Pyrexia case study and Nursing Care Plan
Pyrexia
Health history
1. Biographic data/Identification data/ Patient profile
- Name-Kamal
- Address-A-350 Ambedkar Nagar Alwar
- Gender-Male
- Age-36 years
- Marital status-Married
- Occupation- Businessman
- Rligion- Hindu
- Education- Graduate
- Nationality-Indian
- Family Income-500000/yr.
- Ward No.-10(Male Medical Ward)
- Date of Admission-20 May 2024
- Diagnosis- Hyperthermia/Pyrexia
2.Chief Complains
- Patient say "I am suffering from fever since 5 days and with burning sensation in my eyes, body ache and irritability"
3.History of Present Illness-
- My patient/Client Mr. kamal of age 36 years is suffering from hyperthermia since 5 days.
- Present Surgical history- No present surgical history
4. Past Medical History-
- Medical history-No past medical history
- Past surgical history- No past surgical history
5. Family History
- He is main brad owner of family
- Family's pure Vegetarian and have balanced diet during day.
- His mother and wife bath are house wife.
- He has a girle child.
Family tree-
- Note- Make the family tree according to alloted client.
7. Socio economic Status-
- Mr. Kamal is 36 yrs old married person
- He is businessman
- Family is pure vegetarian and have balance diet during day.
- His mother and wife both are housewife.
- His income is 500000/yr.
- The surrounding are of his house is clean and pollution free.
- There is proper supply of water and electricity at his house.
8. Personal History.
- Mr. kamal was well nourished previously to the condition of pyrexia.
- He use handle his body with care.i.e,no hair problem etc.
- He was suffered from the insomnia condition.
9. Nutritional History
- The family is pure vegitarian.
- He used not to take well balanced diet before condition of pyrexia.
- He can take nutritional by intravenous drips i.e glucose, ringar lactose etc.
General examination
1. General Appearance
- Nourishment-Under Nourished
- Body build- Healthy(According to BMI)
- Health-Un healthy( due to pyrexia)
- Activity- Dull(tired)
2. Mental status
- Consciousness- Conscious
- Look-Anxious
3.Posture
- Body curve- Altered
- Movement-Altered body movement
4. Height-5.6
weight-62
5. Skin condition
- Colour-Pallor
- Texure-Dryness
- Temperature-Warm(103.f/39.4C)
- Lesion- No evidence found
6. Head and Face
- Cleanliness- Not observed in clean status.
- Condition of hair- Normal colour hair.
- Dandruff- No evidence found.
- Pedicule- No evidence found.
Face
- Flushed- Yes
- Puffiness- Yes
- Fatigue-No
- Pain- Yes
- Fear- Yes
- Anxiety-Yes
- Enlargement of parotid glands- No evidence found.
7. Eye
- Eyebrow- Normal
- Eyelashes- Noraml
- Eyelids- Dry
- Eye balls- Burning sensation in eyes
- Conjuctiva- Pale
- Sclera- No evidence found.
- Cornea and Iris- Noraml
- Puplis- Noraml reaction of light
- Lens- Normal
- Fundus- Normal
- Eye muscles- Normal working
- Vision- Normal
8. Ears
- External ear- Normal
- Tympanic membrane- Normal
- Hearing- Altered hearing
9. Nose
- External Nose- Dry
- Nostrils- Normal
10. Mouth and Pharynx
- Lips- lips skin layer is dry and rough/cracked
- Odour of the mouth-Normal
- Teeth- Teeth are 32 in number and are gums free and cavity free with no dental caries.
- Mucus membrane and gume- Normal
- Tongue-Normal
- Throat and Pharynx- Sore throat
11. Neck
- Lymph node- No sweeling observed
- Thyroid gland- No sweeling observed
- Range of motion- Altered because of pyrexia due to jont pain.
12. Chest
- Thorax- Shape- Noraml
- Symmetry- Normal
- Posture- Normal
- Brath sound- Heart, Tachypnea
- Heart- Palpation felt, pulse rate increas
- Size and location- Appropriate observed
13. Abdomen
- Observation- No any alteration found
- Ascultation- No any alteration found
- Palpation - No any alteration found
- Percussion- No any alteration found
14. Extremities-
- Normal both extremities
- Joint pain due to pyrexia
15. Back- Backache
16. Genitalis and Rectum-
- No abnormality observed.
17.Neurological test
- Co-ordination test- ALtered co-ordination.
- Equillibrium test- Normal
18. Investigations-
Complet Blood Count (CBC)
Note- Write down other investigations as per written in case sheet.
Medication-
| Medication name | Type of Administration | Dose | Remark's |
| 1.Paracetamol | Oral | 500 mg | |
| 2. Ofloxacin | Oral | 200 mg | |
| 3. ORS | Oral | 2-4 litres |
Note-Write other medications written in the Case file/Client file.
Nursing Care Plan
| S/N | Assessment | Diagnosis | Goal | Planning | Implementation | Expect out come |
| 1 |
|
Altered body temperature related to infection as evidance by raised in body temperature | To maintain normal body Temperature |
|
|
The temperature of body will be maintain |
| 2 |
Subject Data- The client says "I fell discomfort this raise in body temperature irritate a lot. Objecctive data- By observation and checking vital sign I found patient is fatigue. |
Alteration comfort related to uneasiness due to hyperthermia | To provide comfort to the patient |
|
|
The patient will feel relaxed. |
| 3 |
Subject Data- The client says I fell dryness body. Objecctive data- By Observation and checking vital signs I found fluid volume deficit |
Fluid volume deficit related to dehydration due to fever as evidence by skin turgidity. | To maintain fluid status in body |
|
|
Fluide volume and electrolytic will under control. |
| 4. |
Subject Data- The client says I fell disconfort Objecctive data-By observation I found it may be due to disconfort |
Risk for injury related to uneasiness and disconfort | To prevent from injury |
|
|
Patient will fell comfort and easiness. |
Health education
- Take full course of Antibotics, even if fully recovered.
- Get lot of rest and sleeping.
- Smoking cessation if applicable.
- Drinking planty of fluids, including water, juices and soup and eating fruits to prevent dehydration.
- Practice good hand wasing technoque.
- Eating small, frequent meals to help prevent vomiting if occuring.
- Avoide cross contamination of food.
- Wash fruits and vegitables thoroughly.
- Educate the patient to report dehydration, bleeding and recurrence of symptoms