1

1. INTRODUCTION (SELF):-
As per my clinical posting I was posted in the Male Medicine ward in AGMC & GBP
Hospital. During my clinical posting I was found a patient who was suffering from
generalized weakness, drowsiness, breathing difficulty, mild fever, cough and doctor
diagnosed him as Chronic Anaemia. I had taken this diagnosis for my case presentation.

2. IDENTIFICATION DATA OF PATIENT:-

Name of the patient: Mr. Priyatosh Debnath.

S/o: Lt. Manindra Ch Debnath.

Age: 65 years

Gender: Male

Religion: Hindu

Educational Status: Madhyamik passed.

Occupation: Businessmen

Income: 20000 per month

Marital status: Married

Address: West Howai Bari.

Ward: Medicine Ward.

C. R. No: 70540

Date of Admission: 21/11/2023, 10:37 AM

Diagnosis: Anaemia

Informants: Patient’s family members.

Date of care started: 21/11/2023

Date of care ended: 23/11/2023

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3. CHIEF COMPLAINS WITH DURATION:

He was admitted to the hospital with the complaints of generalized weakness, drowsiness,
breathing difficulty, mild fever, cough.

4. HISTORY OF PRESENT ILLNESS:

Present Medical History:

My patient was admitted in Male Medicine ward of AGMC & GBP hospital on 21/11/23,
with a complaint of generalized weakness, drowsiness, headache, mild fever, cough and On
further investigation from the family members accompanying the patient, it was found that
the patient had HTN. On the day of his admission, he complained of generalized weakness,
drowsiness, breathing difficulty, mild fever, cough.

Present Surgical History:

Nothing significant.

5. HISTORY OF PAST ILLNESS:

Past Medical History:

He had HTN for last 2 years. He had past history of hospitalization due to increased blood
pressure.

Past Surgical History:

Patient is not having any significant history of surgery.

6. FAMILY HISTORY:
Types of Family: Nuclear

No. of family members: 5(five)

History of Illness: There is no any history of illness in his family.

Relationship among the family members: Good.

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Family Chart:

Sl. Name of the Age/ Relation Educatio Occupation Marital Health

No. family Gender with n status Status
members patient
1. Mr. Priyatosh 65 years Self Madhyamik Businessmen Married Unhealthy
Debnath. Male passed

2. Mrs. Namita 59 years Wife VIII passed House wife Married Healthy
Debnath. Female

3. Mr. Rajib 35 years Son BA passed Businessmen Married Healthy

Debnath. Male

4. Mrs. Kajal 27 years Daughter- XII passed House wife Married Healthy
Debnath. Female in- low
5. Mr. Tuhin 5 years Grandson Student Student Unmarried Healthy
Debnath. Male

Family Tree:

Key points

-Death Female

-Male patient

-Female

Mr. Priyatosh Debnath Mrs. Namita Debnath -Male

(Patient, 65 yrs) (Wife, 59 yrs)

Mr. Rajib Debnath. Mrs. Kajal Debnath.

(Son, 35 yrs) (Daughter, 27 yrs)

Mr. Tuhin Debnath.

(Grandson, 5 yrs)
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7. PERSONAL HISTORY:
Nutritional Status: Undernourished
Habits: He is having the habit of bidi smoking and pan
Hygiene: Maintained properly
Allergens: He is not having any allergic reaction from anything.
Sleeping Pattern: He is having the habit of sleeping for 5-6 hours.
Bowel and Bladder Pattern: He passes stool and urine according to his body requirement.
Activities of Daily Living: Dull due to illness.

8. SOCIO-ECONOMIC HISTORY:
Head of the family: Mr. Narayan Ghosh.
Income: Approximately Rs. 20000/- per month
House Type: Pucca
Location: Urban
Water supply: Tap water
Electricity: Available
Ventilation: Good
Sanitation: Pucca
Drainage System: Pucca

9. PHYSICAL EXAMINATION:
Height: 145 cm.

Weight: 52 kg.

VITAL SIGNS:

Vital Signs Patient’s Value Normal value Remarks

Temperature 97.8 F 98.6 F Normal
Pulse beats/min. 60-100 beats/min Normal
Respiration 32 breaths/min. 16-24 breaths/min Increase
Blood Pressure 110/70 mm-Hg. 120/80 mm-Hg. Normal
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GENERAL APPEARANCE:

Body Built: Moderate

Nourishment: Under nourished

Appearance: Dull

Health: Unhealthy

Activity: The patient is not able to do regular activity

MENTAL STATUS:

Look: Patient looks anxious and dull.

Orientation: Patient is oriented

Judgement: Judgement is good.

POSTURE:

Body curves: No kyphosis, lordosis, scoliosis is present

Movement: Patient is having weakness and drowsiness.

SKIN:

Colour: Brown

Texture: Dry

Temp.: 97.80 F

Pigmentation: Absent

HEAD TO TOE EXAMINATION:

HEAD:

Scalp: Dandruff is not present and there is no lesion/wound in scalp.

Hair distribution: Equally distributed

Hair colour: Grey

Hair texture: Thin

EYES:

Eyebrows: Look symmetrical

Eyelids: No edema, lesions are present

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Eyelashes: Normally distributed, there is no sty, infection

Conjunctiva: Pale
Sclera: Pale
Cornea: Corneal ulcer absent
Pupillary Reaction: Reacted to light
Vision: Hyperopic (near objects are blurry)
Use of glasses: Uses spectacles for last 5 years.
NOSE:
External nose: There is no discharge
Nostrils: Nasal flaring absent
Nasal Septum: No deviation is there
Patency: Normal
Sense of Smell: Cannot assess
EARS:
External ear: There is no any abnormality and discharge
Placement: Bilaterally symmetrical
Shape and size: Normal
Hearing ability: Normal
Use of hearing aids: Nothing significant
MOUTH AND THROAT:
Lips: Dry
Odour of the mouth: Halitosis present
Gums: No gingivitis,
Teeth: Discolouration of teeth & dental carries is present
Throat and Pharynx: There is no redness and enlargement in tonsils

NECK:

Lymph Nodes: There is no any enlargement in lymph node

Thyroid Gland: No enlargement

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Range of Motion: Patient can’t perform active ROM

CHEST:

Inspection:
Shape & Symmetry: Normal
Respiratory rate: 32 breaths/min.
Movements: Normal
Palpation:
There is no enlarged lymph nodes in the breast

Percussion:

There is no fluid accumulation in the chest

Auscultation:
Breath Sound: Wheezing sound present.
Heart Sound: S1 and S2 sound heard.

ABDOMEN:

Inspection: There are no skin rashes, scar mark, lesions, and ascites. Abdominal
distension is present.
Auscultation: Bowel sound auscultated
Palpation: No organomegaly, splenomegaly found.
Percussion: There is no fluid accumulation.

EXTREMITIES:

Upper extremities: Syndactyl and polydactyl absent, there is no clubbing of fingers.

Lower extremities: Syndactyl and polydactyl absent, there is no clubbing of fingers.
Range of Motion: Patient can’t perform active range of motion due to generalized
weakness and drowsiness.
BACK:
 Spine continuity normal, no kyphosis, lordosis, scoliosis present.
 There is no decubitus ulcer.

GENITALS AND RECTUM:

Infection: No infection
Secretion: Absent
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Haemorrhoids: Absent.

12. INVESTIGATIONS:
Sl. Name of the Investigation Patient’s value Normal Value
No
.
01. Serum Urea 26 mg/dl 15-40 mg/dl
02. Serum Creatinine 0.9 mg/dl 0.6-1.5 mg/dl
03. SGPT (ALT) 20 IU/L 5-40 IU/L
04. SGOT (AST) 30 IU/L 5-40 IU/L
05. Serum Alkaline Phosphate(ALP) 127 IU/L 50-280 IU/L
06. Serum Na+ 130 mEq/L 135-145 mEq/L
07. Serum K+ 4.6 mEq/L 3.5-5.5 mEq/L
08. Blood glucose (Fasting) 108 mg/dl 90-110 mg/dl
09. Blood glucose (Post Prandial) 120 mg/dl 80-140mg/dl
10. Hb% 5.6 g/dl 13.0-17.0 g/dl
11. Uric acid 6.1 mg/dl 3.5- 7.2mg/dl
12. Chloride 94.8 mmol/L 98-107 mmol/L
13. Neutrophil 71% 40-60%
14. Lymphocyte 26% 18-45%
15. Monocyte 01% 2-8%
16. Eosinophil 02% 1-4%
17. Platelet count 1.1 lac 1.5-4 lac
18. HIV Non-reactive
19. HBsAg Non-reactive
20. HCV Non-reactive
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11. MEDICATION:
Sl. Dose, Nurses Responsibility
No. Drug name Action Route
Frequen
cy
1. Inj. Iron Iron sucrose injection is in a class of 20mg  Monitor Bp during
Sucrose medications called iron replacement (Fe)/ml, infusion
products. It works by replenishing iron IV, Stat  Assess for
stores so that the body can make more hypersensitivity
red blood cells. reactions and
anaphylaxis for at
least 30 min following
injection
2. Inj. EPO interacts directly with the EPO 4000 IU,  Assess the general
Erythropoiet receptor on the red blood cell (RBC) Sc, Stat condition of the
in surface, triggering activation of several patient.
signal transduction pathways, resulting  Monitor vital signs.
in the proliferation and terminal  Don’t shake the vial
differentiation of erythroid precursor of Erythropoietin
cells and providing protection from  Don’t administer
RBC precursor apoptosis. Erythropoietin in
conjunction with other
drug solution.
3 Tab. Nodosis tablet is used as an antacid that 500 mg,  Check the diagnosis
Nodosis helps in neutralizing stomach acid Oral, and age of the patient.
during indigestion and heartburn. It TDS  Monitor vitals signs
works by increasing pH in blood and  Check the medication
urine, which corrects metabolic order
acidosis.  Check the conscious
level of the patient
4 Tab. Shelcal It stimulates bone resorption, renal 500 mg,  Monitor vital signs.
tubular resorption. The drug also Oral, OD  Check any
decreases PTH levels and restores bone complication after
mineralization. Elemental Calcium is administering the
an antacid which works by neutralizing medicine.
the acid released in the stomach.
5 Tab. Rantac It reduce the secretion of gastric acid by 150 mg,  Maintain the time.
reversible binding to histamine (H2) Oral, OD  Check any side effect
receptors, which are found on gastric after administering the
parietal cells. This process leads to the medication.
inhibition of histamine binding to this
receptor, causing the reduction of
gastric acid secretion.
6. Tab. IFA An exogenous source of folate is  Maintain vital signs.
required for nucleoprotein synthesis 120 mg,  Assess general
(Iron Folic and the maintenance of normal Oral, condition of the
Acid) erythropoiesis. Folic acid, whether ODPC patient.
given by mouth or parenterally,  Assess side effect
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stimulates the production of red blood after administration of

cells, white blood cells and platelets in medicine.
persons suffering from certain
megaliblastic anaemia.
7. Tab. Dytor This tablet is also used to treat high 20 mg ,  Monitor for
blood pressure . Dytor plus 10 mg Oral, BD dehydration and
tablet is a combination medicine electrolyte imbalance.
containing torsemide and  Check vital signs
spironolactone. This tablet acts by
lowering blood pressure and removing  Assess any side effect
excess fluid from the body. after administration of
medicine.

12. NURSING ASSESSMENT SHEET:-

Problems Need Nursing Diagnosis

 Shortness of breath  Improve the breathing  Impaired breathing pattern related to

pattern
disease condition as evidence by
patient’s verbalization.
 Activity intolerance related to
 Improve the activity level
 Poor activity level
weakness as evidence by patient looks
very dull.
 Poor nutrition  Improve the nutrition  Imbalanced nutrition less than body
pattern
requirement related to disease
condition as evidence by reduce body
weight.
 Dry skin
 Improve the skin condition  Impaired skin integrity related to
dehydration as evidence by patient
feeling itchy.
 Fear and anxiety  Reduce the fear and anxiety
 Fear and anxiety related to disease
level
condition as evidence by patient’s
verbalization.

13. NURSING MANAGEMENT:-

Imogene M King was born on Jan 30, 1923 in West Point, Lowa (Fig. 29.20). She received
her basic nursing education from St John's Hospital School of Nursing in St Louis, Missouri,
graduating in 1945. Her BS in nursing and education with minors in philosophy and
chemistry in 1948 and MS in nursing in 1957 were from St Louis University and her EdDin
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1961 was from Teachers College, Columbia University, New York. She also did postdoctoral
study in research design, statistics and computers.

King had experience in nursing as an administrator, an educator and a practitioner. Her area
of clinical practice was adult medical-surgical nursing. She served as faculty member at St
John's Hospital School of Nursing, St Loyola University, Chicago, Illinois, and the
University of South Florida, Tampa. She was also the director of the School of Nursing at
Ohio State University, Imogene Columbus. She was an assistant chief of the Research Grants
Branch, Division of Nursing. Department of Health, Education and Welfare, in the mid 1960s
and on the Defence Advisory Committee on Women in the Services for the department of
Defense in the early 1970s.

Theory application
Mr. Priyotosh Debnath was admitted for the first time. He was anxious and very weak about
outcome of disease as well as adjusting in new environment. He was fully conscious, alert
and he can do care himself by minimal assistance. So, I applied King’s goal attainment theory
with the mutual understanding of patient and family members while caring him to improve
his health status by setting the goals with both the nurse and the patient’s mutual
understanding.

According to the King’s goal attainment conceptual framework is-

Perception

Judgement
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Nurse

Action Reaction

Interactio Transaction
n

Action Reaction
Perception

Client
Judgement

Feedback
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In my patient’s condition the framework are as following:

Perception Action

Limited activity Advised or

suggest the
Judgement patient to
Patient have the poor participate in
Reaction Interaction Transaction Goal
Nurse nursing care.
activity level related to attainment
patient’s disease Patient agree To improve - Provide
condition. to take care the activity medication Improvement
from the level. . of
nurse. - Provide
- Activity
proper
Perception Action level.
nutrition.
- Self esteem
Patient can’t do work by Patient - Advise to
own self, Patient said express his do light
that “I have no energy, I words and exercise
am very weak”. willingly regularly.
participate in
Judgement
Client the nursing
 Patient said “give me care
some medication
from where I can get
energy”.
 Patient understand
the basic need of
nursing care.
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Assessment Problem Goal Diagnosis Planning Implementation Evaluation

(Perception & identification (Transaction) (Transaction) (Goal
(A + R)
Judgement) (A + R) (A + R) attainment)

Patient’s
perception:-
Patient said “I am
Limited To Activity -Assess the activity level -Assessed the activity Patient’s
improve
suffering anaemia, Activity. the intoleranc of the patient. breathing
feeling weak and I level of the patient.
activity e related pattern are
can’t do work -Provide proper nutrition
properly”.
level. -Provided proper improved
to to the patient. gradually.
nutrition to the patient.
Nurse’s Perception:- weakness
Patient looks very -Administer IV fluid as
weak and he can’t as -Administered IV fluid
per doctor’s order.
work by own self. evidence as per doctor’s order.
-Provide medication as
Patient’s by patient -Provided medication
judgement:- per doctor’s order.
Patient understand the looks very as per doctor’s order.
need of taking care. dull. -Monitor vitals.
-Monitored vitals.
Nurse’s Judgement:- -Limit movement and
Based on the encourage the patient to
-Limited movement
assessment the
do ROM exercise and encourage the
diagnosis of this
problem is, “activity patient to do ROM
intolerance related to
weakness.” exercise.
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Assessment Diagnosis Goal Intervention Implementation Evaluation

- Assess the breathing - Assessed the

Subjective Impaired To improve Patient’s breathing
data: the breathing pattern. breathing pattern. pattern are improved
breathing
Patient pattern. - Check the vital signs. - Checked the vital gradually.
complaint that pattern
he is suffering - Provide comfortable signs.
related to
shortness of position to the patient. - Provided comfortable
breath. disease
- Administer oxygen to position to the patient.
condition as
Objective the patient - Administered oxygen
data: evidence by
Patient can’t - Administer to the patient
patient’s
take breath medication as per - Administered
properly. verbalization
doctor’s order. medication as per
.
doctor’s order.
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Assessment Diagnosis Goal Intervention Implementation Evaluation

Subjective Impaired -Assess the skin -Assessed the skin

data:
skin condition. condition.
Patient said To improve
that “he is integrity the skin
having itching condition. -Provide fruits juice and -Provided fruits juice and Patient’s activity skin
related to
in is skin and more water. more water. condition improve
his skin is so dehydration gradually.
much dry”.
as evidence
-Administer IV fluid as -Administered IV fluid as
per doctor’s order. per doctor’s order.
by patient
Objective -Provide medication as -Provided medication as
feeling itchy
data:
Patient’s skin per doctor’s order. per doctor’s order.
looks very
dry. -Monitor vitals. -Monitored vitals.
-Provide some -Provided some
moisturiser to the patient. moisturiser to the patient
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Assessment Diagnosis Goal Intervention Implementation Evaluation

Subjective Imbalanced Improve the -Assess the nutrition level -Assess the nutrition level
Patient’s nutrition
data: nutrition of the patient. of the patient. pattern improve
nutrition
Patient said pattern. gradually.
that “I look less than -Provide proper nutrition -Provide proper nutrition to
slimmer that I the patient.
body to the patient.
was before
and my requirement -Instruct the patient to -Instruct the patient to avoid
weight also
related to avoid junk foods. junk foods.
reduce day by
day”. disease
-Check the weight of the -Check the weight of the
condition as patient.
patient.
Objective evidence by
data: -Administer IV fluid to -Administer IV fluid to the
reduce body
Patient looks patient.
the patient.
dull and weight.
weak. -Provide iron rich diet to -Provide iron rich diet to the
patient.
the patient.
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14. NURSES NOTE:-

Sl. Date Time Activity Performed Remarks
No
.
01. 21/11/23 9am-  Bed making done. Gain knowledge
1.30pm  Maintained good IPR with the about the patient’s
patient’s family members. condition.
 Monitored vital signs.
 Administered medications.

02. 22/11/23 9am-  Bed making done.

1.30pm Gain little
 Monitored vital signs.
knowledge about
 Administered medications.
his disease &
 Provided health education about the
treatment process.
disease and treatment process.

 Bed making done.

03. 23/11/23 9am- Patient’s relatives
 Monitored vital signs.
1.30pm feel comfort.
 Provided back care.
 Provided psychological support to the
patient party.
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15. HEALTH EDUCATION:

Regarding dietary management:

To lower the risk of stroke, follow these guidelines:
 Avoid oily fast foods and eat a variety of foods.
 Maintain a healthy weight by balancing the calories with physical activity.
 Choose more whole grains, vegetables and fruits.
 Provide iron rich diet, protein rich diet.

Regarding home management:

 Advised to the patient’s family members to give proper nutrition in home.
 Advised to the family members at least one member stay with the patient every time.
 Advised the family to make good communication with the patient.
 Advised the family members to give psychological support to the patient.

Medication:

 Advised the patient relatives to give medicine at proper time without forgetting.
 Encouraged the patient relatives to complete the full dose as ordered by the
physician/surgeon and to encourage him to promote activity level.

Follow up care:

 Advised the patient relatives to bring the patient for regular check-up.
 Advised the family members to provide physical, psychological support to the patient.
 Encourage the patient relatives to provide a quiet and calm environment.
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16. Journal:

Anaemia epidemiology, Pathophysiology, and etiology in low- and

middle-income countries
Camila M. Chaparro

Abstract

Anemia affects a third of the world’s population and contributes to increased morbidity and
mortality, decreased work productivity, and impaired neurological development.
Understanding anemia’s varied and complex etiology is crucial for developing effective
interventions that address the context-specific causes of anemia and for monitoring anemia
control programs. We outline definitions and classifications of anemia, describe the
biological mechanisms through which anemia develops, and review the variety of conditions
that contribute to anemia development. We emphasize the risk factors most prevalent in low-
and middle-income countries, including nutritional deficiencies, infection/inflammation, and
genetic hemoglobin disorders. Recent work has furthered our understanding of anemia’s
complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the
role of inflammation and infection. Accumulating evidence indicates that the proportion of
anemia due to ID differs by population group, geographical setting, infectious disease burden,
and the prevalence of other anemia causes. Further research is needed to explore the role of
additional nutritional deficiencies, the contribution of infectious and chronic disease, as well
as the importance of genetic hemoglobin disorders in certain populations.

Keywords: anaemia, iron deficiency anaemia, nutritional anaemia, anaemia of inflammation

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17. CONCLUSION:-
As per my clinical posting I had posted in the Male Medicine ward and during my posting I
got a patient with Anaemia. I have given care as per the need of the patient and it will help
me to deal with the same kind of patient in future.
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17. REFERENCES:
Book:

 Nettina SM. “LIPPINCOTT MANUAL OF NURSING PRACTICE”. 10 th ed. New

Delhi: Wolters Kluwer (India) Pvt Ltd; 2013. P. 212-220
 Hinkle JL, Cheever KH. “Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing”. New Delhi: Wolters Kluwer (India) Pvt Ltd; 2019. P.185-193
 Medical Surgical Nursing: A NURSING PROCESS APPROACH. Volume 1. 1 sted.
New Delhi: The Trained Nurses’ Association of India; 2013. P.275-282
 Chintamani. Mani M, Lewis SL, Heitkemper MM, Dirksen SR, O’Brien PG, Bucher
L editors. “Lewis’s MEDICAL-SURGICAL NURSING". New Delhi: Elsevier India
Pvt Ltd; 2011. P. 552-560

Journal:

 Camila M. Chaparro. Anaemia epidemiology, Pathophysiology, and etiology in low-

and middle-income countries . Journal; 2019 Apr 22. Available from:

https://pubmed.ncbi.nlm.nih.gov/31008520/
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Tripura institute of paramedical sciences

Ward:- Male medicine
Subject: ADVANCED NURSING PRACTICE

Care plan on:- Anaemia

SUBMITTED TO SUBMITTED BY
MRS. GARGI MAITY BHOWMIK MS. JOYSREE BOSE.
ASSOCIATE PROFESSOR M.SC (N), 1ST SEM.
(DEPT. OF MEDICAL SURGICAL NURSING) ROLL NO:- 07.

DATE OF SUBMISSION: 13/12/2023.