FACULTY OF NURSING

BACHELOR OF SCIENCE IN NURSING (POST

REGISTRATION)
ASSIGNMENT COVER PAGE

Students Name

Students ID
Year/Semester

MUTHULINGAM KETHEESARAN

LC0007000021

Students NRIC

1ST year / 2nd semester

Lecturers Name

Mr. Regidor

FacultyLINCOLN UNIVERSITY COLLEGE

Programme

BACHELOR OF SCIENCE IN NURSING

Subject Name

Clinical Practice 2

Assignment Title

case study on chronic kidney disease

(LBNS 2207).

No. of Page
excluding this page)
Required words

45
2000

Actual # of words

Date submitted

Soft copy included

4390

Due Date

Yes

No

DECLARATION BY STUDENTS:
I certify that this assignment is my own work in my own words. All resources have been
acknowledged and the content has not been previously submitted for assessment to
LINCOLN or elsewhere. I also confirm that I have kept a copy of this assignment.

Signed:

Date:

A case study of a Angina Pectoris patient admitted to the Teaching Hospital , Batticaloa

Student, Lincoln University College, Malaysia

Table of contents
1.0

OBECTIVES OF CASE STUDY

1.1 GENERAL OBJECTIVES
1.2 SPECIFIC OBJECTIVES.
2.0 BIOGRAPHIC DATA
2.1.1 HEALTH HISTORY.
2.1.1.1
DEMOGRAPHIC DATA.
2.1.1.2
CHIEF COMPLAINTS.
2.1.1.3
HISTORY OF PRESENT ILLNESS
2.1.1.4
HISTORY OF PAST ILLNESS.
2.1.2 FAMILY HISTORY
2.1.3 HEALTH SEEKING PRACTICE
2.1.4 PERSONAL HISTORY.
2.2 SOCIO-ECONOMIC STATUS...
3.0 ENVIRONMENTAL FACTOR
4.0 DEVELOPMENTAL NEED AND TASK COMPARING WITH NORMAL ADULT CLIENTS
4.1 Robert Havighursts Developmental Tasks
4.2 Eric Eriksons Developmental Task
5.0 Physical Assessment
6.0 FINDINGS

7.0 DEFINITION, CAUSE AND PATHOPHYSIOLOGY OF CLIENTS DISEASES

8.0 Stages of Angina Pectoris

8.1 COMPARISON OF..
8.2 SIGNS AND SYMPTOMS..
8.3 INVESTIGATION..
8.4 COMPARISON OF MEDICAL MANAGEMENT.
8.5 COMPARISON OF SURGICAL MANAGEMENT.
8.6 COMPARISON OF NURSING MANAGEMENT.
2

9.0 DRUGS CARD OF MEDICINES

10.0 SUMMARY OF CLIENT DAILY PROGRESS REPORT IN HOSPITAL
11.0 DIVERSIONAL THERAPY USED FOR CLIENT
12.0 APPLICATION OF NURSING THEORIES
13.0 APPLICATION OF THEORY ON MY PATIENT
14.0 NURSING CARE PLAN
15.0 DISCHARGE TEACHING
16.0 WHAT I LEARNED FROM THIS CASE STUDY
17.0 CONCLUSIONS AND SUMMARY OF CASE STUDY
18.0 REFERENCES

1.0 OBECTIVES OF CASE STUDY

1.1 GENERAL OBJECTIVES:The general objective of the case study is to gather the comprehensive knowledge about the
disease to gain the practical exercise about the Adult Health Problem and also to gain Practical
experience working with a patient having chronic kidney disease and to give holistic patient care
according to their need.
1.2 SPECIFIC OBJECTIVES:-

The specific objectives of the case study are given below:-

To assess the patient and find out need of patient according to nursing process.
establish a nurse-client relationship to the client, as well as to the family by rendering a
therapeutic nurse-patient relationship;
gather adequate information to be used in the development of the study
present the clients personal data;
illustrate the patients family tree and trace significant diseases which may be of
relevance to the study
trace the health history of the client and the family by collecting information both of the
past and present illnesses;
To provide holistic nursing care to the client to all ages using nursing process.
To manage promptly as necessary to built up comfort.
To provide psychological support to the patient
To apply knowledge from the science, nursing theory and other related courses to plan
and implement nursing care.
To provide continuous care till discharge and follow-up care.
Counsel and make aware the patient party about importance of continuity of medicine
and psychological support to prevent from worsens.
To provide the discharge teaching to the patient and family member.

2.0 BIOGRAPHIC DATA

4

2.1.1

HEALTH HISTORY

2.1.1.1. DEMOGRAPHIC DATA

NAME:
EDUCATION
DATE OF ADMISSION:
DATE OF DISCHARGE:
IP NO. :
OCCUPATION:
MARITAL STATUS:
ATTENDING Consultant:
INFORMATION SOURCE:
DIAGNOSIS:
BLOOD GROUP:
BED NO:
WARD:

Mr.S.Alahendran
O/L
2015/5/20
2015/5/28
66238/15
Cook
married
Dr. Ahilan(consultant physician)
patient and his son
Angina Pectoris
AB+ve
3
Medical

2.1.1.2 CHIEF COMPLAINTS: Chest pain, Nausea and vomitting

2.1.1.3 HISTORY OF PRESENT ILLNESS: According to the patients, he come for Medical
clininc, due Lower respiratory tract infection . His general condition is ill looking and oriented
with time place and person.

2.1.1.4 HISTORY OF PAST ILLNESS:

antihypertensive medicine.

ALLERGIES
According to the patient, he doesnt have any allergic reaction to any factors.

.
PREVIOUS HOSPITALIZATION: no any

2.1.2 FAMILY HISTORY:

5

Type of family: joint

No. of Family Members: 7

Table 1 Family Medical history

DISEASE

FATHERS RELATION

MOTHERS RELATION

Tuberculosis

Absent

Absent

Cancer

Absent

Absent

Heart disease

Absent

Absent

Jaundice

Absent

Absent

Epilepsy

Absent

Absent

Psychological

Absent

Absent

Hypertension

Present

Present

2.1.3 HEALTH SEEKING PRACTICE: He belongs to literate family, According to Alagendran,

they were not dependent in superstitious beliefs. If someone becomes ill in their family they take
homemade medicine then some times go to hospital.

2.1.4 PERSONAL HISTORY:

Health Habits:
Smoker but has left 1-2 months ago, Non alcoholic,
Non vegetarian.

No food allergy.
Maintain personal hygiene
Religion belief and worship kuldeuta.

Dietry history:
Non vegetarian.
Foods like egg-curry, rice, daal etc.

2.1

SOCIO-ECONOMIC STATUS:
He belongs to middleclass family. The major source of
income is Cook and business. They are the permanent
residence of Kiran. They are well satisfied with their
economic status. They have very good inter relationship in
the community.

3.0 ENVIRONMENTAL FACTOR:

Housing Pattern: Well facilitated

Waste disposal: They are practicing collective approach to manage the

waste product. Such as temporary container, burning and making compost
manure. The people from Kiran also come to take waste from there home.

4.0 DEVELOPMENTAL NEED AND TASK COMPARING WITH NORMAL ADULT

CLIENTS

4.1 Robert Havighursts Developmental Tasks

Developmental
Tasks

Description

Passed or
Failed

1. Adjusting to
Older adults also
decreasing physical have to adjust to
strength and health decreasing
physical strength
and health. The
prevalence of
chronic and acute
diseases increase
in old age. Thus,
older adults may
be confronted with
life situations that
are characterized
by not being in
perfect
health,serious
illness and
dependency on
people.

Passed

2. Adjusting to
retirement and
reduced income

Passed

A central
developmental task
that characterized
the transition into
old age is
adjustment to
retirement. The
period after
retirement has to
be filled with new
projects, but is
characterized by
few valid cultural
guidelines. The

achievement of this
task may be
obstructed by the
management of
another task, living
in a reduced
income after
retirement.

3. Adjusting to
death of a spouse

Older adults may

become caregivers
to their spouses.
Some older adults
have to adjust to
the death of their
spouses. After they
have lived with a
spouse for many
decades,
widowhood may
force older people
to adjust to
loneliness, moving
to a smaller
place,and learning
about business
matters.

Failed

4. Establishing an
explicit affiliation
with one's aged
group

The development
of a large part of
the population into
old age is
historically recent
phenomenon to
modern cities.
Thus,
advancements

Passed

understanding of
the aging process
may lead to
identifying further
developmental
tasks associated
with gains and
purposeful lives for
adults.

5. Meeting social
Older people might
and civil obligations accumulate
knowledge about
life, and thus may
contribute to the
development of
younger people
and the society.

Passed

6. Establishing
Oder adults are
satisfactory physical generally
living arrangements challenged to
create positive
sense of their lives
as a whole. The
feeling that life has
order and meaning
results in
happiness.

Passed

4.2 Eric Eriksons Developmental Task

10

Integrity vs. Despair

Erikson felt that much of life is preparing for the middle adulthood stage and the last
stage recovering from it. Perhaps that is because as older adults we can often look back on our
lives with happiness and are contented, feeling fulfilled with a deep sense that life has meaning
and we've made contribution to life, a feeling Erikson called integrity. On the other hand, some
adults may reach this stage and despair at their experiences and perceived failure.
My patient achieved happiness and contentment in his life based on his actions and
speeches. He is faithful and devoted to his religion. He is ready to accept death completely and
he has shared his experiences to his beloved grandchildren. Even though he accepted death
fully but his faith and love for his worshipped God never changed.

5.0 Physical Assessment

Vital Signs
Axillary T=97 degree F, PR= 90/ min, RR= 22/ min, BP= 150/80 mmHg.
General survey
Height= 5 ft and 4

inches, weight= 66 kilos,. No signs of distress noted upon

assessment, able to smile, cooperate well, responsive to questions, conscious and alert,
conversant. Well oriented. Show calmness during the examination. He has no IVF infused, and
was asleep at initial assessment.
Skin
Skin is brown in color, rough, dry and warm. . Brownish discolorations that resemble
wrinkles are observed on face.
Head
11

Skull is round in shape, symmetrical. No masses noted. Facial movement is

symmetrical, alopecia. Scalp is clear from dandruff and lice. No scars and wounds noted.
Eyes
Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have
same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no
discharges and bilaterally blink. Upper lid covers the small portion of the iris and cornea.
Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid with no
tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils constricted to light,
round in shape. He is able to rotate eyes and has coordinated eye movements.
Ears
Auricle has same color with the skin, has symmetrical shape and located a little bit
higher than the eye. Pinnas are symmetrical with no lesions noted. He has wet cerumen noted
on both ears when pulled down and back for better visualization. he is able to hear on both ears.

Nose
Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when
light is flashed through the nasal passageways; its color is black. No nasal flaring observed
upon respiration. Both nares are patent, air moves freely as client breathes through the nares.
Nasal septum is straight and in midline. Nasal mucosa is pinkish in color, has no discharges and
no lesions. No tenderness of sinuses noted.
Mouth
Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in
color with thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft
palate is light pink in color while hard palate is lighter in color. Gums are pinkish in color.
Plagues are present on his teeth
Pharynx

12

Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils
are not inflamed.
Neck
Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted.
he is able to flex and extend neck and move it laterally (L and R).
Chest and Lungs
Breathing pattern is regular. Anteroposterior diameter to transverse diameter is in 1:2.
Respiratory excursion is symmetrical (thumb separates to 2-3cm). No tenderness, lump,
Presence of breath sound in all area of lungs

Heart and Central Vessels

Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more
audible in apical area upon auscultation.
Back and Extremities
Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color,
and have a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were
noted.. His hands are a little rough. Muscle strength is equal on both sides of the upper and
lower extremities. He is able to stand and walk on both feet independently, and his movements
are well coordinated. Toes point straight ahead. And he is able to sit up straight.
Abdomen
His abdomens color is same with the rest of the part of the body. His umbilicus is coated
with blackish dirt.
Neurologic Assessment
Cranial Nerves: able to identify aromas by smelling with eyes closed; able to see
objects; pupil constricted to light sensation; able to move eyeball downward and laterally; able to
blink eyes; able to smile, raise eyebrows, puff cheeks and close eyes; able to respond to
questions being heard;) has rough and vibrating sound; able to shrug shoulders, elevate and
flex arms and legs against resistance; able to protrude tongue and move it side to side.
13

6.0 FINDINGS:

14

Skin is goond tension

of hair
wet cerumen noted on both ears
plaques are present
Nails are long and untrimmed

History of illness
He has a familial history of hypertension ,diabetic mellitus on her father mothers side and has
positive distress due to her worsen condition. His assessment findings were Fasting blood
sugar-9.3mmol/L,
Troponin I-<0.012,Urine
full report-Albumin-Trace,
Red cells-Nil,Puscells-1-2,Epithelialcells-+
.Serum Electrolyts-Na+-140Mmol/L,K+-3.7Mmol/L.
Full blood count- Heamoglobin-6g/dl,ECG taken T-depression,In echo findings-Left ventricular
Hypertrophy, then they taken endoscopy because his hemoglobin level is low.The findings they
are gastric ulcer he have got.

This is the first time he has the angina pectoris pain.

The patient has pain with nausea with vomiting. Patient states his pain occurs it radiated to left
arm.

Discussion of the disease

a) Discussion of the Angina Pectorise
b) Angina pectoris is commonly known as angina .It is chest pain due
to ischemia of the heart muscle, generally due to obstruction or spasm of the
coronary arteries. The main cause of Angina pectoris is coronary artery disease,
due to atherosclerosis of the arteries feeding the heart. The term derives from
the Latin angina ("infection of the throat") from
the Greek ankhon ("strangling"), and the Latin pectus ("chest"), and can
therefore be translated as "a strangling feeling in the chest".
c) There is a weak relationship between severity of pain and degree of oxygen
deprivation in the heart muscle there can be severe pain with little or no risk of
a Myocardial infarction (commonly known as a heart attack), and a heart attack
can occur without pain). In some cases angina can be extremely serious and has
been known to cause death. People that suffer from average to severe cases of

15

angina have an increased percentage of death before the age of 55, usually
around 60%.

Pathophysiology & Eitiology

Angina results when there is an imbalance between the heart's oxygen demand
and supply. This imbalance can result from an increase in demand (e.g. during
exercise) without a proportional increase in supply (e.g. due to obstruction or
atherosclerosis of the coronary arteries).
However, the pathophysiology of angina in females varies significantly as
compared to males. Non-obstructive coronary disease is more common in
females.

Signs and symptoms

Angina pectoris can be quite painful, but many patients with angina complain of chest
discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness,
tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, angina pains
may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or
shoulders. This is explained by the concept of referred pain, and is due to the spinal level that
receives visceral sensation from the heart simultaneously receiving coetaneous sensation from
parts of the skin specified by that spinal nerve's dermatome, without an ability to discriminate
the two. Typical locations for referred pain are arms (often inner left arm), shoulders, and neck
into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by
16

having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness,
sweating and nausea in some cases. In this case, the pulse rate and the blood pressure
increases. Chest pain lasting only a few seconds is normally not angina (such as Precordial
catch syndrome).
Myocardial ischemia comes about when the myocardia (the heart muscles) receive insufficient
blood and oxygen to function normally either because of increased oxygen demand by the
myocardia or by decreased supply to the myocardia. This inadequate perfusion of blood and the
resulting reduced delivery of oxygen and nutrients is directly correlated to blocked or narrowed
blood vessels.
Some experience "autonomic symptoms" (related to increased activity of the autonomic nervous
system) such as nausea, vomiting and pallor.
Major risk factors for angina include cigarette smoking, diabetes, high cholesterol, high blood
pressure, sedentary lifestyle and family history of premature heart disease.
A variant form of angina (Prinzmetal's angina) occurs in patients with normal coronary arteries
or insignificant atherosclerosis. It is thought to be caused by spasms of the artery. It occurs
more in younger women.[10]

8.Types of Angina pectoris

17

Worsening angina attacks

Sudden-onset angina at rest, and angina lasting more than 15 minutes are symptoms
of unstable angina (usually grouped with similar conditions as the acute coronary syndrome). As
these may herald myocardial infarction (a heart attack), they require urgent medical attention
and are generally treated as a presumed heart attack.

Unstable angina
this is a form of acute coronary syndrome is defined as angina pectoris that changes or
worsens.[1]
It has at least one of these three features:
1. it occurs at rest (or with minimal exertion), usually lasting >10 min;
2. it is severe and of new onset ( within the prior 46 weeks); and/or
3. it occurs with a crescendo pattern ( distinctly more severe, prolonged, or frequent than
before).
UA may occur unpredictably at rest which may be a serious indicator of an impending heart
attack. What differentiates stable angina from unstable angina (other than symptoms) is the
18

pathophysiology of the atherosclerosis. The pathophysiology of unstable angina is the reduction

of coronary flow due to transient platelet aggregation on apparently normal endothelium,
coronary artery spasms or coronary thrombosis. The process starts with atherosclerosis, and
when inflamed leads to an active plaque, which undergoes thrombosis and results in acute
ischemia, which finally results in cell necrosis after calcium entry. Studies show that 64% of all
unstable anginas occur between 10 PM and 8 AM when patients are at rest.
Instable angina, the developing atheroma is protected with a fibrous cap. This cap
(atherosclerotic plaque) may rupture in unstable angina, allowing blood clots to precipitate and
further decrease the lumen of the coronary vessel. This explains why an unstable angina
appears to be independent of activity.

Major risk factors

Age ( 55 years for men, 65 for women)

Cigarette smoking

Diabetes mellitus (DM)

Dyslipidemia

Family history of premature cardiovascular disease (men <55 years, female <65 years
old)

Hypertension (HTN)

Obesity (BMI 30 kg/m2)

Physical inactivity

Prolonged psychosocial stress.

Routine counseling of adults to advise them to improve their diet and increase their physical
activity has not been found to significantly alter behavior, and thus is not recommended.

Conditions that exacerbate or provoke angina

19

Medications

Vasodilators

Excessive thyroid replacement

Vasoconstrictors

polycythemia which thickens the blood causing it to slow its flow through the heart
muscle

hypothermia

hypovolaemia

One study found that smokers with coronary artery disease had a significantly increased
level of sympathetic nerve activity when compared to those without. This is in addition to
increases in blood pressure, heart rate and peripheral vascular resistance associated with
nicotine which may lead to recurrent angina attacks. Additionally, the Centers for Disease
Control and Prevention (CDC) reports that the risk of CHD (Coronary heart disease), stroke,
and PVD (Peripheral vascular disease) is reduced within 12 years of smoking cessation. In
another study, it was found that after one year, the prevalence of angina in smoking men
under 60 after an initial attack was 40% less in those who had quit smoking compared to
those who continued. Studies have found that there are short term and long term benefits to
smoking cessation.

Other medical problems

profound anemia

uncontrolled HTN

hyperthyroidism

hypoxemia

Diagnosis
Angina should be suspected in people presenting with tight, dull, or heavy chest discomfort
which is
1. Retrosternal or left-sided, radiating to the left arm, neck, jaw, or back.
2. Associated with exertion or emotional stress and relieved within several minutes by
rest.

20

3. Precipitated by cold weather or a meal.

Some people present with atypical symptoms, including breathlessness, nausea, or
epigastric discomfort or burping. These atypical symptoms are particularly likely in older
people, women, and those with diabetes.
Angina pain is not usually sharp or stabbing or influenced by respiration. Antacids and
simple analgesia do not usually relieve the pain. If chest discomfort (of whatever site) is
precipitated by exertion, relieved by rest, and relieved by glyceryl trinitrate, the likelihood of
angina is increased.
In angina patients who are momentarily not feeling any one chest pain,
an electrocardiogram (ECG) is typically normal, unless there have been other cardiac
problems in the past. During periods of pain, depression or elevation of the ST
segment may be observed. To elicit these changes, an exercise ECG test ("treadmill test")
may be performed, during which the patient exercises to their maximum ability before
fatigue, breathlessness or, importantly, pain intervenes; if characteristic ECG changes are
documented (typically more than 1 mm of flat or downsloping ST depression), the test is
considered diagnostic for angina. Even constant monitoring of the blood pressure and the
pulse rate can lead us to some conclusion regarding the angina. The exercise test is also
useful in looking for other markers of myocardial ischaemia: blood pressure response (or
lack thereof, particularly a drop in systolic pressure), dysrhythmia and chronotropic
response. Other alternatives to a standard exercise test include a thallium scintigram or
sestamibi scintigram (in patients who cannot exercise enough for the purposes of the
treadmill tests, e.g., due to asthma orarthritis or in whom the ECG is too abnormal at rest) or
Stress Echocardiography.
In patients in whom such noninvasive testing is diagnostic, a coronary angiogram is typically
performed to identify the nature of the coronary lesion, and whether this would be a
candidate forangioplasty, coronary artery bypass graft (CABG), treatment only with
medication, or other treatments. There has been research which concludes that a frequency
is attained when there is increase in the blood pressure and the pulse rate. This frequency
varies normally but the range is 4550 kHz for the cardiac arrest or for the heart failure.In
patients who are in hospital with unstable angina (or the newer term of "high risk acute
coronary syndromes"), those with resting ischaemic ECG changes or those with raised
cardiac enzymes such as troponin may undergo coronary angiography directly.
Other cardiac problems

21

tachyarrhythmia

bradyarrhythmia

valvular heart disease

hypertrophic cardiomyopathy

Myocardial ischemia can result from:

1. a reduction of blood flow to the heart that can be caused by stenosis, spasm, or
acute occlusion (by an embolus) of the heart's arteries.
2. Resistance of the blood vessels. This can be caused by narrowing of the blood
vessels; a decrease in radius. Blood flow is proportional to the radius of the artery to
the fourth power .
3. Reduced oxygen-carrying capacity of the blood, due to several factors such as a
decrease in oxygen tension and hemoglobin concentration. This decreases the
ability to of hemoglobin to carry oxygen to myocardial tissue.
Atherosclerosis is the most common cause of stenosis (narrowing of the blood vessels) of
the heart's arteries and, hence, angina pectoris. Some people with chest pain have normal
or minimal narrowing of heart arteries; in these patients, vasospasm is a more likely cause
for the pain, sometimes in the context of Prinzmetal's angina and syndrome X.
Myocardial ischemia also can be the result of factors affecting blood composition, such as
reduced oxygen-carrying capacity of blood, as seen with severe anemia (low number of red
blood cells), or long-term smoking.

9.Treatment
The most specific medicine to treat angina is nitroglycerin. It is a potent vasodilator that
makes more oxygen available to the heart muscle. Beta blockers and calcium channel
blockers act to decrease the heart's workload, and thus its requirement for oxygen.
Nitroglycerin should not be given if certain inhibitors such
as Sildenafil (Viagra), Tadalafil (Cialis), or Vardenafil (Levitra) have been taken within the
previous 12 hours as the combination of the two could cause a serious drop in blood
pressure. Treatments for angina are balloon angioplasty, in which the balloon is inserted at
the end of a catheter and inflated to widen the arterial lumen. Stents to maintain the arterial
widening are often used at the same time. Coronary bypass surgery involves bypassing
constricted arteries with venous grafts. This is much more invasive than angioplasty.
The main goals of treatment in angina pectoris are relief of symptoms, slowing progression
of the disease, and reduction of future events, especially heart attacks and death. Beta
blockers (e.g.,carvedilol, propranolol, atenolol) have a large body of evidence in morbidity
22

and mortality benefits (fewer symptoms, less disability and longer life) and shortacting nitroglycerin medications have been used since 1879 for symptomatic relief of
angina. Calcium channel blockers (such as nifedipine (Adalat) and amlodipine), isosorbide
mononitrate and nicorandil are vasodilators commonly used in chronic stable angina. A new
therapeutic class, called If inhibitor, has recently been made available: ivabradine provides
pure heart rate reduction[30] leading to major anti-ischemic and antianginal efficacy. ACE
inhibitors are also vasodilators with both symptomatic and prognostic benefit and,
lastly, statins are the most frequently used lipid/cholesterol modifiers which probably also
stabilize existing atheromatous plaque. Low-dose aspirin decreases the risk of heart attack
in patients with chronic stable angina, and was is part of standard treatment. However, in
patients without established cardiovascular disease, the increase in hemorrhagic stroke and
gastrointestinal bleeding offsets any benefits and it is no longer advised unless the risk of
myocardial infarction is very high.
Exercise is also a very good long term treatment for the angina (but only particular regimens
- gentle and sustained exercise rather than intense short bursts), probably working by
complex mechanisms such as improving blood pressure and promoting coronary artery
collateralisation.
Identifying and treating risk factors for further coronary heart disease is a priority in patients
with angina. This means testing for elevated cholesterol and other fats in the
blood, diabetes andhypertension (high blood pressure), and encouraging smoking
cessation and weight optimisation.
The calcium channel blocker nifedipine prolongs cardiovascular event- and procedure-free
survival in patients with coronary artery disease. New overt heart failures were reduced by
29% compared to placebo; however, the mortality rate difference between the two groups
was statistically insignificant.
The fatty acid oxidation inhibitor mildronate is a clinically used anti-ischemic drug for the
treatment of angina and myocardial infarction. Mildronate shifts the myocardial energy
metabolism fromfatty acid oxidation to the more oxygen sparing glucose oxidation under
ischemic conditions, by inhibiting enzymes in the carnitine
biosynthesis pathway including gamma-butyrobetaine dioxygenase. Mildronate also
inhibits carnitine acetyltransferase and therefore acts as a myocardial energy metabolism
regulator

23

1.

Comparison of study book and patients condition.

Risk factors

Sign & symptoms

Investigation

Ideal
Heavy diet
Cold weather,
Heavy exercise&works
Anxiety
Alcohol .smoking
Feeling of tightness in the chest;
Difficulty in breathing
Nausea ,vomiting
Chestpain radiated to his arm left
shoulder lower jaw scapula .

Actual

Troponin I
FBC, ECG
Serum electrolytes

FBC- WBC
Chest X-ray- normal
ESR

Anxiety
Heavy diet,heavy work

Feeling of tightness in the chest;

Difficulty in breathing
Nausea ,vomiting
Chestpain radiated to his arm left
shoulder lower jaw scapula .

complication

Treatment

24

profound anemia

uncontrolled HTN

hyperthyroidism

hypoxemia

Bed rest ,SublingualGTN,

Atrovastadin 10mg
Asprin 75mg
Clopidogrel 75mg

profound anemia

Sublingual GTN
Clopidogrel

The main focus of nursing care is to actively assess the air way and the patient response to
treatment. The immediate nursing care of patient with asthma depends on the severity of the
symptoms. A calm approach is an important aspect of care especially for anxious client
and ones family.
Attaining relief from angina pain
First give bed rest
Monitor vital signs skin colour, retraction, and degree of restlessness.
Provide medication and oxygen therapy as prescribed.
Give sublingual GTN to reduced the pain & dilated the blood vessels temporary.
Instruct patient on positioning to facilitate breathing sitting upright.
Relieving anxiety
Explain rationale for interventions to gain patients cooperation. Provide care in prompt.
Confident manner.
Help patient clarify sources of anxiety; suggest measures to reduce anxiety
Reliving emotional changes.
Preventing adverse effects of drugs

advised the patient about the antiplatelet drugs If any injury happen it will course
hemorrhage

10.0) SUMMARY OF CLIENT DAILY PROGRESS REPORT IN

HOSPITAL
DATE

TIME

TEMPERATUR
E

PULSE

RESPIR
ATION

BP

SUMMARY

20/O5/2015

2am

98 degree F

80/m

20/m

200/80m
m of hg

6pm

97.6 degree F

88/m

28/m

Pts g/c is seems

satisfactory, vital
signs monitored
with rise in blood
pressure.
Prescribed
medicine carried
out. Input and

25

210/80
mm of
hg

output chart
maintained. Paln
for haemodialysis
tomorrow. No any
complain from the
patient side.
021/05/201
5

21/05/15

26

12:30
pm

98 degree F

82/m

24/m

210/100
mm of
hg

1:20p
m

98 degree F

90/m

20/m

210/100
mm of
hg

2pm

98 degree F

100/m

22/m

200/90
mm of
hg

6pm

101.6 degree
F

110/m

24/m

210/80
mm of
hg

pts g/c seems

satisfactory. Vital
signs are taken
and recorded with
rise in blood
pressure. Patient
in normal diet.
Prescribed
medication
carried out. No
any specific
complain from
patient side.

Pts g/c is
satisfactory. Vital
signs are taken and
recorded with rise
in blood pressure
and temperature.
Tab paracetamol
and cold
compresses given
to the patient.All
prescribed
medication was
carried out. Patient
is on normal diet.

22/05/2015

23/05/15

27

10am

97 degree f

90/m

20/m

210/90
mm of
hg

2pm

97 degree f

88/m

20/m

210/90
mm of
hg

10
am

97 degree f

92/ min

20/min

180/80
mm of
hg

2pm

98 degree f

88/min

20/min

180/70
mm of

Pts general
condition is
satisfactory. Vital
signs are taken
with rise in blood
pressure.
prescribed
medicine carried
out. Normal bowel
and bladder habit.
Patient complain is
dry and itching
over skin of hands
and legs. So he is
in dermatology
consultation.
Dermatology
department
prescribed him
coconut oilto apply
in itching and dry
areas three times
a day.
pts g/c seems
satisfactory. Vital signs
are taken and recorded
with rise in blood
pressure. through left.
Put the sand bag
pressure at the femoral
site for 2 hours. Patient
in normal diet.
Prescribed medication
carried out. No any
specific complain from
patient side.

hg
24/05/15

10am

98 degree f

80/min

22/min

150/90
mm of
hg

Patient general
condition seems
satisfactory. Vital signs
taken with rise in blood
pressure. Prescribed
medicine carried out.
Normal bladder habit
but bowel habit is
disturbed.no any such
complain from patient
side

25/05/15

10
am

97 degree f

80/ min

20/min

140/80
mm of
hg

Patient general
condition seems
satisfactory. Patient
general condition
seems satisfactory. Vital
signs taken with rise in
blood pressure.
Prescribed medicine
carried out. Normal
bowel and bladder
habit. No any itching on
the patients skin

2pm

98 degree f

76/min

20/min

170/70
mm of
hg

05/26/2015

10am

98 degree f

78/min

22/min

190/80
mm of
hg

05/27/2015

10
am

97 degree f

80/ min

20/min

190/70
mm of
hg

28

pts g/c seems

satisfactory. Vital signs
are taken and recorded
with rise in blood
pressure.. Friday.
Patient in normal diet.
Prescribed medication
carried out. No any
specific complain from
patient side.

28/15/2015

2pm

98 degree f

88/min

20/min

180/60
mm of
hg

Pts g/c is improved.

Vital signs taken with
rise in blood pressure.
All prescribed
medication was carried
out. . Discharge on
27/05/2015

10am

98 degree f

90/min

22/min

180/70
mm of
hg

Patient general
condition seems fair.
Vital signs are taken
and recorded with rise
in blood
pressure.prescribed
medicine carried
out,normal bowel and
bladder habit.
Wednesday and Friday.
Follow up on medical
out patient department
on Monday or Thursday.

11.0 DIVERSIONAL THERAPY USED FOR CLIENT

Diversional therapies are used to divert ones thoughts from life stresses or to fill time.
I have used the following aspects of diversional therapy to overcome his situation.

Physical therapy: deep breathing and coughing exercise was encouraged to perform.
Proper position of the patient was maintained so that she can feel relaxed and
comfortable.
Group therapy: I gave many examples of other people having the same disease
condition and also introduced him with some of them so that he can realize that many
others have and share problems which are very similar to their own problems and that
they are not alone in their suffering.

29

 Relaxation training: I encouraged my patient for performing yoga and meditation as

relaxation produces physiological effect that are opposite to those anxiety, that is slow
heart rate, increased peripheral blood flow.
Psychological therapy: I encourage my patient to express his feelings and attitude,
and communicate with the care takers as well as the family members. Because of this
his psychological depression can be reduced and he feels better.

Medicine therapy: I provided his medicine to relieve his pain and for his better
recovery.

Recreational therapy: according to this therapy, I encouraged my patient to listen

songs of his choice. I also encouraged him to sing songs as he loves to listen and sing
old melody filmy songs songs. Beside these I also encouraged my patient to read
magazines, newspaper, listen radio, etc. so that it would help patient diverse his mind
away from his anxiety and depression.

12.0 APPLICATION OF NURSING THEORIES

Virginia Hendersons Independent Theory:

In 1955, Henderson formulated unique function of nursing, she purposed
14 components of Basic nursing care. The components are as follows:

30

Breathe normally.
Eat and drink adequately
Eliminate body wastes
Move and maintain desirable postures.
Sleep and rest
Select suitable clothes- dress and undress
Maintain body temperature within normal range by adjusting clothing and
modifying the environment.
Keep the body clean and well groomed and protect the integument.
Avoid danger in the environment and avoid injuring others.
Communicate with others in expressing emotions, needs, fear or opinion.
Worship according to ones faith.
Play or participate in various forms of recreation.
Learn, discover or satisfy the curiosity that leads to normal developmental and
health and use of the available facilities.

13.0 APPLICATION OF THEORY ON MY PATIENT

Breath normally:- I encourage my patient to do deep breathing and

coughing exercise. This helps to
promote lung expansion and gases
extent and also help to loosen and bring out secretion.
Eat and drink adequately:- I encourage my patient to eat and drink
adequately according to body needs and the patient food habit was well
maintained.he was prescribed to have fluid less than 500ml/day
Eliminate body waste:- My patient bowel and bladder habit was normal so
his eliminate body waste pattern was well maintained.
Move and maintain desirable posture:- I helped my patient to move and
maintain the desirable position
Sleep and rest: I encouraged patient to take a adequate rest and sleep
according to body need and disease condition for a positive health.
Select suitable clothe and dress:- Suitable clothe was selected.
Body cleanliness:- I encourage my patient to keep her body clean.
Avoid danger in the environment and avoid injuring others: sometimes my
patient shows aggressive behavior so antipsychotics drugs were
prescribed to my patient to avoid danger in the environment and also to
avoid injuring others.
Communicate with others in expressing emotions, needs, fear or opinion:As my patient was able to communicate, his communication pattern was
maintaining.
Worship according to ones faith
Play or participate in various forms of recreation:- This component help
me inspire my patient to write new poems, story and jokes.

14.0 NURSING CARE PLAN

1. Acute Pain
May be related to

Decreased myocardial blood flow

Increased cardiac workload/oxygen consumption

Possibly evidenced by

31

Reports of pain varying in frequency, duration, and intensity (especially as condition

worsens)

Narrowed focus

Distraction behaviors (moaning, crying, pacing, restlessness)

Autonomic responses, e.g., diaphoresis, blood pressure and pulse rate changes,
pupillary dilation, increased/decreased respiratory rate

Desired Outcomes

Report anginal episodes decreased in frequency, duration, and severity.

Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension
and restlessness
Nursing Interventions

Rationale

Instruct patient to notify nurse immediately

when chest pain occurs.

Pain and decreased cardiac output may

stimulate the sympathetic nervous system to
release excessive amounts of norepinephrine,
which increases platelet aggregation and
release of thromboxane A2. This potent
vasoconstrictor causes coronary artery spasm,
which can precipitate, complicate, and/or
prolong an anginal attack. Unbearable pain
may cause vasovagal response, decreasing BP
and heart rate.

Assess and document patient response to

medication.

Provides information about disease

progression. Aids in evaluating effectiveness of
interventions, and may indicate need for
change in therapeutic regimen.

Identify precipitating event, if any: frequency,

duration, intensity, and location of pain.

Helps differentiate this chest pain, and aids in

evaluating possible progression to unstable
angina.

Observe for associated symptoms: dyspnea,

nausea and vomiting, dizziness, palpitations,
desire to micturate.

Decreased cardiac output (which may occur

during ischemic myocardial episode) stimulates
sympathetic and parasympathetic nervous
system, causing a variety of vague sensations
that patient may not identify as related to
anginal episode.

Evaluate reports of pain in jaw, neck, shoulder, Cardiac pain may radiate. Pain is often referred
32

Nursing Interventions

Rationale

arm, or hand (typically on left side).

to more superficial sites served by the same

spinal cord nerve level.

Place patient at complete rest during anginal

episodes.

Reduces myocardial oxygen demand to

minimize risk of tissue injury.

Elevate head of bed if patient is short of breath.

Facilitates gas exchange to decrease hypoxia

and resultant shortness of breath.

Monitor heart rate and rhythm.

Patients with unstable angina have an

increased risk of acute life-threatening
dysrhythmias, which occur in response to
ischemic changes and/or stress.

Monitor vital signs every 5 min during initial

anginal attack.

Blood pressure may initially rise because of

sympathetic stimulation, then fall if cardiac
output is compromised. Tachycardia also
develops in response to sympathetic
stimulation and may be sustained as a
compensatory response if cardiac output falls.

Stay with patient who is experiencing pain or

appears anxious.

Anxiety releases catecholamines, which

increase myocardial workload and can escalate
and/or prolong ischemic pain. Presence of
nurse can reduce feelings of fear and
helplessness.

Maintain quiet, comfortable environment.

Restrict visitors as necessary.

Mental/emotional stress increases myocardial

workload.

Provide light meals. Have patient rest for 1 hr

after meals.

Decreases myocardial workload associated

with work of digestion, reducing risk of anginal
attack.

Provide supplemental oxygen as indicated.

Increases oxygen available for myocardial

uptake and reversal of ischemia.

Administer antianginal medication(s) promptly as indicated:

Nitroglycerin has been the standard for treating
Nitroglycerin: sublingual (Nitrostat), buccal, or and preventing anginal pain for more than 100
oral tablets, metered-dose spray.
yr. Today it is available in many forms and is
still the cornerstone of antianginal therapy.
sublingual isosorbide dinitrate (Isordil)

33

Rapid vasodilator effect lasts 1030 min and

can be used prophylactically to prevent, as well

Nursing Interventions

Rationale
as abort, anginal attacks.

Long-acting preparations are used to prevent

recurrences by reducing coronary vasospasms
and reducing cardiac workload. May cause
headache, dizziness, light-headedness,
Sustained-release tablets, caplets: (Nitrong,
symptoms that usually pass quickly. If
Nitrocap T.D.), chewable tablets (Isordil,
headache is intolerable, alteration of dose or
Sorbitrate), patches, transmucosal ointment
discontinuation of drug may be necessary.
(Nitro-Dur, Transderm-Nitro)
Note: Isordil may be more effective for patients
with variant form of angina. Reduces frequency
and severity of attack by producing continuous
vasodilation.
Beta-blockers: acebutolol (Sectral), atenolol
(Tenormin), nadolol (Corgard), metoprolol
(Lopressor), propranolol (Inderal)

Reduces angina by reducing the hearts

workload. Note: Often these drugs alone are
sufficient to relieve angina in less severe
conditions.

Calcium channel blockers: bepridil (Vascor),

Produces relaxation of coronary vascular
amlodipine (Norvasc), nifedipine (Procardia),
smooth muscle; dilates coronary arteries;
felodipine (Plendil), isradipine (DynaCirc),
decreases peripheral vascular resistance.
diltiazem (Cardizem)
Analgesics: acetaminophen (Tylenol)

Usually sufficient analgesia for relief of

headache caused by dilation of cerebral
vessels in response to nitrates.

Morphine sulphate (MS)

Potent narcotic analgesic may be used in acute

onset because of its several beneficial effects,
e.g., causes peripheral vasodilation and
reduces myocardial workload; has a sedative
effect to produce relaxation; interrupts the flow
of vasoconstricting catecholamines and thereby
effectively relieves severe chest pain. MS is
given IV for rapid action and because
decreased cardiac output compromises
peripheral tissue absorption.

Monitor serial ECG changes.

34

Ischemia during anginal attack may cause

transient ST segment depression or elevation
and T wave inversion. Serial tracings verify
ischemic changes, which may disappear when
patient is pain-free. They also provide a
baseline against which to compare later pattern

Nursing Interventions

Rationale
changes.

2. Knowledge Deficit
May be related to

Lack of exposure

Inaccurate/misinterpretation of information

Unfamiliarity with information resources

Possibly evidenced by

Questions; statement of concerns

Request for information

Inaccurate follow-through of instructions

Desired Outcomes

Participate in learning process.

Assume responsibility for own learning, looking for information and asking questions.

Verbalize understanding of condition/disease process and potential complications.

Verbalize understanding of /participate in therapeutic regimen.

Initiate necessary lifestyle changes.

Nursing Interventions

Discuss pathophysiology of condition. Stress

need for preventing and managing anginal
attacks.
35

Rationale
Patients with angina need to learn why it occurs
and what they can do to control it. This is the
focus of therapeutic management to reduce

Nursing Interventions

Rationale
likelihood of myocardial infarction and promote
healthy heart lifestyle.

Review significance of cholesterol levels and

differentiate between LDL and HDL factors.
Emphasize importance of periodic laboratory
measurements.

Although recommended LDL is 160 mg/dL,

patients with two or more risk factors (smoking,
hypertension, diabetes mellitus, positive family
history) should keep LDL 130 mg/dL, and
those with diagnosis of CAD need to keep LDL
below 100 mg/dL. HDL below 3545 is
considered a risk factor; a level above 60
mg/dL is considered an advantage.

Encourage avoidance of situations that may

precipitate anginal episode (stress, intense
Doing so would reduce the incidence or
physical exertion, large heavy meals especially
severity of ischemic episodes.
during bedtime, exposure to extreme
temperatures).
Assist patient and/or SO to identify sources of
physical and emotional stress and discuss
ways that they can be avoided.

This is a crucial step in preventing anginal

attacks.

Knowledge of the significance of risk factors

provides patient with opportunity to make
Review importance of weight control, cessation needed changes. Patients with high cholesterol
of smoking, dietary changes, and exercise.
who do not respond to 6-month program of lowfat diet and regular exercise will require
medication.
Encourage patient to follow prescribed
reconditioning program; caution to avoid
exhaustion.

Fear of triggering attacks may cause patient to

avoid participation in activity that has been
prescribed to enhance recovery (increase
myocardial strength and form collateral
circulation).

Discuss impact of illness on desired lifestyle

and activities, including work, driving, sexual
activity, and hobbies. Provide information,
privacy, or consultation, as indicated.

Patient may be reluctant to resume usual

activities because of fear of anginal attack or
death. Patient should take nitroglycerin
prophylactically before any activity that is
known to precipitate angina.

Demonstrate how to monitor own pulse and BP Allows patient to identify those activities that
during and after activities, and to schedule
can be modified to avoid cardiac stress and
activities, avoid strain and take rest periods.
stay below the anginal threshold.

36

Nursing Interventions

Rationale

Discuss steps to take when anginal attacks

Being prepared for an event takes away the
occur, (cessation of activity, keeping rescue
fear that patient will not know what to do if
NTG on hand, administration of prn medication,
attack occurs.
use of relaxation techniques).

Review prescribed medications for

prevention of anginal attacks:

Angina is a complicated condition that often

requires the use of many drugs given to
decrease myocardial workload, improve
coronary circulation, and control the occurrence
of attacks.

These drugs are considered first-line agents for

Lipid-lowering agents: bile acid sequestrants, lowering serum cholesterol levels. Note:
cholestyramine (Questran), colestipol
Questran and Colestid may inhibit absorption of
(Colestid);
fat-soluble vitamins and some drugs such as
Coumadin, Lanoxin, and Inderal.
nicotinic acid, and HMG-CoA reductase
inhibitors: lovastatin (Mevacor), simvastatin
(Zocor)

The HMG-CoA reductase inhibitors may cause

photosensitivity.

Stress importance of checking with physician

before taking OTC drugs.

OTC drugs may potentiate or negate effects of

prescribed medications.

Discuss ASA and other antiplatelet agents as

indicated.

May be given prophylactically on a daily basis

to decrease platelet aggregation and improve
coronary circulation.

May prolong survival rate of patients with

Review symptoms to be reported to physician: unstable angina. Knowledge of expectations
increase in frequency of attacks, changes in
can avoid undue concern for insignificant
response to medications.
reasons or delay in treatment of important
symptoms.
Angina is a symptom of progressive coronary
artery disease that should be monitored and
Discuss importance of follow-up appointments.
may require occasional adjustment of treatment
regimen.

3. Anxiety
May be related to

37

Situational crises

Threat to self-concept (altered image/abilities)

Underlying pathophysiological response

Threat to or change in health status (disease course that can lead to further
compromise, debility, even death)

Negative self-talk

Possibly evidenced by

Expressed concern regarding changes in life events

Increased tension/helplessness

Apprehension, uncertainty, restlessness

Association of diagnosis with loss of healthy body image, loss of place/influence

View of self as noncontributing member of family/society

Fear of death as an imminent reality

Desired Outcomes

Verbalize awareness of feelings of anxiety and healthy ways to deal with them.

Report anxiety is reduced to a manageable level.

Express concerns about effect of disease on lifestyle, position within family and society.

Demonstrate effective coping strategies/problem-solving skills.

Nursing Interventions

Rationale

Explain purpose of tests and procedures: stress Reduces anxiety attributable to fear of unknown
testing.
diagnosis and prognosis.

Promote expression of feelings and fears. Let

patient/SO know these are normal reactions.

Unexpressed feelings may create internal

turmoil and affect self-image. Verbalization of
concerns reduces tension, verifies level of
coping, and facilitates dealing with feelings.
Presence of negative self-talk can increase
level of anxiety and may contribute to
exacerbation of angina attacks.

Encourage family and friends to treat patient as Reassures patient that role in the family and
38

Nursing Interventions

Rationale

before.

business has not been altered.

Tell patient the medical regimen has been

designed to limit future attacks and increase
cardiac stability.

Encourages patient to test symptom control, to

increase confidence in medical program, and to
integrate abilities into perceptions of self.

Administer sedatives, tranquilizers, as

indicated.

May be desired to help patient relax until

physically able to reestablish adequate coping
strategies.

4. Risk for Decreased Cardiac Output

Risk factors may include

Inotropic changes (transient/prolonged myocardial ischemia, effects of edications)

Alterations in rate/rhythm and electrical conduction

Desired Outcomes

Report/display decreased episodes of dyspnea, angina, and dysrhythmias.

Demonstrate increased activity tolerance.

Participate in behaviors/activities that reduce the workload of the heart.

Nursing Interventions

Rationale

Decreases oxygen demand therefore reducing

Maintain bed or chair rest in position of comfort
myocardial workload and risk of
during acute episodes.
decompensation.

Monitor vital signs and cardiac rhythm.

Tachycardia may be present because of pain,

anxiety, hypoxemia, and reduced cardiac
output. Changes may also occur in BP
(hypertension or hypotension) because of
cardiac response. ECG changes reflecting
dysrhythmias indicate need for additional
evaluation and therapeutic intervention.

Auscultate breath sounds and heart sounds.

S3, S4, or crackles can occur with cardiac

39

Nursing Interventions

Listen for murmurs.

Rationale
decompensation or some medications
(especially beta-blockers). Development of
murmurs may reveal a valvular cause for chest
pain (aortic stenosis, mitral stenosis) or
papillary muscle rupture.

Provide for adequate rest periods. Perform selfConserves energy, reduces cardiac workload.
care activities, as indicated.
Stress importance of avoiding straining down,
especially during defecation.

Valsalva maneuver causes vagal stimulation,

reducing heart rate (bradycardia), which may
be followed by rebound tachycardia, both of
which may impair cardiac output.

Encourage immediate reporting of pain for

prompt administration of medications as
indicated.

Timely interventions can reduce oxygen

consumption and myocardial workload and may
minimize cardiac complications.

Desired effect is to decrease myocardial

oxygen demand by decreasing ventricular
Monitor and documents effects or adverse
stress. Drugs with negative inotropic properties
response to medications, noting BP, heart rate, can decrease perfusion to an already ischemic
and rhythm.
myocardium. Combination of nitrates and betablockers may have cumulative effect on cardiac
output.
Angina is only a symptom of underlying
pathology causing myocardial ischemia.
Assess for signs and symptoms of heart failure.
Disease may compromise cardiac function to
point of decompensation.
Evaluate mental status, noting development of Reduced perfusion of the brain can produce
confusion, disorientation.
observable changes in sensorium.
Note skin color and presence and quality of
pulses.

Peripheral circulation is reduced when cardiac

output falls, giving the skin a pale or gray color
(depending on level of hypoxia) and diminishing
the strength of peripheral pulses.

Administer supplemental oxygen as needed.

Increases oxygen available for myocardial

uptake to improve contractility, reduce
ischemia, and reduce lactic acid levels.

Monitor pulse oximetry or ABGs as indicated.

Determines adequacy of respiratory function

and/or O2 therapy.

40

Nursing Interventions

Measure cardiac output and other functional

parameters as indicated.

Rationale
Cardiac index, preload/afterload, contractility,
and cardiac work can be measured
noninvasively through various means, including
thoracic electrical bioimpedance (TEB)
technique. Useful in evaluating response to
therapeutic interventions and identifying need
for emergency care. Note: Evaluation of
changes in heart rate, BP, and cardiac output
requires consideration of patients circadian
hemodynamic variability.

Administer medications as indicated:

Calcium channel blockers: diltiazem
(Cardizem), nifedipine (Procardia), verapamil
(Calan), bepridil (Vascor), amlodipine
(Norvasc), felodipine (Plendil), isradipine
(DynaCirc)

Although differing in mode of action, calcium

channel blockers play a major role in
preventing and terminating ischemia induced
by coronary artery spasm and in reducing
vascular resistance, thereby decreasing BP
and cardiac workload.

Beta-blockers: atenolol (Tenormin), nadolol

(Corgard), propranolol (Inderal), esmolol
(Brevibloc);

These medications decrease cardiac workload

by reducing heart rate and systolic BP. Note:
Overdosage produces cardiac
decompensation.

Acetylsalicylic acid (ASA), other antiplatelet

agents: ticlopidine (Ticlid); glycoprotein IIb/IIa,
abciximab (ReoPro), eptifibatide (Integrilin)

Useful in unstable angina, ASA diminishes

platelet aggregation and clot formation. For
patients with major GI intolerance, alternative
drugs may be indicated. New antiplatelet
medications are being used IV in conjunction
with angioplasty. Oral forms are under
investigation.

IV heparin

Bolus, followed by continuous infusion, is

recommended to help reduce risk of
subsequent MI by reducing the thrombotic
complications of plaque rupture for patients
diagnosed with intermediate or high-risk
unstable angina. Note: Use of low-molecularweight heparin is increasing because of its
more efficacious and predictable effect with
fewer adverse effects (less risk of bleeding)
and longer half-life. It also does not require
anticoagulation monitoring.

41

Nursing Interventions

Rationale

Monitor laboratory studies: PTT, aPTT.

Evaluates therapy needs and effectiveness.

Discuss purpose and prepare for stress testing Stress testing provides information about the
and cardiac catheterization, when indicated.
health and strength of the ventricles.

Prepare for surgical intervention, angioplasty

with/without intracoronary stent placement,
valve replacement, CABG, if indicated.

Angioplasty (also called percutaneous

transluminal coronary angioplasty [PTCA])
increases coronary blood flow by compression
of atheromatous lesions and dilation of the
vessel lumen in an occluded coronary artery.
Intracoronary stents may be placed at the time
of PTCA to provide structural support within the
coronary artery and improve the odds of longterm patency. This procedure is preferred over
the more invasive CABG surgery. CABG is the
recommended treatment when testing confirms
myocardial ischemia as a result of left main
coronary artery disease or symptomatic threevessel disease, especially in those with left
ventricular dysfunction. Note: Stent placement
may also be effective for the variant form of
angina where periodic vasospasms impair
arterial flow.

Prepare for transfer to critical care unit if

condition warrants.

Prolonged chest pain with decreased cardiac

output reflects development of complications
requiring more emergency interventions.

15.0 DISCHARGE TEACHING:Categories

Plan

Medication

Instruct

patient

to

Rationale
take

prescribed

-Compliance to appropriate

medications regularly and comply with

medication and treatment

the treatment regimen prescribed by the

prevents further complications

physician.

and resistance to antibiotics and

promote continuous recovery of

Teach patient regarding the names of

the

42

drug,

its

dosage,

time

of

optimal health.
-The patient has the right to know
his drugs therapeutic effects as

administration, its contraindication and

well as its adverse effects. He

side effects.

also has the right to gain

Inform patient and significant others not

awareness about why is it given

to take drugs not prescribed by the

to him.
-Drug interactions may occur

physician.
Instruct the patient to check for the

which may be fatal to patients

expiration date of the drug before taking

current situation.
-Checking for the expiration date

it.

of the drug before administering it

ensures it potency and safety. It

Do not administer any other drug with

also prevents any unwanted

same action without the physicians

reactions like hypersensitivity.

-Non-prescription drug may have

prescription.
Educate the patient and the significant
others about the expected responses of
drug to the body, side effects, adverse
effects that may possibly seen into the

patient.
Instruct the significant others to report

antagonistic or synergistic effects

if taken with other drugs.
-To be geared up of enough
information that may lead to
immediate medical responses.

any remarkable adverse reactions or

any appearance of side effects noted.

-For immediate remedial action

response and to prevent any
complicated reactions.

Exercise

Explain to patient the significance of

-Exercises promote proper blood

regular

and

circulation and prevent arterial and

stretching. If unable to mobilize alone,

venous stasis thus lessens platelet

instruct the watcher to give assistance

coagulation to aged people. Older

all the time. Encourage to use crutches

people have weakened blood

or any device for support. Stretching

vessel walls which can cause any

upper extremities also promote healthy

alteration in blood flow.

exercise

like

walking

living. Also instruct patient to perform

passive range of motion.

Also exercise prevents atrophy of

the muscles.

Teach patient to wait for 1 to 2 hours

after

eating

before

physical activities.

performing

any

-Older people has slower digestion

rate, thus they need to conserve
more oxygen which will be

43

necessary for digestion of food.

Activities must be limited to
decrease oxygen demand by
organs and tissues other than the
digestive system.

-Deep breathing exercises promote

Instruct the patient to practice deep
breathing exercise.

thoracic expansion which allows air

to enter the respiratory tract and
provide oxygen to the alveoli to
avoid atelectasis or lung collapse
due to increase fluid pressure in
the pleural space.

Treatment

Instruct patient to comply with his

-Maintenance meds should not be

medication treatment like the continuous

forgotten to achieve highest

use of beta blocker Metoprolol for

therapeutic effect.

control of hypertension and Insulin for

diabetes mellitus.

Instruct client to seek medical help if any

unusualties are felt such as tingling
sensation or paresthesia, fatigue and
body malaise, dizziness, headaches,

-These unusualties may be

indicative of worsening condition.

irritability, tremors, diaphoresis, etc.

As part of long-time treatment, advise

patient to wear medical alert bracelet all
the time and wherever he goes. It
contains the patients name, disease

condition, address and contact person.

-Medical alert bracelet provides

Advise to have a family member take

basic information about the client in

your blood pressure to check if youre

maintaining a stable blood pressure.

Since the client has his own glucose

monitor, tell client to continue monitoring

44

case of accidents.

blood glucose level, and immediately

-Monitor of blood pressure is

seek

significant for evaluating the

for

medical

help

if

level

is

abnormally high.

medications effectiveness.
-Glucose monitoring is a big factor
in the management of diabetes
mellitus.

Hygiene

Instruct patient to practice foot care to

-Proper foot care prevents injury to

prevent ulceration and formation of

feet and toes.

gangrenous

tissues

to

the

lower

extremities.
- Check and carefully wash your feet
every day.
-Do not wear shoes that are too small or
socks that do not fit right inside your
shoes.
-Soak your feet in warm soapy water for
10 minutes before cutting your nails.
Trim your toenails straight across to
prevent ingrown toenails. You may also
file down your toenails. Do not cut your
nails into the corners or close to the
skin. You should not dig under or around
the nail.

Emphasize the importance of bathing

everyday. Wash genitals with mild soap.

Instruct client to maintain good oral

hygiene.

Instruct to wear clean clothes and

underwear.

45

-Proper bathing eliminates

proliferation of germs and bacteria
in the body. Mild soap does not
irritate the skin and the genitals.

-Tooth brushing prevents build up

of plaques and cavities.
-Dirty or improperly washed
underwear may become a
sanctuary for microbial growth.
Microbes may enter the genitals
and might worsen the clients
UTI/Cystitis.
Out-Patient
Referral

Encourage patient to undergo physical

-A Physical Therapist is a source of

therapy sessions.

information to understand agerelated changes and offer

assistance for regaining lost
abilities or develop new ones.
Physical therapy can be applied to
the clients condition: arthritis,
urinary and fecal incontinence,
amputation, and cardiac and
pulmonary disorders. It can :
a). increase, restore or maintain
range of motion, physical strength,
flexibility, coordination, balance
and endurance
b.) aids adaptations to make the
home accessible and safe
teach positioning, transfers, and
walking skills

46

c.) promote maximum function and

independence within an individual's
capability
d.) increase overall fitness through
exercise programs
e.) prevent further decline in
functional abilities through
education, energy conservation
techniques, joint protection, and
use of assistive devices to promote
independence
f.) improve sensation, joint
proprioception
g.) reduce pain
-Serves as an evaluation process
to note if condition has progressed
to better or worse.
-To assess for renal function.

Diet

47

Advise to have check-ups after discharge.

Encourage to undergo ABG Test every

month or once every 2 months.

Instruct client to avoid simple sugars.

-Simple sugars easily break down

Take energy from complex carbohydrates

and enter the blood stream.

like unpolished rice, bread and

Complex carbohydrates can

vegetables.

sustain the bodys energy

requirement for a longer time
because they are not broken down
easily.
-A diet rich in fiber relieves

Encourage patient to eat fibrous foods

constipation. It adds bulk to the

like fruits and vegetables. But do not eat

excreta and facilities expulsion.

too much as it can irritate the GI tract and

causes bleeding. Other examples of
sources of fiber are: whole grains, cereals
and legumes.

Limit intake of purine rich foods such as

liver, beef kidneys, brains and meat

-Accumulation of uric acid in the

extracts. Encourage to eat in moderate

joints causes arthritis. Uric acid is

amount: asparagus, cauliflower, spinach,

the by product of purine break

mushrooms, green peas, dried peas and

down in the liver. Because of renal

beans.

malfunction, uric acid is retained in

the blood stream and is shunted to
connective tissues.

48

16.0 WHAT I LEARNED FROM THIS CASE STUDY:-

Case study is the comprehensive study of one selected patient and comparative study with
books. During my case study, I learned the following things.

i. About the disease:I got opportunity to read and gain comprehensive knowledge through various books,
literatures, teachers, doctors, ward staffs, colleagues and via. Secondary internet. I also
obtained a comprehensive knowledge on the disease its treatment and management.

ii. About the patient:My patient was a open book to learn for me, as I got an opportunity in learning through
involving patients care, treatment, diversional therapy and teaching not only from patient but
also from his family member. I learned personal quality of patient and use the information in
treating her. I also taught the families, socio cultural, economical, religious and traditional
beliefs of the patient which influence her health.

iii. About nursing care:I applied holistic approach while giving nursing care to the patient. I followed the
theorie of Henderson in providing nursing care and I gained more knowledge and skill.

iv. About documentation.

17.0 CONCLUSIONS AND SUMMARY OF CASE STUDY

My patient name is Mr.Alagendran, 56yrs old, male with the diagnosis of Angina Pectoris
also known as chronic renal disease,
Heredity
Glomerular dysfunction
49

Diabetic nephropathy
Hypertension
Glomerulonephritis
Polycystic kidney disease
Urinary tract obstruction
Bladder tumour
Urethral obstruction
Hypertensive nephrosclerosis (hardening of the kidney) are some of the causes of
chronic kidney disease
The clinical features of ESRD are: weakness and fatigue, confusion, seizures, burning
soles of feet, thin, brittle nails, hypertension,periorbital oedema,etc

It can be investigate through laboratory test such as cbc, urinalysis, blood urea
,ultrasonography, kub film etc.
During my case study, I provided health education, applied different diversional measures,
treatment, investigation, diet, personnel hygiene etc. I feel great pleasure whenever patient and
his family get treatment satisfaction and getting better. His general condition was improved so
he was discharged.

18.0 REFERENCES

Lippincott nursing practice edition 9

Nursing care plan, Marilynn E. Doengs, Mary. Francesmoorhoose, Alice C.
Geissles. Murs 6th edition
Helth learning materials centre Tu, institute of medicine, maharajgunj, ktm,
textbook of adult helath nursing
Mosbys nursing drug reference,2007
Phipps Monahan and sands marek neighborsmedical surgical nursing health
and illness perspectives 7th edition, page 1260 to 1271

50

 A Lippincott manual the Washington manual of medical therapeutics,33 rd

edition, page 430 to 433
http://www.emedicinehealth.com/chronic_kidney_disease/page2_em.htm
http://www.ehttp://www.emedicinehealth.com/chronic_kidney_disease/page4_
em.htmmedicinehealth.com/chronic_kidney_disease/article_em.htm
http://en.wikipedia.org/wiki/Chronic_kidney_disease

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