SANDRA SHROFF ROFEL

COLLEGE OF NURSING,VAPI.
Case study
ON
Grade IV Rt. Lower Limb varicosity
SUBMISSION ON : /0 /11

PRESENTATION ON : /0 /11

SUBMITTED TO: SUBIMITTED BY:

Mr.Sriram Nagarajan Miss.Revathi Singireedi
Ass. Professor 1ST Year M.Sc.N.

Dep : Medical-Surgical Nursing Spe: Obstetrical Nursing

S.S.R.C.N.;Vapi. S.S.R.C.N.;Vapi.
HISTORY TAKING

I. DEMOGRAPHICAL INFORMATION

Name : Mr.Mithalesh Umashenker Mishra

Age : 29 Years
Sex : male
Address : laji (pawan ) Dubeyki chawla , Ram nagar, Chhiri, Vapi ,
Religion : Hindu
Marital status : Married
Education : 12th class
Occupation : supervisor of the company
Income : Rs.7000 / month
Ward : SJ/2
Date of Admission : 10/07/2011
I.P. No : 1112-10790

DIAGNOSIS : Grade IV Rt. Lower Limb varicosity

II. CHIEF COMPLAINT / CLIENTS REQUEST FOR CARE:

Postoperative client. Patient has pain at surgical site. He prescribed for the complete bed red.
And NBM for 24hrs.

III. PRESENT ILLNESS / PRESENT HEALTH STATUS:

a) Symptoms or complaints

Patient has severe lower limb numbness and pain unable walk and stand. discoloration of the
skin, and ulceration at rt. lower lib. And client posted for surgical treatment from OPD.

b) Onset - chronic
c) Location - lower limb
d) Quality - pricking in nature
e) Quantity - less intense Continues pain
f) Associated phenomenon - Lack of peripheral blood flow
g) Alleviating factors - little elevation of for some time.
IV. PAST HISTORY:
a) He has a history of Diabetes mellitus since 3 years and taking antiglycemic therapy
regularly.
b) He has injury with long nail on the right lower limb and got treatment and taken rest for
one month for the same. Since 5 years he has the complaints of early numbness and pain
over the limbs even for a short period of standing.
 c) Since one he is taking the treatment for the same. And last month he suggested for the
surgical treatment for the same problem.
d) No allergy to any medication and food
e) Immunization – has mark of small pox vaccination and BCG scar
V. FAMILY HISTORY:
He belongs to middle class family, got married 9 years back and has two sons .

Sl. Name of the Age Sex Occupation Education Relation Health

No. family member status
1. Mr.mithalesh 29 yrs Male Supervisor 12th class Self Grade IV
Umashenker Rt. Lower
Mishra Limb
varicosity
2. Mrs.nirmala 22 yrs Female Housewife 10th Wife Healthy
Mishra standard
3. Mr.jayanth 4 yrs Male Student UKG Son Healthy
Umashenker
Mishra
5. Mr.Ranjith 2 yrs Male Student ----- Son Healthy
Umashenker
Mishra

He has no family history of hypertension and heart diseases

VI. PSYCHO SOCIAL HISTORY:

Economic history: He belongs to middle class family and admitted to this hospital with
economic supported by family and friends

Mother tongue - Marati

Language known - Marati, Gujarathi, Hindi,
Cultural Group - Friends
Mood - Social

VIII. NUTRITIONAL HISTORY:

He is taking all types of vegetarian food either only. he used to take alcohol once in a
week and chewing of pan 5packets per day.

IX. ELIMINATION & BOWEL PATTERN:

Bowel – he has regular bowel movement once a day in the morning and no history of
constipation.
 Bladder – bladder patterns are regular, voids approximately 5 times a day. No history of
dysuria, haematuria.

X. ENVIRONMENTAL HISTORY:

He lives with his friends in rent aappartments, which has one 1BKH. They use toilet for
defecation and getting water from the Bhore well. he has electricity supply in his house and
closed drainage system. His wife and children are staying at Maharashtra.

PHYSICAL EXAMINATION

1) GENERAL OBSERVATION:

a) Constitution : Well body built

b) Stature : Normal
c) State of Nutrition : moderately built
d) Personal appearance : anxious
e) Posture : Good
f) Emotional stage : Anxious
g) Skin : Pallor
h) Cooperativeness : Cooperative

2) VITAL SIGNS:

Temperature : 99oF
Pulse : 74 bpm
Respiration : 20 Bpm
Blood pressure : 100 / 60 mmhg
3) HEIGHT : 160 CMS
4) WEIGHT : 60 KGS

5) SKIN AND MUCUS MEMBRANE:

a) Colour of skin : Pallor

b) Edema : Absent
c) Moist Temperature : Normal
d) Turgor : Normal
e) Texture : Moist

6) HEAD :

a) Skull : Has no abnormality noted

 b) Hair : Black hair, hair distribution normal
c) Movements of the head : Full range of movement
d) Fore head : No scars or lesion
e) Face : Anxious looking

7) EYES :

a) Expression : Anxious & fear

b) Eye brows : Equal
c) Eye lids : No lesion
d) Lacrimation : Clear fluid
e) Conjunctiva : Pale
f) Sclera : pallor
g) Cornea : Clear and moist
h) Iris : Normal
i) Pupils : PERRLA

8) EARS :

a) Appearance : No mass
b) Discharge : No
c) Hearing : Normal
d) Lesion : Absent
9) NOSE :
a) Appearance : No Septal deviation
b) Discharge : No
c) Patency : Both nostrils are patent
d) Sense of smell : Good

10) MOUTH AND THROAT:

a) Lips : Dry
b) Tongue : coated
c) Teeth : Intact in upper and lower jaw
d) Gums : Pink and moist
e) Buccal mucosa : No lesion
f) Tonsil : Normal
d) Taste : Normal

11) NECK:

a) General appearance : Normal

b) Trachea : Normal in position
 c) Lymph node : No enlargement
d) Thyroid gland : Feel smooth and firm
e) Cyst and tumor : Absence

12) CHEST AND RESPIRATORY SYSTEM:

a) Inspection : Size and shape normal, chest

expansion equal in both side and
respiration are normal
b) Palpation : No local swelling, no lymphnode
enlarge
c) Percussion : Normal resonance in both lungs
d) Auscultation :Breath sounds are normal, high pitched
in both side. Respiratory rate 20bpm,S1
and S2 heart normal, heart rate–74bpm
13) ABDOMEN:

a) Inspection : No abnormality
b) Palpation : No organomegaly
c) Percussion : No fluid filled spaces could be found
d) Auscultation : Peristalsis present

14) BACK:

a) Spine and curvature : No abnormalities is noted

b) Movements : All range of movements are normal
c) Tenderness : No tenderness noted

15) GENITALIA:

 Normal - no discharges

16) UPPER EXTREMITIES:

 Normal movement
 No deformities
 No lymphnode enlargement

 IV cannula is present

17) LOWER EXTREMITIES:

 Left limb is normal

  Right limb is having the presence of dressing with crape bandage.
 Impaired range of movements.
 Client is on complete bed rest.
18) NERVOUS SYSTEM:

a) Higher function – consciousness

b) Memory – immediate, recent, remote is good
c) Speech – fluent and comprehensive
d) Cranial nerves – no abnormalities
e) Sensory function – good
f) Coordination finger to nose – not impaired

19) INVESTIGATIONS:

Sl.
No. Investigations Patient’s Normal value Remarks
value
1) Blood
 Hemoglobin 13.2 gm/dl 14 – 16 gm/dl Anemia
 Red blood cell 4.65 ml/cmm 4.5 – 6.5 l/cum Normal
 PCV 39.73% 20 – 54 % Abnormal
 Platelets 1.94 lacs 1.5 – 4.5 lacks Infection
 Total WBC 5600 cu/mm 5000 –11000 cumm Normal
Differential count
 Neutrophil 75% 40 – 75 % Normal
 Lymphocytes 20% 20 – 45% Normal
 Esinophills 04% 1 – 6% Normal
 Monocytes 01% 1 – 6% Normal
101 fl 80 – 99 fl Normal
 MCV
28 pg 27 – 33 pg Normal
 MCH
33.7g/dl 32 – 37 g/dl Normal
 MCHC
22mm/hr 0 – 20 mm/hr Normal
 ESR
Routine investigation
58 mgs/dl < 150 mgs/dl Normal
 RBS
23 mg/dl 20 – 45 mg/dl Normal
 Blood urea
1.2 mgs/dl .7- 1.2meq/dl Normal
 S. Creatinine
138 meq /l 135 –145 meq/dl Normal
 S. Sodium
3.9meq /l 3.5 – 4.5 meq/dl Normal
 S. Potassium
LFT
1.2 mgs/dl 1mgs/dl Normal
 S.Bilirubin 8.1 gm/dl 6 – 8 gm/dl Normal
  S.total protein 4.7 gm/dl 3 – 5 gm/dl Normal
 S.Albumin 3.4 gm/dl 1.8 – 3.6 gm/dl Normal
 S.Globulin 1.4
 A/G ratio 32 IU/L 0 – 41IU /L Abnormal
 SGOT 74IU/L 0 – 40IU/L Normal
64 Iu/l 80-120 Iu/l Normal
 SGPT
 Alkaline phosphatase
Lipid
208.0mgm/dl <200mgs/dl Abnormal
 Total Cholestrol
59.0 mgs/dl 60-170mgs/dl Normal
 HDL Cholestreol
127 mgs/dl <150 mgs/dl Normal
 LDL 111.0mgs/dl <150 mgs/dl Normal
 Tri glycerides 22mgs/dl <30 mgs/dl Normal
 VLDL 3.5 5:1 Normal
 Total cholestrol/HDL

Doppler study :

Impression : the greater sephaneous vein is dilated in entire extent. An incompetent perforator is
seen in the medial lower leg. Approx. 15 to 20 cm proximal to maleolus, diverting flow from the
posterior tibial vein towards the great sephaeous vein during vein during valsalva and standing.

The sephanofemoral and sephanopoliteal junction are competent .

USG impression :

Right kidney shows fullness of pelvic calyceal system .

 MEDICATION:

Sl. Name of Rout Dose Freq Action sideeffects Nurses

No. Medication e responsibility

1. Inj. Biotax IV 1g Bd Antibiotic Headache, -- Follow the

dizziness, five rights
lethargy,
paresthesias
vomiting, -- Orient the
diarrhea, anorexia, time place,
person
2. Inj. Pantop IV 40g Od H2 blockers Nausea, vomiting,
antagonist peripheral
neuropathy, liver
impairment -- Help the
client to do his
3. Inj.gentamycin IV 80mg Bd Aminoglycosid Drowsiness, self care
e. Bactericidal: Ototoxicity, activities
Inhibits protein Palpitations,
synthesis in hypotension, -- Check the
susceptible hypertension, blood serum
strains of gram- Hepatic toxicity, electrolyte level
negative
bacteria;
appears to
-- Administer
disrupt
fluids
functional
integrity of
bacterial cell
membrane, -- Give rest to
causing cell the clients
death.

4. Inj. Dynapar IV 40 Od Anti- Headache, -- Check the

mg inflammatory dizziness, fatigue, adverse effect
tiredness, tinnitus, of medication
ophthamologic
effects
 Disease condition

Book picture Patient picture

Definition :

Varicose veins (varicosities) are abnormally Patient has the abnormally dilated
dilated, tortuous, superficial veins caused by
incompetent venous valves

Most commonly, this condition occurs in the lower extremities, the saphenous veins,
lower extremities, the saphenous veins, or the
lower trunk; however,it can occur elsewhere in
the body, such as esophageal varices.

Incidence :

It is estimated that varicose veins occur in up --------

to 60% of the adult population in the United
States, with an increased incidence correlated
with increased age ( Johnson, 1997).

Causes :

1. The condition is most common in women

and in people whose occupations require He is a supervisor in a company and has the
prolonged standing, such as … job to supervise the team of workers where he
 salespeople, needs to stand for prolonged time.
 hair stylists,
 teachers
 nurses,
 ancillary medical personnel, and
 construction workers. ----------
2. A hereditary weakness of the vein wall
may contribute to the development of
varicosities, and it is not uncommon to see
this condition occur in several members of
the same family. -------------
3. Varicose veins are rare before puberty.
4. Pregnancy may cause varicosities. The leg --------------
veins dilate during pregnancy because of
 hormonal effects related to
 distensibility,
 increased pressure by the gravid uterus,
 and increased blood volume which all
contribute to the development of
Grade IV Rt. Lower Limb varicosity Due to
varicose veins ( Johnson, 1997).
etiological factors , A reflux of venous blood in
Pathophysiology : the veins results in venous stasis. If only the
superficial veins are affected.
Varicose veins may be considered primary
(without involvement of deep veins) or
secondary (resulting from obstruction of deep
veins).

Due to etiological factors , A reflux of venous

blood in the veins results in venous stasis. If
only the superficial veins are affected, the
person may have no symptoms but may be
troubled by the appearance of the dilated veins.
All symptoms are present
Clinical Manifestations

Symptoms, if present,

 may take the form of dull aches,

 muscle cramps, and
 increased muscle fatigue in the lower legs.
Ankle edema
 and a feeling of heaviness of the legs may
occur.
 Nocturnal cramps are common.
 When deep venous obstruction results in
varicose veins, patients may develop the
signs and symptoms of …
o chronic venous insufficiency:
o edema,
o pain,
o pigmentation, and Doppler study :
o ulcerations.
o Susceptibility to injury and Impression : the greater sephaneous vein is
infection is increased. dilated in entire extent. An incompetent
perforator is seen in the medial lower leg.
Assessment and Diagnostic Findings Approx. 15 to 20 cm proximal to maleolus,
diverting flow from the posterior tibial vein
Diagnostic tests for varicose veins include the towards the great sephaeous vein during vein
during valsalva and standing.
 duplex scan, which documents the
 The sephanofemoral and sephanopoliteal
anatomic site of reflux and provides a junction are competent .
quantitative measure of the severity of
valvular reflux. USG impression :
 Air plethysmography, measures the
changes in venous blood volume. Right kidney shows fullness of pelvic calyceal
 Venography is not routinely performed to system .
evaluate for valvular reflux. When it is
used, however, it involves injecting an x-
ray contrast agent into the leg veins so that No preventive measures followed
the vein anatomy can be visualized by x-
ray studies during various leg movements.

Prevention

 The patient should avoid activities that

cause venous stasis, such as
o wearing tight socks or a constricting
panty girdle,
o crossing the legs at the thighs, and
o sitting or standing for long periods.
 Changing position frequently, elevating the
legs when they are tired, and
 getting up to walk for several minutes of
every hour promote circulation.
 The patient should be encouraged to walk 1
or 2 miles each day if there are no
contraindications.
 Walking up the stairs rather than using the
elevator or escalator is helpful in promoting
circulation.
 Swimming is also good exercise for the
legs.
 Elastic compression stockings, especially
knee-high stockings, are useful. Patients
are more likely to use knee-high stockings
than thigh-high stockings. Surgical management was done
 The overweight patient should be
encouraged to begin a weight-reduction
plan.

Medical Management:

Surgery for varicose veins requires that the

deep veins be patent and functional. The
saphenous vein is ligated and divided. The vein
is ligated high in the groin, where the
saphenous vein meets the femoral vein.
Additionally, the vein may be removed
(stripped).

After the vein is ligated, an incision is made in

the ankle, and a metal or plastic wire is passed
the full length of the vein to the

point of ligation. The wire is then withdrawn,

pulling (removing, “stripping”) the vein as it is
removed. Pressure and elevation keep bleeding
at a minimum during surgery.

------------

Sclerotherapy:

In sclerotherapy, a chemical is injected into the

vein, irritating the venous endothelium and
producing localized phlebitis and fibrosis,
thereby obliterating the lumen of the vein. This
treatment

may be performed alone for small varicosities

or may follow vein ligation or stripping.
Sclerosing is palliative rather than curative.

After the sclerosing agent is injected, elastic

compression bandages are applied to the leg
and are worn for approximately 5 days. The
health care provider who performed Nursing Management
sclerotherapy removes the first bandages.
Elastic compression stockings are then worn Bed rest is maintained for 24 hours, after
for an additional 5 weeks. which the patient begins walking every 2 hours
for 5 to 10 minutes.
After sclerotherapy, patients are encouraged to
perform walking activities as prescribed to The nurse assists the patient to perform
maintain blood flow in the leg. Walking exercises and move the legs.
enhances dilution of the sclerosing agent.

Nursing Management

Bed rest is maintained for 24 hours, after

which the patient begins walking every 2 hours
for 5 to 10 minutes.
Promoting comfort and understanding:
Elastic compression stockings are used to
 Dressings are inspected for bleeding,
maintain compression of the leg. They are
worn continuously for about 1 week after vein particularly at the groin, where the risk of
stripping. The nurse assists the patient to bleeding is greatest.
perform exercises and move the legs. The foot  The nurse is alert for reported sensations of
of the bed should be elevated. Standing still “pins and needles.”
and sitting are discouraged.

Promoting comfort and understanding:

 Analgesics are prescribed to help patients

move affected extremities more
comfortably.
 Dressings are inspected for bleeding,
particularly at the groin, where the risk of
bleeding is greatest.
 The nurse is alert for reported sensations of
“pins and needles.” Hypersensitivity to
touch in the involved extremity may
indicate a temporary or permanent nerve
injury resulting from surgery, because the
saphenous vein and nerve are close to each
other in the leg.
 Usually, the patient may shower after the
first 24 hours. The patient is instructed to
dry the incisions well with a clean towel
using a patting technique rather than
rubbing.
 Application of skin lotion is to be avoided
until the incisions are completely healed to
decrease the chance of developing an Promoting home and community-based
infection. care:
 If the patient underwent sclerotherapy, a
 burning sensation in the injected leg may 
be experienced for 1 or 2 days.
 The nurse may encourage the use of a mild
analgesic (eg, propoxyphene napsylate and
acetaminophen [Darvocet N], oxycodone
and acetaminophen [Percocet], oxycodone
and acetylsalicylic acid [Percodan]) as 
prescribed by a physician or nurse
practitioner and walking to provide relief.
Promoting home and community-based
care:
Patients require long-term elastic support
of the leg after discharge, and plans are
made to obtain adequate supplies of elastic
compression stockings or bandages as
appropriate.
Exercises of the legs are necessary; the
developed the an individualized plan by
consultation with the patient and the health
care team.

 Patients require long-term elastic support

of the leg after discharge, and plans are
made to obtain adequate supplies of elastic
compression stockings or bandages as
appropriate.
 Exercises of the legs are necessary; the
development of an individualized plan
requires consultation with the patient and
the health care team.
 APPLICATION OF THEORY

Name : Mr.Mithalesh Umashenker Mishra

Age : 29 Years

Sex : Male

Ward : SJ/2.

Present complaints : Postoperative client. Patient has pain at surgical site. He

prescribed for the complete bed red. And NBM for 24hrs.

DIAGNOSIS : Grade IV Rt. Lower Limb varicosity

Theories applicable:

i) Dorothy E. Johnson Behavioural System Model

ii) Sister Callista Roy Adaptation Model

iii) Orem self care deficit theory

iv) SELYE’s stress – adaptation theory

In this case I am going to give care according to Sister Callista Roy Adaptation Model

Problems Identified
1. Acute pain related to surgical incision
2. Imbalanced nutrition ,less than body requirement related to decreased intake of food as
evidenced by weight loss
3. Activity intolerance related to bed ridden secondary immediate postoperative condition
 The Roy Adaptation Model

Sister Callista Roy developed the Adaptation Model of Nursing in 1976. This model comprises
the four domain concepts of person, health, environment, and nursing and involves a six step
nursing process. Andrews & Roy (1991) state that the person can be a representation of an
individual or a group of individuals. Roy's models sees the person as "a biopsychosocial being in
constant interaction with a changing environment" (Rambo, 1984).

INTRODUCTION

Born at Los Angeles on October 14, 1939 as the 2nd child of  Mr. and Mrs. Fabien Roy.
At age 14 she began working at a large general hospital, first as a pantry girl, then as a
maid, and finally as a nurse's aid.
 She entered the Sisters of Saint Joseph of Carondelet.
 she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's College,
Los Angeles in 1963.
 a master's degree program in pediatric nursing at the University of California ,Los
Angeles in 1966.
 She also earned a master’s & PhD in Sociology in 1973 & 1977 ,respectively
 Sr. Callista had the significant opportunity of working with Dorothy E. Johnson
 Johnson's work with focusing knowledge for the discipline of nursing convinced Sr.
Callista of the importance of describing the nature of nursing as a service to society and
prompted her to begin developing her model with the goal of nursing being to promote
adaptation.
ASSUMPTIONS
Scientific

 Systems of matter and energy progress to higher levels of complex self-organization

 Consciousness and meaning are constitutive of person and environment integration
 Awareness of self and environment is rooted in thinking and feeling
 Humans by their decisions are accountable for the integration of creative processes
 Thinking and feeling mediate human action
 System relationships include acceptance, protection, and fostering of interdependence
 Persons and the earth have common patterns and integral relationships
 Persons and environment transformations are created in human consciousness
 Integration of human and environment meanings results in adaptation
Philosophical

 Persons have mutual relationships with the world and God

 Human meaning is rooted in an omega point convergence of the universe
 God is intimately revealed in the diversity of creation and is the common destiny of
creation
 Persons use human creative abilities of awareness, enlightenment, and faith
 Persons are accountable for the processes of deriving, sustaining, and transforming the
universe
PERSONS AND RELATING PERSONS

 An adaptive system with coping processes

 Described as a whole comprised of parts
 Functions as a unity for some purpose
 Includes people as individuals or in groups (families, organizations, communities,
nations, and society as a whole)
 An adaptive system with cognator and regulator subsystems acting to maintain adaptation
in the four adaptive modes: physiologic-physical, self-concept-group identity, role
function, and interdependence
ENVIRONMENT

All conditions, circumstances, and influences surrounding and affecting the development
and behavior of persons and groups with particular consideration of mutuality of person
and earth resources
 Three kinds of stimuli: focal, contextual, and residual
 Stimulus-something that provokes a response, point of interaction for the human system
and the environment
 Focal Stimuli-internal or external stimulus immediately affecting the system
 Contextual Stimulus-all other stimulus present in the situation.
 Residual Stimulus-environmental factor, that effects on the situation that are unclear.
 Significant stimuli in all human adaptation include stage of development, family, and
culture
HEALTH AND ADAPTATION

 Health: a state and process of being and becoming integrated and whole that reflects
person and environmental mutuality
 Adaptation: the process and outcome whereby thinking and feeling persons, as
individuals and in groups, use conscious awareness and choice to create human and
environmental integration
 Adaptive Responses: promote the integrity of the human system. responses that
promotes integrity in terms of the goals of the human system, that is, survival, growth,
reproduction, mastery, and personal and environmental transformation
 Ineffective Responses: neither promote not contribute to the integrity of the human
system. responses that do not contribute to integrity in terms of the goals of the human
system
 Copping Process-innate or acquired ways innate or of interacting with the changing of
environment
 Adaptation levels represent the condition of the life processes described on three different
levels: integrated, compensatory, and compromised
NURSING

 Nursing is the science and practice that expands adaptive abilities and enhances person
and environment transformation
 Nursing goals are to promote adaptation for individuals and groups in the four adaptive
modes, thus contributing to health, quality of life, and dying with dignity
  This is done by assessing behavior and factors that influence adaptive abilities and by
intervening to expand those abilities and to enhance environmental interactions
NURSING PROCESS

 A problem solving approach for gathering data, identifying the capacities and needs of
the human adaptive system, selecting and implementing approaches for nursing care, and
evaluation the outcome of care provided

1. Assessment of Behavior: the first step of the nursing process which involves gathering
data about the behavior of the person as an adaptive system in each of the adaptive modes
2. Assessment of Stimuli: the second step of the nursing process which involves the
identification of internal and external stimuli that are influencing the person’s adaptive
behaviors. Stimuli are classified as: 1) Focal- those most immediately confronting the
person; 2) Contextual-all other stimuli present that are affecting the situation and 3)
Residual- those stimuli whose effect on the situation are unclear.
3. Nursing Diagnosis: step three of the nursing process which involves the formulation of
statements that interpret data about the adaptation status of the person, including the
behavior and most relevant stimuli
4. Goal Setting: the forth step of the nursing process which involves the establishment of
clear statements of the behavioral outcomes for nursing care.
5. Intervention: the fifth step of the nursing process which involves the determination of
how best to assist the person in attaining the established goals
6. Evaluation: the sixth and final step of the nursing process which involves judging the
effectiveness of the nursing intervention in relation to the behavior after the nursing
intervention in comparison with the goal established.
ROY ADAPTATION MODEL (RAM) –TERMS

 System-a set of parts connected to function as a whole for some purpose.

 Regulator Subsystem-automatic response to stimulus (neural, chemical, and endocrine)
 Cognator Subsystem-responds through four cognitive responds through four cognitive-
emotive channels (perceptual and information processing, learning, judgment, and
emotion)
 Behavior -internal or external actions and reactions under specific circumstances
Physiologic-Physical Mode

 Behavior pertaining to the physical aspect of the human system

 Physical and chemical processes
 Nurse must be knowledgeable about normal processes
 5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)
Self Concept-Group Identity Mode

 The composite of beliefs and feelings held about oneself at a given time. Focus on the
psychological and spiritual aspects of the human system.
 Need to know who one is, so that one can exist with a state of unity, meaning, and
purposefulness of 2 modes (physical self, and personal self)
Role function Mode
  Set of expectations about how a person occupying one position behaves toward a
occupying another position. Basic need-social integrity, the need to know who one is in
relation to others
Interdependence Mode

 Behavior pertaining to interdependent relationships of individuals and groups. Focus on

the close relationships of people and their purpose.
 Each relationship exists for some reason. Involves the willingness and ability to give to
others and accept from others.
 Balance results in feelings of being valued and supported by others. Basic need - feeling
of security in relationships

CONCEPTUAL FRAME WORK BASED ON ROY’S ADAPTATION MODEL

INPUT CONTROL PROCESS OUPUT

Mr.Mithalesh Regulators and Physiological

Umashenker Mishra cognator response - Pain in surgical area
Internal environment -Accept the situation as - Anxiety
-Age- 29 years it is - NBM
- Complete bed rest
-Personal habits- habit of -Prayer to god
- Risk of infection
smoking occasionally -Involve in distraction - Thirst
Self-concept
External environment therapy
-He has fear about
-Family type – nuclear recurrent attack of
-Hope things
varicose vains
-Education-12th class
-Well get better
Inter dependent -
-Monthly income –
Rs.7000/- - Family members- he
family is residing in UP.
-Friends- more
-Health personnel-
-Occupation - supervisor doctors , nurse,
of the company physiotherapist,
dietician , ward boys

FEED BACK
 Theory Assessment Diagnosis Objective Interventions Implementations Evaluation
applied
For Clients Acute pain Client will  Assess the pain  Assessed the pain Client taking
Mr.Mithalesh verbalized that “ related to have the rest and no
Umashenker I am having pain surgical reduced pain  Provide comfort position  Provided comfort complaints of
Mishra I am in surgery site. incision  Monitor the vital signs position pain
going to
provide care  Eliminate additional  Monitored the vital signs
by applying stressors or sources of  Eliminated additional
Sister
Callista Roy discomfort whenever stressors or sources of
Adaptation possible.  discomfort whenever
Model
 Use the divertional possible. 
therapy  Used the divertional
 Observe the surgical site therapy
for any signs of infection  Observed the surgical
 Provide rest periods to site for any signs of
facilitate comfort, sleep, infection
and relaxation.   Provided rest periods to
 Administer the facilitate comfort, sleep,
medications as prescribed and relaxation.
 Administer the
medications as prescribed
 Theory Assessment Diagnosis Objective Interventions Implementations Evaluation
applied
For Client is on Imbalanced Patient will  Assess the nutritional status  Assess the nutritional status Periodic
Mr.Mithalesh NBM status nutrition ,less maintain of the client. of the client. feeding i.e is
Umashenker than body balanced  Provide care to the NG  Provide care to the NG every 1 hrly
Mishra I am requirement nutritional tube. tube.
going to related to status as  Before and after each feed  Before and after each feed
provide care decreased evidenced by flush the NG tube with little flush the NG tube with little
by applying intake of food weight gain amount of water. amount of water.
 Maintain the periodic  Maintain the periodic
Sister as evidenced
administration of food. administration of food.
Callista Roy by weight loss
 Prepare the food freshly  Prepare the food freshly
Adaptation and administer it or get and administer it or get
Model food just before time for food just before time for
every feed. every feed.
 Informed the family  Informed the family
members to bring the food members to bring the food
accordingly menu planned. accordingly menu planned.
 Feed the client every 1  Feed the client every 1
hrly .about 200ml . hrly .about 200ml .
 Maintain the record after  Maintain the record after
each feed each feed
 Maintain the strict I/O  Maintain the strict I/O
chart. chart.
 Monitor the blood sugar  Monitor the blood sugar
levels. levels.
 Maintain the IV fluids as  Maintain the IV fluids as
prescribed. prescribed
 Theory Assessment Diagnosis Objective Interventions Implementations Evaluation
applied
For Client verbalized Activity Client will  Assess potential for  Assessed potential for Client will
Mr.Mithalesh that I want to go intolerance have physical injury with physical injury with meet ADL
Umashenker to out to have related to bed adequate activity. Injury may be activity. Injury may be
Mishra I am walk ridden mobility . related to falls or related to falls or
going to secondary Patient
provide care immediate overexertion. overexertion.
maintains  Monitor patient's sleep  Monitored patient's sleep
by applying postoperative
activity pattern and amount of pattern and amount of
Sister condition
Callista Roy level within sleep achieved over past sleep achieved over past
Adaptation capabilities few days. few days.
Model  Assess emotional  Assessed emotional
response to change in response to change in
physical status.  physical status. 
 Encourage adequate rest  Encouraged adequate rest
periods periods
 Assist with ADLs as  Assisted with ADLs as
indicated. indicated.
 Provide bedside  Provided bedside
commode as indicated. commode as indicated.
 Encourage verbalization  Encouraged verbalization
of feelings regarding of feelings regarding
limitations.  limitations. 
 Progress activity  Progress activity
gradually gradually
 Theory Assessment Diagnosis Objective Interventions Implementations Evaluation
applied
For Self care deficit, Client will  Assess patient’s need  Assessed patient’s need Client v
Mr.Mithalesh Bathing/Hygiene; meet the for assistive devices.  for assistive devices. 
Umashenker Dressing/Grooming basic needs  Identify preferences  Identified preferences
Mishra I am ; Toileting for, personal care
for, personal care items,
going to related to complete items, and other
provide care bed rest prescribed things.  and other things. 
by applying secondary to  Assist patient in  Assisted patient in
Sister immediate accepting necessary accepting necessary
Callista Roy postoperative amount of dependence. amount of dependence.
Adaptation condition  Provide patient with  Provided patient with
Model appropriate utensils. appropriate utensils.
 Maintain privacy
 Maintained privacy
during bathing as
appropriate.  during bathing as
 Encourage patient to appropriate. 
comb own hair  Encouraged patient to
 Offer bedpan or place comb own hair
patient on toilet every  Offered bedpan or place
1 to 1½ hours during patient on toilet every 1
day and three times
to 1½ hours during day.
during night. 
 Assist patient in  Assisted patient in
removing or removing or
replacing necessary replacing necessary
clothing.  clothing. 
Nurses record:
DAY-1

 Assessed the general condition of the patient. Patient has severe lower limb numbness and
pain unable walk and stand. discoloration of the skin, and ulceration at rt. lower lib.
And client posted for surgical treatment from OPD. He undergone surgery for the
same problem
 Postoperative client. Patient has pain at surgical site. He prescribed for the complete
bed red. And NBM for 24hrs.
 Monitored the blood glucose levels
 Administered the medications like analgesics, anticoagulants and by the physician
 IV fluids administered periodically
 Changed the position every 2 hourly
 Administered the due medicine
 Maintained the input –output chart

DAY-2

 Maintain the therapeutic drug regimen

 Patient has pain at surgical site. He prescribed for the complete bed red. Oral food
started in the liquid form.
 Routine care is given

DAY-3

 Routine care is given

DAY-4

 Remarkable progress, pain is reduced patient is still advised to stay in hospital for
complete one week.
 Routine care is given
Dietary management
 Calorie should be sufficient to maintain appropriate body weight for a given height
 Total fat intake should be between 15 – 30 % of total calories
 Cholestrol should not exceed 300mg/ day
 Protein should provide around 10-15 % of total calories
 Carbohydrates should be constitute55% - ^5% of total calories
 Sugar should be less than 10% of total calories
 Salt intake should be between 5-7 gm/ day
 Dietary fibre should be around 40 g/day
Sample menu plan for one day

Time Item Quantity Total calories

Early morning Tea One cup 60 Kcal
Break fast Plain dosa Two 250 Kcal
sambar 3 tsp 125 Kcal
Tea one cup 60 Kcal
Mid morning orange 2 nos 80 kcal
Lunch Rice 1 katori 520 kcal
Dhal 1 katori 80 kcal
vegetable 1 katori 130Kcal

Evening Sundal ½ cup 200 kcal

Tea 1 cup 60 kcal
Dinner Chapatti 3 nos 460 Kcal
Any vegetables 1 katori 80 Kcal
and dhal
Bed time Skimmed Milk 1 cup 50 Kcal
Total Kcal 2155 K cal
 Health education
S.No Topic Education Av aids
1 Disease chart
condition and - Varicose veins (varicosities) are abnormally
treatment dilated, tortuous, superficial veins caused by
incompetent venous valves.
- Most commonly, this condition occurs in the
lower extremities, the saphenous veins, or the
lower trunk; however, it can occur elsewhere in
the body.
- The condition is most common in women and in
people whose occupations require prolonged
standing ophageal varices.
- Surgical management is the major treatment,
along with this need to follow the preventive
measures to prevent recurrence.

2 Health - Exercise for healthy heart, exercise relieve tension

education and helps one to relax, Briskly walking half an hour
a day at least 3-4 times per week can bring down the
risk.
- avoid standing for a prolonged period, take rest by
sitting during work period.
- use the bandage for prescribed period as prescribed
by the physician.
- Avert stress by following relaxation technique, it
force one to adopt unhealthy behaviour like drinking
smoking or over eating
- Avoid smoking it increase the risk of second
attack
- Practice YOGA which repercussion of physical
well being
- Follow the treatment regimen which prescribed
by the physician
3 Dietary - Maintain the body weight by avoiding the fat diet.
management - Take fiber diets,
- Advice the patient to take high protein diet which are
dhal, egg white yolk, fish and chicken
- Avoid alcohol and salt intake and smoking.
- Take plenty amount of fluid .
4 Medication and - Advice the patient to take the medication properly
exercise - Advice to have regular medical checkup.
- Follow the relaxation technique
- Do the regular aerobic and anaerobic exercise
- Go for daily walking.
Summary :

My Patient has severe, Patient has severe lower limb numbness and pain unable walk and
stand. discoloration of the skin, and ulceration at rt. lower lib. Diagnosed as Grade IV Rt.
Lower Limb varicosity , And client posted for surgical treatment from OPD, now
Postoperative client. Patient has pain at surgical site. He prescribed for the complete bed red.
And NBM for 24hrs. After providing 5 days care, Patient was maintaining good nutritional status.
Patient is maintaing stable vital parameters.

Conclusion :

Varicose veins (varicosities) are abnormally dilated, tortuous, superficial veins caused by
incompetent venous valves. Most commonly, this condition occurs in the lower extremities,
the saphenous veins, or the lower trunk; however, it can occur elsewhere in the body.

During my clinical posting in Silver jubilee ward-3, I got chance to provide care to
Mr.Mithalesh Umashenker Mishra , by this study I learn in detail about varicose veins and its
management. I thank my client for his cooperation and my clinical co ordinator. Mr. Sri
Ram Nagrajan . for his valuable guidance .

Bibliography :

Books :
1. Black . Joyce M . Hawks Jane Hokanson. Medical Surgical Nursing,vol. 1. 7th ed.india
:Elsevier pubilication;2005.p.1179-1185.
2. Smeltzer Suzanne C. Brane Brenda G. Brunner &Surddarth’s Text book of
MEDICAL – SURGICAL NURSING. 10.ed.New York: Lippincott Williams &
Wilkins; 2004. P.1150-1200.
3. Lewis Mantik Sharon. Collier Idolia Cox. Heitkemper Margaret M. MEDICAL
SURGICAL NURSING. 4th ed. USA: Mosby publications; 1996.p.1438-1376.
4. Potter A.Patrica.Perry Anne Griffin.Fundamentals of nursing.1st ed. St.
Louis :Mosby; 2006. P.17-18.
5. http://en.wikipedia.org/wiki/varicoseveins .
6. http://mnhealthandmedical.com/varicoseveins_series_part_2.html