BIOGRAPHIC DATA

Name : ms lalita

Age : 45 yearsnar

Sex : feMale

I.P no 45346

Education : 7th std

Occupation : Labor work

Marital status : Married

Religion : Hindu

Mother tongue : Gujarati

Ward : ICU

Date of admission : 08/04/2022

Address :

Waghodia,Vadodara,Gujrat Provisional Diagnosis:

Tuberculosis

Chief complaint:

Fatigue

Weakness

Fever

Coughing

Blood in

sputum Weight

loss Joint pain

Anxiety
HISTORY COLLECTION

Medical history

Patient has Fatigue, Weakness, Fever, coughing, blood in sputum, anxiety. So, he
admitted in the hospital for the further treatment.

Surgical history

There is no plan of any surgery.

Past history of illness

Medical history: There is no history of same complaints, tuberculosis, and

hypertension etc. and there is no other history of hospitalization.

Surgical history: There is no history of any surgery. But the patient had undergone
tooth extraction 1 year before the date of admission.

Personal history

Habits: Mr. Mukeshbhai had no history of bad habits like alcohol consumption and
smoking and there is no history of chewing tobacco.

Diet: Mr. Mukeshbhaiis taking mixed diet and usually eats three times/ day. Now he
is taking soft diet.

Sleeping habits: Mr.Mukeshbhai usually sleep for 7 – 8 hours/ day, but now he is
unable to sleep well because of pain.

Bowel and bladder habits: Mr. Mukeshbhai bladder and bowel pattern is disturbed.

Socialization: Mr. Mukeshbhai socializes well with the people and is a loving person.

Family history

There are five members in his family.Ms lalita is staying with his wife and his family.
He is the bread winner of his family. They have three children. There is no family history of
diabetic mellitus, cardiac problem, epilepsy and communicable diseases.
 CARE PLAN ON HYPERTENSION

 Family profile :

Sr Name of the family Relatio- Age sex Marital Occup- Health

no members nship with status ation problem
HOF

1 Gunvatbhai patel Head of 57 F Married Farming

family

2 Lalitaben gunvatbahi Wife 55 M Married House Hypertens-

wife ion

3 Hemantbhai gunvatbhai Son 28 M Married Worker

4 Sangitaben hemantbhai Daughter 26 F Married House

in low wife

5 Virat hemantbhai Grand son 6 M Unmarried -

6 Shreya hemantbhai Grand 1 M Unmarried -

daughter

Family tree :
 : male

:Female

 Selection of family member based on health problem need age ,gender and other reason
:
 Name : lalitaben gunvatbhai
 Age : 55 yr
 Sex : female
 Education : non educated
 Occupation : house wife
 Marital status : married
 Types of family : nuclear family
 Personal history :
 Habit: no any bad habit
 Diet : take vegetarian diet
 Hobby : watch TV serial

 Chief complain : my patient chief complain is giddiness , increase blood pressure , ,

headache .
 Present complain : Mrs lalitaben have present history of hypertension with complains
of giddiness, increase blood pressure ,palpitation, and headache. She go to the
vadodra hospital and take treatment for hypertension.
 Past medical history : mrs. lalitaben had no any past medical and surgical history

 Housing condition:
 Types of house : pucca
 Number of room : 5 room
 Ventilation : adequate
 Lighting : electricity
 Water supply : use water in panchayat
 Kitchen : separate
 Types of fuel use : gas
 Smoke out let :

present Bathroom :

present
  Latrine : present
 Drainage : closed
 Refuse disposal : burning

 Nutrition pattern :
 Types of diet : vegetarian
 Source of vegetable : market
 Staple food : wheat
 Socio economical status :
 Number of earing members : 2 members
 Other source of income : no any other source
 Total income year : 50000/
 Per capital income : 10000/
 Surrounding of the house: compound
 Disposal system : burning
 Drainage / sewage : closed
 Pet and street animal : dogs
 Water stagnation place : nil
 Municipal / corporation services : municipal services
 Other social available services like market, church, temple ,school, PHC and
other health care facility etc. social interaction and family member interaction
with good .

HEAD TO TOE ASSESSMENT

 General appearance :
 Body built : obeys
 Health : unhealthy
 Activity : normal
 Mental status :
 Consciousness : conscious
 Look : anxious
 Posture :
 body curves : normal
 movement : normal
 skin condition :
 color : normal
  texture: normal
 temperature : 98.4 f
 lesion : nil
 head and face
 skull circumference:
 scalp : clean no any dandruff
 hair : groomed and black
 face : anxiety
 eye :
 eye brows : normal
 eye lashes : sty
 eye lid : entropion
 eye balls : sunken
 conjunctiva : pink
 sclera : white
 cornea iris : normal
 pupils : dilated
 lens : transparent
 eye muscle : squint
 vision : normal
 EARS :
 External ear : normal no any abnormality
 Hearing : sound hearing is normal
 Nose :
 Eternal nose : normal
 Nostril : normal and clean
 Mouth and pharynx :
 Odor : no foul smelling is present
 Teeth : discoloration
 Mucus membrane and gums : normal no any gums in teeth
 Tongue : normal
 Throat and pharynx : normal
 Neck :
 Lymph nodes : palpable
 Thyroid gland : palpable
 Range of motion: range of motion is normal
 Chest :
 Thorax : symmetry & expansion
 Breath sound : breath sound is normal
 Heart : heart rate and heart sound is normal

 Abdomen :
  Observation : no any lesion and abnormality present
 Auscultation : bowel sound is present
 Palpitation : normal
 Spleen : spleen is palpable
 Appendix : appendix is normal
 Percussion : no any abnormality
 Extremities: normal
 Genital and rectum :
 Inguinal lymph gland : normal
 Urinary meatus and rectum : normal
 Vaginal discharge : no any vaginal discharge is present
 Name of disease illness / problem : hypertension

 Health problems of all family members

Mrs lalitaben suffer from hypertension . the rest of the family member are healthy and
free from all disease .

 Nursing diagnosis :
1. Decrease cardiac output related to disease condition as evidence by check the
patient pulse rate.
2. Acute pain related to breathlessness as evidence by patient observation
3. Activity intolerance related to giddiness as evidenced by patient verbal reports .
4. Fear and anxiety related to disease condition as evidence by patient facial
expression .
5. Knowledge deficit related to disease condition as evidenced by frequent question
by client.
 NURSING PROCESS

Assessment Nursing diagnosis Goal Planning Implementation Evaluation

Subjective data Decrease cardiac Client will Assess the Assess the general Theory apply
: output related to get normal general condition of the on Henderson
disease condition cardiac condition of client theory use 14
Patient said I as evidence by output the client components
have giddiness check the patient provide use
-provide comfortable
Objective data pulse rate. physiological
comfortable position to the need . After
: observing
position to the client semi fowler’s implementation
and monitoring
client position of
blood pressure
-monitoring -monitoring blood client
blood pressure pressure to the maintain
to the client client 140/80 mm normal cardiac
of hg output to some
advice
Subjective data Acute pain related Client will Assess the Assess the general Theory apply
: to breathlessness get relief general condition of the on Henderson
as evidence by from pain condition of patient theory use 14
Client said : I patient the patient components
have pain in -assess the pain of
observation Client get relief
chest some -assess the the client and give for pain
time pain of the advice for patient
client to take deep breath
Objective data
: -provide -provide
medication as medication as per
On observation per dr order dr order
of facial
expression

Subjective data Activity Client will Assess the Assess the general Theory apply
: intolerance related get proper general condition to the on Henderson
to giddiness as activity condition to client theory use 14
Client said : I evidenced by the client components
have feel patient -Give advice to the After
verbal
weakness -Give advice patient to take implementation
reports .
to the patient nutrition diet like client fell better
to green leafy
Objective data take nutrition vegetables , low
: diet salt intake diet

Observation of To give advice To give advice for

dull activity of for the take the take rest and
client rest and sleep sleep regularly
regularly sleep regular in 6
hrs

HEALTH EDUCATION

 DIET :
 Instruct to take green leafy vegetables
 Instruct to use less amount of salt in food
 Exercise:
 Instruct the patient to regular exercise deep breathing exercise
 Explain the benefits of exercise
 Instruct the reduced the weight to the body
 Rest and sleep :
 Instruct to take 6 to 8 hours sleep during night and 2 hr sleep in day time
 Medication :
 Instruct to take regular medication
 Instruct the client to regular check up blood pressure
 Instruct to follow the doctors

advice. SUMMARY

Mrs Lalita is suffering from hypertension and she also had complain of giddiness,
weakness, pain and increase blood pressure all other member in the family are hearing mrs.
Lalita is taking medicine regularly.

BIBLIOGRAPHY

1. P.V TEXT BOOK OF “COMMUNITY HEALTH NURSING” 3 rd addition

published by s. vikas & company , India.
2. www. Elsevier.com
3. K. Park . Essential of community health nursing M/S bansaridas , bhanot publisers :
forth edition
4. Javed Ansari devinder kaur “ A TEXT BOOK OF MEDICAL SURGICAL
NURSING 1; Pee vee edition 2015 publication by s. vikas & company ( medical
publisher ) india
5. www,wekipidia.com