ERA UNIVERSITY /

ERA’S COLLEGE OF NURSING

NURSING CARE PLAN ON

CYSTOCEE WITH DIABETIC MELLITUS

SUBMITTED TO:SUBMITTED BY
MS.GODHULI GHOSH MS. ARCHANA DEVI

ASSISTANT PROFESSOR M.Sc. NURSING 1ST YEAR

ERA COLLEGFE OF NURSING ERA COLLEGFE OF NURSING

SUBMITTED ON : 21-04-2019
 STUDENT PROFILE

Name – Archana Devi

Course- M.sc Nursing 1 st year

Subject – Medical Surgical nursing

Name of Institution- Era College of nursing

Patient selected from- Gynae ward, Era medical college lucknow

INTRODUCTION –
Mrs Sushma Devi got admitted in the {Gynae ward} Era medical college lucknow on 26-2-
2019 at 2:30 pm, with complaints of lower back pain ,feeling of something coming out per
vagina , fever , loss of appetite . The case was diagnosed 3 grade rectocele with diabetic
mellitus by Dr, Parul Saini.

As a part of my obstetrics and gynecology nursing of MSc nursing requirement, I took this
case for my case study, I started care from 27.2.2019 at end. I gave hygienic care to the
patient and educated about post-operative care at home, diet and follow up and medication,
the patient health status gradually improved and now she is better.
 NURSING CARE PLAN

PATIENT’S IDENTIFICATION DATA

a) Name Of The Patient : Mrs.Sushmadevi

b) Age : 40 yrs
c) Gender : Female
d) Bed no : unit 1 (bed no 2)
e) Address : Sandila ,hardoi , U.P.
f) Nationality : India
g) Religion : Hindu
h) Educational Status : 12
i) Occupation : Housewife
j) Marital Status : Married
k) Family members : Married
l) Addiction : No any drug addiction
m) IPD No. : 19005876
n) Diganosis : P5+2L5 with 3 Rectocele with diabetic mellitus
o) Consultant Doctor : Dr.Parulsoini
p) Source of information : Patient
q) Date of Admission : 26.02. 2019
r) Time of admission : 2:30 pm

CHIEF COMPLAINTS: My patient Mrs.Sundari was admitted to ERA’S hospital

lucknow on 26.02.2019 at 2:30 pm with the complaints of –

 lower back pain ,

 feeling of something coming out per vagina ,
 fever ,
 loss of appetite

HISTORY OF PRESENT ILLNESS: Mrs.Sundari was apparently well when

suddenly she developed lower back pain, feeling of something coming out per vagina, fever,
loss of appetite.
 Patient has no history of trauma, injury falling. So she came to the hospital and admit
as per doctors’ orders.
PAST MEDICAL HISTORY –
Childhood illness – Patient is having no history of any disease in childhood.

Immunization status – complete vaccinations.

Medical history - Patient having DM for 3 years,and there are no history of

hypertension , tuberculosid.

History of abortion -2

No history of still birth and pre mature labour.

PAST SURGICAL HISTORY – There is no any past history of surgery is noted.

MENSTRUAL HISTORY -
Menarche – 14 yrs

Cycle – 28-30 days

Duration – 3-4 days

Amount of blood flow- normal

Dysfunctional uterine bleeding – abnormal

OBSTETRIC HISTORY –

S.NO. YEAR PREGNANCY LABOUR METHOD PUERPERIUM BABY

AND EVENT AND OF DELIVERY STATUS
DATE EVENT
1 Feb 1997 Full term Full term NVD Normal Normal male
NVD baby
2 May 2000 Full term Full term NVD Normal Normal male
NVD baby
3 Dec 2001 Abortion of 8 -------- D&C UNEVENTFUL --------------
weeks
4. April 2003 Full term Full term NVD Normal Normal male
NVD baby
5 Aug 2004 Abortion of -------- D&C UNEVENTFUL --------------
8 weeks
6 May 2006 Full term Full term NVD Normal Normal male
 NVD baby
7 March Full term Full term NVD Normal Normal female
2008 NVD baby

PERSONAL HISTORY

a) Dietary habits : Vegetarian

b) Diet /day : 3 times / days
c) Immunization : taken all T.T.dose.
d) Food habit : non vegetarian
e) Contraceptive prior to pregnancy: no any contraceptives.
f) Smoking : No history of Smoking.
g) Alcohol : No history of alcohol.
h) Pervious history of blood transfusion : No
i) Pervious history of drug allergy : absent
j) Pervious history of anti D immunoglobin: absent

FAMILY HISTORY

-Male died
 FAMILY TREE

-Male

Mr.RakeshMrs.Sushma

45 yrs 40 yrs

Mr.sunilMr.sameerMr.sudhirMr.rohanms.Roshni

Name of Relationship Age/ Sex Marital Occupatio Health Status Educational

the family with patient status n Background
member

Mrs.Sushm 40 yrs Married House wife Unhealthy B.A.

a
Patient

Mr.Rakesh Husband 45 yrs Married bussiness Unhealthy B .A

Mr.sunil Son 22 yrs Student Healthy B .A

unmarried
Mr.sameer Son 19 yrs unmarried Student healthy 12 th
Mr.sudhir Son 16 yrs unmarried Student Healthy -10 th
Mr.rohan Son 14yrs Student Healthy 8th
unmarried
ms.Roshni Daughter 12 yrs unmarried Student Healthy 6 th

22 yrs19 yrs 16 yrs 14 yrs 12 yrs

PSYCHOSOCIAL HISTORY –
 a) Primary language : Hindi

b) Secondary language :Hindi

c) House :Own

d) Type of family : Nuclear

e) Relationship of patient with family : Satisfactory

f) Mood of patient : Anxious

g) Position of patient in the society : Respectable

h) Position of patient in the family : Respectable

i) Socio economic status of the patient: low socio economic status.

ENVIRONMENTAL HISTORY -

a) Cleanliness of house : clean house

b) Type of residence : clean

c) Area : Village

d) Hazards : No environmental hazards.

e) Pollutants : Smoke and dust

f) Water supply : Hand pump

g) Sanitation : Adequate

h) Drainage system : Adequate

i) Method of disposal of waste : Deep burial

j) Method of cooking pratices : frying and boiling

k) Any epidemic disease : Absent

l) Sanitation : Adequate

m) Environmental hazards : Near industrial waste dispose

 n) Mode of transportation : Public transport service

VITAL SIGNS –

S.NO. VITAL SIGN PATIENT NORMAL EVALUATION

VALUE VALUE
1 Temperature 98.4F 98.6F Slightly low
2 Respiration 20 b/m 16-20 b/m Normal
3 Pulse 80 b/m 70- 100 b/m Normal
4 Blood pressure 120/70 mmof hg 120/80 mmof hg Normal
5 Oxygen saturation 96% 95-100% Normal

INVESTIGATION: (3 days)

Day -1

S.No. Tests Normal Value Patient Value

1 Haemoglobin 10-16.5 g/dl 12.5 g/dl
2 WBC 4000- 11000 cells/cumm 7000 cells/cumm
3 Neutrophills 40-75% 58%
4 L ymphocyte 20-45% 26%
5 Eosinophills 1-6% 15%
6 Monocytes 2-8% 01%
7 Platelet count 1.5 -4 lakh 2.6 lakh
8 RBC 3.8- 6 m/mm3 4.21 m/mm3

Day -2

S.No. Tests Normal Value Patient Value

1 Blood urea 15.0- 36.38 mg/dl 38 mg/dl
2 Creatinine 0.52-1.04 mg/dl 2.0 mg/dl
3 Sodium 135-145 mmol/L 145 mmol/L
4 Potassium 3.4- 5.1 mmol/L 5.4 mmol/L
5 PT 9.8- 12.1 sec 12.9 sec
6 INR 0.6 – 1.5 1.14

Day -3

S.No. Tests Normal Value Patient Value

1 SERUM BILIRUBIN 0.2 – 1.3 mg/dl 0.4 mg/dl
2 S.G.P.T 9-52 U/L 25 U/L
3 S.G.O.T 14-36 U/L 30 U/L
 ULTRASOUND FINDINGS_

Bulky uterus (visualized part appears bulky) measuring 7.6X5.9X5.1 cm with volume 120 cc.

MEDIACTION –

S.NO. MEDICATION DOSE ROUTE FREQUENCY ACTION

1 Tab. Iron 100 mg Oral OD Increased HB
level

2 Tab. Calcium 500 mg Oral BD Increased

calcium level

3 Syp. Cremaffin 2 tsf Oral HS Stool softness

4 Tab. Limcee 100 mg Oral OD

OTHER SUPPORTIVE THERAPIES-

 Provide complete bed rest to the patient.

 Provide balance diet to the patient.

 Provide blood transfusion to increase blood and maintain HB level.

PHYSICAL EXAMINATION

GENERAL EXAMINATION:

 Consciousness : Conscious

 Orientation : Altered

 Nourishment :Well nourished

 Body Built : Moderately built

 Activity : dull

 Look : Dull
  Hygiene : Proper

 Speech : normal

 Height : 5’’ inch

 Weight : 56 kg

INTEGUMENTARY SYSTEM

SKIN

 Colour : Pale in colour

 Texture : dryness

 Skin Turgor : Normal

 Hydration : Normal

 Lesions/ Masses : No lesions present

NAILS

On observation :

 Nail beds : Normal

 Nail plate :Normal

HAIR

 Colour : white

 Texture : Normal

 Grooming : Normal

 Distribution : Normal

HEAD

 Scalp :Clear, no lesion or dandruff present

  Distribution of hair : Equally distributed

 Hair colour: blackish

 Pediculosis : Absent

 Alopecia : Absent

 Headche: Present

 Dizziness : Absent

FACE

 Cholosma : Absent

 Colour : Fair

 Turgor : Absent

 Texture : Normal

 Scar : Absent

EYES

 Symmetry : Normal

 Eye brows : both eyebrows look symmetrical and regular in shape.

 Eye lashes :There are no inflammation present.

 Eye lids : no edema, swelling or redness found.

 Pupillary reflex : Normal

 Pupil shape : Normal

 Sclera : White in colour

 Conjunctiva : Moist

 Vision : Normal
  Discharge : No discharge present

 Spectarles: Absent

EARS

 Pinna : Normal

 Shape and size : Normal

 Location : Symmetrical

 Hearing : Normal , Good

 Discharge : No discharge present

 Crust formation : Absent

NOSE

 Nasal septum : No septal deviation present.

 Nasal pathway : Clear

 Smell : Good

 Sinuses : Normal

 Discharge :Absent

MOUTH AND PHARYNX

Lips-

 Colour :Pinkish

 Cracking : Absent

 Symmetry : Normal

 Cheilosis : Absent

Mucosa –
  Hydration : Poor

 Integrity : Normal

Tongue –

 Coating : Absent

 Colour :pallor

Teeth-

 Colour : white

 Dental caries : present

 Dental infection : absent

 Gums : Pallor

NECK

 Range of Motion : Stiff neck

 Lymph nodes : Palpable, no lymphadenopathy.

 Trachea : Normal

 Thyroid Gland : No goiter present, no inflammation.

 Jugular vein distention : Absent

CARDIO- RESPIRATORY SYSTEM

 Thorax : Normal

 Thorax expansion : Normal

 Heart Sounds : normal sound heard.

 Breath Sounds : Normal sound heard.

 Apical Pulse : 120 b/min

  Cough : Present

 Sputum : Present sputum.

ABDOMEN

 Inspection

 Size : Normal

 Abdominal girth : 95 cm

 Linea nigra : Absent

 Lesion : Present

 Palpation-

 Fundal grip : Absent

 Lateral grip : Absent

 Pelvic grip : Absent

 Powlick grip : Absent

 Percussion

 Brauton hicks contractions : Absent

 Bowel Sounds : No abnormal accumulation of fluid or gas bowel sounds 3

beat/ min.

 Appetite : Loss of appetite.

UPPER EXTREMITIES

 Symmetry : Normal

 Range of motion : No restriction of range of motion , normal flexion

LOWER EXTREMITIES

 Symmetry : Normal
  Range of motion : No restriction of range of motion , normal flexion

 Edema/ swelling : Absent

 Cyanosis : No cyanosis present

 Joints : No joint pain present.

 Deformity : No any deformity present

 Gait : Normal

GENTIO- URINARY

 Lesions/ Scars : No scars and lesions present

 Discharge/ Infection : discharge present

 Hygiene : Present

RECTUM AND ANUS

Bowel Elimination Pattern : Normal

NURSING MANAGEMENT –

 Proper assessment of the patient should be done

 Administer prescribed medicine.

 Monitor vital signs every 4 hourly.

 Provide education regarding hygiene, medication, diet and exercise.

 Educate to avoid sitting for long time.

 Maintain fluid and electrolyte balance.

 Strickly monitor intake and output chart.

NURSING DIAGNOSIS –
 Acute abdominal pain related to bulky size of uterus as evidence by verbal report or facial
expression.

 Altered body temperature related to physiological changes as evidenced by taking vital

signs or as thermometer reading.

 Altered sleep pattern related to pain and vaginal discomfort as evidence by frequent
awakening during night and verbal speech.

 Anxiety related to surgical procedure as evidenced by change facial expression.

 Fluid volume deficit related to dehydration as evidence by altered fluid and electrolyte
balanced.

SHORT TERM GOAL –

 To relieve pain.

 To reduce infection.

 To improve condition of the patient.

 To provide comfortable position.

 To reduce anxiety and fear related to disease condition of the patient.

 To restore the normal functioning.

LONG TERM GOAL –

 To relieve post-surgical pain.

 To prevent further complication.

 To provide health education regarding diet and exercise and follow up.

 To encourage patient for adherence treatment.

 To rehabilitate the patient.

NURSING PROCESS-
  Acute abdominal pain related to bulky size of uterus as evidence by verbal report or facial
expression

Assessment Nursing Goal Planning Rationale Implementation Evaluation

Diagnosis
Subjective  Acute To -To assess -Assessed the To know the Expected
Date- abdomi relieve the general general condition of the outcome is
Patient is nal pain patient condition of condition of patient. partially
complaining related from the patient. the patient. - met as
about the to bulky pain. -Assess the - assessed the To know evidenced
pain size of duration, duration, characters of that patient
uterus intensity and intensity, and pain. pain is
as character of character of reduced. .
Objective evidenc pain. pain.
Data- On e by
observation verbal -
that patient report Psychologica
facial or facial Psychologica l support -To provide
expression expressi l support. given. support
changed on
and looking  -Provided
dull. -Provide diversional -To divert patient
diversional therapy. mind.
therapy -changed the
-Change the position of -To provide
position of the patient comfort.
the patient -provided
-Provide medication as -To provide
medication as per doctors comfort.
per doctors order. To reduce pain.
order
 2-Altered body temperature related to physiological changes as evidenced by taking vital
signs or as thermometer reading.

Assessm Nursing Goal Planning Rationale Implementation Evaluation

ent Diagnosis
Subjecti To  Assess  Know the  Assessment Expected
ve data- Hyperther maintain the general was done. outcome is
patient is mia the general condition. partially met
complain related to normal conditi as evidenced
ing about infection body on of that patient
he is as temperatu the gastrointestin
feeling evidence re. patient. al function
warm. by patient  Provid It helps to make Fiber soft diet maintained.
verbalizati e fiber defecation easier. provided like
Objectiv on and soft banana.
e data- increased diet.
on respiratory  Prevent
observed rate. Encourage stools from
that fluid become dry
patient intake. and hard.
facial  Maintain the Fluid was
expressio Provide thermoregulat encouraged.
n sponge ion system.
changed bath to the
Provided the
and patient.
sponge bath to
increased the patient.
respirator
rate..

 Anxiety related to surgical procedure as evidenced by change facial expression.

Assessment Diagnosis Goal Planning Rationale Implementatio Evaluation

 n
Subjective  Anxiety To -To assess To know the -Assessed the Patient
data related reduce the level of level of level of anxiety knowledge
Patient is to anxiety anxiety of anxiety of of the patient. level has been
complainin surgical of the the patient. the patient. improved after
g about the procedur patient. explanation.
fear related e as -Clarify -To clarify -Clarified
to surgery. evidence patient’s the patient patient’s doubts
Objective d by doubts doubts. regarding
data change regarding postoperative
Patient facial postoperativ care.
looks expressi e care.
anxious. on. -
-Explain -To explain Explained
patient about patient about patient about
postoperativ exercise of postoperative
e exercises. postoperativ exercise.
e care.
-To -To reduce -encouragement
encourage the anxiety. was done.
patient to ask
questions.

4- Deficit knowledge about treatment as evidenced by patient asking frequent question

regarding postoperative care.

Assessment Diagnosis Goal Planning Rationale Implementatio Evaluation

n
Subjective Deficit To increase -To assess To know the -Assessed the Patient
data knowledge the the knowledge knowledge knowledge
Patient is about knowledge knowledge level of level of patient. level has
asking treatment as level of level of patient. been
question evidenced patient patient. improved
regarding by patient regarding after
postoperativ asking postoperativ -Clarify -To clarify -Clarified explanation
e care. frequent e care. patient’s the patient patient’s doubts .
question doubts doubts. regarding
regarding regarding postoperative
Objective postoperativ postoperativ care.
data e care. e care.
Knowledge -
deficit is -Explain -To explain Explained
experienced patient patient patient about
by frequent about about postoperative
questioning. postoperativ exercise of exercise.
e exercises. postoperativ
e care

OTHER INTERVENTIONS-

- Provide assessment of the patient should be done.

- Vital signs should be checked daily.

- All prescribe medicine is given at right route and time, dose and frequency.

- Monitor intake and output.

- Blood transfusion is given to correct anemia.

- Patient is under close observation.

- Psychological support is given.

- Clarify all the patient doubts.

- Documentation should be properly.

HEALTH EDUCATION; HYGIENE-

MEDICATION

- Advise patient to take home medications following right drug, frequency, dosage and timing
as prescribed by the Physician.
Iron and folic acid supplement, calcium and vitamins tablets provided.

NUTRITIONAL ADVICE-

- Advice patient to take iron rich diet like spinach, apples and green leafy vegetables.

- Advice patient to take nutritious and fibers rich diet to reduce constipation.

- Advice the patient to take light and fibers diet after surgery.

EXERCISE-

- Advice patient to do minimum exercise like morning walk.

- Do not lift heavy objects.

- Avoid long time sitting.

- Educate patient to perform kegal exercise.

H – Health Teachings

- Inform patient to avoid lifting heavy objects for 1-2 weeks- Stress the importance of proper
hygiene like handwashing, toileting, toothbrushingand bathing.

- Encourage client to engage to range of motion exercises.

- Instruct patient to increase intake of protein-rich foods to promote faster woundhealing

- Advise patient to increase adequate fluid intake for hydration purposes.

- Discourage patient to participate in strenuous activities that might precipitate stressand

trauma to the wound.

- Tell patient not to hesitate to ask for assistance when waking up in bed or whengoing to
comfort room.- Promote rest periods among the client but also encourage ambulation

FOLLOW UP –

- Advice the patient to come on proper date as per doctor advice.

- Advice patient if any complication or problem occurs immediately come for proper
follow up.
BIBLIOGRAPHY- Black M. joyce, Hwkshokansonjane,medical surgical nursing.8th edition.
Volume 1. New delhi; Reed elsevierindia private limited: 2009.p 645-647.

 Suddarth’s and brunner, Hinkle L.Janice, Cheever H.Kerry. Text book of medical
surgical nursing.13th edition. Volume 1.New delhi: wolterskluwerindiaPvt ltd;
2014.p550-555.

 https://emedicine . Medscape.com/article/overview.

 https://www.healthline.com/human-body-maps/heart failure..