BIOGRAPHIC DATA:

Name : Mr. Mahesh

Age : 45 years
Sex : Male
Address : Halebidu
IP No. : 15862
Education : 7th standard
Occupation : Farmer
Income : Rs. 1700/ month
Marital Status : Married
Religion : Hindu
Mother tongue : Kannada
Language known : Kannada, Telgu
Ward : Cardiac surgery Male
Date of admission : 21.11.2010
Diagnosis : Hypertension

1. HISTORY COLLECTION:

Chief complaints:-

- Chest pain since 3 months

- Dysphnea
- Difficulty in walking
- Perspiration & Palpatation

Present history of illness:-

Medical- Mr. Mahesh was apparently anxious & the symptoms started as
Chest pain started with pain & palpitation. He is getting more sweating
and weakness It was reducing at rest.

Surgery:- Nothing significant

Past history of illness:

Medical- There is no history of medical illness, except occasional cough

and cold, he is allergic to dust.

Surgical- Nothing significant

Personal Habits:

Habits No bad habits

Diet- He takes a mixed diet, and eats two to three meals per day.
Sleeping habits- Regular, 5-6 hours per day, but the last 2-3 days he is
not able to sleep due to traction and pain

Bowel and Bladder habits- Bladder pattern was normal, but after the
trauma there is history of urge incontinence and frequency

Socialization- He is cooperative and sociable.

Family history:-

45yr 39yr
s s

25yrs
30y
rs

There is no any history of any hereditary disease like HTN, DM, asthma,
epilepsy or seizures in the clients family. The client is married and has
two children, one son and one daughter. All of them are enjoying a good
and healthy life.

Sl Name Age Qualification/ Relation to Health

no Occupation Mr. Suresh status
. S

1. Mr. Mahesh 45 7th standard Client unhealthy

yrs

2. Mrs. Divya 39 5th standard Wife Healthy

yrs

3. Mr. Suresh 25 Plumber Son Healthy

yrs

4. Mrs. Jyothi 30 Housewife- Daughter Healthy

yrs

Socio- economic status:

 Condition of the house- the client lived in his own house with his son,
which is kaccha with two small rooms including the kitchen. They used
stove for cooking. The house is supplied with electricity.

Water supply- water supply is from the corporation.

Drainage system- Open drainage system.

Surrounding environment- Their surrounding environment is unhealthy.

Economic status- the client is the only source of income in their family,
his monthly income is Rs: 1700 per month.

2. PHYSICAL EXAMINATION:

Vital signs:-
Temperature : 990 F
Pulse : 80 beat per minute
Respiration : 18per minute
Blood Pressure: 150/100 mmHg

Height and weight:-

Height: 160cm
Weight: 56 kg

General appearance:-
Constitution : Thin
State of nutrition : Poor
Personal appearance : Anxious
Posture : Normal
Skin and hair : Dark complexion
Emotional state : Worried
Co-cooperativeness : cooperative

HEAD TO FOOT EXAMINATION:-

Head:
Skull - Normal
Hair - black and gray color, hair distribution
normal
Movement of head- Normal
Fore head - No scar or lesion noted
Face - Normal
Eyes:
Eye brows- Equal and even distribution
Eye lids - No lesion or scar noted.
Lacrimation - Clear fluid expression
Conjunctiva- Appears pale and clear
Sclera - Appears white
Cornea - Appears moist
 Irish pupil - Appears round and central in the sclera.
Pupil - Normal

Ears:

Appearance- No mass or lesion noted

Discharge - None
Hearing - Normal
Lesion - None
Nose:
Appearance - No septum deviation, Ryles tube present on the
left nostril.
Discharge - None
Patency -Both nostrils are patent
Sense of smell- Good
Mouth and throat:
Lips - Dry
Tongue - Coated tongue
Teeth - Yellowish in colour
Gums - Pink
Buccal mucosa- No lesion and ulceration
Tonsil - Not palpable
Taste - Normal
Neck:
General appearance- Normal
Lymph nodes - not palpable
Thyroid glands - Not palpable
Cysts and tumour - Absent
Chest:
Inspection-Size and shape are normal
Palpation- No local swelling noted
Auscultation- Murmur
Abdomen:
Inspection- Normal in shape and size
Palpation- soft, no organomegally
Percussion- tenderness present
Auscultation- peristalsis movement present, bowel sound absent

Spine and back:

Spine and curvature- No lordosis or kyphosis noted.

Movement - Normal
Tenderness - No tenderness noted
Gait - Normal
Genitalia:
Normal
Upper and lower extremities:
Upper pain on the left hand
Lower- Normal
Skin:
 Colour of skin- Dark complexion
Edema- No edema
Moisture- Dry
Turgor- Moderate

SYSTEMIC ASSESSMENT:-

Nervous system:

Conscious- Client is conscious

Orientation- Oriented to time, place and person.

Obeys commands- Client obeys commands.

Cardiovascular system:

Inspection- size and shape of chest is normal

Palpation- carotid and peripheral pulse is present, which is

regular normal sinus rhythm, rate 78beats/minute

Percussion- Cardiac boarders are within the normal limit

Auscultation- Murmurn person

Respiratory system:

Inspiration & expiration- Breathing difficulty

Respiration rate- 16 per minute

Ronchi/ wheezing- Absent

Gastro-intestinal system:

Peristalsis movement- present

Bowel pattern- Irregular, constipated for the last 3days.

Organomegally- Absent

Urinary system:

Urge incontinence and frequency

Burning micturation- Absent

Catheter - Absent Output = 2200ml

Urine colour- Yellow -colour

INVESTIGATION:
Sl Investigatio Patients value Impres Normal value
n n si-on
o.

1. Blood Test
Complete Hb= 14 g/dl Normal Hb= 14 - 16 g/dl
blood count- Total WBC= Normal WBC= 5,000-
5,900cells/cmm 10,000cells/cmm
Platelet Normal Platelet count=1.5- 4lac/L
count=2,10,000lac/L Normal RBS= 70-120mg/dl
2. RBS= 92mg/dl
Electrolyte Normal Sodium=135-145mmol/L
Sodium= Normal Potassium=3.5-5.0mmol/L
139mmmol/L Infection Chlorine=97-107mmol/L
Potassium=4.6mmol/ Normal Serum creatinine=0.7-
L 0.6mg/dl 1.4mg/dl
Chlorine=107mmol/L 26U/L 0.3 1.2mg/dl
Serum 16U/L 0 -35U/L
creatinine=0.9mg/dl 90U/L 0 45U/L
Total Bilirubin 40 -129U/L
SGOT
SGPT
Alkaline Phosphatase

CT Spine: Mobile AAD, Posterior osteophytes at C4, C5, C6 level

Heart Rate Variability Report: HRV parameters show reduction in
power with maintained sympathovagal balance. Cardiac autonomic
function normal.
PFT: Moderate suspected restrictive abnormality
X- Ray : Shows good reduction, Flexion extremity show mild
reduction on flexion
MRI: Post compression on the cord by the C1arch and with cord
integrity changes.
2D Echo: Normal valves and chambers, No regional wall motion
abnormality at rest.
3. MEDICATION:

Sl Medicatio Dose, Action of drug Side effect Nursing

n n route responsibilit
o & y
time

1. Inj. Dexa- 4gm Weight gain, - Monitor for

methasone IV Long acting indigestion, fluid gastric
6th glucocorticoid or retention, muscle
 hrly long acting anti- weakness, mood irritations
inflammatory and changes, acne and - Do not
immunosuppressi skin changes withdraw
BD suddenly after
ve hormone
prolonged use
- Special
2. precaution
Tab. should be
Sulphonanilide Pruritis, dizziness,
Numelside 150m taken in
derivative somnolescence,
g patients with
headache,
IV liver
BD Epigastric distress,
dysfunction,
heart burn, nausea,
glaucoma.
diarrhoea,
vomiting, skin rash - Monitor for
3.
volume or salt
H2 Receptor depletion
Tab. SOS Nausea, vomiting,
blocker -Do not
Rantac anaphylaxis, rash,
administer to
headache,
OD patients with
dizziness,
active peptic
constipation,flatule
ulcer
4. nce.
-Monitor vital
OD functions
Calcium - Monitor for
Tab.Osteoc hypersensitivi
supplement
al ty reaction
Nausea, vomiting,
constipation, - Special
hypersensitivity precaution
reaction. should be
taken in
severe renal
impairment
- Check for
calcium level
in the blood
-
Advise to
have more
intake of fluid.

-
APPLICATION OF THEORY

Name : Mr. Mahesh

Age : 45 years

Sex : Male

Ward : Cardiac surgery male

Present compliant : - Chest & Neck pain since 3 months

- Dysphnea
- Difficulty in walking
- Bladder disturbance
- Mild Ataxia

Diagnosis : Hypertension

Theories applicable:

i) Dorothy E. Johnson Behavioural System Model

ii) Sister Callista Roy Adaptation Model

iii) Orems self care deficit theory

In this case, the most suitable theory is Orems Self care deficit
theory.

OREMS SELF CARE DEFICIT THEORY

Self care is a learned goal oriented activity of the individual. The persons
ability to perform self care is in laces by 10 power components.

1. Ability to maintain attention and exercise

2. Controlled use of available physical energy

3. Ability to maintain the correct position of the body and its parts

4. Ability to reason with in a self care frame of reference.

5. Motivation

6. Ability to acquire technical knowledge about self care.

7. Ability to take decision about care of self and to optionally these

decision
 8. A repotire of cognitive perceptual, manipulating communication
and interpersonal skill.

9. Ability to order discrete, self care actions or action system into

relationship

10. Ability to consistently perform self care aspects in relevant

aspects of personal family and communities.

Self care requisites

Self care requisites are expression of purpose to be attained results

desired from deliberate engagement in self care.

Universal self care requisites; that are common to all human

being and includes the maintenance of air, water, food and
elimination, activity rest and solitude.

Development of self care requisites; these requisites promote

process of life, malnutrition; prevent condition and maturation of
those effects.

Health deviations self care requisites:

Orem defines health deviation; self care requisites as follows, which

is deviate from normal healthy behaviour.

Self care Agency: The complex acquired ability to meet ones continuing
requirement of care that regulate life process that maintain or promote
integrity of human structure and functioning, human development and
promote well being.

Agent: The term is used in the sense of persons taking actions

Self care agent: A self care agent is the provider of self care. Dependent
care agent

Self care deficit: A relation between the human property therapeutic self
care are demand and self care agent in which constituent developed self
care abilities within self care agency are not operable or adequate for
knowing and meeting some or all components self care demand.

Nursing Agency: the goal of nursing agency is to help the people meet
their own and their depended other therapeutics self care demands.

Nursing system Theory: 3 ways of nursing systems are identified: the

type of nursing systems is determined by who can or who should perform
the self care action.
 Wholly compensatory system :

These systems are needed when nurse should be compensating

for a patient, totally inability for engaging self care activities that
require ambulation and manipulation movements.

Partly compensatory system

These systems exist when nurse and patient perform care

measure or other actions involving manipulation tasks and
ambulation.

Supportive educative system

when the patients able to perform or should learn to perform

require measure internally and externally oriented self care but
can do so without assistance.

APPLICATION OF OREMS SELF CARE DEFICIT THEORY MODEL

IN ASSESSMENT OF MR. MAHESH, 45YRS OF AGE.

A. BASIC CONDITIONING FACTORS

Name : Mr. Mahesh

Age : 45 years

Developmental state : Adult

Health status : Hypertension

Socio cultural : Hindu

Health care system : Unhealthy

Family system : Wife and children

Patterns of living : Lives in his own home and doing all

home activities

Environment : Environment is not healthy, open

drainage system

Resources : Rs. 1700/month

B. UNIVERSAL SELF CARE REQUISITES

Air : breathing difficulty

Water : Fluid and electrolyte normal and output of
2200ml

Food : Normal diet

Elimination : Normal

Activity/rest : Restricted

Solitude : Social and cooperative

Prevention of hazards: He is on IV and oral medication for pain

and prevention of infection

Promotion of normalcy: Has a good relationship with everyone

C. DEVELOPMENTAL SELF CARE REQUISITES

Maintenance of developmental

Environment :Not able to do his daily activities .He needs

assistance

Prevention of conditioning in

Normal development: He is aware of his condition and he is taking

medications and on traction as per the
physicians order

Awareness and management of

Disease process : He knows that it will take time to get healed

and know the importance of medication and
to prevent infection

Adherence to medical

Regiment : Aware of the treatment regimen.

Awareness of the potential

problem : He knows the importance of prevention of

infection and the need to maintain hygiene
and the importance of restrictive movement.
Modification of self image to incorporate

Changes in health status: Accepting her general conditions,

knows the limitation of activity.

Adjustment to lifestyle to accommodation changes in

Health status and regimen: He adjust to the disease condition &

follows the treatment regimen correctly
 OREMS SELF CARE MODEL:

Universal self care deficits

Developmental self care Health deviation self care deficits
aaaaaaaa
Assess the breathing pattern of the deficit
Assess the type of pain and the breathlessness
patient Assess the Mr. Mahesh
Assess the pain level of the patient perform self care activities Assess the potential factor of infection
Assess the anxiety level of the with assistance or without
patient assistance Assess the activity of the patient
Assess the nutritional status of the
patient Self care
Altered breathing pattern
Mr. Mahesh
Self Pain and discomfort
Nurse Self care
Nursing care demand Impaired tissue perfusion
agency s
Agency Supportive compensatory system

- Give education about self care activities

- Explain about the disease condition and

Conditioning factors Partially compensatory system treatment regimen of this condition

Age 50years - Administer oxygen to the - Education about hygiene and nutrition
patient
Developmental status young age
- Monitor cardiac function
Health care delivery- supportive
health care system - Administer medication
 NURSING DIAGNOSIS
(Problems identified)

1. Ineffective Myocardial tissue perfusion secondary to CAD, as evidenced by Chest Pain

2. Impaired skin integrity related to skull tong placement, immobility as evidenced by reddened skin over bony
prominences
3. Nutritional balance impaired related to disease process, immobility as evidenced by constipation, weakness
4. Ineffective therapeutic regimen management related to lack of knowledge regarding treatment regimen,
traction, immobility and prevention of infection.
5. Anxiety related to fear of death as evidenced by Verbalization.
6. Deficit knowledge about the disease condition and complication as evidenced by verbalization.

NURSING ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION EVALUATI

THEORY DIAGNOSIS` ON
Orems self care Sub: I feel Disturbed in To maintain 1. Assess the 1. Assessed the
theory model: sleeplessness sleeping normal sleeping sleeping
Sleep is
&weak pattern, sleeping pattern of the pattern of the
It is identified improved
insomnia, pattern patient in day patient in day &
with the mode of Object: than the
related to & night. night.
intervention is weakness & previous
pain as
wholly swelling on 2. Provide 2. Provided day
evidenced by
compensatory the eyes & comfortable comfortable
verbalization.
system. Identified face position & bed position & bed
that patient is not
3. Reduce the day 3. Reduced the
getting sleep due
time sleeping day time
to pain & proper
habit of the sleeping habit
intervention is
patient of the patient
planned.
4. Provide calm & 4. Provided calm
quiet & quiet
environment at environment at
night night

5. give a cup of 5. given a cup of

warm milk warm milk before
before going to going to bed.
bed.

NURSING ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATIO EVALUATIO

THEORY T DIAGNOSIS N N
 Assess the kind of pain the -Assessed the
patient is having pain at working &
Orems self Sub: I am Acute pain To Pain is
resting time
care theory having severe related to relieve Continue the pain reduced
model: pain on the infection as pain management therapy as than the
Patient is in chest evidenced by prescribed by the physician previous
Continuing the
wholly verbalization day
Obj: Advise client to avoid pain therapy by
compensatory
movements that exaggerate the analgesics
system and Pain, & facial
the pain provided by the
identified grimace
physician
problem of Give a comfortable position
acute pain to minimize the pain
and taken
appropriate Certain no pharmacological Music and
intervention therapies such as relaxation relaxation tapes is
tapes, music, visualization to given to the
be given for the patient. patient

Avoid carrying heavy weight

to reduce pain
Advised the
patient to avoid
carrying heavy
weight
 NURSING ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION EVALUATION
THEORIES DIAGNOSIS
Orems self care Sub: I am not Nutrition To maintain Assess the - Daily caloric need is
theory model: able to have imbalanced: less nutrition, fluid nutritional calculated and is
it is identified food properly than body and electrolyte status,assess the administered as Nutrition, fluid
that patient is requirement balance degree of collaborated with and electrolyte
in partial Obj: the patient related to burns dehydration the dietician level is
compensatory is dehydrated maintained
system. and cannot Daily caloric need - Nasogastric tube is
identified swallow food should be put and liquid diet is
problem of due to calculated with the given for the patient
decreased constriction of collaboration with
nutrition and the esophagus the dietician and
take provide soft food - IV fluids is
appropriate especially juice. calculated needed
action or - If the patient is for the patient and
intervention unable to eat is administered
then nasogastric accordingly
tude should be - Assessed the input
put and liquids and output chart
diet should be daily
considered
- Patient is weight
- IV fluids should regularly and
be calculated checked
and administerd
to the patient.
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Lewis SM, Heitkemper MM, Dirksen SR. Medical surgical nursing, Assessment and management of clinical problems. 6th ed. Missouri:
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Suzane CS, Brenda GB, Jonice LH, Textbook of Medical-Surgical Nursing.10th ed. Wolters klwwer; 2004.p.
Silverstri LA. Comprehensive review of nclex. rn. examination. 3rd ed. Pennylvania: Saunders;2006.