PATIENT IDENTIFICATION DATA

Name of patient: - Rajvir Kaur

Age: - 28 years

Sex: -Female

Address: - Raikot ferozpur

Nationality: - Indian

Religion: - Sikh

Language: - Punjabi

Diagnosis: - 55%

Doctor Incharge: - Dr.saini sethi

Date of admission: - 10-10-2020

Ward: ICU

Bed number: - 25

CHIEF COMPLAINTS: - On admission patient suffer from

 Blisters.
 Pain.
 Swelling.
 White or charred (black) skin.
 Peeling skin.

PRESENT MEDICAL HISTORY: - Patient Rajbir kaur of 40 years old admitted in hospital with
complaints of blisters, Pain, Swelling. White or charred (black) skin., Peeling skin patient reached at
local hospital.

PRESENT SURGICAL HISTORY: - Patient has no significant surgical history.

PAST MEDICAL HISTORY: - Patient has no taken medicine in past.

PAST SURGICAL HISTORY: - Patient has no surgical history in past.

FAMILY HISTORY: - Type of family: - Nuclear

Number of family members: - 3

S.No. Name Age/Sex Relation Education Occupation Health

Status
1. Mandeep 40/F Mother 10th Housewife healthy
kaur
2. Daljit singh 45/M Father 8th Farmer Healthy
3. Jasprit kaur 28/F Daughter B.A. Student UnHealthy

FAMILY TREE:-

MOTHER FATHER
45yrs. 40yrs.

DAUGHTER

Personal History:-
Language: - Punjabi
Dietary Habits: - Vegetarian
Likes: - House made food
Dislikes: - Spicy food
Food Allergy: - No
Exercise: - Not Performed
Hobbies: - Watching TV
Addiction: - No addicted
Marital status: - Married
Age at marriage: -20yrs.
Duration of marriage: - 20yrs.
No. of children: - 2

PHYSICAL EXAMINATION
General appearance and behavior
Body built: - Thin
Nourishment: - Undernourished
Posture:-Good posture
Activity:-dull
Head to toe examination
Head
Shape: - Oval
Scalp: - Dandruff present
Hairs: - Black
Lesion:-Absent
Ears
Symmetry: - Present
Discharge:-Absent
Hearing: - Proper hearing capacity
Eyes
Shape: - Oval
Sclera: - White
Conjunctiva: - Light pink
Vision: - Normal
Eye brows: -Proper shaped
Eye lashes: - Normal
Neck
Lymph nodes: - Absent
Thyroid gland: - Thyroid enlargement present
Range of motion: - no proper flexion, extension due to respiratory obstruction
Nose
Shape: - Normal
Nasal septum: - No deviation
Nasal mucosa: - Moist
Sensation: - Normal
Sinus percussion: - Sinusitis Is present
Mouth and pharynx
Lips: - Redness
Odor of mouth: - Foul smelling
Teeth: - pale
Dental cavities: - Present
Oral hygiene: - Not maintained
Gums
o Dry gums
o Pink in color
o No inflammation
Tongue
o Pink in color
o Dry tongue
o Ulcers absent
o Proper taste sense
Throat and pharynx
o Tonsils enlarged
Chest
Thorax: - Symmetrical
Breath sounds: - Wheezing sound
Chest tenderness: - Present
Abdomen
Inspection: - No scar or lesions
Palpations: - Abdomen tenderness present
Auscultation: - Sounds abnormal
Percussion: - Abdominal fluid accumulation present
Extremities
o Impaired skin integrity
o Dry skin
o Functional extremities
o Joint pain no more on movement
SYSTEMIC EXAMINATION
Nervous system
Level of consciousness: - Subconsiousness
Reflexes: - bicep, tricep reflexes are not too good.
Respiratory system
Respiratory rate: - Respiratory rate is 28/MIN
Inspection: - Dysponea
Palpation: - Chest tenderness
Cardiovascular system
Heart rate: -88 beat per minute
Blood pressure: - 120/100 mm of Hg
Gastrointestinal system
Inspection: - Mucus membrane intact
Palpation:-Abnormal mass present
Percussion: - Fluid accumulation present
Musculoskeletal system
o Function of extremities is normal
o Range of motion is normal
o Patient is able to perform activities
Urinary system
Urinary output: - 500ml/day
Urinary system: - normal
Integumentary system
o Skin is dry and burned
o Sense of pain is present
Reproductive system
o Normal functioning

VITAL SIGNS: -

S.NO Vital signs Patient value Normal value Remarks

.
1. Temperature 100.80F 98.60F Normal
2. Pulse 88beats/min 72beats/min Tachycardia
3. Respiration 32breaths/min 16-20breaths/min Abnormal
4. Blood pressure 160/100mmHg 120/80mmHg Hypertension

INVESTIGATIONS: -
S.no. Investigations Patient value Normal value Remarks
1. Hb 11.0gms 10-15gms Normal
2. T.L.C 5800cells/mcl 4000-11000cells/mcl Abnormal
3. Creatinine 1.1mg/dl 0.6mg/dl Normal
4. Sodium 134mE/L 138-145 mE/L Abnormal
5. Potassium 4.4mE/L 3.5-5.5Me/L normal

DIAGNOSTIC EVALUATIONS:-
Chest x-ray
Sputum examination
CT scan
MRI
Thoracentesis
Needle biopsy
NURSING ASSESSMENT:-
 Assess the vital signs of the patient.
 Assess the dysponea and lung sounds.
 Assess the pain intensity of patient.
 Assess the swallowing capacity of the patient.
 Assess the restlessness, skin color, extremities.
 Assess the lung capacity to remove and exchange of gases.
 Assess the level of consciousness.
NURSING DIAGNOSIS: -
 1. Impaired gas exchange related to removal of lung tissues, altered oxygen supply and decrease
oxygen carrying capacity of blood as evidenced by dysponea, restlessness/ changes in
mentation, hypoxemia and hypercapnia.
2. Ineffective airway clearance related to increased amount of secretion, restricted chest
movement, decrease coughing effectiveness due to pain and fatigue as evidenced by
changes in rate or depth of respiration rate.
3. Fluid volume deficit related to loss of fluids through wound and lacerations.
4. Fear and anxiety related to situational crises, threat to change in health status and perceived
threat of death as evidenced by with drop, apprehension, anger, increased pain, sympathetic
stimulation and expression of denial, shock, guilt, and insomnia.
5. Deficient knowledge regarding condition, treatment, prognosis, self care and discharge needs
related to lack of exposure, unfamiliar with information and lack of recall as evidenced by
statement of concern, request for information, inadequate follow through of instruction and
inappropriate or exaggerate behaviors.
SHORT TERM GOAL:-
 To reduce cough and dysponea.
 To reduce chest pain.
 To reduce dysphasia.
 To reduce shoulder pain.
 To reduce anxiety.
 To reduce nausea and vomiting.
LONG TERM GOAL:-
 To improve respiration rate.
 To improve breathing pattern.
 To provide comfort to the patient.
 To relieve the patient from lungs other infections like pneumonia.
 To improve the digestion capacity of the patient.
 To reduce the stress of the patient.
 To improve activity tolerance of the patient.
 To improve the gas exchange capacity of the patient.