BHARATI VIDYAPETH UNIVERSITY: COLLEGE OF NURSING

MSc NURSING FIRST YEAR : 2008-09

ADVANCE NURSING PRACTICE
NURSING PROCESS
HISTORY TAKING:
Name of the patient:Mr Choudhari Kisan Sukaram
Name of the student: Mr.Jom Geo
Age :61 yrs
Sex:Male

Date of data collection:07-08-08

Address: A/P Majaruvadi, Bher Taluk, Pune.

Diagnosis: Left Hemiplegic

Marital status :Married

Date of admission:1-08-08

Marital status :Married

Occupation status: Retired
Religion: Hindu
Occupation: Retired
Family Income:10,000/month
PATIENTS COMPLAINTS:
Mr.Choudhari got admitted with the complaint of weakness at left half of the body, Giddiness,
Vomitting and slurred speech at 7am on the date of admission.

SOCIO-ECONOMIC STATUS:
Patient is living in joint family with 7 members. They are getting monthly income of Rs.10, 000
and he follows all religious practices. He is the head of the family.

HISTORY OF PRESENT ILLNESS:

Patient got admitted in ICU with the complaint of giddiness, vomiting, and left side weakness
His blood pressure was elevated by 150/100mmHg.Due to increased blood pressure, there is
an intracranial bleed of 4.8x 3.2 cm in ganglia capsular area, including all ventricles. And a
midline shift of 0.6cm. He got diagnosed as hemiplegia.

PAST MEDICAL HISTORY:

Mr.Choudhary had hypertension and not taking any medicine. There is no history of major
injuries , accidents, food and drug allergies. No past surgical history.

MEDICATION HISTORY:
Name of the
drug

Dosage

Route Frequency Duration

1.Inj.mannitol

100mg

IV

TID

7th day

2.Tab.Amplodipine

2.5mg

Oral

OD

7th day

Oral

OD

Oral

OD

3.Tab.Homocheck

4.Tab.Folvit
5.Raslet

5mg

Oral

HABITS:
No Habit of smoking, alcohol and tobacco.

Timing
6am-2pm10pm
10am

FAMILY HISTORY OF ANY ILLNESS:

There is no significant of illness in his family.
SELF-PERCEPTION-SELFCONCEPT PATTERN:
Mr.Choudhary maintains eye contact. His voice and speech pattern is altered.
Patient is not able to maintain normal body posture and movemen.Patient is
drowsy and arousal and not respond to vocal commands. He is responding to
pain stimulus. He has impulsive behavior.
SEXUAL REPRODUCTIVE PATTERN:
Mr.Choudhary has disturbed sexual pattern.
COPING STRESS TOLERANCE:
Patient has decreased tolerance to stressful situation and poor self control.

VALUES AND BELIEVES:

He is unable to follow the values and believes to made decision.

FUNCTIONAL HEALTH PATTERN:

HYGIENE:
He is unable to maintain personal hygiene.

DIETIC HISTORY:
He takes only vegetarian food. He is on Ryles tube feeding and only liquid diet is
recommended.

HEALTH PRACTICES:
He is unable to follow any health practices.
II.PHYSICAL EXAMINATION:
GENERAL APPEARANCE: He looks old aged,weak , not aware of his
personal appearance, emotional liability, moderately nourished, poor

hygiene, hemiplegic, moderate body build. Abnormal gait, mobility and

speech oriented to environment and maintain proper eye contact.
Height:

Weight:

VITAL SIGNS:
Temperature: 98degree F

Pulse:80 beats/min

Respiration:18 breaths/min

Blood pressure:150/90mmHg

HEAD:
Scalp: No dandruff and lice.
Face: facial symmetry is equal.
Sinus areas: No tenderness and inflammation
Cranium: No head injury
EYES:
Visual acuity: not checked

Visual fields: Blurred vision

Ocular movement: Normal

Convergence lids: Normal

Lacrimal glands: No edema and pain.

Conjunctiva: No discoloration

Sclera: no discoloration

Cornea: Normal

Lens and media: No spectacles

Pupils: reacting to light

EARS:
External structures: No edema ,pain.

Ear canal: Wax present, pinkish.

Tympanic membrane: Intact

Hearing: Normal

NOSE:
External structure: No deviation

Septum: No septal deviation

Mucus membrane: Moist and reddish

Patency: Clear

Olfactory sense: Present

ORAL CAVITY:
Lips: Pink&Dry

Buccal mucosa: Dry ,White&No lesion.

Gums: Pink&dry

Teeth: No dental carries

Palate and uvula: In center &freely movable.

Tonsilar areas: Pink small.
Tongue: Coated tongue

Taste: Not present

Breath: Halitosis present

NECK:
General structure: Limited ROM

Trachea: Midline

Thyroid: No enlargement

Nodes: Not palpable

Muscles: No tenderness
BREASTS AND NODES:
Inspection: No gynecomastia
Palpation: No enlargement
CHEST AND RESPIRATORY SYSTEM
Chest shape: Barrel shape
Type of respiration: On nasal probe

Chest expansion: Equal chest expansion.

Fremitus: Mild vibratory sensation is present.

General palpation: Symmetrical expansion, no tenderness and normal breathing

pattern.
Percussion: Resonance sound present.
Breath sound: Bronchovesicular and vesicular sounds heard over the chest.
Adventitious sound: Not present.
CARDIOVASCULAR SYSTEM
Rate & Rhythm: Radial-80 beats /min & normal
Apical- 82 beats/min & low pitch sound heard.
Precordium: Visible pulsation is not present during inspection.
No pulsation is present during palpation.
S1, S2 heard during auscultation.
Other sounds: not present during systolic and diastolic auscultation.
Carotid Arteries: Bilaterally equal.
Jugular vein distension: Absent.
Description of peripheral pulses:
Brachial

Radial

Femoral

Popliteal

Dorsalis
pedialis

Post tibial

80bpm,equal 80bpm,equal 78pbm,equal 78equal,

bilateral
bilateral
bilateral
bilateral

78equal,
bilateral

78bpmequal,
bilateral

ABDOMEN AND INGUINAL AREAS:

Contour and tone: Symmetrical.
Scars and marks: Not present.

Liver: Not palpable.

Spleen: Not palpable.
Kidney: Not palpable & no tenderness.
Bladder: Not palpable.
Hernia: Not present.
Masses: Not palpable.
Palpation: Soft, relaxed and no tenderness.
Percussion: Dullness present.
Auscultation: Bowl sound heard.
GENITALIA AND AREA NODES:
Not palpable
RECTAL EXAMINATION:
No hemorrhoids and fistula is observed.
MUSCULOSKELETAL SYSTEM:
Gait: Impaired gait.
Upper Extremities: Firm, Strengh & normal tone
Lower Extremities: Firm, Strengh & normal tone
Deformities: Not present.

Joint Evaluation:
Muscle strength: Present
Range of motion: Present

 SPINE
Contour: Normal contour.
Position: Asymmentry.
Motion: Normal range of motion.
NERVOUS SYSTEM
Mental status: Not oriented to time and place, Conscious, loss of memory.
Language: Slurred speech.
Cranial nerves: Normal.
Motor co-ordination:
Upper extremities: Equally bilateral
Lower extremities: Equally bilateral
Involuntary movements: present.
Deep tendon reflexes: Present.
Sensory:
Light touch: No response.
Pain: Responds.

SPINE
Contour:
Position:
Motion:
NERVOUS SYSTEM
Mental status:
Language:
Cranial nerves:
Motor co-ordination:
Upper extremities:
Lower extremities:
Involuntary movements:
Deep tendon reflexes:
Sensory:
Light touch:
Pain(pin prick)
Position:

MEDICATION PRESCRIBED:
S/
N

Drug name

1.

Mannitol

2.

Homochell

Prepara Dosag Route

tion
e
injection 100mg IV

Action

Side
effect