Nursing Care Plan For Pericarditis

Nursing Care Plan On Pericarditis

[1]. Patient Identication Data -

Patient Name: Raju Sharma

Age: 30yr
Sex: Male
I.P No.: 2210
Unit: Cardiac Unit
Bed No. : 9
Address: H22 Ganesh Nagar, Kota Rajasthan
Religion: Hindu
Language Know: Hindi
Marital Status: Married

(A). History of Present Illness -

Chief Complain: Chest Pain, Dyspnea, Excessive Sweating, Fever.

Present History of Illness:
Patient Presented With Acute Onset Chest Pain Associated With Shortness of Breath And Excessive Sweating, Which Started Suddenly. Fever Was Also Reported.
Duration: Symptoms Present Since 2 Days.

Provisional Diagnosis: Pericarditis

(B). Past Medical History -

Past History of Illness:
No Known History of Chronic Illness Such As Hypertension, Diabetes, Asthma, or Tuberculosis.

History Of Hospitalization: No Previous Hospital Admissions Reported.

Diagnosis: Present Admission Suspected For Acute Pericarditis / Cardiac-Related Chest Pain.

Treatment:
Patient Started On NSAIDS (Ibuprofen/Aspirin) For Chest Pain And Inflammation.
-         Colchicine Given To Reduce Pericardial Inflammation.
-         Antipyretics (Paracetamol) For Fever.
-         Oxygen Therapy To Maintain Adequate Oxygenation.

(C). Past Surgical History -

History Of Any Surgery (If Yes, Name Of Surgery):
No History of Previous Surgery Reported

Post Operative Duration: No History
H/O Accident or Blood Transfusion:
No History of Accident Or Blood Transfusion.

[2]. Health History of The Family -

S/N	Name	Relationship With Patient	Age And Sex	Education Status	Occupation	Health
1.	Ram Sharma	Father	58, Male	10 Pass	Shopkeeper	Healthy
2.	Suman Sharma	Mother	55, Female	10 Pass	Housewife	Healthy
3.	Priya Sharma	Wife	28 ,Female	12 Pass	Housewife	Healthy
4.	Rohan Sharma	Brother	25, Male	Graduate	Student	Healthy

(A). Family Tree -

[3]. Socioeconomic Data -

Occupation: Factory Worker
Salary: : ₹18,000 per month
Type of House: Pucca House
Water Supply: Municipal Tap Water
Pet And Domestic Animals: None

[4]. Personal History -

Immunization: Up To Date As Per Schedule
Smoking: Yes (2–3 Cigarettes/Day)
Alcohol: Occasional
Use Of Drugs: No
Hobbies: Watching TV, Music

[5]. Head To Toe Examination -

(A). Physical Assessment -

General Appearance: Well Built
Behavior: Alert And Cooperative

(B). Skin -

Color: Normal
Turgor: Normal

(C). Head -

Scalp: Clear
Any Abnormalities: None

(D). Face -

Pluffiness/Wrinkles/Scar: No Pluffiness, No Scar

(E). Eye -

Surgery: No
Blurring/Burning: No
Inflammation: No
Color Of Conjunctiva/Sclera: Conjunctiva Pink; Sclera White
Visual Acuity: Normal

(F). Ear -

Hearing Ability: Good
Ear Discharge: No

(G). Nose -

Septal Deviation: No
Allergic Rhinitis: No
Nose Bleeding: No
Sense Of Smell: Normal
Sinus Inflammation: No

(H). Throat And Mouth -

Difficulty In Swelling: No
Condition Of The Lips: Moist And Pink
Tongue: Moist
Sense Of Taste: Normal
Stomatitis: No

(I). Neck -

Color: Normal
Symmetry: Symmetrical
Any Enlargement: No Thyroid or Lymph Node Enlargement

(J). Respiratory System -

Cough: Occasional
Dyspnea: Present on exertion
Activity Intolerance: Present
Chest Pain: Present
Hemoptysis: No
Respiratory Rate: 22 breaths/min

(K). Abdomen -

Distended: No
Ascites: No
Peristalsis: Present
Umbilicus: Normal

(L). Liver -

Palpable: No
Tenderness: No

(M). Cardiovascular System -

Chest Pain: Yes
History of Cardiac Disease: No Known History
B.P: 140/90 Mmhg
Heart Rate: 102 Beats/Min (Tachycardia)
Edema: No
Cyanosis: No
Numbness: No
Extremities: Warm, No Cyanosis

(N). Nutrition -

Veg/Non-Veg/Mixed: Mixed Diet
Anemia: No
Appetite: Decreased
Usual Time For Meals: 3 Times/Day
Amount of Fluid/Day: Approx. 1.5 Liters
Anorexia: Mild
Vomiting: No
Heart Burn: Occasional
Body Weight: 62 Kg
Weight Loss: Mild (2–3 Kg In Last Month)

(O). Hygiene -

Kind Of Bath: Daily Bath
Dental And Mouth Care: Once Daily

(P). Elimination (Bowel) -

No. of Stool: Once/Day
Time of The Day: Morning
Use of Laxative: No
Constipation: No
Diarrhea: No
Melena: No
Ostomies: None
Hemorrhoids: No

(Q). Reproduction -

Pregnancies: Not Applicable
Children: No
Last Pap Smear Test: Not Applicable (Male)
Bleeding: No
Vaginal Discharge: Not Applicable
Breast Self Examination: Not Applicable
Prostate Enlargement (In Male): No Symptoms Reported

(R). Neurological -

Syncope: No
Confusion: No
Convulsion: No
In-Coordination: No
Headache: Yes (Mild, Due To Fever)
Feeling Of Cold And Hot: Yes (Temperature Fluctuations Due To Infection)

[6]. Investigation -

S/N	Test	Patient Value	Normal Value	Remark
1.	ECG	St-Segment Elevation / Pr Depression	Normal ECG Pattern	Suggestive Of Pericarditis
2.	EST	45 Mm/Hr	0–20 Mm/Hr	Elevated → Indicates Inflammation
3.	CRP	Positive / Elevated	Negative	Indicates Inflammatory Process
4.	Troponin I	Mildly Elevated	< 0.04 Ng/Ml	May Increase In Pericardial Inflammation
5.	Echocardiography	Mild Pericardial Effusion	No Fluid	Supports Diagnosis Of Pericarditis

[7]. Medical Diagnosis (Final Diagnosis) - Pericarditis

[8]. Diet Plan -

Types Of Diet Plan Required/Advised.

-Cardiac Diet (Low Fat, Low Salt Diet)
-High-Protein Diet → To Support Recovery
-High-Calorie Diet → For Weakness And Weight Loss
-Plenty Of Fluids (2–3 Liters/Day) Unless Restricted
-Avoid Spicy, Oily, Fatty Foods
-Avoid Caffeine And Alcohol
-Frequent Small Meals To Maintain Energy
-Fruits And Vegetables Rich In Antioxidants

Diet Instructions:

-Salt Intake < 2 Grams/Day
-Prefer Boiled, Steamed, Grilled Foods
-Include Whole Grains, Legumes, Lean Meat, And Fish
-Avoid Red Meat, Fried Items, Packaged Food
-Encourage ORS/Fluids Due To Fever

NURSING CARE PLAN -