 20 cm2 /hr 30 cm2/hr Increased

 MEDICATIONS

DRUG DOSAGE ROUTE FREQUENCY ACTION SIDE-EFFECTS

Tab. Deriphiline 500 mg Orally BD Relaxation of smooth muscles Diarrhea, epigastric pain,
of the bronchial wall palpitation and tachypnoea
Tachy cardia
Tab. brufen 400 mg Oral BD Inhibits prostoglandin Palpitation
synthesis by decreasing Preganancy
enzyme needed for bio Blurred vision
synthate analgase

Inj. Rosella 500 mg IV QID Infers with cell wall respiration Rash
ampicillin of microorganism the cell wall Utricaria
rended osmality unstable swell Anemia
blank pneumonia pressure Bleeding
Depression
Nausea
Vomitting
Lethargy

Tab. Pantoprazol 40 mg Oral Tid Gastro eosophago reflux Head ache

disease severe oesophagitis Insomnia
zoolinger Ellison syndrome Diarrhea
Abdominal pain
Flatulence
Hypersensitivity
Hyperglycemia
 NURSING DIAGNOSIS

1. Ineffective breathing pattern related to pneumonia anxiety and pain as manifested by

rapid respiration, dyspnea and tachycardia.

2. Ineffective airway clearance related to pain, fatigue and thick secretions as manifested

by ineffective cough or thick abnormal breath sound.

3. Impaired nutritional status less than body requirement related to anorexia, nausea and

vomiting as manifested by weakness.

4. Activity intolerance related to fatigue treatment regimen and weakness as manifested

by fatigue dizziness as explained.

5. Risk for health maintenance deficit related to lack of knowledge regarding treatment

regimen after discharge.

 Care plan

Assessment Nursing Objective Planning Implementation Evaluation

Diagnosis
Subjective Ineffective Patient maintains Assess the pattern of breathing Assessed the pattern of Patient expressed some
Data: Patient breathing pattern normal respiratory to provide guidance for breathing. feeling of comfort.
says that I related to rate and express intervention.
can’t breathe pneumonia feeling of comfort
properly anxiety and pain Take vital signs and auscultate
lungs to provide ongoing Checked vital signs and
as manifested by auscultate lungs.
rapid respiration patients response to therapy to
dyspnea and identify the response to
tachypnea treatment.

Administer oxygen as inhaled

Objective data: to maintain optimal oxygen Administered oxygen to
On observation level and to increase patient patien.
Patient is comfort to increase patient
having comfort
breathlessness

Provide semi fowlers position

Provided semi fowlers
for breathing to maximize lung
position for patient.
expansion to maximize lung
expansion
Assessment Nursing Objective Planning Implementation Evaluation
Diagnosis
Subjective Ineffective airway Patient will have Assist the patient to cough by Assisted the patient to Patient maintained
Data: patient clearance related breath sounds splinting chest, and teach cough by splinting chest, clear breath sounds
says that he to pain, fatigue effective cough with patient how to cough and teach patient how to
can’t breathe and thick exploration of sputum effectively to clear airway by cough effectively to clear
properly secretions as bringing secretion to the mouth airway by bringing
manifested by to bring out secretion secretion to the mouth
cough or thick
abnormal breath
sounds
Administered expectorant
Administer expectorant to to increase bronchial fluid
Objective data: increase bronchial fluid
patient is product and promote
product and promote expectoration and cough
having thick expectoration and cough to
secretions in remove secretions
the airway and
can’t cough
properly Maintained fluid intake of
Maintain fluid intake of 3L 3L daily to liquefy
daily to liquefy secretions to secretions
liquefy secretions
Assessment Nursing Objective Planning Implementation Evaluation
Diagnosis
Subjective Impaired Patient maintains Assess the food preferences so Assessed food preferences Patient maintained
Data: patient nutritional status normal nutritional the preferred foods will be of the patient. normal nutritional
verbalizes that less than body status and maintain available. status than before.
he is not requirement normal weight.
having appetite related to
and feeling so anorexia, nausea Weigh patient daily and use Checked the weight of the
weak. and vomiting as same scales and at the same patient daily.
manifested by time of the day to provide
weakness. accurate evaluation of weight.
Objective data:
On observation
patient is Provided caloric intake as
Provide caloric intake as
looking so ordered to meet body
ordered to meet body
weak . requirement.
requirement.

Advised the patient to take

Advice to take high protein
high protein and high
high caloric small frequent
caloric diet.
feeding to prevent negative
nitrogen balance and excessive
weight loss.
Assessment Nursing Objective Planning Implementation Evaluation
Diagnosis
Subjective Activity Patient experiences Assess response to activity To Assessed response to Patient experienced
Data: patient intolerance related increased tolerance evaluate patients hypoxemia activity increased tolerance for
says that I am to fatigue for activity and plan changes accordingly activity than before
feeling tired treatment regimen
and weak and weakness as Provided bed rest and limit
manifested by Provide bed rest and limit physical activity
fatigue and physical activity to evaluate
Objective data: dizziness as patients hypoxemia
On observation explained.
patient is
giving Verbal Assist with the activities as Assisted with the activities
response of needed to ensure that patients of the patient
weakness basic needs are met to ensure
that patients basic needs are
met

Place needed items within easy

reach to conserve energy while
Placed needed items
facilitating independence to
within easy reach of
conserve energy while
patient
facilitating independence
Assessment Nursing Objective Planning Implementation Evaluation
Diagnosis
Subjective Risk for health Patient gains enough Assess the ability to continue Assessed the ability to Patient got knowledge
Data: Patient is maintenance knowledge regarding self care at home to identify continue self care at home. regarding treatment
asking doubts related to lack of treatment regimen. patients knowledge about self regimen follow up and
regarding to knowledge care and ability to manage self activity schedule.
treatment. regarding care.
treatment regimen
after discharge.
Objective data:
On observation Encourage patient to continue Encouraged the patient to
patient is on full course of antibiotic continue full course of
unaware of her therapy to prevent relapse of antibiotic therapy.
disease pneumonia and development.
condition.

Encourage patient to obtain Encouraged the patient to

adequate rest, nutrition and obtain adequate rest and
fresh air to assist healing nutrition.
process.
 DIET PLAN

Time Food Amount

8.00 a.m Tea 1 Glass

Breakfast
Dosai 2 Piece

Bengal gram Curry 1 servings

12.30 p.m Rice

Lunch
Fish Curry 2 servings

Cabbage side dish 1Servings

4.00 p.m Tea 1 Cup

Tea time
Biscuit 2 Numbers

8.00 p.m Chappthi 4 Numbers

Dinner
Green piece curry 1 Servings

10.30 p.m Hot Milk 1 Cup

Bedtime
 HEALTH EDUCATION

 Avoid cigarettes smoking. Avoid alcohol ingestion.

 To take all medications as prescribed. This includes both anti-inflammatory and

antibiotic drugs. Failure to take these medications as prescribed can result in relapse.

 Advised about the follow up measures and to take medications at correct time.

 Explain the relationship between symptoms and stress. Stress-reducing activities or

relaxation strategies are encouraged.

 Explain about the importance of rest and sleep and to take at least 6-8bhrs. Adequate
rest and sleep keep the mind and body fresh

 Explain the importance of nutrition and told him to take high protein containing diet
and to include diet containing vegetables and fruits

 Advised the patient to do exercises like walking, flexion, extension, abduction and
adduction of extremities

 Explained to the patient regarding follow up measures and its importance. I told him
to take prescribed medication properly and correct time

 Advised the patient to take bath daily and to wear clean clothes

 Advised the patient to take high protein containing diet and include diet containing
vegetables and fruits etc.
 Conclusion

Mrs. Kannikamma was admitted to Sanjaygandhi general hospital,banglore on

11/03/12 at 4.34 p.m with complaints of fever, chills, persistent cough and chest pain since 3
months. The doctor diagnosed the case as Pneumonia.

I started the care on 12/03/2012 and I ended my care on 15/033/2012. During my

care I gave care to my client like mouth care, nail care, and provided nebulization, fowlers
position.

The patient was health educated on various aspects of her disease condition such
as, the diet or nutrition required for his disease, the personal hygiene necessary, and the need
for exercise during the recovery stage.

Mrs. Kannikamma received three days of nursing care from me. And the patient
recovered well from her disease condition.

From this case, I had gained immense knowledge regarding Pneumonia and its
Medical intervention.
Bibliography

1. Suzanne c. Smelzer and Brenda Bare, Brunner and Suddarth’s, “Text book of medical
surgical Nursing”, 10th Edition, Philadelphia, Lippincott Publishers.

2. Joyce M. Black, “Medical Surgical Nursing”, 6th Edition, New Delhi, Harcous Publishers.

3. B. T. Basavanthappa, “Medial Surgical Nursing”, 1st Edition, Jaypee Publishers (P) Ltd.,
Bangalore.

4. Anne Waugh and Allison Grant, “Ross and Wilson, Anatomy and Physiology in Health
and Illness”, 9th edition, Churchill Livingstone Publication, Philadelphia.