DEMOGRAPHIC DATA:

PATIENT IDENTIFICATION DATA

 Name - Mrs. Priti Sachin Gurnule

 Age - 23

 Sex - Female

 Address - Sindhi (Meghe), Wardha

 Occupation - Housewife

 Marrital status - Married

 Religion - OBC

 Income - 50,000/-

 Diagnosis - Anemia

 Type of Family - Nuclear

 Family size - 4 Members

CHIEF COMPLAINT:

Mrs. Priti Gurnule residence of district wardha, come in urban health centre
wardha with the complaint of:

 dysphagia

 angular stomatitis
  glossitis

 pain in legs

 fever and cold since 7day

HISTORY OF PRESENT ILLNESS:

My patient Mrs. Priti Gurnule 23 years old female patient having complaint of
pain fever, glossitis, angular stomatitis, and diagnosed with Anemia.

PAST MEDICAL HISTORY:

My patient Mrs. Priti Gurnule 23 years old female, patient doesn't have any
significant past medical history like hypertension, diabetes etc.

PAST SURGICAL HISTORY:

My patient Mrs. Priti Gurnule 23 years old female, doesn’t have any significant
of past surgical history like appendicitis, etc.

FAMILY HISTORY:

My patient Mrs. Priti Gurnule 23 years old female, patient lives in nuclear
family. There are 4 members in my patient's family.
 FAMILY COMPOSITION:

Name of Age / Education Occupatio Marital Relationship Health

the family Sex n status With habit
members Client
Mr. Sachin 27 BA 2nd yr. Worker Married Husband Healthy
Gurnule yr.

Mrs. Priti 23 BA 2nd yr. Housewife Married Client Anemia

Gurnule yr.

Ku. Shrusti 2.5 _ _ Unmarried Daughter Healthy

Gurnule yr.

Ku. Saloni 2.5 _ _ Unmarried Daughter Healthy

Gurnule yr.
 FAMILY TREE:

Sachin 27yr. Priti 23yr.

Shruti 2.5 yr. Saloni 2.5 yr. Key terms:

Male:
Female:
Patient:

DIETARY HISTORY:

My patient Mrs. Priti Gurnule 23 years old female, Having only vegetarian. She
having diet 3 times like Breakfast, Lunch and Dinner. She like to eat
Cauliflower, spinach etc.

PERSONAL HISTORY:

My patient Mrs. Priti Gurnule 23 years old female maintain good interpersonal
relationship and having regular bowel bladder habit. She like to do exercise
every early morning her habits are writing, poetry etc.
 SOCIO-ECONOMICAL HISTORY:

My patient Mrs. Priti Gurnule 23 years old female, having nuclear family. Her
income is 50,000/-yearly. Her house is well maintained, ventilation was proper.

ENVIRONMENTAL HISTORY:

Mrs. Priti Gurnule 23 years old female they live in their own kaccha house with
all adequate facilities such as tap water supply, electricity, good drainage
system, well sanitation and clean environments.

PHYSICAL EXAMINATION
Name - Mrs. Jyoti Vittalrao Raut
Age - 43yr. old
Gender - Female
Vital Sign
Temperature - 98.4 F
Pulse - 72 beat/min
Respiration - 22 breath/min
Blood Pressure - 110/70 mmhg
General Appearance
Nourishment - Well nourished
Body Built - moderate as seen by observation
Health - anemic
Activity - dull (tired)
Mental Status
Consciousness - conscious
Look - dull
Orientation - oriented to time, place, person
Mood - tensed
Posture
Body curve - Normal
Height - 5 feet
Weight - 40 kg
Skin Condition
Colour - fair
Texture - dry
Temperature - warm
Hydration - moderate
Head And Face
Scalp - clear
Hairs - black
Texture - Normal
Eyes
Eyebrows - equally distribution
Eyelashes - equally distribution
Eyelids - Normal
Vision - Normal
Conjunctiva - pink
Sclera - white
Ear
External ear - No discharge
Tympanic membrane - No perforation
Hearing activity - clear and normal rang
Nose
External nose - No discharge
Nostrils - No infection
Mouth And Pharynx
Lip - No swelling
Odours - No foul odour
Teeth - pale yellow
Mucus membrane - No ulcer
Tongue - Slightly dry
Throat and pharynx - No enlargement tonsils
Neck
Lymph node - Palpable
Thyroid gland - No enlargement
Range of motion - Flexion, extension.
Chest
Thorax - Symmetric shape is present
Breath sound - Wheezing
Heart - No cardiac murmur
Abdomen
Inspection - No lesion present
Palpation - Soft and non-tender
Percussion - Dullness
Auscultation - Bowel sound present
Extremities
Movement of joint - Regular
Tremor - Absent
Genital and rectumNo discharge and sexually transmitted diseases present in
patient.
INVESTIGATION CHART:

SR. NAME OF NORMAL VALUE PATIENTS REFERENCE

NO. VALUE
INVESTIGATION

1. RBC’S 9.1-5.5milli/mm3 3.2milli/mm3 Decreased

2. WBC’S 4,800-11,000/mm3 3.9/mm3 Decreased

3. Platelets 1,50,000- 1,30,000mm3 Decreased

4,00,000mm3

4. Basophils 0.5-1 % 0.9 % Normal

5. Esinophils 0-8 % 0.11 % Normal

6. Sr. creatinine 0.7-1.2 mg/dl 1.1 mg/dl In range

7. Sr. potassium 3.5-5.0 mEq/L 4.2 mEq/L In range

8. MCV 80-100 FL 84 FL Normal

9. MCH 28-35 pg 32 pg In range

10. Haemoglobin 12-16 g/dl 9 g/dl Decreased

11. Hematocrit 37-47 % 39 % Normal

12. Folic acid 5-25 ng/ml 7 ng/ml Normal

13. Vitamin B12 160-950 pg/mi 162 pg/mi Normal

 MEDICATION CHART:

SR. MEDICATION DOSE FREQUENCY ROUTE ACTION

NO.

1. Inj. Monocef 1 gm BD IV Antibiotic

2. Inj. Rantac 50 mg BD IV H2 blockers

3. Tab. PCM 500 500 mg OD Oral Antipyretic

4. Tab. Cetrizen 10 mg OD Oral Antiallergic

5. Tab. Victofol 1 mg TDS Oral Multivitamin

6. Inj. Epotin alfa 2000/mu TDS IV To treat

Anemia

7. Tab. Ferrous 200 mg BD Orally To treat

sulfate Anemia

8. Tab. Procrit 50 mg TDS Orally To treat

Anemia
SR. NO. DRUG DOSE/ROUTE ACTION INDICATION CONTRAINDICATION NURSES
TRADE FREQUENCY RESPONSIBILITY
NAME
1. Inj. Monocef Dose: -1gm. Blind to the 1)Bone and 1)Hypersensitivity to 1)Assess the
Route: - IV bacterial cell joint infection cephalosporin patient for
Frequency: - wall 2)Urinary and 2)Creatinine infection
BD membrane glycogenic deficiency 2)Before
causing cell infection. initiating therapy
death. 3)Respiratory 3)Inborn error of obtain a history to
tract infection. metabolism. determine
4)Preoperative Side effects: previous use of
prophylaxis.  Nausea and reactions to
 Dizziness penicillin.
 Vomiting 3)Lab test
 Vertigo consideration.
 Weakness 4)check the vitals
 Stomach pain routinely.
SR. NO. DRUG DOSE/ROUTE ACTION INDICATION CONTRAINDICATIONS NURSES
TRADE FREQUENCY RESPONSIBILITY
NAME
2) Inj. Dose: - 50mg Inhibit the 1)short term 1)Hypersensitivity 1)Assess the patient for
Rantac action of treatment of infection.
histamine at
Route: - IV active duodenal 2)Cross sensitivity
the H2
receptor site ulcers. 2)Before initiating
Frequency: - BD located 2)prophylaxis of 3)Some oral liquid contain therapy obtain a history.
primarily in
duodenal ulcers. alcohol and should be
gastric
partial cells 3)Management of avoided in patients with 3)Assess patient for the
resulting in GERD. known intolerance. epigastric or abdominal
inhibition of
4)Treatment of pain.
gastric acid
secretion. prevention of Side effects: - s
heartburn.  Headache 4)Ranitidine may cause
5)Sowe stomach  Constipation false positive results for
 Nausea urine protein test with
 Vomiting sulfosalisydic acid.
 Pain
SR. DRUG DOSE/ROUTE ACTION INDICATIONS CONTRAINDICATIONS NURSES
 NO. TRAND FREQUENCY RESPONSIBILITY
NAME
3) Tab. PCM Dose: - 500mg It has good 1)Pain 1)Overactive thyroid 1)Assess the
analgesic gland. general condition
2)Headaches
Route: - Orally and 2)Acidosis. of patient.
3)Dental pain
antipyretic 3)A high level of acid in 2)Monitoring for
Frequency: -OD properties. 4)Postoperative pain the blood. efficacy.
4)High blood pressure. 3)Vital nursing
5)Pain in connection
5)A heart attack. responsibilities for
with colds.
6)coronary artery disease. IV use.
6)Migraine 7)Partial heart block. 4)Patient education
is also an important
headache.
Side effects: - nursing function
7)Dysmenorrhoea.
 Vertigo with all medication.
8)Joint pain.  Nausea
 Constipation
 NURSING DIAGNOSIS

1) Glossitis: -

Impaired mucous membrane related to poor oral hygiene as evidenced by

checked oral examination.

Goal: Improve oral mucous membrane.

2) Dysphagia: -

Difficulty in swallowing related to poor oral hygiene as evidenced by

patient’s verbalisation.

Goal: Improved swallowing pattern.

3) Pain: -

Acute back pain related to hospitalization as evidenced by observing

patients’ painful expression.

Goal: To reduce pain.

4) Fever: -

Hyperthermia related to infection as evidenced by checking patient’s vital

signs.

Goal: To reduce body temperature.

5) Vomiting: -

Fluid and electrolyte imbalance related to excessive vomiting as

evidenced by poor skin turgor.

Goal: To reduce vomiting.

6) Physical intolerance: -
 Impaired physical tolerance related to dehydration as evidenced by

observed patient working pattern.

Goal: To improve physical intolerance.

7) Anxiety: -

Anxiety related to any anemia as evidenced by observed facial

expression.

Goal: To reduce anxiety.

8) Fatigue: -

Fatigue related to hospitalization as evidenced by facial expression.

Goal: To reduce fatigue.

9) Knowledge deficit: -

Lack of knowledge related to anemia as evidenced by observing patients’

doubtful question regarding disease.

Goal: To improve the knowledge.

ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

Subjective Impaired oral To improve -Assess the general -To know -Assessed the Improved
Data: - mucous oral mucous condition of patient. baseline data. general condition of integrity of
membrane related membrane -Plane and -Prevents patient. oral mucous
My patient told to poor oral integrity. implement a formation of -Planned and membrane.
that “I am hygiene as meticulous mouth oral plaques. implemented a
having pain in evidenced by care regimen after -To improve meticulous mouth
tongue”. checking oral each meal regularly integrity. care regimen after
examination. and every 4hours -To avoid each meal regularly
Objective wrile awake. bleeding. and every 4hours
Data: - -Increasing -To improve while awake.
frequency of oral oral mucous -Increased the
I observed hygiene. membrane. frequency of oral
patient painful -Discontinue hygiene.
expression and flossing if it causes -Discontinue
talking oral pain. flossing if it cause
examination. -Provide systemic pain.
or topical analgesic -Provided systemic
as prescribed. or topical analgesic
E.g.: -Zplactin-B as prescribed.
 ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

Subjective Data: Altered body To reduce -Assess the -To know -Assessed the Reduced fever at
temperature body general condition baseline data. general condition of normal level.
Patient says
related to temperature. of patient, patient.
that “I feel
infection as
warm”
evidenced by -Provide quiet -To feel -Provided quiet and
observation of and calm fresh. calm environment.
vital signs. environment.
Objective Data:

I observed -Provide sponge -To reduce -Provided sponge

alteration in bath. body bath.
body temperature.
temperature.
-Provide cool -To relieve -Provided cool
drink. fatigue. drinks.

-Administer -To reduce -Administered

antipyretic drug fever. antipyretic drugs as
as per doctor’s per doctor’s
prescription. prescription.
ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

Subjective Severe pain in To reduce -Assess the -To know the -Assessed the Reduced fever
Data: back related to pain. general baseline data. general condition of at normal
new condition of patients. level.
Patient say that hospitalization patient.
I am having as evidenced by
back pain. observation by -Provide -To feel -Provided
observing comfortable comfort. comfortable
Objective Data: patients’ painful position. position.
expression.
I observed -Provide quite -To feel fresh. -Provided quite and
patient’s and calm calm environment.
painful environment.
expressions.
-Provide back -To reduce -Provided back
massage. pain. massage.

-Administer -To relief pain. -Administered

analgesic as analgesic as per
per doctor’s doctor’s
prescription prescription.
DISCHARGE SUMMARY:

Mrs. Priti Gurnule 23 years female admitted in PHC with chief complaint of

angular stomatitis, dysphagia, glossitis, pain in leg, fever and cold since 7 days

when we do investigation found some abnormalities is physical examination.

Patient was undernourished, foul smell of mouth present.

In investigation of blood RBC'S, WBC'S, platelets are decreased in number.

During treatment medications used are as follows:

1) Inj. Monocef 1gm-------BD

2) Tab Rantac 50gm ------BD

3) Tab PCM 500 500mg -----OD

4) Tab cetrizen 10mg -------OD

5) Tab victofol 1mg --------TDS

6) Tab epoetin alfa 2000w/ml --- TDS

After discharge if you notice any signs and symptoms or worsen pain then

immediately consult to the doctor or visit to the hospital. Review again after 10

days.
 HEALTH EDUCATION

Health education is given to the client and her family are as follows.

 Diet -

Advised the client to take low fat diet and high calories diet and also take all

types of green vegetables and fruits and instruct the client to avoid oily and

spicy food and to maintain good nutritional pattern.

 Medication -

Advised the client take the daily medicine and do not miss the dose and any

irregulating in correct time and explained its advantages and side effect.

 Personal hygiene -

Advised the client maintained personal hygiene take daily bath and proper oral

care frequently and nail care etc.

 Exercise -

Advices the client for breathing and coughing exercise daily in morning and if

possible, then also evening walk and also to yoga.

 Rest and sleep -

I told the importance of rest and sleep to the client and advice to take adequate

amount of rest and sleep and do not take stress.

  Follow up -

I advise the client to come in hospital for follow up if any complication than

immediately contact with doctor.

SUMMARY

My patient Mrs Priti Gurnule 23 years female which complaint's angular

stomatitis, glossitis pain, weakness and her diagnosis is Anemia. I took her
history for my nursing care plan and treat to reduce patient's problems.

CONCLUSION

In this family health care plan, I conclude that the client able to understand the
topic i.e., anemia.

The client as well as the family members are able to explain the topic and I give
the all information regarding the prevention and control of disease.

BIBLIOGRAPHY

1. K. Park, “Textbook of preventing and social medicine”,26th Edition,

Bhanot publication.

2. Kamalan, “Essential of community health nursing 1st Edition, Jaypee

brothers’ publications new delhi.
3. http://slideplayer.com

4. http://apps.who.int

5. http://www.scribd.com

6. http://www.mfine.com