Care plan family 2 --deveshwar

M.Sc. Nursing Care Plan For Special Group

1. COMMUNITY HEALTH NURSING
SUBMITTED TO - SUBMITTED BY-
MRS. MALLIKA ROY MR. DEVESHWAR P. DWIVEDI
ASSISTANT PROFESSOR MSC NSG 1
ST
YEAR
R.D. MEMORIAL COLLEGE OF R.D. MEMORIAL COLLEGE OF
NURSING ,BHOPAL NURSING ,BHOPAL

2. HEALTH ASSESSMENT
Name of the Infant :- Mrs. REKHA SAHU
Age ( in month) :- 32 year .
Gender :- Female.
Educational status :- 12
TH
Pass.
Occupation :- Housewife
Marital Status :-. Married.
Type of family :- Nuclear family.
Income of the family :- 20000 per month.
Nature of house :- Pucca.
Address :- Nanakhedi Kalan Bhopal
PRESENT MEDICAL HISTORY:---
Mrs.Rekha Sahu has the gas problem since the 2 month due to constipation and loss of
appetite.
Mrs.Rekha Sahu has the Anemia and taking the medicine prescribed by the doctors (due
to weakness.).
Mrs.Rakhi Grandfather has suffer with Skin disorder.
PAST MEDICAL HISTORY:-
8 month before the Mrs. Rekha Sahu take medicine regarding the Abortion.
1 year ago Mrs. Rekha Sahu taketreatment related to the back pain.
PERSONAL HISTORY:-
1.Habit :-She's habbit is chewing chocolate and Tophy .

3. 2. Healthy practice :-Morning walk
3. Diet :-Vegetarian diet
4. Hobbies :-Cooking foods and Singing song.
SOCIO ECONOMICAL HISTORY:-
1)The socio economical history of client is well.
2)Client family member doing the private job.
ENVIRONMENTAL HISTORY:-
1)Client surrounding environment is well.
2)Water facility is available.
3)Electricity are proper available.
4)Waste disposable are proper.
FAMILY HISTORY:-
S.No.Name Of Family Member Age/Sex
Occupatio
n
Relation Healthy Status
1Mr. Hariram 40y/M Former Husband Healthy
2Mis. Madhu 12y/FStudent Daughter Healthy
3Mr. Sonu 4y/m -- Son Healthy
Family Tree:-

PHYSICAL EXAMINATION :-
Hariram
Rekh
a
Sahu
Madh
u
sonu

4. General Appearance:- I observed that the she is looking well and healthy.
Anthropometric measurements:-
Height :-154 cm
Weight :-38 kg
Dietary history:-Vegetarian diet
Vital signs :- Temperature -98.6f ,Pulse- 74 /mt , Resp-22 bit/ Min. , B.P -130 / 90 mmhg
 PHYSICAL EXAMINATION:-
1)SCALP
Colour of the hair- Black.
Anterior fontonellae- Closed.
Posterior fontonellae- closed.
Any wounds or birth markings-Scar on face.
2) FACE AND NECK
Eyes (colour, bitot spots ,foreign body) :-Brownished.
Ear :-Pinna are normal placed.
Nose (running, blocked , deviation) :-Normal.
Mouth ( teeth eruption, odour, any abnormality):- Yellowish teeth.
Tongue :-Moisture tungue.
Throat ( odour , any signs and symptoms of tonsillitis) :-Odour in breath.
White patches on the check :-No Patches.
Distensions of the neck veins :-No Distension.
3)CHEST
Shape of the chest ( barrel pigeon,cylindrical.) :-Barrel Shaped.

5. Auscultation ( breath ,sounds, heart sounds ) :-Breath sound
Percussion(fluid,aircollection) :-No fluid collection
Sign and symptoms of Pneumonia :- No sign of pnuemonia.
4)ABDOMEN:
Any distension :-No any distension.
Auscultation( bowel sounds ) :-Bowel sound present.
Percussion :-Bowel and
Palpation (liver , other organs of the abdomen) :-Bladder
Bowel and bladder movements :-Movement present.
5)EXTREMITIES :
Any Abnormalities seen :-No any abnormalitis.
Manipulation ( movements of the joints) :-Proper movement of joint.
6)SKIN INFECTION:
Color of the skin :-Normal skin colour.
Skin rashes :-No skin rashes.
Any sign and symptoms of dermatitis :-No any symptom.
ABNORMALITIES DETECTED:-
1)I detected the abnormalities like the rshes in the neck.
2)The gas problems are detected in the patient .
3)The anemia's sign and symptoms are detected in the patient.
MEDICAL HISTORY:-
S.NO NAME OF DRUG DOSE ROUTE FREQUENCY ACTION
1 TAB. Heam up 500MGORAL BD Vit.-B9

6. 2 SYP. Dexorange 2ML ORAL BD Multi vit.-B12
3 TAB. ACILOC 150 ORAL OD ANTACID
4
INVESTIGATION:-
1.C.B.Cs TEST.
2.ESR TEST
3.THYROID TEST
4.ECG TEST
5.URINE ANALYSIS.
SUGGESTIONS GIVEN :-
1)I suggested to the Mrs. Rekha Sahu regarding the exercise for well health.
2)I suggested to the Mrs. Rekha Sahu regarding for the taking the balance diet and take the
iron rich diet like papaya, etc.
3)I suggested to the Mrs. Rekha Sahu Sharma regarding for a proper personal hygiene.
4)Give advice regarding the take proper iron diet daily.

8. CARE PLAN
ASSESSMENT NSG.
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data:-
My client says that she has
feel the joint pain, fatigue,
leg pain, weakness, and
uncomfortness.
Objective data:-
I observed that that the my
client are sick. She has ill.
She has suffering from
anemia the weakness.
Impaired
nutrition
level less
than body
requirement
related to
less intake
of food.
To maintain
the nutritional
level.
To assess the general
condition of client.
To check the nutritional level
of client.
To assess the risk of anemia.
To check the nutritional level.
To provide the safety and
security to the client.
To provide the knowledge
regarding the anemia.
General condition of
client are assessed.
the mobility of client
are checked.
Risk of anemia are
checked.
the nutritional level
are checked.
provided the safety
and security to the
client.
provided the
knowledge regarding
the remove of
anemia.
Anemia are
decreased.
Health is
normal.

Nutritional
level
normal.

9. ASSESSMENT NSG.
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data:-
My client says that she has
feel the joint pain, fatigue,
leg pain, weakness, and
uncomfortness.
Objective data:-
I observed that that the my
client are sick. She has ill.
She has feeling the
weakness.
Impaired
physical
mobility
related to
the joint
pain.
To remove
the leg pain
and joint
pain.
To assess the general
condition of client.
To check the mobility of
client.
To assess the risk of joint
pain.
To check the nutritional level.
To provide the safety and
security to the client.
To provide the knowledge
regarding the remove of joint
pain.
General condition of
client are assessed.
the mobility of client
are checked.
Risk of joint pain are
checked.
the nutritional level
are checked.
provided the safety
and security to the
client.
provided the
knowledge regarding
the remove of joint
pain.
Joint pain
sre
decressed.
Health is
normal.

10. ASSESSMENT NSG.
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data:-
My client says that she has
feel the joint pain, fatigue,
leg pain, weakness, and
uncomfortness.
Objective data:-
I observed that that the my
client are sick. She has ill.
She has feeling the
weakness.
Impaired
physical
mobility
related to
the joint
pain.
To remove
the leg pain
and joint
pain.
To assess the general
condition of client.
To check the mobility of
client.
To assess the risk of joint
pain.
To check the nutritional level.
To provide the safety and
security to the client.
To provide the knowledge
regarding the remove of joint
pain.
General condition of
client are assessed.
the mobility of client
are checked.
Risk of joint pain are
checked.
the nutritional level
are checked.
provided the safety
and security to the
client.
provided the
knowledge regarding
the remove of joint
pain.
Joint pain
sre
decressed.
Health is
normal.