SISTER NIVEDITA GOVT.

NURSING COLLEGE

                              I.G.M.C., SHIMLA

SUBJECT – MEDICAL SURGICAL NURSING

NURSING CARE PLAN

ON

TAKAYASU ARTERITIS

SUBMITTED TO:                                  SUBMITTED BY:

    MADAM SUNITA VERMA                                   BANDANA DEVI
     LECTURER- Med.Sug.Nsg       MSc (N) 1st yr                      
   SNGNC, IGMC SHIMLA  SNGNC, IGMC,SHIMLA

                                   SUBMITTED ON:

                                                 24 -FEB 2020

IDENTIFICATION DATA
  Name = Ashmita
 Age = 23 years
 Sex = female
 CR. No. = 20206693089
 Marital Status = Married
 Ward/Bed No = Cardiology / Bed No-4
 Address = Vill. Darlaghat Distt. Solan H.P.
 Religion = Hindu
 Education = 8th Pass
 Occupation = Housewife
 Date of Admission = 12-02-2020
 Date of Discharge = Not planned yet
 Consultant = Dr.
 Diagnosis = Takayasu arteritis

CHIEF COMPLAINTS:
On Admission: Patient was admitted in the hospital with chief complaints of:
 Chest Pain ×1months
 Shortness of breath ×1 months
 Restless on doing activities of daily living × 1 months
 Case of Young hypertension × 2 years

On Assessment: (13/02/2020) On assessment patient is having

 Hypetension (B.P. 160/110 mm of Hg)
 Intermittent claudication
 Restless on doing activities of daily living

History of Present illness: The patient was apparently well 2year back and there were no signs and
symptoms present in patient. But patient had blunt trauma in chest and after that she had shortness of breath,
weakness in extremities, fatiguability, and restlessness, tingling sensation in extremities few months back
but had no any checkup. On 12/02/2020 patient came I.G.M.C and Hospital for checkup. At that time patient
vitals are checked and get all the tests done. Patient is having complaint of lower extremity edema,
intermittent claudication and also inflammation of aorta and its branches. Patient is diagnosed Sepsis with
septic shock.
Present surgical history: There is no any surgery planned for patient till now.
History of Past illness: Patient is having history of
 Chest pain×2 year
 No history of diabetes, and ATT intake

Past surgical history: Patient had not any past surgical history.
Family History: In the family there is
 No history of diabetes .
 No history of hypertension.
 No history of hypothyroidis.
 No history of ATT intake.
Family tree:
 Bheem singh Ashmita
Age 26 years Age 23 years

Nikhil
Age 2 years

Type of family: Joint family KEY

Male
No. of family members: 03
Female

Married

Patient

Death

Sr. Name Age Relations Education Occupation Marital Health status

no. (Yrs hip with status
) patient
1 Ashmita 23 Patient 8th pass Housewife Married Unhealthy
2 Bheem 26 Husband 10th Shopkeeper Married Healthy
Singh
3 Nikhil 2 Son -- -- -- Healthy
Personal and Social History:-
 Health Facility Near home: Civil Hospital, Hamirpur
Type: Government
Distance from home: 3 kms
Transportation facility: Yes
 Housing: Owned
Type: Pucca
No. of Rooms: 2
Toilet: Indian
Electricity: Yes
Drinking water source: Tap Water
 Personal Hygiene: Maintained
Oral Hygiene: Maintained
Diet: Non- Non Vegetarian
Sleep and rest: Patient used to sleep 8 hours/day.
Elimination: Normal pattern
 Mobility and Exercise: Regular walking habits
  Substance Use:
Alcohol: Not alcoholic
Drugs: No drug abuse
 Sexual & Marital History: Spouse: General Health: Good
Relationship: Satisfactory
Staying: Together

PHYSICAL EXAMINATION
General status
 Nourishment: Patient is under-nourished.
 Body build: Patient body build is average.
 Look: Patient looks anxious and worried.
 Health: Patient is unhealthy.
 Activity: Patient activity level is reduced
 Gait: Normal
 Foul body odour: Not present
 Weight: 40 kg
 Height: 5’5

Mental status:
 Consciousness: Patient is conscious

Vital signs:
 Temperature: 98.70 F
 Radial pulse: 58 b/min
 Respiration: 22 b/min
 Blood pressure: 160/110 mm of Hg
Skin:
 Color: Patient looks pallor
 Lesions: Not present
 Scars: Not present
 Bruises: Present
 Edema: Not Present
Head:
 Hair color: Black in color
 Scalp: Clean
Eyes:
 Vision: Normal
 Eyebrows: Symmetrical
 Cornea, sclera, conjunctiva are dry
 Papillary response: Pupils are 2mm reacting bilaterally
Ears:
 Symmetry: Symmetrical
 Auditory acuity: Normal
 Abnormal discharge: Not present
Nose:
  Shape: Normal
 No any blockage, polyps, abnormal discharge is present.
 DNS: No septal deviation
Mouth:
 Lips: Lips are dry
 Buccal mucosa: Buccal mucosa is dry
 Teeth: Brown discoloration, dental caries Absent
 Dentures: Absent
 Gums: Swollen
 Tongue: Tongue is dry
Neck:
 Range of motion: normal
 Glands: Not enlarged
Cardiovascular System:
 Inspection: capillary refill: > 3seconds
 Percussion: Pericardial Effusion: Absent
 Palpation: No any swelling
 Auscultation: Heart sounds: Diminished Heart sounds
 Peripheral pulses: Decreased peripheral pulses.
Respiratory System:
 Inspection: Chest shape: Normal
 Symmetry: Symmetrical
 Breathing pattern: Shortness of breath
 Percussion: Pleural effusion absent
 Auscultation: breath sounds normal
Lymphatic System:
 Inspection: No visible lymph node enlargement
 Palpation: No lymphadenopathy
Gastrointestinal System:
 Inspection: Shape: Normal
 Abdominal girth: Normal
 Scar: No visible scar on abdomen
 Distention: Absent
 Auscultation: Bowel sounds: Normal
 Percussion: Ascites: Absent
 Palpation: No any lump is palpated
 Organomegaly: Spleenomegaly: Absent
 Other complaints: Bowel per day: Normal bowel pattern.
Genitourinary System:
 Inspection: no abnormal scar or lesion
 Urine colour and amount: Pale urine
 Palpation: Bladder distention: Absent
Musculoskeletal System:
 Inspection: no Scars.
 Range of motion of upper and lower extremity: normal range of movement in both upper and lower
extremities.
  Muscle tone: Normal
 Palpation: Joint tenderness: absent
Nervous system:
 Level of consciousness: GCS: E4V5M6
 Memory: Intact
 Attention span: Normal
 Reflexes: Normal
 Motor functions: Intact
 Sensory functions: Intact
Integumentary system:
 Complexion: Pale
 Skin turgor: Decreased
 Leisons: absent
 Edema: absent
 Temperature: normal

INVESTIGATION/ DIAGNOSTIC EVALUATION

GENERAL INVESTIGATIONS:
 Complete blood count:
Sr.No. Investigations Normal value Patient’s value Remarks
(Units) 03-12-2019
1 Hemoglobin gm/dl 12-14 11.0 Decreased

2 Platelet counts per 150-400×109 231 Normal

microliter
3 TLC cells/cumm 4000-11000 20000 Increased
4 PT(seconds) 9-12 12.2 Increased
5 INR <1.1 0.89 Normal
6 APTT(seconds) 30-40 27.4 Decreased

 Renal function test:

Sr. Investigations Normal value Patient’s value Remarks
No. (Units) 03-12-2019
1 Potassium (mEq/L) 3.5-4.5 2.8 Decreased
2 Sodium (mEq/L) 135-145 143 Decreased
3 Chloride (mEq/L) 96-110 90 Normal
4 Calcium (mg/dl) 8.2-10 8.5 Normal
5 Phosphorus(mg/dl) 2.5-4.5 mg/dl 3.5 Normal
6 Urea (mg/dl) 7-20mg/dl 13 Normal
7 Creatinine (mg/dl) 0.6-1.2 mg/dl 0.9 Normal

 Liver function test:

Sr.No. Investigations Normal value Patient’s value Remarks
(Units) 03-12-2019
1 SGOT/AST 10-40IU/L 60 Increased
2 SGPT/ALT 10-40IU/L 55 Increased
3 ALP 40-112U/L 120 Increased
4 Protein total (gm/dl) 6-8.5g/dl 6.7 Normal
5 Albumin (gm/dl) 3.5-5g/dl 4.2 Normal
 6 Bilirubin total (U/lt) 0-1mg/dl 0.42 Normal
7 Bilirubin Direct (U/lt) 0-0.35mg/dl 0.12 Normal
8 Bilirubin Indirect (U/lt) 0.2-0.65mg/dl 0.30 Normal

 Thyroid function test:

Sr.No. Investigations Normal value Patient’s value Remarks
(Units) 03-12-2019
1 T3 (ng/dl) 80-180 125 Normal
2 T4 (ng/dl) 0.7-1.9 0.8 Normal
3 TSH (mIU/L) 0.4-4.0 2.8 Normal

SPECIFIC INVESTIGATION:
 ECG: ECG findings showed prolonged PR interval.
 ECHO: EF is 40%
 Treadmill examination: It is a form of lower extremities stress testing, measures the decrease of
arterial pressure with ambulation and the rapidity with which it returns to base.
 Pleural fluid analysis:
Vol=43.0
Appearance=Hazy
Colour = Pale yellow

 Doppler ultrasound: Determine the quality of blood flow. The femoral, popliteal, dorsalis pedis,
and posterior tibial arteries are evaluated in the lower extremities.

MEDICATIONS

Sr. DRUG NAME DOSE ROUT FRE ACTION NURSING

No E QU- RESPONSIBILITIES
ENC
Y
1 Tab. Calcimax 1gm P.O. B.D. Calcium Obtain current calcium level
forte supplement and apical pulse rate; if normal
hold the drug and notify
physician.
2 Tab. Supradyn 1tab P.O. B.D. Multivitamin Educate the patient about the
action of medication.
3 Tab. Dytor 10 mg P.O. B.D. Diuretics Monitor I&O with daily
weights. Assess for
improvement in edema.
4 Tab. Pulmoday 20mg P.O BD Antihypertensive Educate patient to consult
physician to determine
Cardiovascular status and
capacity before reestablishing
walking as exercise.
5 Tab. Pantop 40 mg OD Orally Protein pump Give medication in empty
empty inhibitor stomach.
stomach Assess GI symptoms such as
 epigastric pain, bleeding and
anorexia.
Monitor for possible drug
induced adverse reactions.
6. Inj. 50mg TDS IV Antinflammatory Assess the infection status of
Hydrocortisone the patient and oedema
level.Educate the patient about
action of medication.
7. Inj. Atropine 1ml TDS IV Anticholinergic Monitar apical pulse.Cardiac
monitor should be used I
patient receiving atropine.

NURSING MANAGEMENT:
Nursing Assessment:
 Assess the general condition of patient.
 Vitals of patient are monitored.
 Breathing pattern of patient is assessed i.e. patient is having shortness of breath.
 Assess the pain level, intensity, location.
 Assess the mobility level of patient.
 Assess the urinary pattern of patient.
 Assess the nutritional status of patient
GOALS:
Short term goals:
 To maintain adequate cardiac output.
 To maintain adequate tissue perfusion.
 To maintain fluid and electrolyte balance.
 To restore patient ability to perform daily activities.

Long term goals:

 To prevent further complications of disease condition.
 To provide psychological support to patient and family members.
 To provide health education to patient and family regarding patient condition, treatment and
prognosis.
 To encourage patient for regular follow up.

NURSING DIAGNOSIS:
1) Diagnosis: Ineffective peripheral tissue perfusion related to interruption of blood flow secondary to
arterial occlusion as evidenced by cyanosis, pallor extremities skin.
2) Diagnosis: Acute pain related to inadequate arterial blood supply to the legs as evidenced by facial
expressions of patient.
3) Diagnosis: Impaired skin integrity related to decreased peripheral circulation as evidenced by dry,
wrinkled and pallor skin.
4) Diagnosis: Activity intolerance related to insufficient oxygenation as evidenced by weakness, fatigue,
pulse and BP changes.
5) Diagnosis: Knowledge deficit related to disease condition, treatment and its prognosis and evidenced by
frequent questioning by patient and family members of patient.
HEALTH EDUCATION

DIET:
 Patient is educated to avoid consuming alcohol.
 Patient is educated to take low-salt and low-fat diet e.g limit butter, red meat, fried foods.
  Patient is educated to eat high-fibre foods such as fruits and vegetables such as beans, legumes.
 Patient is educated to take diet rich in whole grains to maintain proper weight.
 Patient is advice to take adequate water and fluids to maintain hydration.
 Patient is educated to maintain adequate weight.

EXERCISE:
 Patient is educated to DO NOT stand or sit in the same spot for too long. Move around a little bit.
 Walking is a good exercise for the lungs and heart. Take it slowly at first.
 Patient is advised to climb stairs carefully because balance may be a problem. Hold onto the railing.
Rest part way up the stairs if you need to. Begin with someone walking with you.
 Patient is educated to stop activity if she feels shortness of breath, dizzy, or have any pain in your
chest.
 Patient is educated to DO NOT do any activity or exercise that causes pulling or pain across chest,
(such as using a rowing machine, twisting, or lifting weights.

PERSONAL HYGIENE:
 Patient is educated to limit contact with people after with colds or viruses to prevent further chances
of infection.
 Patient is educated to wash hands properly and maintain personal hygiene to reduce risk of infection.

REST AND SLEEP:

 Patient is educated to take proper rest and sleep.
 Patient is educated to follow alternative rest and activity period.

FOLLOW UP:
 Patient is educated to report immediately to physician about any complication after surgery.
 Education regarding wound care is given.
 Patient is encouraged for regular follow up.
 Health education regarding prescribed medicine with rational and common side effects is given to
patient and family members.
 Health education regarding patient disease condition, treatment and prognosis is given to patient and
his family.

NURSING RECORDS:
Patient Mr. Parkash Chand admitted in hospital on 03-12-2019 with chief complaints of
Patient was admitted in the hospital with chief complaints of:
 Severe pain in extremities
 Weakness in all extremities ×2 months
 Restless on doing activities of daily living × 2 months
 Fatiguability× 1 year

On Assessment: (10/12/2019) On assessment patient is having

 Hypotension (B.P. 130/80 mm of Hg)
 Pain in lower extremities
 Intermittent claudication
  Restless on doing activities of daily living

On 10-12-2019: General condition of patient is assessed.

 History collection is done
 Physical examination is done.
 Vitals of patient are monitored.
 Intake output is strictly monitored.
 Back care is given.
 Medicine given as per chart.
 Investigation reports are collected and analyzed and informed to physician.
 Health education regarding surgery is given to patient to reduce anxiety level.
 Psychological support is provided to patient.
 Health education is given to patient and family regarding patient condition, treatment and prognosis.