Assessment

Subjective data

 Identification data

Name of the patient:-Md Yunush

Age-55years. Sex-Male Address:- vill:- Paruldanga, P.o.-Bolpur Dist:-

Birbhum

Reg. No:-63723 ward:-ICCU Bed:-P5 unit:-VI

Date of admission:- 18/09/10

Diagnosis:- DCM (Dilated Cardiomyopathy)

Religion:-Muslim

 History:-

Social history:-

Type of family:-nuclear family Family member:- 5 Male:- 3 female:-

2. Adult:-4 child:-1

Earning member of the family:-1

Total family income per month:-Rs 2500/-

Education:-

Patient:-class II wife:- illiterate son:- class VI daughter in law:-

illiterate Grand son :-class II

Occupation:-

Patien:-security guard (but can not work for 5to 6 years ) wife:-housewife son:-tailor
daughter in law house wife.

Socioeconomic class:-poor. Type of house:-kaccha no of rooms:-2

ventilation:-well ventilated

Sanitation:-use 0pen field source of water:- tap water.

Personal history:-

Marital status :-married habits:- nothing significant addiction:-no history of drug

addiction, even no history of chewing pan.

Allergy:- no history of allergy

Medical and surgical history:-

Past medical history:-

he was a bus driver about 10 years ago. Then an accident was occurred during driving.he was
then admitted in the SSKM hospital Kolkata with chest injury. From then he was suffering
from respiratory distress time to time and so that he was under supervision of a doctor. About
5-6 years ago this respiratory difficulty was exasserated then he was admitted at SD
Hospital , Bolpur, Birbhum. It was reduced by medical treatment.

Present medical history;-

He was suffering from renal disorder for last one month. Urine output was less and
respiratory distress was increased. Then he was admitted at this hospital. When respiratory
distress was severe he was referred to ICCU. Now he is diagnosed as DCM.

Family history:-

His daughter has died from stroke about about 2 years ago at the age of 24 years. Nothing
else significant.

Diet history:

Breakfast:-chapatti and vegetable lunch:-rice and vegetable dinner:- chapatti and

vegetable

Remarks:- they are not taken fish/meat/ egg.

Objective Data

Physical assessment:-

General condition:-

Height:- 5 feets and 7 inches weight:-70 Kg temperature:-98.4 degree Fahrenheit

pulse :- 74 b/m respiration:-24 b/

BP:-112/84 mm of Hg.

Head to foot examination:-

Hair and scalp:- hair is healthy and clean, no dandruff is present. No pediculosis, tenderness
and masses.
Eyes:- colour is redish but clean eye brows symmetrical and hairy. No discharge ,no vision
problem. Eye movement good. Sclera is not yellow. Conjnctiva is not pallor.

Lips:-lips are symmetrical moist and intact with no lesions. client can purse lip. No pallor.

Nose:-nose is in midline and symmetrical. No discharge or flaring, client breaths freely

through both naires.nasal mucosa pink, moist intact,

Mouth:- oral mucosa pink, moist , intact. No lesions, no caries, no white spot on the teeth,
tongue is moist, pink in color,

Ears:-helix, antihelix, tragus and antitragus are present in external ear, symmetrical in shape,
color consistent with surrounding skin. No discharge, masses, tenderness, no hearing loss.

Thyroid:- not enlarge, tender.

Lymph nodes:-mobile, not enlarge or tender.

Extrimities:- size and shape of both extremities are normal.

Hands:-skin intact, no lesion, no extra finger, capillary refill in the

nail bed is within 3 second, brachial and radial pulsation are palpable.

Leg:-joints are movable not tender, skin intact, no extra digit,

symmetrical, arteries are palpable, no varicose vein.

Chest:- size and shape symmetrical, no masses or tenderness, skin is intact with no lesion, on
osculation clear breath sound is clear.

Heart:- normal heart sounds present, no extra murmur, carotid pulsation visible, no distended
jugular vein.

Abdomen:- soft, skin intact, no lesion, no masses or tenderness, spleen not palpable, liver not
palpable.

Back and spine:-skin intact, no lesion, vertebral colum is straight. No masses or tenderness.

Investigation:-

1. E.C.G.- reveal Dilated cardiomyopathy.

2. Blood is taken for urea, creatinine, Na+, K+, lipid profile,

Today’s morning report:- respiratory distress and chest pain are not present, urine output is
less( 200am from 6am to 1pm)catheterization done, edema is present, bowel is not clear.

Nursing care plan

Date Nursing Planning Implementation Evaluation

diagnosis
20.9.1 Risk for 1. Cardiovascular 1.cardiovascular The following
0 decreased status to be status monitored parameters are
cardiac monitored. 2. peripheral within the patient’s
output 2. Peripheral pulses pulses are normal ranges.
related to to be assessed assessed. 1. All
structural 3. ECG is peripheral
disfunction 3. ECG pattern to be monitored pulses are
caused by monitored for present
cardiopathy. cardiac 4.heart sounds 2. ECG shows
disarrythmias. are ausculted. no
4. Heart sounds and 5. urine output is Disarrythmia
rythm to be monitored by .
ausculted continuous 3. Urine output
5. Urine output to be catheterisation. is less( less
monitored 6. Buccal than
mucosa, nailbeds, 30ml/hr),rep
extremities are orter to
6. Buccal mucosa, observed. doctor.
nailbeds, earlobe 7. Signs of 4. Buccal
to be observed. cardiac failure mucosa and
such as nail beds are
7. Signs of cardiac hypotension, not dusky or
failure such as tachycardia, cyanosed.
hypotension, restlessness, 5. Blood
tachycardia, agitation, pressure
restlessness, cyanosis, venous 112/84 mm
agitation, distension, of Hg
cyanosis, venous dyspnoea, moist
distension, crackle, ascites is
dyspnoea, moist observed.
crackle, ascites to
be observed.
Risk for 1. Closed urinary 1.Asepsis has No sign of infection
infection drainage to be maintained Body temperature is
related to maintained. during 98.4 degree
altered 2. Patency of catheterisation farenheight.
urinary drainage system and providing
drainage to be assessed other care.
3. asepsis and hand 2. patient is
hygiene when assisted in
providing care turning and
should be moving.
maintained 3.catheter is
4. during turning and cleaned gently
moving patient with soap.
should be assisted 4.body
to prevent trauma temperature is
from catheter assessed.
5. clean catheter
gently with soap
during bath
6. body temperature
 to be assessed.
Risk for 1 any trauma to the
impaired extremities to be avoided
skin 2.meticulous hygiene to
integrity be maintained
related to 3. during bathing nutral
oedema. soap should be used and
lotion should be applied
4.nail trimming to be
done carefully
5.scraching or vigorous
rubbing to be avoided
6.good nutrition with
adequate intake of vit
A&C , protein, Zinc to be
provided
1.Advice is given Skin is intact.
to the patient to
use nutral soap
during bath and
trimmed nail
carefully.
2. scratching and
rubbing of the
skin is avoided
by gentle
handling

Potential 1.Abnormal breath 1.Abnormal No audible

impaired sounds, abnormal heart breath sounds, abnormal heart
gas sounds and intolerance to abnormal heart sounds, no crackles
exchange specific activities to be sounds and in chest
related to assessed. intolerance to auscultation,
fluid specific activities respiratory
overload are assessed. difficulties absent.

Imbalance 1.Nutritional status to be 1.weight is taken Weight-70 k.g.,but

nutrition assessed 2.past dietary edema may increase
related to 2.patient’s dietary pattern history has taken the weight
disease to be assessed 3. factors Diet history-
process 3.factors contributing contributing Breakfast:-chapatti
altered nutritional factors altered nutritional and vegetable
to be assessed factors assessed lunch:-rice and
4.pleasent surrounding 4.pleasent vegetable
and mealtime to be surrounding and dinner:- chapatti and
Provided mealtime is vegetable
5.patient’s food Provided
preferences within dietary 5.patient’s food
restriction to be provided. preferences
within dietary
restriction is
assessed

Activity 1.factors contributing 1.factors Fatigue is present

intolerance activity intolerance to be contributing He has taken her
related to assessed activity breakfast alone and
fatigue 2.independence in self intolerance are bath also alone with
characteristic to be assessed help of health
promoted assessed. personel
3. activity and exercise 2.promoted for
within limits and doing
 adequate rest to be independently
promoted. 3. rest is
promoted

Deficient 1. in teaching 1.his son is Written instruction

knowledge programme family included in are explained and
regarding and significant teaching has taken with the
self care others to be 2. written patient
activities included instruction are
2. written given regarding
instruction about self care
foot care, leg care
and exercise to be
provided
3. Patient to be
referred to self
help groups as
indicated such as
stress
management,
weight
management and
exercise
programme,
smoking.
Altered 1. Motivate to 1.Explanation is Bowel was clear
bowel maintain regular given about
movement bowel movement regular bowel
related to time movement
changing 2. Privacy should be 2.privacy is
environmen maintained maintained by a
t 3.Roughage containing screen
diet to be encouraged 3.patient is
instructed to take
roughage
containing diet
and.

Anxiety 1.explanation about 1.explanation Patient expresses

related to disease condition and about disease feelings of less
disease treatment to be provided condition and anxiety
condition 2.adequate explanation treatment are
should be provided before provided
doing any procedure 2.adequate
3.what the patient want to explanation is
say should listen with provided before
patience. doing any
4.Communication with procedure
the patient should be 3.what the patient
done with open ended want to say is
 questions listen with
patience.
4.Communicatio
n with the patient
is done with open
ended questions
Potential 1.some relaxation method 1.deep breathing Patient had a good
risk for to be provided exercises are sleep at night
sleep 2.a calm and quite taught to the
disturbance environment to be patient
due to provided 2.calm and quite
changing 3.a hot drinks to be environment is
environmen provided before going to provided during
t and bed sleep time
disease
process
Deficient 1.causes of heart failure, 1.causes of heart 1.Expresses the
knowledge renal failure, failure, renal understanding of
regarding edema, respiratory failure, matters taught
disease difficulties to be assessed edema,
condition 2. causes of heart failure, respiratory
and renal failure, difficulties are
treatment edema, respiratory assessed
difficulties to be 2. causes of heart
explained failure, renal
3.oral and written failure,
information to be edema,
provided as appropriate respiratory
about difficulties are
a. heart function and assessed
failure 3.oral and written
b. fluid and dietary instructions are
restriction provided
c. medications regarding
d. follow up schedule associated
e. community resources informations