IDENTIFICATION DATA

Name: Mr. Manoj Singh

Age: 48 years

Sex: Male

Ward: Male surgical ward

Bed no: 5

DOA: 12/11/2018

Time of admission: 11 am

Diagnosis: Intestinal Obstruction

Under Dr.: Dr. Sandeep

IP no: 290123

Religion: Hindu

Address: Kankharkheda , Meerut

Education: High school

Occupation: Farmer
 Monthly Income: 8000/- per month

Marital status: Married

CHIEF COMPLAINTS OF PATIENT:

 Pain in lower abdomen, colicky in nature since one year.

 Dysphagia,since 1 month.
 Nausea and vomiting since 15 days which is projectile in nature.
 Inability to pass flatus since 10 days.
 Constipation since 1 day.

PRESENT MEDICAL ILLNESS:

 Mr. ManojSingh presented with the Pain in lower abdomen, colicky in nature since one year, on and off in nature, dysphagia since 1
month ,nausea and vomiting since 15 days which is projectile in nature ,Inability to pass flatus since 10 days, Constipation since 1 day.

PAST MEDICAL ILLNESS:

 Nothing abnormal detected, patient is not known case of HTN/DM/Bronchial Asthma/coronary artery disease, No history of allergy,
rheumatic disease, sleep apnea, snoring, patient is known case of abdominal hernia.

PAST SURGICAL HISTORY: No surgical history

FAMILY TREE:

Name:Manoj Singh Name: SavitaSingh

Age: 48 years Age: 36 years
 Occupation: government job Occupation: Housewife

Name: Ritu Name: Manisha Name: Rakesh

Age: 25 years Age: 14 years Age: 12 years

Occupation: Housewife Occupation: Student Occupation: Student

Key:

Patient

Female

Male

FAMILY COMPOSITION:
Name of the Relation Age/ Marital Education Occupati Income
family members with Head Sex Status on

Rampal Singh Head of 48year/ Married 10th Farmer 8,000/

family M month
(Patient)
Savita Singh Married 8th House
Wife 30 wife Nil
Ritu Singh year/F Unmarried 8th
Daughter Married Nil
ManishaSingh 25 Unmarried 8th

Son year/F Student Nil

Rakesh Singh Unmarried 7th
Son 14 Student Nil
year/M

12
year/M

FAMILY MEDICAL HISTORY:

PERSONAL HISTORY:

Dietary pattern: Vegetarian diet

Sleep: Not able to sleep properly because of dyspnea.

Bowel habits: Normal

Bladder habits: Constipation

Recreational: No such recreational habits, not willing to watch T.V. because of abdominal pain.
Social relationship: Patient is having good relationship with family members and relatives.

Socioeconomic condition: socioeconomic conditionof family is good, patient is only earning person in their family, also they are having their
own family business and monthly income is about 18,000 RS/month approximately.

Environmental status:

Housing type: - Pucca

No of rooms: - 4
Toilet: - Indian
Electricity: - yes
Drinking water: - Tap and Hand pump
Transport facilities: - Cycle, bus

FINDINGS ON PHYSICAL EXAMINATION

GENERAL APPEARANCE AND MENTAL STATUS:

Height: 152 cm (approximately)

Weight: 48 kg (approximately)

BMI: 20.86 (approximately 21) = underweight

Health: Patient is thin.

Gait: Patient is looking anxious, erect posture, labored breathing.

Attitude: Patient was cooperative and able to follow instructions.

Affect/mood: Patient’s affect was appropriate to the situation.

Quality of speech: Understandable speech, clear tone, exhibits thought association.

ASSESSMENT OF INTEGUMENTARY SYSTEM:

ASSESSING THE SKIN:

Color of skin: Light brown in color. No pallor, no cyanosis, no jaundice, no erythema seen, uniformity of skin color

Edema: No ankle/sacral edema seen.

Lesion: No abrasion or other lesion seen.

Moisture: Excessive dryness of skin.

Temperature of skin: Uniform; within normal range.

Skin turgor (elasticity): When pinched, skin springs back slowly to previous state (dehydrated).

ASSESSING THE HAIR:

Growth on scalp: Normal hair growth, noalopecia.

Thickness/thinness of skin: Thin hair

Texture: Dry hair

Infection: No infection and no infestation of lice, ringworm seen.

Amount of body hair: variable

ASSESSING THE NAIL: No clubbed nails seen, No cyanosis seen.

PHYSICAL EXAMINATION OF CHEST AND LUNGS (CARDIOVASCULAR SYSTEM):

Inspection: Skin color even capillary refill less than 3 seconds. Thorax symmetrical without visible lifts or point of maximal impulse
(PMI).Jugular venous distension absent with client at 45 0 angle.

Palpation:Skin warm forceful thrusts, heaves and pulsations absent. No palpable thrills, carotid and peripheral pulses equal and readily palpable
bilaterally, no edema evident.

Percussion:Right heart border not discerned.

Auscultation:S1 and S2 heard without splitting, apical rate, 72 beats/ minute regular. Murmurs and extra sound absent.

ASSESSMENT OF NEUROLOGICAL EXAMINATION:

Mental status:

General appearance and behavior: Patient is dressed in the dress provided by hospital staff and hygiene is not maintained, hair is not combed
and nails were dirty.

State of consciousness: Patient is alert and oriented to time, place and person. Insight was normal, memory intact.

Mood and affect: appropriate mood and affect.

Thought content: orderly thought process, no delusion, illusion and hallucination present.

Intellectual capacity: normal

Cranial nerves: Smell intact to soap and coffee, visual acuity 20/20 in eyes, intact extra ocular movements, no nystagmus, pupils equal round,
reactive to light and accommodation, intact facial sensation to touch and pinprick, facial movement full, intact gag and swallow reflex,
symmetrical elevation of soft palate, full strength with head turning and shrugging of shoulders against resistance, midline protrusion of tongue.

Motor system: normal gait and station, normal walk, negative Romberg test, normal and symmetrical muscle bulk, tone strength, smooth
performance of finger- nose, heel- shin movements.

Sensory system: Intact sensation to light touch, position sense, vibration and heat and cold.
 Reflexes: normal biceps, triceps, patellar and Achilles tendon reflexes bilaterally.

ASSESSMENT OF RESPIRATORY SYSTEM:

Symmetrical chest movement, bilateral equal air entry, dullness on percussion over consolidated area, copious amount of sputum, green in color.

ASSESSMENT OF MUSCULOSKELETAL SYSTEM:

Normal spinal curvature, no muscle atrophy or asymmetry, no joint swelling, deformity or crepitation , no tenderness on palpation of spine, full
range of motion of all joints without pain or laxity, muscle strength of 5.

ASSESSMENT OF GASTROINTESTINAL SYSTEM:

Abdominal distension, hypoactive bowel sound abdominal cramps absent, constipation.

INVESTIGATION FINDINGS

S. Date Name of Patient’s value Normal value Remark

N investigation
.
1. 3/2/2014 Hb 9.4 gm/dl M- 12-16 gm/dl Abnormal
F- 11-
14gm/dl
TLC 11,000/mm3 4,000-11,000/ Normal
mm3
 Serum sodium 146.0% 136-146meq/lit Normal
Serum potassium 2.80 meq/lit 3.50-5.0 meq/lit Normal
Serum calcium 8.40mg/dl 8.7-10.2 mg/dl Normal
Platelet 2.1 lacs/mm3 1.5- 4.5lakh/cum2 Normal
ESR 16 mm - -
Blood group ‘B’ positive - -
Blood glucose 251mg/dl - -
2. 4/2/2014 Ultrasound Right kidney is normal in - -
normal in shape and
contour and parenchymal
echo texture.
Corticomedullary ratio is
normal bilaterally, no
calculus hydronephrosis is
seen.
Left kidney shows a
calculus of size 14mm, no
hydronephrosis seen.
Impression: left renal
calculus.

3. 5/2014 Echocardiogram Normal - -

4. 5/2/2014 Stress test Positive stress test - Abnormal

5. 5/2/2014 ECG ST elevation, Dysrhythmia - Abnormal
ABG Ph -7.45 Normal
PCO2- 40 Ph-7.35- 7.45
HCO3- 26 PCO2- 35-45
Base effect- (-2) HCO3- 22-26
Base effect- (-2 to
 +2)

S.N. Drug name Mechanism of Dose/Route Indication Contraindicatio Side effects Nursing consideration
action n
1. Trade name :
Tab Atorva An anti – Tablets 10 Hyperlipidemia, Acute hepatic Atrovastatin  Use cautiously in
Chemical hyperlipidemic that mg/oral reduction of risk disease, lactation is generally patients withhepatic
name: inhibits HMG-Co of myocardial , well tolerated disease, hypotension,
Atrovastatin reductase,the infarction(MI) Pregnancy, side effects major surgery, severe
enzyme that Unexplained are usually acute infection,
catalyzes the early elevated hepatic well uncontrolled seizure,
step in cholesterol function test tolerated. severe endocrine and
synthesis. results metabolic syndrome.
Therapeutic  May be given without
effect: regard to food.
Decreases LDL and  Monitor the patient for
VLDL cholesterol headache. Assess the
and plasma patient for malaise,
triglyceride levels, pruritus and rash.
increases.  Check the patient’s
cholesterol and
triglyceride values.
2. Trade name :
Digoxin A cardiac glycoside 50 mcg/oral Rapid Ventricular Not known  Assess the apical pulse
Chemical that increases the loadingdose for fibrillation ,ventr of patient for atleast 60
name: influx of calcium the management icular seconds,if pulse rate is
Cardiac from extracellular and treatment of tachycardia, 60/minute or lower
glycoside to intracellular CHF. untreated to CHF than withhold the drug
cytoplasm. and contact the
Therapeutic effect: physician.
Potentiates the  Use digoxin
activity of the cautiously in patient
 contractile cardiac with acute MI,
muscle fibers and coronary disease,
increases the force corpulmonale,
of myocardial hypokalemia,
contraction. Slows hypothyroidism,
the heart rate by impaired hepatic and
decreasing renal function,
conduction through incomplete AV block
the SA and AV or pulmonary disease.
nodes.

3. Trade name : A non steroidal Tablets : 325 Suspected MI, Allergy to GI distress  Assess the duration
Aspirin salicylate that mg prevention of MI, tartrazine dye, (including location and type of
Chemical inhibits prevention of bleeding abdominal inflammation pain.
name : prostaglandin stroke after disorders, distention ,  Inspect the arthritic
Acetyl synthesis, acts on transient ischemic chickenpox or cramping, patient’s affected joints
salicylic acid the heat regulating attack. flu in children Heartburn deformities, immobility
centre and and teenagers and mild and skin condition.
interferes with the GI bleeding or nausea,allerg  Use aspirin cautiously
production of ulceration, ic reaction in patients with chronic
thromboxane, a hepatic including, renal insufficiency,
substance platelet impairment bronchhospa vitamin k deficiency or
aggregation. history of sm, the aspirin triad of
hypersensitivity Pruritus, and asthma, nasal polyps
to aspirin or urticaria and rhinitis.
NSAIDs  Give aspirin with water,
milk or meals if GI
distress occurs.
 Assess patient’s skin
for evidence of
echymosis.
 Because of increased
 risk GI bleeding, advise
the patent to avoid
taking NSAIDs and
drinking alcohol while
taking aspirin.
4. Trade name: A benzimidazol 40 mg / oral Hypersecretory Not known Diarrhea,  Obtain the patient’s
Tab Pan 40 that is converted to conditions. headache, serum cholesterol level,
Chemical active metabolites ,pruritus, laboratory values.
name: that irreversibly dizziness and  Give pantaprazole
Pantoprazole bind to and inhibit rash without regard to food.
hydrogen- Assses the patient for
potassium GI discomfort and
adenosine nausea.
triphosphate, an  Teach the patient to
enzyme on the take tablet before
surface of gastric eating.
parietal cells,
inhibits hydrogen
ion transport into
gastric lumen.
Therapeutic
effect:
Increases gastric
pH
and reduces gastric
acid productions.
5. Trade name: A loop diuretic that 10 mg/ml Edema , Anuria ,hepatic Increased  Monitor patient’s vital
Inj. Lasix enhances excretion (injection) hypertension coma, severe urinary signs especially
Chemical of sodium, chloride electrolyte frequency, temperature and BP
name: and potassium by and urine (for hypotension)
Furosemide direct at the volume , before giving
ascending limb of nausea, furosemide.
 the loop of Henle. dyspepsia,  Assess patient’s
Therapeutic Abdominal baseline electrolyte
effect: cramps, levels especially for
Produces dieresis diarrhea hypokalemia.
and lowers B.P. constipation,  Examine the patient’s
electrolyte mucus membrane and
disturbances skin turgor and edema to
assess hydration status.
 Evaluate patient’s
mental status and
muscle strength.
 Obtain patient’s
baseline weight.
 Monitor fluid intake and
output.

6. Trade name: A benzodiazepine 0.5 mg/oral Panic disorder Narrow angle Mild  Use cautiously in
Rivotril that depresses all glaucoma, transient impaired renal, hepatic
Chemical levels of CNS significant drowsiness ,a function, patients with
name: inhibits nerve hepatic disease. taxia, chronic respiratory
Clonazepam impulse behavioral disease.
transmission in the disturbances(  Warn the patient to
motor cortex and aggression, avoid tasks that requires
suppresses agitation,) mental alertness or
abnormal discharge Especially in motor skills until his or
in petit mal children. her response to the drug
seizures. is established
Therapeutic  Urge the patient to stop
effect: smoking and to avoid
Produces anxiolytic alcohol. smoking
And anticonvulsant reduces the drug’s
effects. effectiveness and
 alcohol increases
Drowsiness
DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF CARE DEFFICIT
COMPONENT SUBJECTIVE OBJECTIVE INVESTIGATIONS NURSING DIAGNOSIS
ASSESSMENT ASSESSMENT
1. Universal self
care requisites:
 Air Patient is Patient is having Hb-9.6gm%,SPO2 was-88%,pulse rate-  Impaired gas exchange related to
complaining of dyspnea, 60b/m,RR-18b/m increased preload, mechanical
breathlessness difficulty while Inspection: failure, fluid in alveoli immobility
and chest talking, coughing Chest normal in shape. No distended as evidenced by increased
Pain. with frothy neck vein, JVP0, no pedal and ankle respiratory rate, shortness of
sputum, pallor edema .
breath, dyspnea on exertion and
skin, no cyanosis, Palpation: patient’s statement, “I just can’t
no clubbing of Weak pulse, carotid and extremity pulses seem to catch my breath.”
fingers, capillary 2+ and equal bilaterally.
refill less than 5 Auscultation:  Anxiety related to dyspnea or
seconds. Air entry reduced in left lung, normal perceived threat of death as
Patient was breath sound heard, S1S2 heard, no evidenced by restlessness,
looking anxious. additional heart sounds heard, no ronchi irritability, expression of feelings
or crepitus. Apical radial pulse felt of life threat and patient’s
normal in rhythm, rate and depth. No statement, “Don’t leave me alone,
murmur. No bruit. I’m afraid I might die.”
Percussion:
Unable to distinguish right side heart  Ineffective airway clearance
border. related to retained secretions as
Positive TMT test. evidenced by PaO2 < 90% and
productive cough.
 Water Patient was Fluid intake was Intake -500 ml,output-200ml
complaining of insufficient, dry
nausea. skin, coated
tongue, skin
turgor normal.

 Food Patient was Weight-48 kg, Bowel sound present, liver normal in size  Imbalanced nutrition less than
complaining of height- 150 cm, and shape, tenderness in abdomen felt. body requirement as evidenced by
weakness and BMI-20.86 reduced weight and fatigue.
loss of appetite Refuses to take  Constipation related to bed rest as
and soft diet as felling evidenced by subjective feeling of
constipation. of nausea and fullness, abdominal cramping and
vomiting. painful defecation.
 Activity/rest Patient was Patient was Patient is having pain in chest and lower  Activity intolerance related to
asking help for unable to change extremities. fatigue secondary to cardiac
changing the position on Pain assessed: With the help of pain insufficiency and pulmonary
position on bed. bed without help. scale: dull pain in left side, Annoying in congestion as evidenced by
nature. dyspnea, shortness of breath,
weakness, increases in heart rate on
exertion and patient’s statement,”I
feel to week to do anything.”

 Self care deficit related to chest

pain as evidenced by poor hygiene,
poor self esteem.
 Social Patient was Patient -  Powerlessness related to near
interaction asking help communicates death experience and anticipated
from his wife. well with his wife lifestyle changes as evidenced by
and relatives. feeling of doom, crying.

 Prevention of Patient was Patient needs -  Risk for impaired skin integrity
hazards asking help for instruction related to decreased tissue
 changing regarding perfusion and activities.
position in bed. prevention of
pressure ulcer,  Ineffective tissue perfusion related
range of motion to decreased cardiac output as
exercises evidenced by weakness dizziness.
techniques of
deep breathing
exercises and to
save energy.
 Promotion of Patient was He has good -
normalcy asking help relations with his _
from his relatives.
relatives.
Development self
care requisites: -
 Maintenance of Patient was Patient’s cloth _
developmental telling that he was dirty and
environment was unable to needs assistance
eat and needs in activities of
help during daily living.
toileting. Hygiene was not
maintained.
 Prevention Patient was Feels the - _
/management of telling that he problems are due
the conditions feels fatigue so to his smoking
threatening the much that he habits and
normal was unable to irregular eating
development do self care. habits.

Health deviation self  Ineffective therapeutic regimen

care requisites - management related to lack of
 Adherence to Patient was Reports the knowledge of risk factors ,
medical regimen asking about his problems to the disease process, rehabilitation,
disease and physician when in home activities and medications
treatment the hospital. as evidenced by frequent
schedule. Cooperates with questioning about
Doctors and staff, illness ,management and care
not much aware after discharge.
about the use and
side effects of the
medication.
 Awareness of Patient was Patient was not -  Deficient knowledge related to
potential problem asking about the aware about the disease process as evidenced by
associated with the procedure to be actual disease questions about the disease and
regimen performed. process. patient’s statement, “I don’t
Not aware about know why I keep getting sick.”
the after care of
cardiac
catheterization.
 Modification of Patient was Has adapted to -
self image to telling that he limitation in -
cooperate was unable to mobility, the
changes in walk because of adoption of new
health. weakness. ways for activities
leads to
deformities and
progression of the
disease.
 Adjustment in life Patient was Patient was -  Anxiety related to perceived or
style to asking about looking anxious actual threat of death, pain,
accommodate how to make about his future, possible lifestyle changes as
changes in the health changes in the and about his evidenced by restlessness ,agitation
status and medical life style and to treatment and verbalization of concern over
 regimen. reduce pain. schedule. lifestyle changes and prognosis as
substantiated by patient’s
1. Impaired gas exchange related to decreased cardiac output as evidenced by increased respiratory rate, shortness statement, “what
of breath, is going
dyspnea on to happen
exertion and patient’s statement, “I just can’t seem to catch my breath.” when I die…………everyone relies
on me.”
2. Ineffective airway clearance related to retained secretions as evidenced by PaO2 < 90% and productive cough.
3. Ineffective tissue perfusion related to decreased cardiac output secondary to myocardial ischemia as evidenced by weakness, dizziness.
4. Imbalanced nutrition less than body requirement as evidenced by reduced weight and fatigue.
5. Constipation related to bed rest as evidenced by subjective feeling of fullness, abdominal cramping and painful defecation.
6. Activity intolerance related to fatigue secondary to cardiac insufficiency and pulmonary congestion as evidenced by dyspnea, shortness of
breath, weakness, increases in heart rate on exertion and patient’s statement, “I feel to week to do anything.”
7. Powerlessness related to near death experience and anticipated lifestyle changes as evidenced by feeling of doom, crying.
8. Anxiety related to dyspnea or perceived threat of death as evidenced by restlessness, irritability, expression of feelings of life threat and
patient’s statement, “Don’t leave me a/lone, I’m afraid I might die.”
9. Anxiety related to perceived or actual threat of death, pain, possible lifestyle changes as evidenced by restlessness ,agitation and
verbalization of concern over lifestyle changes and prognosis as substantiated by patient’s statement, “what is going to happen when I
die…………everyone relies on me.”
10. Risk for impaired skin integrity related to decreased tissue perfusion and activities.
11. Ineffective therapeutic regimen management related to lack of knowledge of risk factors , disease process, rehabilitation, home activities
and medications as evidenced by frequent questioning about illness ,management and care after discharge.
12. Deficient knowledge related to disease process as evidenced by questions about the disease and patient’s statement, “I don’t know why I
keep getting sick.”
 NURSING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT

Nursing diagnosis Goal Planning Implementation Rationale Evaluation

1. Impaired gas The client will  To administer  Oxygen administered at  Increase amount of Client reports
exchange related demonstrate improved oxygen as ordered the rate of 2lit/minute by Oxygen available improved
to decreased gas exchange as and monitor oxygen nasal canula maintained for myocardial breathing
cardiac output as evidenced by absence saturation. continuous pulse oximetry. uptake, oximetry Pattern.
evidenced by of dyspnea. measures the Verbalizes
increased peripheral oxygen comfortable
respiratory rate, saturation. while sitting in
shortness of  To auscultate breath  Breath sound heard semi fowler
breath, dyspnea sound. symmetrically bilateral  To notify the area of position.
on exertion and equal air entry, S1S2 heard. decreased or absent
patient’s Ventilation and
statement, “I just presence of
can’t seem to adventitious sounds
catch my breath.”  To monitor ABG as  Monitored ABG of patient. to assess congestion.
ordered.  Ph -7.45  The presence for of
 PCO2- 40 hypoxia indicated a
 HCO3- 26 need for
 Base effect- (-2) supplemental
oxygen. Monitoring
provides data on the
adequacy of tissue
 To assess respiratory perfusion and
status for dyspnea  Respiratory rate- oxygenation.
and crackles. 30 b/ minute and no
 Dyspnea may
crackles heard.
indicate inadequate
oxygenation and the
presence of crackles
may impair gas
exchange because of
 decreased exchange
of oxygen and
 To assess client’s carbon dioxide
skin capillary refill, through fluid in
and level of  Capillary refill less than 5 alveoli.
consciousness every seconds, patient was
2-4 hours. conscious, oriented to tie  Cyanosis indicates
place person. hypoxia; capillary
refill greater than 3
seconds indicates
poor perfusion and
possible hypoxia.
2. Acute pain related Patient will report  To assess the  Assessed pain , it was  Pain is indication of  Patient
to myocardial reduced pain, characteristic of sudden in nature, sharp myocardial verbalizes less
ischemia as improved comfort in chest pain including pain radiating to jaw and ischemia, assisting pain and will
evidenced by chest as evidenced by duration, location, left arm, precipitating client in quantify not exhibit
severe chest pain decrease in rating scale quality, intensity, factor are stress, alleviates pain may associated
and tightness of pain; increased presence of radiation with rest, associated differentiate pre- manifestations
radiation of pain ability to rest and sleep precipitating and manifestations are existing and current of pain.
to the neck and comfortably reduced alleviating factors headache, tenderness in pain pattern.
arms. anxiety. and associated stomach.
manifestations.
 To assess  Assessed respiration,
respiration, blood blood pressure and heart  Respiration may
pressure and heart rate with each episode of increase as result of
rate with each chest pain. pain, and associated
episode of chest anxiety, release of
pain. stress induced
catecholamine
increases heart rate
and blood pressure.
 Obtained ECG, indicates
 ST elevation.  Serial and stat ECG
 To obtain ECG. record help to record
any abnormality.
 Administered nitrates as
ordered.  Pain control is
 To monitor the priority because it
patient’s response indicates ischemia.
to drug and notify
physician if pain
does not reduce in  Asked patient’s relative
15-20 minutes. to  Limiting visitors
 To limit visitor as Visit one by one. prevents
the client request. overstimulation and
promotes rest.
3. Ineffective airway Client will  To assess breath  Assessed breath sounds, Assesmemt will help Saturation of
clearance related demonstrate airway sounds. bilateral air entry, to identify patient increased,
to retained clearance as evidenced diminished breath sound adventitious breath PaO2 -90%
secretions as by reduced cough. in left side of lung. sound. maintained.
evidenced by  To administer  Administered Help to reduce
PaO2 < 90% and bronchodilators as nebulization of duolin, bronchospasm and
productive cough. prescribed. budecort and mucomix loosen the secretion.
TDS.
 To administer Improve myocardial
oxygen as  Administered oxygen at oxygen demand.
prescribed. the rate of 2 lit /minute.
Help to remove
 To provide chest  Chest physiotherapy secretions and
physiotherapy. provided to patient. improve muscle
Asked client to do strength of lung.
respirometric exercises.

4. Ineffective tissue To achieve optimal  To assess pain by  Pain assed by using 7  Assessment will  The return of
 perfusion related level of tissue using pain scale. point pain scale score. help to indentify ST segments to
to decreased perfusion and the intensity of baseline is
cardiac output reduction of pain. pain. dependent on
secondary to Objectives:  To provide support  Quiet environment is  Stress activates the the degree of
myocardial The client will (keep the client on provided to the client by sympathetic ischemia and
ischemia as demonstrate improved bed rest with a asking client’s relatives to nervous system rapidness of
evidenced by cardiac tissue quiet talk slowly and to slow and myocardial treatment.
weakness, perfusion as evidenced environment.) down the volume of T.V. oxygen needs.
dizziness. by a decrease in the
rating of pain and  Oxygen is administered  Oxygen increases  Client
resolving ST segment.  To administer by using nasal canula at myocardial supply understood the
Design of nursing oxygen as ordered. the rate of 2lit/minute. of oxygen. treatment
system: regimen and
supportive educative was willing to
 Administered  Thrombolytic continue
 To administer nitroglycerin tab 2.6 mg therapy or treatment.
thrombolytic and as advised by doctor. angioplasty can
antianginal drugs. break apart the  Verbalizes
thrombus and reduction in
increases pain in the pain
myocardial tissue scale sore from
perfusion. 7-4
 ECG of patient was taken  ST segment
 Monitor client’s (shows ST elevation.) elevation indicates
ECG the myocardial
tissue perfusion
and depression
indicates the
myocardial
perfusion.
5. Imbalanced Patient will maintain  To provide balanced  Provide balanced diet as  To maintain Patient will
nutrition less than adequate weight and diet. prescribed by dietician. adequate weight. maintain desired
 body requirement intake and output as  To take weight of  Checked weight of  It will help to weight and
as evidenced by evidenced by reduced patient. patient. Weight-48 kg. check weight gain. accepted change
reduced weight fatigue.  To maintain intake  Intake-800ml,output-  To maintain in diet.
and fatigue. and output of 500ml hydration,
patient.  To prevent anxiety
 To provide clean,  Clean, Calm and pleasant and nausea.
calm environment environment is provided
while eating. while eating.

6. Constipation The client will have  To teach client to  Told client to take high  Bulk and fluid  Patient
related to bed rest improved bowel have adequate bulk roughage diet and adequate within the colon verbalizes
as evidenced by elimination as in diet and adequate fluid intake. (Less than prevent straining. reduced feeling
subjective feeling evidenced by fluid intake. 750 ml). of fullness and
of verbalization of  To monitor the  Provided stool softener  Stool softeners abdominal
Fullness, reduction in painful effectiveness of syrup cremaffin 30 ml HS. decrease the cramping.
abdominal defecation. stool softener or myocardial
cramping and laxatives. workload of
painful defecation. straining.
 Asked client to reduce
 To instruct the client straining.  Valsalva maneuver
to reduce straining causes bradycardia
and avoiding the decreasing cardiac
valsalva maneuver. output.
7. Activity intolerance Patient will regain  To provide  Asked relatives to  To provide  Client
related to fatigue optimal level of assistance in provided assistance in the emotional support verbalizes
secondary to strength to perform activities of daily activities of daily life like to the client. reduced
cardiac activities of daily life. changing clothes, eating, fatigue.
insufficiency and life.  To plan activities of brushing.  To reduce fatigue.
pulmonary client and to  Planning of activities
congestion as provide adequate done to provide rest
evidenced by rest period in period in daily schedule.
 dyspnea, shortness between activities.  To reduce exertion.
of breath, weakness,  Encouraged client to ask
increases in heart  To encourage client help for reducing fatigue.
rate on exertion and to ask for help.
patient’s
statement,”I feel to
week to do
anything.”
8. Powerlessness Client will regain a  To provide  Asked client to express  The opportunities Client expresses
related to near sense of control as opportunities for the his feeling regarding his create a supportive his feeling and
death experience evidenced by feeling client to express illness. climate and send the willing to talk.
and anticipated able to express feeling feeling about oneself message that care
lifestyle changes as of powerlessness over and the illness. givers are willing to
evidenced by feeling the present situation help.
of doom, crying. and future outcomes.  To explore reality Listening client’s
perceptions and  Asked patient to express feelings and words
clarify as necessary. his feeling regarding can help the client
change in diet, medication acquire more
and clarified the doubt of hopeful outlook.
 To reinforce the patient. Reinforcement will
client’s right to ask  Encouraged him to ask help client as well as
questions. questions. family members to
participate in care.
 To provide positive Helps client to feel a
reinforcement for  Encouraged client to
sense of control and
increased change clothes and to
will encourage them
involvement in self brush his teeth.
to follow action.
care.

9. Anxiety related to Client will not exhibit  To provide calm  Provided calm environment A calm environment Patient expressed
perceived or actual manifestation of environment. to the client. decreases additional reduce anxiety.
 threat of death, anxiety and will be anxiety.
pain, possible able to express  To explain all  Provided adequate By providing
lifestyle changes as concerns. procedures and routine knowledge regarding advance information
evidenced by examinations. angiography to the client. to client, client will
restlessness ,agitati not feel anxiety.
on and
verbalization of  To provide support to  Provide emotional support Help client to reduce
concern over the client. to the client by asking his anxiety.
lifestyle changes queries.
and prognosis as  To encourage the Such as religious
substantiated by client to use additional  Encouraged client to do leaders, close
patient’s support systems. meditation and to verbalize relatives will
statement, “what is his feeling to his relatives. provide emotional
going to happen support to client
when I
die…………
everyone relies on
me.”

10. Risk for impaired The client will have  To inspect the  Inspected client’s skin,  Altered skin color Client is free
skin integrity intact client’s skin, bony ankle edema present, dry in isolated areas from pressure
related to Skin integrity, as prominences, skin, thrombosis seen at suggests damage ulcer.
decreased tissue evidenced by absence Edema , Altered canula site, no cyanosis caused by pressure Edema in legs
perfusion and of reddened area and circulation, seen. Applied or decreased was reduced.
activities. no areas of pigmentation and thrombofobe on the circulation. Skin integrity is
breakdown. emaciation. canula site. maintained.

 To assist with active  ROM and

or passive range of  Assisted client to perform stretching exercises
 motion (ROM) active or passive range of enhances venous
exercises. motion and told some return. Isometric
stretching exercises for exercises may
lower extremities. adversely affect
Cardiac output by
increasing
myocardial work
and oxygen
 To reposition the consumption.
client every 2 hours
 Repositioning
in a bed.  Repositioned the client
increases
every 2 hours in bed.
circulation and
reduces the time
that weight
deprives any one
area of blood flow.
11. Ineffective Client will able to  To provide  Provided adequate  Client will identify Client understood
therapeutic regimen maintain therapeutic knowledge regarding knowledge regarding the importance of the importance of
management related regimen. action and side action and side effects of treatment regimen change to done
to lack of knowledge effects of prescribed medications. and identify and and verbalizes the
of risk factors , Medications. report if any side importance of
disease process, effects occur. diet modification.
rehabilitation, home  To provide  Client is told about the  Client will able to
activities and knowledge regarding activities to be done at cope with the
medications as cardiac home, to reduce strenuous situation and make
evidenced by rehabilitations and activities and to take a plan of
frequent questioning activities to perform adequate rest in between management of
about at home. the activities. disease.
illness ,management  Ask client to reduce salt,  Client will identify
and care after  To provide teaching cholesterol rich diet and areas to make a
discharge. related to diet to take roughage and change and it will
modification. green leafy vegetables in help to improve
 diet. quality of life of
patient.
12. Deficient Client will describe  To provide  Asked patient to tell about  To identify the Patient
knowledge related to disease process and description about disease process. patient’s current understands the
disease process as provide rationale for disease process. knowledge and areas disease process
evidenced by dietary and medication to provide teaching. and verbalizes the
questions about the regimen. rationale behind
disease and patient’s  Told patient about sign and  Help patient to diet modification
statement, “I don’t  To provide symptoms of disease and prevent episode of and treatment.
know why I keep description about complications of disease. heart failure and to
getting sick.” complication. report physician as
soon as possible.
HEALTH EDUCATION GIVEN TO PATIENT:

Health promotion:

 Consider smoking cessation and weight reduction if possible.

 Plan a daily rest and activity program.
 After exertion such as exercise plan for rest period.
 Avoid emotional upsets.

Drug therapy:

 Take each drug as prescribed.

 Take pulse rate each day before taking medication.
 No signs and symptoms of internal bleeding (bleeding gums, increased bruises, blood in stool and urine.

Dietary habits:

 Limit salt and cholesterol intake in diet. Limit saturated food.

 Take more vegetables and fruits in diet.
 Eat smaller and more frequent meals.
  Take healthy snacks like almonds, oats, Dalia in breakfast.

Activity program:
 Increase walking and another activities gradually.
 Avoid extreme heat and cold
 Avoid exertion, try to do yoga meditation and listen music to reduce stress.

Ongoing monitoring:
Report immediately if following symptoms occur:
 Difficulty in breathing, especially with exertion and when lying back.
 Walking up breathless at night.
 Frequent dry, hacking cough, especially when lying down.
 Fatigue, weakness.
 Swelling in ankle, feet or abdomen, swelling on face or difficulty in breathing.
 Nausea with abdominal pain, swelling and tenderness.
 Dizziness or fainting.
 Weight gain (1.4kg) in 2 days, 2.3 kg in one week.
 Follow up with health care provider on regular basis.

Prognosis of patient: Patient came in hospital with the complaint of pain in chest and diagnosed with acute myocardial infarction. After
angiography patient got discharged with the advice to take regular medication and come from follow up.

Bibliography:

 Black M. Joyce, Hawks Howkanson Jane, Medical Surgical Nursing , volume -2 , 7th edition , Elsevier publication, Chapter -56,
Assessment of the cardiac system , Page No: 1561- 1598
 Chintamani , Lewi’s ,Medical Surgical Nursing , Elsevier publication, Year- 2011, Chapter -25, nursing assessment and
management of cardiovascular system, page no: 786-816
 Mosby’s drug consult for nurses, Elsevier publication, Year- 2006,page no-499-500,570-571,633-634,997-998,1018-1019
 Hardin R. Sonya, Roberta Kaplow, Cardiac surgery essentials for critical care nursing, Jones and Barlett publication, year-
2011,Chapter -3, Indications of cardiac surgery, Page No- 27-33
 Smeltzer C. Suzanne ,Bare G. Bare, Brunner and Suddarth’s, Medical Surgical Nursing, Volume: 2, Chapter-26, Assessment of
cardiovascular Function, page no: 648 -671.