SPURTY COLLEGE OF NURSING

SUBJECT: Medical Surgical Nursing

Care Plan On: Influenza

SUBMITTED TO: SUBMITTED BY:

Umar Firdous
M.Sc (N) 1st Year
SUBMITTED ON:

INTRODUCTION
Family illness History : All the family member are healthy.
Personal history:
Habit- Patient is A chronic smoker.
Hygiene - Well maintained.
Dietary pattern : Patient takes meal & times a day.

Sleeping pattern: Disturbed pattern.

Elimination pattern : Patient elimination pattern is irregular.
Post medical history: Patient used to suffer from headache.
Post surgical history: Patient has not under gone any surgery.
Patient surgical history: Patient has no surgical history.
 Socio Economic Status

Family history: All the members of the family are health accept patient total no of family member 4
family tree.

PHYSICAL EXAMINATION
General appearance :
Nourishment - Well nourished.
Body build- Weak.
Health- unhealthy.

Mental Status :
Consciousness- yes.
Height- 6 ft
Weight- 60 kg
Skin:
Skin colour - Pale.
Dryness – Skin is Dry.
Hair - Normal distribution of hair.

Eye:
Eye brows - Present.
Sclera- Normal.

NURSING DIAGNOSIS
-Acute pain related to the disease condition of evidence, by patient facial expression of patient.
-Imbalanced nutritional pattern related to anxiety obey as evidenced by hypertension of the
patient.
-Ineffective therapeutic regimen management abend treatment as evidenced by frequent
questioning the patient.
 GOAL'S
Short term Goals :

- To reduce the pain of patient.

- To maintain nutritional status of patient
- To maintain sleep pattern of patient.
- To enhance knowledge of patient.

Long term Goals :

- To provide rehabilitation therapies to patient.

- To provide diversional therapies to patient nutritional diet.

Vital Sign Normal Vital Patient Vital Remarks
Temperature 98.5 'F 98.2 'F Normal
Pulse 72-80 b/m 72 Normal
Respiration 16-24 b/m 18 Normal
Blood Pressure 120/80 mmHg 120/80 mmHg Normal

Lab Investigation

Lab Test Patient Value Normal Value Remarks

Hemoglobin 10.6 mg/dl 14.5 mg/dl Abnormal

CBC 10.4 mg/dl 16.5 mg/dl Abnormal

 Treatment / Medication
Drug Name Dose Route Frequency Action
Diclofenac O.D I.M 3 ml Analgesic

Lasin B.D I.V 0.5 mg Antihyper-tensire

Benzobri
Hydrochroid B.D I.M 1 mg Antihibit

Skeletal System:
Arms : Normal movement.
Legs : Normal movement.
Musculoskeletal System:
Reflex: Normal.
Deformity: Absent.

Reproductive system-
Discharge : No discharge.

Genital urinary system :

Roidiry pattern: Normal.

Digestive System:
Bowel sound: Normal.
Symmetry of abdomen : Abdomen fs extended.
Respiratory rate : Decreases.

Abdomen :
Rashes: Absent
Bowl sound - Normal.
Distnsion- No.

Genitalia :
Discharge: Absent.
M.C- Normal.
Mass formation : Absent.
Systemic examination:
 Nervous System
Consciousness : Conscione.
Loom- Depressed.

Cardiovascular System :
Heart : Normal heart sound.

Respiratory System:
Chest - Normal airway.
Thorax- Normal expansion.
Breath sound: wheezing sand absent.

Light:
Lens - Normal.
Vision- Normal.

Ear:
Hearing capacity : Normal.
Tympanic Membrane : No preformation.

Nose:
Nasal septum :No deviated Nasal septum.
Nostrils - Normal.
Nasal discharge - Present.

Mouth & Pharynx: Tongue Dryness

Neck : Lymph nodes enlargement

Chest: Symmetry - Normal

Nursing Nursing Goal Planning Implementation Evaluation

Assesment Diagnose
-To assess rate -General condition Sleep pattern of
Subjective ineffective - To maintain of respiration & of patient is patient is
data: airway airway of breath sound. assessed. maintained.
Patient clearance Patient -To assess -Comfortable
complaints that related to refer general position &
feels difficulty of fluid to fluid condition of comfortable
in breathing. into Larynx & patient. device are provide
threat as -To provide to patient.
objective data : evidenced by comfortable - Well ventilated
Assessment is dysprea. position to room is provided.
done by deep patient.
breathing of -To encourage
patient. patient for deep
Breathing.
Nursing Nursing Goal Planning Implementation Evaluation
Assesment Diagnose
 -To check general -General condition
Subjective Fluid and -To maintain condition of of patient .
data: electrolyte fluid and patient. - Check the intake
-To check the
Patient Says related to electrolyte patient output
output chart of
hat I am weak. contaminent balance in chart of patient patient.
water as patient body. -Patient provides -Give I.R fluid to
objective data : evidence dry fluid to patient. the patient.
Nurses observe lips intake -To give patient -Check vital signs
that patient is output Chart ORS. of patient.
having dry skin. -To check vital
signs of patient
dehydrated

Nursing Nursing Goal Planning Implementation Evaluation

Assesment Diagnose
-To check -General condition Patient is
Subjective general checked of patient . feeling better,
data: After body To reduce condition of - Monitoring vital now feeling
The Patient temperature. body patient. sign of patient. better fever
Says hat I am To infection as temperature of -To maintain reduce some
feeling warm evidence by patient. vital signs. - Comfortable eaten.
sweating. vital sign. -To provide position to
comfortable patient
objective position to
data : patient.
Nurses observe -To provide
that patient is calm
having fever. environment.
-To provide
healthy diet to
patient
Nursing Nursing Goal Planning Implementation Evaluation
Assesment Diagnose
-To asses -General condition Sleep pattern of
Subjective general of patient is assed. patient is
data: Acute pain To reduce pain condition of -Comfortable maintained.
Patient is related to of patient. patient. device are
complain about inflammation of -To assess rate provided.
the having chest cardiac as of respiration . -Well ventilated
pain. evidenced by -Depth & room is provided.
objective data : facial breath sound. -Calm atmosphere
expressional -Provide O2 is provided.
Nurse asses patient. therapy to
pain from facial patient.
expression.