The document contains medical details of a 50-year old male patient named Mr. Anshu Kumar who was admitted to the hospital with chief complaints of breathlessness and cough for one month and was diagnosed with COPD. It includes his medical history, physical examination findings, investigations conducted, medications prescribed, and nursing care plan to address issues like ineffective airway clearance, imbalance nutrition, and activity intolerance.

1. * B10-DATAOF THE PATIENT *
Name- Mr. Anshu kumar
Age - 5o yr.
Gender- Male
º Marital stotu- Maried
Religion Hindu
º Occupation - IT-fMangger
lo come 60,ooo Rs./months
Address- Rarapur, Sitamo-hi,Bhar
Word Name - General Medicine (male)
Diagnosis COPD
Date of Admision-- 07lol2023
> Hospital - c.p Hospital, Patna
Doctors Name- Dr. Anand Kumar

2. Chief:
-+ The batient is admited in hos prtal Hith
chief Comþlains t
" Breathlessness
History of Patient [llness -
à Fever
Coughing since One rmoulh
A. History of Present illness ;
" Rest le ssness
B. History of Past illness :
" Not significant
" Family Hictory
Comosifion of History : Nuclcar family
History amopg fomily :Not significant H/o of illnes
ame family
Family free ’
Husband
(Patient)
Son
-
Wife
Key Þoint
U-Patient
I - Male
female
Complains

3. "Socio-Economie status
Monthly Lncorme 6900o/mon hv
Educatiagal status- All tnembers are educated
k FAMILY DETAILS k
Name of
nember
Health
RelatioD Educatienstatus
Ansho kuma 50yrsPatient
2.Rani Deri 48yrs ife
3. Raa Kumar28 Yrs Son
P.HD (toa
4-N.M
UnheaHhy
Personal History
Healthy
Bsc. Comp Hea<hy
Patient is havig Weakness and Coygh
Patient looks very lean and thin

4. + Physical Examination
General Condition
APþeatance
Sensoriu m
B Co- Cooþerativenes ;
Gait and posture:
" Height and Weight
Mood and affect:
# HEAD :
:
Lean cand thin
Face -
loss of Vision
Co-operatre
Lite cHrve body structure
HEAD To TOE ExAMINATION:
5ft, 60 kg
Feeling itritable sometimes.
" Hairs of the client is White in colour &dry
" Texture of hairs is rough
Ears -
face of the clientis round in shape.
S There is ho Scar mark tnjury þresent over
the face .
o No fat is present on thecheek
" Vision of the client is not appropriate
Alignment of the eyes is normal /symmetrical.
OSclerg js
Auricles ot the client is normal
No discharge is from ears.
Hearing Is norma
is siightly yellouish in colour

5. t# Nose &Sinuses :
" External nose is normal, no Sephum isthere
" No dischage is present, infrction or any growth
is not present
F Mouth gPhyrnx :
#
"
Lips are dry &eh cracked
o
Tonsis are nor nal
o Sense of taste is nor mal
* chin &cheek i
Scar or
injury is þresent
Neck :
There is no
lymphadenopathy .
There is no abnormal mass formation
There is no
deriation in the trachea-
Patient bre athing þatern is abnormal
(tachyaphca) &
respiration rate of pahent is
28b/min
No enlargement of Hhiyroidgland
Ronge of motion of the neck is normal
Over neck.
# Trunk chest,Abdomen & Back:
There is no
diaphragmatic dulneM in
each sde

6. 4 chest /Anterior Thorax ond Lusge i
shabe of chest is normal
No scar oarks is pres ent
Breathing s0und is abnormal
# Abdo men :
o Lnspection : No stretch marks over the abdomen
Palpation: Tenderness Over the hypochondriacreon
D Aus cultation: Bowel sounds gre present
° No ehlargement ef spleen ,kidneys &liver.
>
Extremitties : UPper & Lower
Skin &Nails : skin is dry &shape ofnails is
4
Reflexes :
o Some reflexes
Dormal
fal
SI
Proper joint mobility there is þain Over the joint
Vital Sin
Norme
are normal
Vaue
I. Termperatw 98-6'f
Rafient
2. Pdse 7e-&ob/mi 8ob/min
Kespirationt6-24 breath
Vue
24 breath.) min
Blooj Pressuwe i20/&ommtgo/7o mmHg
Remarks
Nor mal
Nor mal
Nor ma
Norm a

7. sOInves tigecion
1
2.
3.
2.
3.
I.Hemeglobin14-123 m<a
4,
G.
Total leu cocyte
coynt
M.c-v
MCHC
Dry
RBCcount
* Investiaatien
Deriphylin
mono(ef
Jnj.
Rantac
Actual Normal
Dose
Value
604
4.43
99fo
32·|0
3230
Route
Po
Value
13-7gm/d
4-|| |o43 cmm
420-6SD
m/cmm
82--98 {!
26-34 Pg
Medication
30-36 .
Freqqency
BD
BD
Inference
Normal
Normal
Normal
Abnormal
Norm a
Nor mal
action
Works by relaxing
muscles qnd opening air
Passage.blockirg,adenosine
receptors for smooth
muscle relaxation
Works by kllig the
bacterio by interruptig
the bacterial cellwall
formation
1treduces theamount
of aud seueted by
stomach to reduce ulkes
and heart burns

8. (Nurzing Dignoi
I. InefHective air oay clearante related to
bronchospa«m
5.
evidented by
diticly in breathigt,chane in rate
of Resþiration .
2. Imbolanced putrition less han body
feqirenent teleted to anoexia as
evidenced by lean body
3.
Activity intolerance related to imblance
beteen Oxygen supplies with demand
evidenced by unable to w
ork proferly.
4. Distrbed slecping Pattern telated to dis
4-Comfort, sleeping possihion as evidenced by
irritability,rest lessness.
as
Self Care defict related to fatigue
evidenced by poor personal hygiene
as

9. Assessnent
Subjetive
Þate:
Patient
Comploints
objecive
pate:
of
inabiltyl-spasm qs
to breathsevidenced by
roperly.
Patient
Diacs45
|havig
dyspnceq.
Ineffective
diiculty in
breathing
airway clear
-ance telated
change in
.
tate of res
-Piration
Goal
Nursing Plan Care
To maintain
airway potency
Auscultation
breath:Sound
Mointain he
Posifion of
patient for
Comfort
Irgplernentotion
Auscutated ueng
steHhoseope.
Inspiration qnd expirati
i's noted.
Comfortable þosifion is
changed
Environment is kept
clean by dustig and
clganing th kad
Abdomina exepises
qre
do
en cowayed to
Rotional
To find he Proper ly
maintain ahie
dezee of
|brenchocpaem,f air way
lear ed
Tachypnea i's
usually present
to some
deyce
and may be
pronounced on
admiss ion or
|durin stress.
To remore e
Evaluation
allegens for
Testiratory
function
telaledith breoll
|to bronchoSound clear
Sounds

10. Assessit)ent
Subjeetive
Patient
objective
Date:
Pahient having
9norexiq and
Date :-|nutritienlesseued det ot patient is taken ine data.
desired
than the
Imbalance
Complaints of|body require- of
signotTheeating patern of |s
ot wanting -ment related
|to ave
nutrition les
Nurst ng
than nor ma
body wleight
2. Nursing Care Plan
Caonl/plannin
|Igbalance in Heistt Height and WeightTo findbaue Normal
to qnrexia
thin body
2oa nd free
rnplemenation
qs evidenced observe patinPatient is provided
by lean and ability to
eat
Provide
|before and
|after mel
Smal diet
leekly aleighing is
Rationsl
done
oral hygieneOral hygiene is
maintaned
T find Pate
able to
feed bim
Proper nutrifien
the patient
To find the
improvement
(n bedy Wt
ein
Evaluation
To enhance
Peite
eght is
gain ed
have focd nnutritonPatient is observed.

11. Assessment
"
Subjective |Actiuity
Patient
Date
4ble to ork
Properly and
Corflains tonot irmbalanced
daily acfiaies
okjective
Data:
Nursi
activity.
jntolergn
intolerance
telated to
between
OxYg suppli
Nursing Care
|Gol/plaonig
by unable
Patient havi Pre poly
to Work
Assess
Physical
heal h levell
With demand A
ssist the
and Pofential
injuri es
ds evidencedPatient in
dnd illnes
|Performig
atrities
Physical
health is
qssecsed
plan
Iriplernentation
find out the level
of qctivity.
4
activities
Rtional
|To have the Patient
base line
data
|To helo the
Patient in
|doing his
ahivitie
Without
Fvaluaier
Problems
Verbelizes
of able
to ort
tle more
Hicely han
before
sted in

12. Heal!h Education
Walk unil i is o lile hard to
breathe.
slowly increase how far your Walk.
Try not to talk when you walk.
Ask you healthcare provider how far to
Walk.
Ride astationary bike. Ack your provider
long and how hard to ride.
bow
Buld your strength even
when you are sitig
Use smallweights or an excerise handto
Sttengthen you arms and sholders.
Stand up and sit down Sereral times.
Hold yow legs straught out in front of you,
then put them down. Reeat this movement
Several times.