Академический Документы
Профессиональный Документы
Культура Документы
Religion : Hindu
Caste : Gowda
Date : 25/01/06
B. ECONOMIC STATUS:
House : Rented
Land : Nil
Main Occupation : Son is working as a clerk
Income of the family: Rs. 2,500/- month
C. RELATIONSHIP OF MEMBERS:
Family Members : There is healthy family relationship between family
members
D. DECISION MAKING:
Whole family member together and taking decision for all the family
matters.
E. NUTRITION PATTERN:
Food is being prepared by Mrs. Saraswathi separate diabetic food for Mrs.
Sarojamma. They are cooking 3 times a day. There is no separate kitchen.
They are taking both vegetarian and non – vegetarian foods. Monthly three or
four times they are taking non – vegetarian food. There is no separate kitchen
garden. They are cooking the food very hygienically. The nutritional status of
the mother and child is moderate. Mrs. Sarojamma having some beliefs
regarding food habits.
A. HOUSING:
Katcha house
Roof - cement sheet
Wall - Bricks
Floor - Mud
No. of rooms - 1
There is no separate kitchen
They are not having any domestic animals
Accidental Hazards:
There is a very big open drainage system in front of their house.
B. SANITATION:
1) There is no adequate light or ventilation in their house. There is electricity
in their house. They are disposing the waste in waste box, they are using
common latrine.
Water supply:
They are getting water from public tap.
Presence of insects:
There are mosquitoes, flies, and stray dogs.
PHYSICAL EXAMINATION
General Examination:
Name : Mrs. Saraswathi
Age : 30 years
General Appearance : Dull, moderately nourished
Body built : moderately built
Activity : Active
Posture:
Body curve : No lymphosis, lordosis, scoliosis
Movements : All range of motion is possible
Skin condition:
Colour : Dark in complexion
Texture : Firm
Lesions : No lesions seen
Temperature : Warm
Vital Signs:
Temperature : Normal
Pulse : 80 / mt
Respiration : 22 / mt
B.P : 130 / 80 mm Hg
Ears:
External ears : No discharge
Hearing : Normal
Nose:
External hares : No cuts or discharge
Nostrils : No inflammation of mucous membrane
Neck:
Lymph nodes : Not enlarged or palpable
Thyroid gland : normal
Range of motion : All range of motion is possible
Chest:
Thorax : Symmetrical movement
Breath sound : Normal, bilateral air entry
Heart sound : Normal
Breast:
No lumps felt on palpation
Abdomen:
No scar, or ascites
No enlargement of liver or spleen
Back:
Spine and curvature : No abnormalities noted
: No lumps or lesions
Symmetry : No abnormalities
Movement : All movements are possible
Tenderness : No tenderness detected
Genitalia:
Normal female genitalia
No abnormal discharge
Upper Extremities:
No deformities noted, no swelling edema
No muscle waisting
No lymph nodes enlargement
Normal range of motion possible
Blood Vessels:
All peripheral pulse are felt
Fingers:
No abnormalities, grip strength is good
Nails:
No cyanosis
No dryness or lesion
Lower Extremities:
Both lower extremities
No deformities
No edema
No muscle waisting
Lymph nodes not palpable
All range of motion possible
Nervous System:
Higher function : Conscious, coherent, answer to all questions
relevantly
3) Dietary History:
Non vegetarian
4) Family History:
type of Family : Nuclear family
disease : No illness
6) Obstetrics History:
LMP : 06/06/05
EUD : 13/03/06
7) Menstrual History:
age of puberty : 13 years
Menstruation : Regular
Flow : Normal / 3 days
8) History of previous pregnancies:
Number of pregnancy : 2
Date of delivery : 02/02/02
Full term : Yes
Weight at birth : 28 kgs
Condition during pregnancy: Normal
Condition during labour : Normal
Nature of labour : Normal
Nature of pure : Normal
9) Investigations:
Urine : Albumin / Sugar – Normal
Blood : Hb 12 gms
Weight : 55 kgs
BP : 120/80 mm of Hg
Height : 150 cms
Medication:
Tab. Calcium T od 15 days
Tab Iron and folic acid T od x 15 days
Action:
For the growth and development of the foetus for the formation of bones,
teeth and hair for increase RBC in the blood and prevention of anemia.
Nursing Diagnosis:
1) Explains the mother the importance of personal hygiene and taking rest
2) Altered nutritional status to increase body requirement and growth and
developments of the foetus
3) Explains the mother the importance of regular check up
4) Explains the mother about taking care of the baby
5) Explains the mother about small family norm
APPLICATION OF SISTER CALLISTA ROY’S ADAPTATION
THEORY:
Sister Callista Roy began her model and expanded from 1970 to the
present. She focused individual as a bio psychosocial adaptive system and
describe nursing as a humanistic discipline that places emphasis on the persons
own coping abilities. The model contain five essential elements:
Systems:
A system is a set of units related or connected as to form a unity or whole
and characterized by input, output, control and feed back processes.
Input is defined as stimuli which can come from the environment or from
with in a person.
Stimuli are:
1) Focal – immediately confronting the person
2) Contextual – all other stimuli that are present
3) Residual – non specific such as cultural beliefs or attitude about illness
Adaptation level:
Range of stimuli to which a person can adapt easily, each person’s
adaptation level is unique and constantly changing.
Coping Mechanisms:
These are processes or behaviour patterns that a person uses for self-
control. These are of two types.
1) Regular: It include input stimuli can come from the external environment
or from with in the person. Internal process includes chemical, endocrine
stimuli.
Assessment of stimuli:
Focal - Pain in the back and the leg due to pregnancy
Residual - Anxious due to pregnancy