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Care plan

1. Introduction: Why I'm choosing this case?


Meet professional standards of practice to deal with same cases
Identify strengths, problems, and needs for me to deal with pt.
Apply what we study in theory on practice.
This case has one of common disease in our society.
So this case has clinical manifestation and data that allow me to achieve of
previous goals.

Information & Identifying Data


60-years-old male was admitted to the Medical ward, he complains of shortness of
breathing, chest pain and tired. (This symptom related to angina as he said)
Patient's No : 28412
Date : 24 / 11 / 2009
Patient age : 60
Room No : 4 -Bed 3
Sex : Male
Date Admitted : 22 / 11 /
2009
Marital status : Married
Have 4 sons and 10 girls

Diagnosis "medical":
IHD ischemic heart disease : Unstable angina

Chief Complaints :
1. Exertional chest pain with radiation to the left side of the neck and down the left
arm
2. Shortness of breathing
3. Tired

Vital Signs
Pulse: 70 bpm ; regular in rhythm.
Temperature: 36.5 C Axillary
Respiration: 24 Breathing / min
Blood pressure: (130/80 mm Hg)

History of present illness:


Seven years ago patient has chest pain with radiation to the left side of the neck and
down the left arm especially when tired and this symptom developed and become
more sever
This diseases affect the patient life by decrease the activity and as he said he stop
smoking, he try to be quite and not anger because it affect them , the disease also
decrease his sexual function ( some time sexual practice make him tired but he use
cordel sublingual )
He said : Some time he has anorexia (loss of appetite)
Heartburn may be produced by heavy meals.

Past medical history:


The patient came to hospital many time because he complain the same symptom, but
four years ago he make cardiac catheterization in Jordan after the symptom
developed to sever form and put 3 stent (2 in coronary artery and one in the neck)
After this the symptom become less severity and improves his status.

Nutritional history:
Now he eats three regular meals daily, and some snakes between meals.
As he said he eat various type of food include meat, vegetables and fruits.
He drinks some of tea and juice daily.

Allergies:
Un Known allergy to Drug, food or other Allergen.

General Appearance:
The patient awake, alert, and responsive, he hasn't healthy appearance, his facial
expression at pale and tired conversation, and during the physical examination, and
he Interact with others patient in room and with relative.
He has coordinated weakness movement, he is clean and neat.
Quality and speech: understand and clear tone.
Height 170 cm long
Weight 85 kg
BMI = 85/ (1.7)2 = 29

Skin:
He has light brown skin color, moisture present in some area and other less moist,
warm, and intact skin; with no lesions or nodules.
He has thick nails clubbing in shape, with poor capillary refill, rough in texture, no
lesions or fungus.
He has dry, soft in texture white in color hair with good distribution, no scalp
lesion.

Head:

He has normal rounded, symmetrical skull, with no masses or nodules, and he has
area with hear loss.

Face:

He has normal face with symmetrical facial movement, his facial expression at
pale and tired.

Neck:
He has head centered neck, muscle equal in size and coordinated smooth
movement normal in function with no discomfort.

Eyes:
He said Both eyes are normal vision, eye brows symmetrical and coordinated in
movement.
black in color, equal in size, round pupils.
Pink, smooth conjunctiva.
Hair of eyebrow evenly distributed.

Ears:

He has symmetrical, same as facial in color.


Able to hear in both ears as he said; Normal voice tones audible.
No abnormal discharge

Nose:

Symmetrical and straight, nasal septum midline, pink mucosa.


He said "he can smell good in both nostrils".

Mouth and Throat:

Pink in color, soft, moist, smooth in texture of lips and gum and inner mucosa
Some teeth loss
The tongue central position, pink in color, slightly rough and move freely.

Chest and Lungs:

He has symmetrical chest, right and left shoulder and hips are at same height.
Chest wall intact, no tender ness or masses.
Bronchi breath sound audible in auscultation.
The anteroposterior (AP) diameter less than transverse diameter.
As patient said (Anxious patients may have episodic dyspnea during both rest and
exercise, and hyperventilation, or rapid, shallow breathing Cyanosis may also
appeared that's appeared when make an activity and some time in rest period.
Mild to moderate pain in Retrosternal or across the anterior chest, sometimes
radiating to the shoulders, arms, neck, lower jaw, or upper abdomen.
Sometimes perceived as discomfort rather than pain)

Heart and Circulatory system:

Heart rate is 70 beat per minute.


Blood pressure: (130/80 mm Hg)
S1, S2 audible, no murmur
Pulse detected in pulse palpated place as carotid, radial, and apical.
Dysrhythmia and palpitation may some time present as in his history and as he
said.

Abdomen:

Smooth and relaxed abdomen, counter is flat rounded shape and symmetrical.
The umbilicus in the middle.
Audible bowel sound.
Little fat accumulates in the lower abdomen and near the hips.
No any large dull areas.
No masses or nodules.

Musculoskeletal system:
The patient has equal size on both side of body and smooth coordinated movement.
But current disease affect his ability to do exercise and he spend most of time
relaxed.

Social environment:
The patient has many visitors some of them from his family and other from his
friends.
Also patient has good relation with other patient in room.
And he interacts with his visitor .

Laboratory data
Test

Patient
value

Normal
value

Meaning
of
abnormal
value

13.8 g/dl
4.70 million/mm3
5600 /mm3
230*103/mm3

13.8 16 g/dl
4.5 5.3 million/mm3
4500 11000/mm3
(150350)*103/mm3

Normal
Normal
Normal
Normal

Straw
Acid
Nil
Nil

Straw
Acid
Nil
Nil

Normal
Normal
Normal
Normal

18.7 mg/dl
1.3 mg/dl

10 20 mg/dl
0.7 1.4 mg/dl

Normal
Normal

18 U/l
26 U/l

4 36 U/l
4 36 U/l

Normal
Normal

CBC test
Hb%
RBC
WBC
PLTS

Urine
Color
PH
Sugar
Blood

Chemistry
BUN
Creatinine
work reagent
ALT (SGPT)
AST (SGOT)

Medication
Drug
Name
& Dose
isosorbide
dinitrate

Rational

Action

Side effect
(with pt)

preventing angina attacks

T(Cordil)
20mg X 2
salicylic acid
to reduce the risk of recurrent
T(Baby aspirin) stroke

Nitrates are vasodilators Headaches


(coronary vasodilators). palpitations
weakness
dizziness
aspirin inhibits the action Vertigo
of blood clotting element weakness
(platelets)
dizziness

100 mg X 1
Rout :Po
Atenolol
Beta-blocker
T(Normatin)

treatment of hypertension &


and reduce the risk of heart
complications

blocking activity on
feeling light-headed
myocardial 1-receptors short of breath
tired feeling

Decreases the heart pain cause


by high amount of HCl

Decreases amount of
HCl produced by
stomach by blocking
action of histamine on
histamine receptors of
parietal cells in the
stomach

headache, nausea,
fatigue, , dizziness,

Decrease amount of LDL and


for reduce
hypercholesterolemia

For use as adjunctive


therapy to diet to
reduce elevated LDLC, TotalC,Triglycerides and
Apo B, and to increase
HDL-C in adult
patients with primary
hypercholesterolemia
or mixed dyslipidemia

Gastrointestinal:
Digestive, gastric or
intestinal disorders
(abdominal pain,
nausea, vomiting,
Skin Reactions:
Rashes, Pruritus,
urticaria or
photosensitivity
reactions.

100 mg X 1
Rout :Po
Ranitidine
hydrochloride
T(Ratidine)
50 mg X 3
Rout :IV
Fenofibrate
T(Lipidex)
40 mg X 3
Rout :Po

Pathophysiology of the current


disease.
Pathophysiology of Angina By patient:
The Pt said that he came to hospital after he complains of sever
chest pain, shortness of breathing and very tired.
As he say this symptom appear frequently and usually I take
sublingual tablet these symptom disappear, but this time
symptoms more sever than any time previous so my family bring
me to hospital.

Pathophysiology of Angina:
Angina pectoris is the medical term for chest pain or discomfort
due to coronary heart disease. Angina is a symptom of a
condition called myocardial ischemia. It occurs when the heart
muscle (myocardium) doesn't get as much blood (hence as much
oxygen) as it needs. This usually happens because one or more
of the heart's arteries (blood vessels that supply blood to the
heart muscle) is narrowed or blocked.
Insufficient blood supply is called ischemia.
Angina also can occur in people with valvular heart disease,
hypertrophic
cardiomyopathy (this is an enlarged heart due to disease) or
uncontrolled high blood pressure. These cases are rare, though.
Typical angina is uncomfortable pressure, fullness, squeezing or
pain in the center of the chest. The discomfort also may be felt in
the neck, jaw, shoulder, back or arm. Many types of chest
discomfort aren't related to angina. Acid reflux (heartburn) and
lung infection or inflammation are examples.
What is unstable angina?
In people with unstable angina, the chest pain is unexpected and
usually occurs while at rest. The discomfort may be more severe
and prolonged than typical angina or be the first time a person
has angina. The most common cause is reduced blood flow to the

heart muscle because the coronary arteries are narrowed by fatty


buildups (atherosclerosis).
An artery may be abnormally constricted or partially blocked by a
blood clot. Inflammation, infection and secondary causes also can
lead to unstable angina.
Unstable angina is an acute coronary syndrome and should be treated as an
emergency.

People with new, worsening or persistent chest discomfort should


be evaluated in a hospital emergency department or "chest pain
unit" and monitored carefully. They're at increased risk for
Acute myocardial infarction (heart attack).
Severe cardiac arrhythmias. These may include ventricular
tachycardia and fibrillation.
Cardiac arrest leading to sudden death.

Nursing care

Nursing Priorities

Relieve/control pain.
Prevent/minimize development of myocardial complications.
Provide information about disease process/prognosis and
treatment.
Support patient/SO in initiating necessary lifestyle/behavioral
changes.

Nursing diagnosing:
Acute Pain

May be related to

Decreased myocardial blood flow


Increased cardiac workload/oxygen consumption

Planning and Goals


patient goal include immediate and appropriate treatment and relive of pain

Nursing intervention
ACTIONS/INTERVENTION

RATIONALE

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.
unstable angina is more intense,
occurs unpredictably, may last longer,
and is not usually relieved by
NTG/rest.)

Observe for associated symptoms,


e.g., dyspnea, nausea/vomiting, dizziness,
palpitations, desire to micturate.

Decreased cardiac output stimulates


sympathetic/parasympathetic
nervous system, causing a
variety of vague sensations that
patient may not identify
as related to anginal episode

Place patient at complete rest during anginal


episodes.

Reduces myocardial oxygen demand


to minimize risk of tissue necrosis.

Monitor heart rate/rhythm.

Patients with unstable angina have


an increased risk of acute lifethreatening dysrhythmias, which
occur in response to ischemic
changes and/or stress.
Decreases myocardial workload
associated with work of
digestion, reducing risk of anginal
attack.
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;

Provide light meals. Have patient rest for 1 hr


after meals.
Morphine sulphate (MS)

effectively relieves severe chest pain.

Evaluation (Expected Patient Outcomes)


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

Nursing diagnosing:
Risk for decreased Cardiac Output
May be related to

Alterations in rate/rhythm and electrical conduction

Planning and Goals


patient goal include maintain of cardiac out put

Nursing intervention

ACTIONS/INTERVENTION
Provide for adequate rest periods. Assist
with/perform
self-care activities, as indicated.
Stress importance of avoiding straining/
bearing down,
especially during defecation.
Assess for signs and symptoms of heart
failure.

Note skin color and presence/quality of


pulses.

Administer supplemental oxygen as needed.

RATIONALE
Conserves energy, reduces cardiac
workload.
Valsalva maneuver causes vagal
stimulation, reducing heart rate
(bradycardia), which may be followed
by rebound tachycardia, both of
which may impair cardiac output.
Angina is only a symptom of
underlying pathology causing
myocardial ischemia. Disease may
compromise cardiac function to point
of decompensation.
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.
Increases oxygen available for
myocardial uptake to improve
contractility, reduce ischemia, and
reduce lactic acid levels.

Evaluation (Expected Patient Outcomes)


Demonstrate increased activity tolerance.
Participate in behaviors/activities that reduce the workload of the heart.

Nursing diagnosing:
Anxiety

May be related to

Situational crises
Threat to self-concept (altered image/abilities)
Underlying pathophysiological response
Threat to or change in health status (even death)
Negative self-talk

Planning and Goals


patient goal include relive of anxiety

Nursing intervention
ACTIONS/INTERVENTION

RATIONALE

Explain purpose of tests and procedures,

Reduces anxiety attributable to fear


of unknown diagnosis and prognosis.

Promote expression of feelings and fears,

Unexpressed feelings may create


internal turmoil and affect self-image.
Verbalization of concerns reduces
tension, verifies level of coping, and
facilitates dealing with feelings.

depression, and anger. Let patient/SO


know these are normal reactions. Note
statements of concern, such asHeart
attack is inevitable.
Tell patient the medical regimen has
been designed to Reduce/limit future
attacks and increase cardiac stability.
Administer sedatives, tranquilizers, as
indicated.

angina with certain levels of activity),


to increase confidence in medical
program, and to integrate abilities
into perceptions of self.
May be desired to help patient relax
until physically able to reestablish
adequate coping strategies.

Evaluation (Expected Patient Outcomes)


Report anxiety is reduced to a manageable level.
Express concerns about effect of disease on lifestyle, position within family
Demonstrate effective coping strategies/problem-solving skills.

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Nursing diagnosing:
Knowledge, deficient [Learning Need] regarding condition, treatment needs,
self-care and discharge needs
May be related to

Lack of exposure
Inaccurate/misinterpretation of information
Unfamiliarity with information resources

Planning and Goals


Patient goal include awareness of the disease process and understanding of
the prescribed care, adherence to the self-care program,

Nursing intervention
ACTIONS/INTERVENTION
Discuss pathophysiology of condition.
Encourage avoidance of factors/situations
that may precipitate anginal episode
e.g., emotional stress, extensive or intense
physical exertion,

Review importance of weight control,


cessation of smoking, dietary changes,
and exercise.

Discuss steps to take when anginal


attacks occur,
Review symptoms to be reported to
physician, e.g., increase in
frequency/duration of attacks, changes
in response to medications.

RATIONALE
Patients with angina need to learn
why it occurs and what they can do to
control it.
May reduce incidence/severity of
ischemic episodes.
Helps patient manage symptoms.
Knowledge of the significance of risk
factors provides patient with
opportunity to make needed
changes.
Patients with high cholesterol who
do not respond to 6- month program
of low-fat diet and regular exercise
will require medication.
Being prepared for an event takes
away the fear that patient will not
know what to do if attack occurs.
Knowledge of expectations can avoid
undue concern for insignificant
reasons or delay in treatment of
important symptoms.

Evaluation (Expected Patient Outcomes)

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Participate in learning process.


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

DISCHARGE GOALS
Achieves desired activity level; meets self-care needs with
minimal or no pain.
Free of complications.
Disease process/prognosis and therapeutic regimen
understood.
Participating in treatment program, behavioral changes.
Plan in place to meet needs after discharge.

POTENTIAL CONSIDERATIONS following


discharge from care setting (dependent on
patients age, physical condition/presence of
complications, personal resources, and life
responsibilities)
Acute Painepisodes of decreased myocardial blood
flow/ischemia
Activity intoleranceimbalance between oxygen
supply/demand, sedentary/stressful lifestyle
Denial, ineffectivelearned response patterns (e.g.,
avoidance), cultural factors, personal and family value
systems
Family Processes, interruptedsituational transition and
crisis
Home Maintenance, impairedaltered ability to perform
tasks, inadequate support systems, reluctance to request
assistance.

References

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1. Brunner & Suddarth's Textbook of Medical - Surgical Nursing (11th


edition) Philadelphia: Lippincott Williams & Wilkins(2008).
2. Kozier & Erb's Fundamentals of Nursing Concepts, Process, and
Practice (7th edition) (2007)
3. Amy M. Karch lippincott's nursing drug guide: Lippincott Williams
& Wilkins (2009).
4. Bates Instructors Manual Guide to Physical Exam and History
Taking (8 th edition) Philadelphia: Lippincott Williams &
Wilkins(2006).
5. Meg Gulanick, Judith L. Myers Nursing Care Plans : Nursing
Diagnosis and Intervention (6th edition) : Elsevier Health Sciences
(2006)
6. Client profile No: 28412

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