SAMPLE /EXAMPLE OF FULL HISTORY COLLECTION &
CARE PLAN:
Prepared by : M. Luxmi Devi, PG-Tutor
PATIENT PROFILE
Name of the patient: Mr. [Link]
Age: 59years
Sex: Male
Marital status: Married
Religion: Hindu
Education: Degree ([Link])
Occupation: Employee, Dept. ESR
Spoken language: Telugu, English
Address: V. Nookaraju, sector-6, 302, steel plant
Date of admission: 26/3/13.
Medical diagnosis: Chronic Obstructive Pulmonary Disease
Physician: Dr. Venkata Challam, [Link] (Medical physician)
Date and duration of nursing care: 5 days of nursing care plan
Date of discharge: 14-4-13.
HISTORY COLLECTION
Chief complaints:
My patient Mr. V. Nookaraju, age 59years, admitted in ICU ward in Visakha steel
general hospital complains of breathlessness, severe cough weakness, chest tightness from last
2days onwards
History of Present illness:
My patient Mr. V. Nookaraju, age 59years, admitted in ICU ward in Visakha steel
general hospital complains of breathlessness, severe cough weakness, and chest tightness from
last 2days onwards and it was diagnosed as chronic obstructive pulmonary disease.
Past medical history:
My patient not having any previous Injuries/ accidents and any communicable diseases.
My patient is hypertensive. He is taking medication last 4 years on wards.
Present surgical history:
There is no significant or evident present surgical history.
Past surgical history:
Previous hospitalization – 2006 appendectomy; and there is no other surgical histories.
Family history:
Any hereditary:
There is a history of diabetes and hypertension and there is no hereditary of congenital
abnormalities.
Family tree:
Index:
Female
Male
Expired
Patient
Family profile:
[Link] name of the family age sex R/ship occupation income Health
member status
1 [Link] 59 M husband employee 45,000/m Ill
2 V. Pydithalli 50 F wife house wife - Healthy
3 [Link] 45 M son employee Healthy
15000/m
4 [Link] 30 F daughter in house wife - Healthy
law
5 V. Prasad 24 M son employee 10,000/m Healthy
6 V. Ratnam 20 F daughter in house wife - Healthy
law
Socio – economic history:
Housing: building house
Ventilation: well ventilated
Electricity: present
Water supply: municipality
My Patient is a hardworking person that’s why he was able to give what his family needs.
In their community hazard, patient was living in visakha steel plant quarters.
Personal history:
Diet:
Patient diet includes vegetarian and non-vegetarian 3 times / day. Non –vegetarian is the
favorite food habit.
Rest and sleep: Disturbed sleep pattern.
Nutrition: mixed diet
Elimination:
Pattern of Elimination: Before illness present
BOWEL ELIMINATION
Frequency – normally passing the stools
Character of stool Problems encountered such as constipation, diarrhoea, etc.
Every other day Yellowish brown, solid Constipation.
URINARY ELIMINATION
Frequency- 4-6 times
Quantity- 900ml
Character of urine Problems encountered such as pain, burning. Yellow to reddish in colour.
PHYSICAL EXAMINATION
Vital signs:
vital signs patient value normal value remarks
temperature 98.60 f 98.60f normal
pulse 82b/m 70-100b/m abnormal
respiration 24b/m 16-20b/m abnormal
blood pressure 150/100mmhg 120-80mmhg abnormal
GENERAL EXAMINATION:
Conscious: conscious
Orientation: oriented to time, place and date
Nourishment: moderate nourished
Health: un healthy
Body build: moderate
Activity: dull
Look: anxious
Hygiene: moderate hygiene
Speech: clear
REVIEW OF SYSTEM(head to toe examination)
Skin / integumentary system:
Colour: black/ dark colour
Texture: dry skin texture is smooth
Skin turgor: bad skin present
Hydration: well hydrations and Cold to touch
Discoloration: lower extremities discolouration of skin oedematous; redness and breaking down
of skin.
Head:
Distribution of hair: The hair is distributed well
Color: The color of the hair is brown and some white hair, Dry hair
Head, dandruff: No head lice, dandruff or any infection
Size: Round head
Scalp: Scalp is smooth, No nodules or masses
Eyes:
Vision: normal vision, no visual disturbances
Glasses: not evident
Discharge: no discharges
Pain: no history of pain
Itching: no history of pain
• Proportion the size
• Eyebrows are black in color and symmetrical
• Conjunctiva is pale in color – due to decrease in RBC, Hgb and Hct. count
• Sclera are white in color and cornea are shiny
• No abnormal involuntary movements
• Can able to move in all direction
Ears:
Hearing: Poor hearing, Proportion to the size of the head
Pain: No pain, No presence of discharge
Itching: No itching
Ringing: no ringing sensation
Vertigo: no history of vertigo
Nails:
Nail beds: pale in colour
Nail plates: flat; absence of clubbing
Cyanosis: no central and peripheral cyanosis
Colour: black
Texture: dry
Nose& sinuses:
Deviated nasal septum: no deviation septum found
Discharge: no history of nasal discharge
Allergies: no history of allergies
Frequent cold: no history of any colds
Obstruction: no evident of obstruction
Pain: no history of pain
Epistaxis: no history of Epistaxis
• No tenderness, masses and displacement of the bone
• Maxillary and Frontal sinus is normal and not inflamed
Mouth and throat:
Tongue: The tongue is negative in lesions and tenderness
Lesions: Absent of any swelling, lesions and ulcerations
Lips: Lips are pale in color
Bleeding: no history of bleeding
Tooth decay: no history of tooth decay
Dental caries: No teeth in upper and lower incisors the pt. used dentures
Neck:
Stiffness: no history of stiffness
Limited motions: normal range of motion
Swelling: no history of swelling
Pain: no history pain
Thyroid disease: history of thyroid disease ( type –II DM)
• Symmetrical and freely movable without difficulty
• presence of jugular vein distension
Thorax:
• Crackles present
• Tachypnea- inadequate blood supply/decrease blood flow resulting to decrease oxygen,
the lungs need to compensate
• Cheynestokes breathing
CARDIO- VASCULAR SYSTEM:
Heart:
• murmur – abnormal heart sound present
• Tachycardia – 105bpm
History of hypertension: hypertensive
Varicose veins: no history of varicose veins
Dyspnoea: dyspnoea present
Chest pain: evident
palpitation: present
Heart sounds: present s1 &s2 sounds
Pulse: tachycardia
Heart beat: normal rate, rhythm
Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected.
Palpations: on palpations masses are detected
Percussion: no percussion done
Auscultations: on auscultation at 5 areas, pulmonic, aortic, erbs point, mitral and apical area, s1
& s2sounds are heard, no abnormal gallop sounds.
Respiratory system:
Lesions: absence of lesion
Scars: absence of scars
Dysnea: present
Cough: present
Sputum: thick secretions are present
Inspection: on inspection the thoracic cavity is normal and clear, no lesions detected.
Palpations: on palpations masses are detected
Percussion: no percussion done
Auscultations: on auscultation at wheezing sounds & murmurs sounds are heard.
Gastro-intestinal system:
Auscultation: bowel sounds present; peristalsis movement are present.
Inspection: no scars; lesions; hernia are not evident
Palpations: no tenderness/ hardness.
Percussion: abnormal sounds are present.
Genitor-urinary system:
Lesions: absence of lesion
Scars: absence of scars
Discharge: no discharges
Infections: no infections
Voiding: passing urine 6 to 7 times a day
Colour of urine: dark yellowish colour.
Muscular skeletal system:
Postural curve: kyposis, lordosis are absent
Muscle tone: no depth
Muscle strength: weakness than normal
Upper extremities:
Symmetry: symmetrical
ROM: normal range of motion
Reflexes: present
Joints: oedematous & swelling and tenderness is present
Lower extremities:
Symmetry: symmetric
ROM: normal range of motion
Gait: abnormal
Varicose veins: present
INVESTIGATIONS
Date Specimen/ Type of Result Normal values Significance
investigation
27-3-13 hematological 120-160 g/L abnormal
• Hgb • 162.0
• Total Red Cell 4.5-5.0 x 10-12
g/L
• Total WBC • 10.2 5-10 x 10-19 g/L abnormal
• Segmenters • 0.80 0.40-0.600. normal
• Lymphocytes • 0.12 20-0.400. abnormal
• Monocytes 02-0.080.
• Eosinophiles • 0.80 01-0.03 abnormal
• Basophiles 0-0.01
27-3-13 blood chemistry • 98.0 75-115 mg/dL normal
Glucose mg/dL
FBS • 5.44 4.2-6.4 mg/dL normal
mg/dL
Uric acid • 8.4 mg/dL 2.4-7.0 mg/dL abnormal
Creatinine • 2.7 mg/dL 0.5-1.7 mg/dL abnormal
BUN 10.1-50.0 mg/dL
Cholesterol • 159.2 suspect normal
mg/dL >220mg/dL
Triglycerides • 80.0 suspect normal
mg/dL >150mg/dL
chest x-ray normal normal
MEDICATIONS
slink drug action side effects nurses responsibility
1 Inj. Monocef 1gm BD antibiotic nausea, - Assess the general
vomiting, condition of patient
2 Inj. Amkacin 500mg BD antibiotic anorexia, - Observes for the
tachycardia, drug side effects
3 [Link],150mg,BD analgesic subsided fluid - Immediate nursing
4 T. Pantop, 400mg, BD retention, intervention are to
5 oxygen administration 4l/m antacid insomnia, etc be done
continuous administration - Administration of
inhalation duodline and alternative agonist
6 sarbutrate BD to prevent the side
effects.
NURSING DIAGNOSIS:
Based on the assessment data, major nursing diagnoses for the patient may include:
• Ineffective airway clearance related to: bronchoconstriction, increased sputum production,
ineffective cough, fatigue / lack of energy, broncho pulmonary infection.
• Ineffective breathing pattern related to: shortness of breath, mucus, bronchoconstriction,
airway irritants.
• Impaired gas exchange related to: ventilation perfusion inequality
• Activity intolerance related to: imbalance between oxygen supply with demand.
• Imbalanced Nutrition: less than body requirements related to: anorexia.
• Disturbed sleep pattern related to: discomfort, sleeping position.
• Bathing / Hygiene Self-care deficit related to: fatigue secondary to increased respiratory
effort and ventilation and oxygenation insufficiency.
• Anxiety related to: threat to self-concept, threat of death, purposes that are not being met.
• Ineffective individual coping related to: lack of socialization,anxiety,depression,'low activity
levels and an inability to work.
• Deficient Knowledge related to: lack of information, do not know the source of information
NURSING CARE PLAN:
ASSESSMEN NURSING GOALS/OUT PLANNING IMPLEMENT EVALUATIO
T DIAGNOSIS COMES ATION N
SUBJECTIV SHORT
E DATA: TERM GOAL:
LONG TERM
OBJECTIVE GOAL:
DATA:
HEALTH EDUCATION:
Heath education related to medication:
• Advised the patient to take the medication on time.
• Advised to take the medication at regular interval of time.
• Advised to take medication with adequate amount of water.
• Advised not to move or drive immediately after taking medication.
Health education related to nutritional diet:
• Advised to have high fibre rich diet.
• Advised to have adequate amount of fluid/ water.
• Advised to have small and frequent amount of food.
• Advised to have green leafy vegetables and less spices food.
Health education related to daily living activities:
• Advised the patient to involve in daily living activities like household activities,
gardening, farming or agriculture.
• Advised to have a regular morning and evening exercises.
Health education related to follow up:
• Advised to follow the instruction given during the time of discharge by doctor.
• Advised to come up for regular check up/follow up in time without delay.
• Advised to inform any harmful effects of drugs which occur during medication time
at home.
Health education related psychological support:
• Advised the family member to give psychological support by staying along with the
patient.
• Advised the family member not to keep the patient alone at home.
CONCLUSION:
A 59 years old married man got admitted in ICU with chief complaints of breathlessness, severe
cough, chest tightness and weakness and he was diagnosed with COPD. He was got treated with
medication……. ………for three week and nursing care was given by me for two weeks. During
care he was cooperative and understandable, follows instructions. He was got discharged from
the hospital on ………
