INTRODUCTION: - My client name was Mr. Vijay Kumar, he was came to the Dr.

Bhimrao
Ambedker hospital on 15/01/2021, with the complaints of severe chest pain, , fast breathing ,breathing
difficulty at the night time , excess urination at the night time, dizziness, fatigue and loss of appetite last
1week . Doctor has seen the client in critical care unit, client’s general condition was very poor & after
investigation & examination he was diagnosed chronic heart disease.

PROFILE OF THE CLIENT

Name of client : Mr. Vijay Kumar
Age/Sex : 55 yr/male
IP No. : c54890
Date of admission : 15/01/2021
Unit/ward : Critical care unit -II
Religion : Hindu
Education : Illiteracy
Occupation : Self employment
Income : 15000/month
Diagnosis : Chronic heart disease.
Name of surgery : Nil
Date of surgery : Nil
Post of day : Nil
Address : Bhatagaon Raipur C.G.
Date of care started : 15/01/2021
Date of care ended : 18/01/2021

CHIEF COMPLAINTS:-
My client present chief complains of a severe chest pain, fast breathing, and breathing difficulty at the
night time, excess urination at the night time, dizziness, fatigue and loss of appetite last 1 week.

HEALTH HISTORY:-
Past medical history: - As per the history given by patient and his attainder my client is having severe
chest pain, fast breathing ,breathing difficulty at the night time before 1 month and my client is already
diagnosed previously known case of chronic heart disease. And he was under home treatment advice tab-
aspirin 75 mg daily and tab – nitroglycerin.
Present medical history:- - As per the history given by patient and his attainder my client is having
severe chest pain, fast breathing, and breathing difficulty at the night time, excess urination at the night
time, dizziness, fatigue and loss of appetite last 1 week. But last 3 day increase breathing difficulty severe
chest pain and fast breathing. He was immediately admitted in Dr. Bhim Rao Ambedker hospital Raipur
C.G. and patient go for investigation ECHO, chest x-ray, USG chest, CECT chest and blood test, after
investigation patient diagnosed chronic heart. After that investigation treatment advice medicine Inj-
tazobact 4.5gm, Inj- Tramadol, Inj- Zofer, Inj- Aciloc, Inj- deriphyllin, tab- aspirin 75mg, tab-
nitroglycerin, Nebulization and plan for angioplasty.
Past surgical history: - No any type of past surgical history of my client.
Present surgical history: - No any type of present surgical history of my client.

FAMILY HISTORY:-
 Family health history:- My client Vijay Kumar was suffer to Chronic Heart disease and my client
other family member are healthy, No any history of hereditary disease like systemic illness (DM,
hypertension, asthma, convulsion, malignancies), communicable disease, psychiatric disease,
cardiovascular disease and congenital disorders.
 Pedigree chart:-

male
55 yr. /M 50 yr. /F
Vijay Kumar Ram Bai
Female

30 yr. /M 25 yr. /F Patient

Manish Reena

5Yr/ M 3 Yr/ M
Vikki Rajesh

FAMILY COMPOSITION:-
Name of the Relationship Age/Sex Educational Occupational Marital Health Status
Family with Patient Status Status Status
Member
Vijay Kumar Self 55 yr./M Illiteracy Driver Married Chronic heart
disease
Ram bai wife 50 yr./F Illiteracy House wife Married Healthy
Manish Son 30 yr./M 10th class Farmer Married Healthy
Reena Daughter in 25 yr./F 10th class House wife Married Healthy
law
Vikki Grand son 5 yr. 1st class Student Unmarried Healthy
Rajesh Grand son 1yr. Unmarried Healthy

PERSONAL HISTORY:-

1. HABITS:-
 Smoking: My client has habits of smoking last 3 year.
 Tobacco chewing: - my client has habits of tobacco chewing last 1 year.
 Alcohol: No habits of drinking alcohol.
 Drug addict (specify): No any harmful drugs addiction of my client such a sedative drug.

2. DIET:-
 Vegetarian: My client is a non-vegetarian.
 No. of meals per day: normally 3 times take meal per day.
 Any allergic to any food items: No any allergy.
3. SLEEP AND REST PATTERN:-
 Timing of sleep: - disturb sleeping pattern due to chest pain only 3 hr sleeping in night time.
 Timing of rest: - only 2hr rest in day time because of discomfort, breathing difficulty and pain in
chest.

4. ACTIVITIES OF DAILY LIVING (ADLS):-

 Taking care and himself/herself: -Now my client unable to self care and activities.
 Needs assistance: require assistance for daily activities and care.
 Any problems with ADL: my client unable to move self activity and impaired mobility due to
breathing difficulty.
 Bladder frequency: Bladder control is impaired decrease urine out.
 Bowel condition: Bowel movement is impaired and my client not motion passed.

5. RECREATIONAL AND HABITS:

 Exercise activity and tolerance (specify): My client doing no exercise regular.
 Habits (specify): No habits of extra activity.
 Spiritual history: - my client believes in god prayer.

6. SOCIOECONOMIC STATUS:
 Social factors:- Good relationship with other family member, My client belong to joint family,
Monthly income is 15000-/-, my client house and own house, ventilation facilities is adequate, electricity,
drainage, lighting, water, waste disposal and latrine facilities available in own house, availability of
hospital under 5 km, clinic, health centres, market, temple, school and transportation also present near
house.
 Economic factors:- My client family income is 15000-/- and belong of lower middle class, Manish
kumar is a bread winner of family, sources of income is own businessmen, financial status is not
adequate.

PHYSICAL EXAMINATION
GENERAL APPERANCE:
 Level of consciousness: My client is semiconscious.
 Orientation: My client is slightly confused of time, place and person.
 Activity: My client activity is impaired and dull due to chest pain, weakness and breathing
difficulty.
 Body built: My client is obese.
 General grooming: Clean and appropriate.
 Position/posturing: Normal posture position.
 Facial expression: My client facial expression is dull and blank.
 Body language: No eye contacts with me and slow in movement.
 Other observations: My client feels very dull.

Vital sign:-
 Temperature:- 98.6 f
 Pulse:- 110b/m
 Respiration:- 26 b/m
 BP:- 130/90mmHg
 RBS:- 130 mg/dl
 Spo2%- 92%

SKIN INSPECTION AND PALPATION (Integumentary System):

 Color and vascularity: My client skin color is black and no any incision mark of over all the body
skin.
 Turgor and mobility: My client skin elasticity abnormal and oedematous tight skin due to old age
and no any other abnormalities like tenting and redness skin.
 Temperature and moisture: My client skins are warm and moist, diaphoresis, and sweating skin
over all the body skin and other abnormalities clammy, oily, are absent in my client.
 Texture: My client skin texture is rough and other abnormalities rough, fine, thick, puffy and
smooth skin are absent in my client.
 Nails: My client nails are dry, hard, clean and clean manicured and other abnormalities brittle,
cracking and clubbing nail are absent in my client.
 Nails beds and lunulae: My client nail beds are pale and other abnormalities pink, cyanotic, red,
blanching and spooning nail are absent in my client.
 Body hair growth: my client hair color is a white and thin.
 Skin integrity: loss of skin integrity due to old age and other abnormalities fissure, acules, papules,
nodules, cysts, senile purpura and ulceration skin absent in my client.

HEAD INSPECTION AND PALPATION:

 Shape: My client head is round shape and other abnormalities like head injury, cephalic head and
cephalic disorder are absent in my client.
 Face: My client face is oval shape and facial expression was absent due to chest pain and breathing
difficulty.
 Facial (CN VII): My client facial expression is dulls, no smile.
 Hair: abnormal hair distribution in all over the body due to old age and other abnormalities curly,
straight, permed, glossy, and shiny hair are absent in my client,
 Condition of scalp: My client’s scalps are clean, no dandruff seen.
 Messes and lumps: Not present any masses and lump in my client head.
 Facial puffiness: Absent.

EYES INSPECTION AND PALPATION:

 Eyebrows: My client eyebrows are thin and other abnormalities straight, curved, thick, scaly and
sparse eyebrows are absent in my absent.
 Eyelashes: My client eyelashes are short and other abnormalities curved, artificial and long
eyelashes are absent in my absent.
 Eyelids: My client eyelids are dark and close slowly and other abnormalities swollen, inflamed,
discharge, stye, entropion, ectropion, and lid leg are absent in my client.
 Shape and appearance: My client eyes are sunken and tearing eye and other abnormalities almond,
rounded, squinty, nystagmus and strabismus shape are absent in my client.
 Sclera: White and other abnormalities creamy, yellowish, infected and pterygium sclera are absent
in my client.
 Conjunctiva: My client conjunctiva is pale pink and other abnormalities inflamed, swelling, nodule
and red conjunctiva are absent in my client.
 Iris: Black color and round shape no any abnormalities flat, coloboma, arcus, senile seen in iris. .
 Cornea: Clear and other abnormalities milky, Opague, and cloudy cornea are absent in my client.
 Pupils: Equal pupil size and round shape and other abnormalities anisocoria, consensual reaction,
constricted, fixed and unequal pupils are absent in my client.
 Lacrimal glands: Tearing and other abnormalities tender, inflamed, swollen are absent in my client.
 Visual field: Normal intact.
 Vision: Normal reading 6/6 in both eye.
 Use of glasses: No uses of any type of contact lens.

EARS INSPECTION AND PALPATION:

 Pinna: Large and Pinna shape are oval and other abnormalities pinnae irregular, skin intact, redness,
swelling tophi, cauliflower and furuncles ear are absent in my client.
 Level in relation to eyes: Top of Pinna level with outer canthus of the eye.
 Canal: Ear canal is clean and other abnormalities discharge, redness and foreign body are absent in
my client.
 Cilia: Present.
 Cerumen: Present.
 Tympanic membrane: Pearly white and no any inflamed, cone of light, land mark, scarring,
bubbles and fluid in my client.
 Hearing (audition-CN VIII): Present.
Bone conduction test:-
 Tuning fork test: Listen in moderate frequency.
 Weber test: Lateralizes equally to left/right side.
 Rinne test: Air conduction is more than bone conduction.
 Hearing aids: No any type of hearing aids uses my client.

NOSE AND SINUSES INSPECTION AND PALPATION:

 Size and shape: My client nose is small and shape is nares symmetrical and other abnormalities
long, short, in proportion to face, flat, board based, thick, thin and swollen size and shape are absent in
my client.
 Nasal septum: Nasal septum normal located in midline and no any perforation seen in nasal septum.
 Nasal mucosa and turbinate: Nasal mucosa is dry and cilia present and other abnormalities
redness, bluish, pink and pale nasal mucosa are absent in my client.
 Patency of nares: Right patent no partial obstruction
 Olfactory (CN I): My client correctly identifies the familiar odors.
 Sinuses: Normal and no any inflammation and tenderness absent in my client.

MOUTH AND PHARYNX INSPECTION:

 Lips: My client lips color is a slightly black, lips are symmetrical and thin. And lips are dry and
cracked.
 Teeth: My client’s teeth color is a brownish and other abnormalities notching, protruding, crowded
and loose teeth are absent in my client.
 Dental caries and fillings: dental caries present in my client due to tobacco chewing for long
period.
 Dental hygiene: Not properly maintain dental hygiene.
 Breathe odor: bad odor present and no any musty, acetone, fetid, odor of food or drug are absent in
my client.
 Gums: Color in pink, moist gum and sensitivity is present and other abnormalities hypertrophy,
nodules, irritated, ulcerated and spongy gums are absent in my client.
 Facial and glossopharyngeal (CN VII and IX): My client identifies the correct taste.
 Tongue: My client tongue is brown color and thin and dry tongue and other abnormalities
macroglossia, microglossia, glossitis, and swollen tongue absent in my client.
 Hypoglossal (CN XII): Tongue movement are symmetrical.
 Mucosa: Intact and dry. No any lesion, leukoplakia and masses are absent in my client.
 Palate: Moist and no any other abnormalities dry palate and color changes are absent in my client.
 Uvula: Normal
 Pharynx: Normal, no seen any type of petechiae beefy, and dysphasia.
 Tonsils: Normal tonsil present. Not seen crept and beefy tonsils.
 Temporomandibular joint: Fully mobile symmetrical joint. Not any tenderness and crepitus.

NECK INSPECTION AND PALPATION:

 Appearance: My client neck is short symmetrical.
 Thyroid: Thyroid palpable no any tenderness and nodules.
 Trachea: trachea present in midline. Not deviated right and left trachea
 Lymph nodes: Lymph node present in occipito preauricular and other abnormalities
lymphadenopathy, shotty, deep cervical and hard and firm lymph node are absent in my client.

THORAX AND LUNG EXAMINATION (Respiratory system):

 Inspection: Due to the severe breathing difficulty chest will be redness and swelling over the chest
skin, increased respiration and rhythm is irregular.
 Palpation: pain in palpation and tenderness present.
 Percussion on lung field: fluid collection in left side and tenderness present on percussion on lung
field.
 Lung auscultation: hoarseness sound present on auscultation of lung diaphragmatic exertion was
dull, increase respiration rate 24b/m.

BREASTS AND AXILLAE INSPECTION AND PALPATION:

 Male breasts: Breasts are asymmetrical, left side normal breast size but right side breast swelling
due to infection of chest.
 Nipples: Present and asymmetrical.
 Axilla: Odour present because of not proper maintain hygiene.

CARDIOVASCULAR EXAMINATION:
 Inspection: mild swelling and tenderness present over the chest.
 Palpitation: present tenderness, increase heart rate and pain in palpitation
 Percussion: during percussion acute pain complains, volume and rhythm are week and change
cardiac vital during percussion.
 Auscultation: S1,S2 sound heard, volume and rhythm is irregular beat, pulse rate is 110 b/m and
blood pressure is 130/80 mmHg

ABDOMINAL EXAMINATION:
 Inspection: Distended, dry, normal color and intact. No any lesion, striae, shiny and scar are absent.
 Palpitation: absent tenderness of liver and spleen.
 On percussion: Distended and dull because of presence of gas acidity evidence by empty stomach.
 Auscultation: bowel sound absent due to present of gas.

MUSCULOSKELETAL EXAMINATION:
 Back: normal functioning of both upper and lower extremities but now my client is semiconscious
and Other abnormalities lordosis, scoliosis and kyphosis are absent.
 Vertebral column alignment: Straight
 Joints: all joint are normal and complete range of motion present.
 Range of motion: all extension, flexion of lower limb and trunk flexion and extension movement
are active.
 Extremities: Symmetrical lower and upper extremities.

GENITOURINARY AND RECTUM INSPECTION:

 Rectum: normal
 Male genitalia: Normal pubic hair distribution, decrease urine output and not present any
abnormalities.

NEUROLOGICAL EXAMINATION:
 Mental status examination:
 Abnormal co-ordination.
 Level of alertness: my client is semiconscious
 Orientation: my client is now confused.
 Memory: present long time memory.
 Language and speech: My client languages are Hindi and speak slowly.
 Responsiveness: not respond to verbal command.
 Motor response: normal both lower limb and upper limb joint are normal.
 Reflex: Normal elicit gag reflex, blink reflex, coughing reflex and sneezing reflex are present.
 Coordination: abnormal co-ordinations, test done in left hand through finger
 Sensory response: all facial touch sensation, identify all familiar odor, normal bone conduction
test, fine touch sensation over all body, normal 6/6 and all sensory function is normal.
 Cranial nerves: all cranial nerve are normal functioning.

INVESTIGATION:-
INVESTIGATION NORMAL VALUE PATIENT VALUE REMARK
Hemoglobin 14-18gm% 10.5gm% Low
WBC 4000-11000/cumm 18800/cumm High
R.B.C. count 4.5-6.5mil./cmm 4.31 mil./cmm Low
Neutrophil 50-65% 82% High
Lymphocytes 20-45% 10% Low
Platelet count 150000-450000/cumm 90000/cumm Low
heamatocrit 40-54% 33.7% Low
ESR 2-10mm/hr 72mm/hr High
Urea nitrogen 20-40mg% 46% High
Serum creatinine 0.5-1.5mg/dl 0.4mg/dl Normal
Sodium 135-145mmol/L 146mmol/L High
Glucose <140 mg/dl 144mg/dl High
S. urea 10-45mg/dl 69mg/dl High
Bilirubin total .2-1.2mg/dl 3mg/dl High
Bilirubin direct 0-3mg/dl 4mg/dl High
Potassium 3.5-5mg/dl 4.2mg/dl Normal
SPECIAL BLOOD TEST
S.NO. TEST PATIENT VALUE NORMAL VALUE REMARK
1 LDL Cholesterol 185 mg/dl < 130 High
2 HDL cholesterol 65 mg/dl >= 40 Normal
3 VLDL cholesterol 14 mg/dl < 30 Normal
4 Total cholesterol 265 mg/dl < 200 High
5 Triglycerides 36 mg/dl < 150 Normal
6 Non HDL chol.(LDL+VLDL) 199 mg/dl <160 High
7 Apo B100-CALC 120 mg/dl <109 High
2 D ECHOCARDIOGRAPHY REPORT:-

 Narrowing of the cardiac chamber.

 IAS/IVS Intact
 LVEF-30%
 Mild concentric LVH, type I LVDD
 Mitral flow: E= 0.46, A= 0.75 m/sec
 Pulmonary flow : 1.12 m/sec
 Aortic flow:- 1.36 m/sec
DRUG DOSE ROUTE TIME INDICATION CONTRA SIDE EFFECT NURSES
INDICATION RESPONSIBILTY
Tab Enalapril P/O B/D This medicine is an Contraindicated •   Most frequent: • Caution should be
- Enalapril maleate 10 mg angiotensin- in patients with Dizziness, headache, exercised in patients with
and and converting enzyme anuria, fatigue, muscle cramps, history of heart,
Hydrochlorot hydrochlorothia (ACE) inhibitor angioedema and weakness, impotence, parathyroid, liver or
hiazide zide 25 mg: ½- and Thiazides hypersensitivity. diarrhea and increased kidney disease, lupus,
1 tab/day. diuretic cough.  sugar, any allergy,
combination, •   Body As A Whole: asthma, gout,
prescribed for high Fainting, chest pain and angioedema, who are
blood pressure. abdominal pain.  taking other medications,
•   Heart: Low blood elderly, children, during
pressure, palpitation and pregnancy and
fast heart rate.  breastfeeding. 
•   Gastrointestinal: • Avoid alcohol
Vomiting, indigestion, consumption. 
constipation, flatulence • It may cause diarrhea or
and dry mouth.  vomiting which leads to
•   Central Nervous dehydration, drink
System: Sleeplessness, enough fluid to avoid this
nervousness, tingling, problem
drowsiness and
unsteadiness. 
•   Skin: Itching and rash.
Tab -Losartan 50 mg P/O B/D This medicine is an Contraindicated •   Most Frequent: • Caution should be
angiotensin II in patients with Swelling, abdominal pain, exercised in patients
receptor blocker severe kidney chest pain, nausea, with history of blood
(ARB), prescribed problem, during headache, inflammation of vessel problems, poor
for high blood third trimester of pharynx, diarrhea, blood circulation, fluid
pressure. It is also pregnancy, and indigestion, muscle pain, retention, heart, liver or
used for prevention hypersensitivity. sleeplessness, cough and kidney problems,
of stroke, and sinus disorder.  diabetes, stroke, recent
diabetic •   Body as a Whole: heart attack, electrolyte
nephropathy. Facial swelling, fever and problem, any allergy,
fainting.  during pregnancy and
•   Heart: Chest pain, low breastfeeding. 
blood pressure, heart • It may cause dizziness,
attack, fast heart rate and lightheadedness, or
slow heart rate.  fainting, do not drive a
 •   Gastrointestinal: Loss car or operate machinery
of appetite, constipation, while taking this
tooth pain, dry mouth, medication. 
flatulence, stomach • Avoid alcohol
inflammation and consumption.
vomiting. 
•   Blood: Anemia. 
•   Metabolic: Gout.
Tap- digoxin 0.75-1.5 mg in P/O B/D This medicine is a Contraindicated •   Most Common: • Caution should be
the 1st 24 hour purified cardiac in patients with Diarrhea and nausea.  exercised in patients with
glycoside derived ventricular •   Heart: Heart block and history of thyroid
from leaves of fibrillation fast heart rate.  problems, abnormal heart
digitalis plant, (severely •   Gastrointestinal: Loss rhythm, cancer, kidney,
prescribed for abnormal heart of appetite and vomiting.  liver or lung problems,
congestive heart rhythm) and •   Central Nervous Wolff-Parkinson-White
failure. It helps the known System: Blurred or yellow syndrome, any allergies,
heart work better, hypersensitivity. vision, headache, who are taking other
which controls the weakness, dizziness, medications, elderly,
heart rate. confusion and mental newborns, during
disturbances.  pregnancy and
•   Miscellaneous: Muscle breastfeeding. 
weakness and sensitivity to • It may cause dizziness
light. or blurred vision, do not
drive a car or operate
machinery while taking
this medication. 
• Monitor ECG,
electrolytes, kidney
function and blood
digoxin levels regularly
while taking this
medication.
Tab - 150 mg P/O B/D This medicine is a Contraindicated •   Central Nervous • Caution should be
Metoprolol beta-blocker, in patients with System: Tiredness, exercised in patients with
prescribed for high cardiogenic dizziness, depression, history of heart attack,
blood pressure shock, severe confusion, short-term slow or irregular
either alone or with heart diseases, memory loss, headache, heartbeat, heart failure,
other medications. anuria (absence drowsiness, abnormal chest pain, poor blood
It is also used for of urination) and dreams and sleeplessness.  circulation, liver
 chest pain, migraine hypersensitivity. •   Heart: Shortness of impairment, sugar,
and breath, slow heart rate, breathing problems,
hyperthyroidism.  It palpitations, heart failure, adrenal gland tumor
reduces elevated swelling in the extremities, (Pheochromocytoma),
blood pressure by fainting, chest pain, and any allergy, who are
relaxing blood low blood pressure.  taking other medications,
vessels. •   Respiratory: Wheezing elderly, children, during
and difficulty in breathing.  pregnancy and
•   Gastrointestinal: breastfeeding. 
Diarrhea, nausea, dry • It may cause
mouth, gastric pain, drowsiness, dizziness, or
constipation, flatulence, lightheadedness, do not
digestive tract disorders, drive a car or operate
and heartburn. machinery
Tab- 0.2 mg/hour P/O B/D This medicine is an Hypersensitivity Headache, • Caution should be
Nitroglycerin organic nitrate, lightheadedness, fainting, exercised in patients with
prescribed for chest increased chest pain and history of heart failure,
pain.  It works by low blood pressure. overactive thyroid, head
relaxing blood injury, recent heart
vessels. attack, stroke, low blood
pressure, any allergy,
who are taking other
medications, during
pregnancy and
breastfeeding. 
• It may cause dizziness
or blurred vision, do not
drive a car or operate
machinery and get up
slowly from while taking
this medication
LIST OF NURSING DIAGNOSIS

1. Decreased cardiac output r/t impaired contractility, increased preload and after load, altered heart
rate and rhythm as evidenced by bradycardia.
2. Fluid volume excess related to decreased cardiac output and sodium and water retention as
evidenced by crackles on both lung field and edema on extremities secondary to CHF.
3. Ineffective tissue perfusion related to decreased cardiac output.
4. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by
exertional Dyspnea in activity.
5. Risk for impaired gas exchange related to alveolar capillary changes such as fluid collection as
evidenced by impaired breathing pattern and Tachypnea
6. Risk for impaired skin integrity related to impaired circulation as evidenced by hypotension.
 NURSING THEORY
PEPLAU’S THEORY
Peplau’s theory focuses on the individual, the nurse & the interactive process, the results is the nurse-
client relationship. The client is an individual with a felt need & nursing is a interpersonal-therapeutic process
who’s goal is to educate the client & family, help the client reach mature personality development, strives to
develop a nurse-patient relationship in which she serves in many versatile personalities

PEPLAU’S THEORY AND NURSING’S METAPARADIGM

MAN:-According to peplau,it Is defined as an organism that strive its own way to reduce tension generated by
needs

HEALTH:-It is defined as a word symbol that imples forward movement of personality and other ongoing
human process in the direction of creative, constructive ,productive, personal and community living.

ENVIRONMENT:-Peplau’s defined it in terms of exiting forces outside the organism and content of culture
from where customs and beliefs are acquired.

NURSING:-It is the significant, therapeutic, interpersonal process. She defines it as a human relationship
between an individual who is sick or in need of health services and a nurse especially educated to recognize and
to respond to the need for help.

MAJOR CONCEPTS OF PEPLAU’S THEORY

 Nurses should apply principles of human relations to the problem that arise at all levels of experience.
 Peplaus theory explains the phases of interpersonal process, roles in nursing situation and methods for studying
nursing as interpersonal process
 Nursing is therapeutic in that it is a healing art, assisting an individual who is sick or in need of healthcare.
 Nursing is an interpersonal process because it involves interaction between two or more individuals with a
common goal.
 The attainment of goal is achieved through the use of series of steps following a series of pattern.
 The nurse and the patient work together so that both become mature and knowledgeable in the process..

THE PHASES OF NURSE-PATIENT RELATIONSHIPS ARE:-

1. ORIENTATION:-
During this phase, the individual has a felt need and seeks professional assistance. The nurse helps the
individual to recognize his/her problem and determine the need for help.

2. IDENTIFICATION:-
 The patient identifies with those who can help him/her. The nurse permits exploration of feelings to aid the
patient in undergoing illness as an experience that reorients feeling and strengthens positive forces in the
personality and provides needed satisfaction.

3. EXPLOITATION:-
During this phase the patient attempts to derive full value from what he/she are offered through the
relationship. The nurse can project new goals to be achieved through personal effort and power shifts from
the nurse to the patient as the patient delays gratification to achieve the newly formed goals.

4. Resolution
The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient frees
himself from identification with the nurse.

1. ORIENTATION 2. IDENTIFICATION
 Patient expresses pain on chest  Goal setting was done along with patient
 Also the measures to reduce pain were  Patient will have reduction in pain as evidenced by
discussed. her verbalization of reduction in pain responses
 Duration of pain  Provide non- pharmacological measures for pain
 Coughing relief such as divisional activity which diverts the
patients mind
 Provide back massage cough excretion

3. EXPLOITATION 4. RESOLUTION

 Carried out plans mutually agreed upon  Patient was free to express problems of pain
 Provided non pharmacological measures  Expressed that she got slight relief from pain.
like diversion, massaging  Patient’s coughing was slightly reduced
 NURSING CARE FOR CHRONIC HEART DISEASE

Assessment Nursing Goal Planning Implementation Rationale Evaluation

diagnosis
SUBJECTIVE Decreased Maintaining 1. Assess the cardiac 1. Auscultate heart 1. Indications of reduced cardiac After
DATA:- cardiac output cardiac rhythm and sound. sounds frequently and output caused by mechanical nursing
My client is r/t impaired output. monitor cardiac failure, pulmonary edema. intervention,
having severe contractility, rhythm. the patient
breathing increased shall have
2. Assess for 2. Auscultation of 2. Allow detection of left- sided
difficulty and preload and participated
abnormal heart and heart sound. heart failure that may occur with
chest pain. after load, in activities
lung sounds. chronic renal failure patients due
altered heart that reduced
rate and rhythm to fluid volume excess as the the
as evidenced by diseased kidney are unable to workload of
bradycardia. excrete water. the heart.

3.place patient at 3. Provide rest in –

physical and 3. Reduces work of heart,
recumbent position or
OBJECTIVE emotional rest to increases heart reserve, and
in armchair in air –
DATA:- reduce work of heart reduces BP, Decreases work of
conditioned
respiratory muscles and oxygen
environment.
I observe my utilization.
client is having
breathing 4. Check vital sign. 4. Assess for blood
4. Signs of reduced cardiac output
difficulty as pressure, increased
as heart attempts to compensate
evidenced by pulse and respiration
for decreased contractility.
-increase and central venous
respiration. pressure.
- sweating. 5. Observe for sign
-change facial and symptoms of 5. Assessment of 5. Systemic venous congestion
expression. reduced peripheral physical examination with reduced cardiac output
tissue perfusion; especially cardiac affecting peripheral tissue
cool temperature of system. perfusion caused by
skin, facial pallor, vasoconstriction.
and poor capillary
refill of nails beds.
NURSING CARE FOR CHRONIC HEART DISEASE

Assessment Nursing Goal Planning Implementation Rationale Evaluation

 diagnosis
SUBJECTIVE Fluid volume Restoring 1. Monitor for 1. Check body weight 1. Excess fluid is indicated by Patient shall
DATA:- excess related fluid balance. edema, weight gain, through the weight edema, sudden weight gain, JVD, have
to decreased jugular vein machine. and crackles in the lungs. verbalized
My client is cardiac output distension, and lung understandin
having breathing and sodium crackles. g causative
difficulty due to and water factors and
excess fluid 2. Ausculte breath 2. Auscultation of 2. When increased pulmonary
retention as demonstrate
volume. sounds increase 2hr heart sound and lungs capillary hydrostatic pressure
evidenced by behaviors to
and PM for the sound through the exceeds oncotic pressure, fluid
crackles on resolve
presence of crackles stethoscope. moves within the alveolar septum.
both lung field excess fluid
and edema on and monitor for volume.
OBJECTIVE
extremities frothy sputum
DATA:-
secondary to production.
I observe my CHF. 3. Provide inj – lasix 3. Acts on distal tubule to increase
3. Administer 10 mg for increase water and potassium excretion or
client is having
prescribed diuretic urine output. loop of henle to promote excretion
breathing
as ordered. Give of sodium and chloride.
difficulty as
diuretic early in the
evidenced by
morning night time
- Edema both diuresis disturb
upper and sleep. 4. Weight checks 4. Body weight is a sensitive
lower daily morning time. indicator of fluid balance and an
4. Weight patient
extremities increase indicate fluid volume
daily and compare to
- Decrease excess.
previous weights.
urine output
- Breathing 5. Keep
difficulty 5. Intake and output will show
documentation of
- Change vital 5. Keep input and imbalance
urine output and fluid
sign. output record patient intake.
may lose large
volume of fluid after
a single dose of
diuretic.
 NURSING CARE FOR CHRONIC HEART DISEASE

Assessment Nursing Goal Planning Intervention Rationale Evaluation

diagnosis
Ineffective Improving 1. Assess patient 1. Check pain level 1. To identify intensity, The patient
SUBJECTIVE tissue circulation. pain for intensity through the pain scale. precipitating factors and location shall have
DATA:- perfusion using a pain rating to assist in accurate diagnosis. demonstrate
related to scale, for location d behaviors
My client is decreased and for precipitating to improve
having chest cardiac output. factors. circulation.
pain and fast
2. Provide inj- 2. The vasodilator nitroglycerin
pulse rate and 2. Administer or nitroglycerin and inj- enhances blood flow to the
increase assist with self lasix 10 mg. myocardium.
breathing administration of
pattern. vasodilators, as
ordered.
3. Check vital sign 3. Assessing response determines
3. Assess the and recorded. effectiveness of medication and
response to whether further interventions are
medications every 5 required.
OBJECTIVE minutes.
DATA:-
4. Given inj-
I observe my 4. Beta blockers decrease oxygen
4. Give beta blocker metoprolol 150mg
client is having consumption by the myocardium
as ordered. stat.
difficulty in and are given to prevent
breathing related subsequent angina episodes.
to decreased
cardiac output as 5. Administration
oxygen through the 5. Oxygenation increases the
evidenced by 5. Provide oxygen
oxygen mask and amount of oxygen circulating in
and monitor oxygen
- Deep check oxygen the blood and decreasing
saturation via pulse
breathing saturation. myocardial ischemia and pain.
oximetry.
- Increase
heart rate
- Edema

NURSING CARE FOR CHRONIC HEART DISEASE

Assessment Nursing Goal Planning Intervention Rationale Evaluation
diagnosis
Risk for Maintain 1. Perform 1. Auscultate breath sounds, 1. Reveals presence of -adequate
SUBJECTIVE impaired gas normal physical noting crackles and wheezes. pulmonary congestion or ventilation and
DATA:- exchange respiratory examination of collection of secretions, oxygenation of
related to pattern chest. indicating need for further tissues by
My client alveolar intervention. ABG values
complains is a 2. Provide 2. Instruct client in effective
capillary 2. Clears airways and and oximetry
severe breathing breathing coughing and deep breathing.
changes such facilitates oxygen delivery. within client’s
difficulty and as fluid exercise. normal ranges
restlessness. 3. Encourage frequent
collection as 3. provide 3. Helps prevent atelectasis and be free of
position changes.
evidenced by mobilization and pneumonia. symptoms of
impaired 4. Maintain chair rest and respiratory
breathing 4. Provide 4. Reduces oxygen distress.
bedrest in a semi-Fowler’s
pattern and comfortable consumption and demands -Participate in
position, with head of bed
OBJECTIVE Tachypnea position. and promotes maximal lung treatment
elevated 20 to 30 degrees
DATA:- inflation. regimen within
5. Perform ABG 5. Monitor and graph serial level of ability
I observe my 5. Hypoxemia can be severe
analysis. ABG values and pulse and situation.
client is having during pulmonary edema.
oximetry.
breathing Compensatory acid-base
difficulty as changes are usually present in
evidenced by chronic HF.
Tachypnea and 6. Provide 6. Administer supplemental
change oxygenation. oxygen, as indicated. 6. Increases alveolar oxygen
breathing concentration, which may
pattern. correct or reduce tissue
hypoxemia.
7. Provide 7. Administer medications, as
medication as per indicated, such as the 7. Reduce pulmonary
doctor’s order. following: Diuretics, such as congestion, enhancing gas
furosemide (Lasix) exchange.

NURSING CARE FOR CHRONIC HEART DISEASE

Assessment Nursing Goal Planning Intervention Rationale Evaluation

 diagnosis
Activity Meet own 1. Assess the vital 1. Check vital signs before 1. Orthostatic hypotension -meet own
SUBJECTIVE intolerance self-care sign. and immediately after activity can occur with activity self-care
DATA:- related to needs. during acute episode or because of medication effect needs.
imbalance exacerbation of HF, (vasodilation), fluid shifts
My client is between especially if client is (diuresis), or compromised -Achieve
complains oxygen supply receiving vasodilators, cardiac pumping function. measurable
unable to self and demand as diuretics, or beta blockers. increase in
2. Perform
activity due to evidenced by 2. Document 2. Compromised myocardium activity
physical
increase exertional cardiopulmonary response to and inability to increase tolerance,
examination of
Dyspnea. Dyspnea in activity. Note tachycardia, stroke volume during activity evidenced by
cardiovascular
activity. system. dysrhythmias, Dyspnea, may cause an immediate reduced fatigue
diaphoresis, and pallor. increase in heart rate and and weakness
oxygen demands, thereby and by vital
aggravating weakness and signs within
OBJECTIVE 3. Assess the fatigue. acceptable
DATA:- anxiety level. 3. Assess level of fatigue, and 3. Fatigue because of limits during
evaluate for other advanced HF can be profound activity.
I observe my precipitators and causes of and is related to
client is having fatigue, for example, HF hemodynamic, respiratory.
breathing treatments, pain,.
4. Avoid extra
difficulty during 4. Evaluate accelerating 4. May denote increasing
activity.
activity so activity intolerance. cardiac decompensation
decrease self 5. Provide rather than overactivity.
activity. 5. Provide assistance with 5. Meets client’s personal
comfort measure.
self-care activities, as care needs without undue
indicated. Intersperse activity myocardial stress or
6. provide cardiac with rest periods. excessive oxygen demand.
exercise
6. Implement graded cardiac 6. Strengthens and improves
rehabilitation and activity cardiac function under stress
program. if cardiac dysfunction is not
irreversible.

NURSES RECORD
CLIENT NAME:- Mr. Vijay Kumar.
AGE/SEX:-55 yr /male.

DIAGNOSIS;- Chronic heart disease.

S.NO. DATE/TIME MEDICATION INTAKE OUTPUT VITAL SIGN NURSES NOTE SIGN
T P R BP O2%
1. 16/04/18 Tab – Losartan 50 Tea- 150ml by 99.F 110b/m 18b/m 130/90mmhg 94% Check complication of
10am mg, Cap- nitro- 20ml, urine drug, check vital sign,
glycerine 0.2 mg, Water- record and reporting
Inj – metoprolol 500ml, and assess pain scale
150 mg, tab Iv fluid – and oxygen saturation.
aspirin 75mg 500ml.
2. 17/04/18 Tab – Losartan 50 Milk- 200ml by 98.6F 100b/m 20b/m 130/90mmhg 96% Check complication of
10am mg, Cap- nitro- 200ml, urine drug, check vital sign,
glycerine 0.2 mg, Iv fluid record and reporting
Inj – metoprolol 500 ns, and assess pain scale
150 mg, tab water- and oxygen saturation.
aspirin 75mg 500ml

3. 18/04/18 Tab – Losartan 50 Milk- 250ml by 98.6F 90b/m 22b/m 120/90mmhg 97% Check complication of
mg, Cap- nitro- 200ml, urine drug, check vital sign,
glycerine 0.2 mg, Iv fluid record and reporting
Inj – metoprolol 1000 ns, and assess pain scale.
150 mg, tab water-
aspirin 75mg 200ml
Tea-
25ml
SUMMARY-
Mild swelling and tenderness present over the chest. Present tenderness, increase heart rate
and pain in palpitation. During percussion acute pain complains, volume and rhythm are week and

change cardiac vital during percussion. S1, S2 sound heard, volume and rhythm is irregular beat,
pulse rate is 110 b/m and blood pressure is 130/80 mmHg

CONCLUSION:
My client name was Mr. Vijay Kumar, he was came to the Dr. Bhimrao Ambedker hospital
on 16/04/2018, with the complaints of severe chest pain, , fast breathing ,breathing difficulty at the
night time , excess urination at the night time, dizziness, fatigue and loss of appetite last 1week .
Doctor has seen the client in critical care unit, client’s general condition was very poor & after
investigation & examination he was diagnosed chronic heart disease.
 HEALTH EDUCATION
FOR HEALTHY HEART:-

 Avoid smoking and alcohol.

 Reduce stress level.
 Low fat and low cholesterol diet.
 Regular exercise.
 Intake low sodium diet.
 Intake fibers diet.

MEDICATION

 Advice the client proper takes medicine.

HYGIENE

 Advised the client maintain personal hygiene.

 Advised the client for take daily bath.
 Advised the client clean for perineal area.
 Advised the client change for cloth.

REST AND SLEEP

 Advised the client for proper take rest and sleep.

DIET

 Advised the client take healthy diet, egg, green leaf, vegetables.
 Advised the client take fruit and juice.
 Advised the client take 3-4 litre amount of water daily.

EXERCISE

 Advised the client daily do exercise.

 Advised the client daily do relaxation therapy.

FOLLOW UP

 Educate the patient follow up check-up.

 BIBLIOGRAPHY

Teacher’s references
 Ansari, Javed. A Text Book Medical Surgical Nursing (Part A) .S.Vikas & Compeny publisher; 1st edition
2015.
 Black, Joyce M. Medical Surgical Nursing – II. Mosby an Affiliate of Elsevier Science Publication; 7 th edition
2003.
 Davis durg guide, eblott’s publication, second edition.
 Hinkle, Janice L.S.Brunner & Suddarths Texbook of Medical Surgical Nursing – I. wolters Kluwor India
publication; 8th edition 2015.
 Liwis, Sharon L. Lewis's .Medical Surgical Nursing – I. Elevier India publisher; 26th edition 2013.
 Polaski, Arlene L. Luckmann's .Care Principles & Practice of Medical Surgical Nursing. Jaypee Brothers
Medical Publisher; 1st edition 2014.

Student’s references
 Black, Joyce M. Medical Surgical Nursing – II. Mosby an Affiliate of Elsevier Science Publication; 7 th edition
2003.
 Davis durg guide, eblott’s publication, second edition.
 Liwis, Sharon L. Lewis's .Medical Surgical Nursing – I. Elevier India publisher; 26th edition 2013.

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