DR. D.Y.
PATIL COLLEGE OF NURSING
PIMPRI PUNE –18
INDIVIDUAL PRSENTATION
ON
NURSING PROCESS
Submitted to :- Submitted by:-
[Link] kochewad [Link] bhalerao
Clinical instructor 1st yr bsc nursing
Dr .D.Y patil DR .D.Y patil
College of nursing College of nursing
Pimpri pune –18 Pimpri pune –18
Submitted on :- 18/06/2024
HISTORY TAKING
Patient name :- [Link] dalvi
Age :- 49year
Sex:- female
Address :- Talegaon dabade pune 18
Adm. Date :06/06/2024
Ward no :-310 female surgery ward
Maritial status:- married
Religion :- Hindu
Nationality :- Indian
IPNO:- PRN- 124-012772
Education :- 10th
Occupation :- housewife
Income:- none
Medical diagnosis :- umbilical hernia
Date of surgery :- 8/06/2024
Name of consultant :- Dr. dakshayani nirhale
Chief complaints :- Mrs. Pooja dalvi 49 years old female was admitted on
[Link] patil medical college hospital in FSW on 06/06/2024 with chief
complaints of pain in abdomen region (since 10 days ) burning micturition
and vomiting .
HISTORY ILLNESS :-
Present medical history :-patient has been dignosed with umbilical hernia .
Past medical history :- patient has a past medical history of nephrolithiasis (8
days ago )
Present surgical history:- mrs. Pooja has a present surgical history of
herniorrhaphy on 08/06/2024
Past surgical history :- mrs. Pooja has past surgical history of percutaneous
nephrolithotomy (PCNL) TYPES OF FAMILY :- join
Total no of family mem:-4
ENVIROMENT HISTORY :- mrs. Pooja is a middle class family and lives in an
clean and healthy environment.
NUTRATIONAL HISTORY:- patient is taking full diet as prescribed by the
doctpr which include both veg and non-veg food group.
PERSONAL HISTORY:-
HYGEINE:- well maintained hygiene
SLEEP pattern :- regular sleep pattern
ELIMATION:- patient has maintained proper bowel and bladder pattern of
elimation elimation pattern is normal.
PHYSICAL EXAMINATION:-
GENERAL APPEARANCE:-
• Level of conscious:- patient is conscious. • Height :-54cm
• Weight:-50kg.
• Body built:-thin
• Health status:-unhealthy
• Hygience:- hygience well maintained
VITAL SIGNS:-
• Temperature:-96 degree f
• Blood pressure:-120/80mmHg
• Respiration:-18bpm
• Pulse:-88bp
HEAD:-
• Head circumference :-52cm
• Size and shape of skull:-normal and round
• Scalp:- no dandruff,oily
• Hair :- black in colour,
• Appearance of face:- symmetrical.
EYES:-
• VIision:-normal
• Eyelid:-normal
• Eyelashes:-normal black
• Eyeball:- movement are normal
• Conjunctiva:-absence of redness or infecrtion
• Discharge:-watery discharge
• Inflammation:- absence of swelling or inflammation
• Visual activity:- visual activity is normal
NOSE:-
•
•
•
•
Symmetry:- symmetrical
Flaring:-absent
Deformity:- absent
Discharge :- absence of abnormal discharge
MOUTH:-
• Dental hygiene :- clean ,maintained
• Halitosis:-absence of abnormal
• Colour and moister of lipids:-pinnk and moist lips
• Lymph nodes:-absence of infection
• Oral hygiene :-maintaine
• Denture:-absent
• Tonsil:-normal
• Thyroid gland :-no enlargement absent of goiter RESPIRATORY
SYSTEM:-
• Chest shape and symmetry :- symmetrical
• Cough:- dry cough
• Dyspnea:-absent
• Respiratory rate :- 16 breath per mi
• Sputum:- absent
CARDIOVASCULAR SYSTEM:-
• Pulse rate:- 88bpm
• Blood pressure :-120/80mmhg
•
•
•
•
• Colour of skin :-brown
• Numbness :-absent
• Peripheral pluse :-80bpm
• Hypertension :-present
• Cyanosis:-absent
• Edema :-absent
GASTROINTESTINAL SYSTEM :-
Appetite:- decreased appetite
Bowel sound :-absent
Constipation :-no constipation
Diarrhea:-absent
• Nausea/vomiting :-absent
• Abdominal pain:- presence of pain abdominal GENITOURINARY
SYSTEM:-
• Urinary pattern :- normal
• Urinary micturition:- presence of burning
• Hemature :-absent
REPRODUCTIVE SYSTEM :-
• Number of pregnancy :-two
• Nature of delivery:-intrauterine
• Vaginal bleding :-absent
• Aborstion :-nil
• Pain:-normal
•
•
•
•
NUROLOGICAL SYSTEM:-
Level of conscious :- conscious
Headache :-absent
Confusion:-no confusion
Weakness :-present
Paresthesia:-absent
Sensation :-present
Memory :-normal
Orientation :-oriented .
INTEGUMENTARY SYSTEM:-
• Overall appearance :- unhealthy and week
• Skin turgor :-normal
Skin texture :-dry skin
Lesions:-absent
Rashes :-present
Bluish discoloration :-absent
NURSING DIGNOSIS
1. Acute pain related to abdominal muscle strain and pressure from hernia
as evidenced by pain scale score 7/10 and patient verbalize.
•
•
•
•
2. Risk for impaired skin integrity related to surgical incision as evidence by
inspection.
3. Imbalanced nutration less than body requrment related to decreased
appetite due to pain and discomfort as evidence by facial expression
and body posture.
4. Risk for infection related to impaired skin integrity as evidenced by
increased redness.
NURSING CARE PLAN
ASSESSMENT NURSING PLANING INTERVENTION EVALUATION
DIAGNOSIS
Subjective Acute pain Assess Assessed On evalution
data :- related to patients patient outcome is
Patient hernia as condition condition partially met
reports evidenced Moniter Monitored and pain is
severe pain by pain scale vital sign of vital signs of reduced.
in abdomen score of patient patient
7/10 and Administer Administered
patient medication prescribed by
verbalization prescribed doctor . Assist
by doctor the patient in
Assist the finding
patient in comfortable
finding position.
comfortable Provided
position. quiet
Promote environment
rest and for rest and
sleep. sleep.
Objective
data:-
On
assessment
pain intensity
was rated
7/10
2.)
ASSESSMENT NURSING PLANING INTERVENTION EVALUATION
DIAGNOSIS
Subjective Risk for Inspect the On evalution
data :- Patient infection hernia site the patient
reports related to daily for Inspected the maintained
increased on impaired skin redness hernia site intack skin
skin integrity as swelling or Taught the without signs
evidenced breakdown patient of irritation or
by increases. Teach proper regarding breakdown.
hygine and hygine and skin
skin care care techniques
techniques Used protective
to patient barriers to
Educated on protect skin
from friction
signs of
and irritation
infection to
Asked the
report
patient to wear
promptly.
loose
fiting clothes
Educated the
patient on the
signs of
infections.
Subjective
data:-on
assessment
there is a risk
for infection
THANK YOU….
