GOVT.

COLLEGE OF NURSING,
M.B.S. HOSPITAL, KOTA (RAJ.)

SUBJECT: - MEDICAL SURGICAL NURSING – II

CRITICAL CARE NURSING

CASE PRESENTATION
ON

CORONARY ARTERY DISEASE

SUBMITTED TO:- SUBMITTED BY:-

MR. GAJRAJ MEENA MR. INAMUDDIN AHMED
H.O.D. OF MEDICAL SURGICAL NURSING M.Sc. NURSING, FINAL YEAR
BATCH 2018-19

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IDENTIFICATION DATA OF PATIENT:-
INTRODUCTION:

Mr. Harish malav 40 year old male patient, who had come to the hospital with
complaints of chest discomfort, breathing difficulty, fatigue and swelling of feet and ankles,.
He got admitted to New medical college and Hospital on 08/02/2020. He was admitted to the
CCU of the hospital .Various laboratory investigations were performed and treatment was
prescribed accordingly. He was diagnosed as a case of Coronary artery disease. I have selected
this patient for my case presentation and providing appropriate nursing care.

PATIENT PROFILE:

Name : Mr. Harish malav

Age : 40 yrs.

Sex : male

Marital Status : married

IPD No. : 201902270217

Ward/Bed No. : CCU

Religion :- Hindu

Education :- 8th class

Date of Admission :- 08/02/2020

Date of Discharge :-

NURSING ALERT:

Sensitivity / Allergy / Precaution: no specific allergy

Weight : 56 kgs

Height : 5’2”

SOCIO ECONOMIC STATUS :-

A)Housing : –
o Type of house : Small house of three rooms made up of bricks.
o Lighting : Proper lighting facilities are available.
o Ventilation : Eight windows and door, good ventilation facility are available.
o Water facility : Everyday.
o Sanitation : Lack of sanitation and hygiene.
B)Food hygiene practices :- They wash vegetables & cooking food in hygieniccondition.
7|Page

C)Personal hygiene practices :- They are maintaining personal hygiene, taking bathe daily,
washing hands, cutting nails, brush daily etc.

D)Community resources :- Resources like bus and train are available for transportation ,
educational resources are available up to 12th std. there is lack of health resources.

E)Religious practices : Client and her family members are strong believers of Hindu religion.
F)Family income and expenditure :-
▪ Food – 2000/-
▪ Clothing – 500/-
▪ Education – 1000/-
▪ Health – 1000/-
▪ Others – 1000/-

ALLERGIES AND MEDICATION:-

• Drugs / Foods / Dyes / Others: Client doesn’t have any kind of allergies from
drug, food and dyes.
• Signs and symptoms : Nil
• Blood reaction : Nil

HISTORY OF ILLNESS

Chief complaints with duration : chest discomfort, breathing difficulty, fatigue

and swelling of feet and ankles since 1 month

History of present Illness: Onset / Rx taken : presently the client is suffering from

Coronary artery disease and treatment started

as per doctors order

History of past Illness: Illness/ Medications / Any restrictions :

no significant past medical history of any

illness

FAMILY HISTORY:

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S.No. Name of Age/ Relationship with Occupation Health status/ Health
Family Sex patient Habits
H/o significant
Member
Illness

1. Mr. Harish 40 yrs Self farmer Unhealthy

malav

1. Mrs. Meena 38 yrs Wife housewife Healthy/ no walking

history of
significant illness

2. Mr. kanishk 28yrs Son Private Healthy Walking

teacher

3. Mr. Sunil 20yrs Son Student Healthy cycling

FAMILY TREE-
Patient

Female
Patient wife
Male

Kanishk 28 yrs Sunil 20 yrs

FUNCTIONAL HEALTH PATTERN -

• Inter Personal Relationship :- Patient maintains good IPR with every hospital staff.
He is very calm and co-operative.

• Hygiene :- Patient is able to do his daily routine activities.

• Activity / Exercises :- He is able to do active and passive exercise using both the
upper and lower extremities.

• Rest / Sleep :- He is not able to take proper sleep at night because of hospitalization
and anxiety about disease condition.

• Elimination Pattern :- The bowel and bladder elimination patterns are normal.

• Cognitive / Perceptual :- Cognitive function are normal.

• Self perception / self concept pattern :- Patient has insight and he is having general
sense of emotions.
9|Page

• Coping Stress Tolerance :- Patient is able to tolerate the stress.

• Values and Beliefs :- patient is a believer of Hindu religion.

• Personal Habits :- He use to take rest and sleep.

DIETARY HISTORY :

❖ General appearance : Thin / Average / Obese

❖ Appetite : Good / Fair / Poor
❖ Diet : Veg. / Non veg.
❖ Meal pattern : Two times in day and breakfast in the morning
❖ Need assistant / Feed self : No need of assistant.
❖ Any other method of feeding : Nil

SURGICAL HISTORY:

Past Surgical History:-

There is no significant past surgical history.

PHYSICAL EXAMINATION:
General appearance:

❖ Level Of Consciousness:- Conscious / Unconscious / Semiconscious / Coma

❖ Orientation:- To Place / Person / Time
❖ Activity:- Active / Dull / Lethargy
❖ Body Built:- Mild / Moderate / Thin / Obese

Anthropometric measurement:

❖ Height : 5”2’
❖ Weight : 56kg.

Vital signs:

❖ Temperature : 98.6oF
❖ Pulse : 76 beats/ minute
❖ Respiration : 28 breaths/minute
❖ Blood pressure : 160/60 mm of Hg.

Head and Face:

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 ❖ Hair:- Equally Distributed / Baldhead
❖ Colour of Hair:- Gray / White / Black
❖ Scalp:- Clean / No Dandruff
❖ Pediculosis:- Present / Absent
❖ Face:- Symmetrical / Asymmetrical
❖ Facial Puffiness:- Present / Absent
Eyes:

❖ Eye Brows:- Symmetrical / Asymmetrical / Scaling / Lesions

❖ Eye Lid / Lashes:- Redness / Swelling / Discharge / Lesions = Nil
❖ Eye Ball:- Sunken / Protrusion / Normal
❖ Conjunctiva:- Colour / Swelling / Lesions = Nil
❖ Sclera:- White/Pink/Yellow/Tenderness/Discharge/Lesions
❖ Cornea:- Regular / Irregular Ridges
❖ Iris:- Flat / Irregular Shape
❖ Eye Discharge:- Present / Absent
❖ Use of Glasses:- Yes / No.
Ears:

❖ Redness:- Present / Absent

❖ Discharge:- Present / Absent
❖ Cerumen:- Present / Absent
❖ Lesions:- Present / Absent
❖ Foreign Body:- Present / Absent
❖ Use of Hearing Aids:- Yes / No
❖ Tympanic membrane : no perforations, lesions and bulging.
❖ Hearing acuity : medium.

Nose:

❖ External nares : no crusts or discharges.

❖ Patency : patent
❖ Olfactory Sense : present
❖ Nasal Septum:- Deviated / Central
❖ Nasal Polyps:- Present / Absent
❖ Nasal Discharge:- Present / Absent

Mouth:

❖ Number of Teeth:- 28
❖ Dentures:- Present / Absent
❖ Dental Carries:- Present / Absent
❖ Odour of Mouth:- Foul Smell / Acetone Smell / Others
❖ Gums:- Weak / Swollen / Pale Colour / Healthy

❖ Palates and Uvula : visible

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❖ Tonsillar area : no inflammation

❖ Hygiene : hygienic

Lips:

❖ Crack / Healthy
❖ Cleft Lips:- Unilateral / Bilateral
❖ Stomatitis:- Present / Absent

Neck:

❖ Muscles : normal range of motion.

❖ Trachea : no abnormalities
❖ Thyroid : no thyroid enlargement.
❖ Nodes : no lymph node enlargement.
❖ Vein distension : no distension.

Thorax:

❖ Chest shape : normal

❖ Respiratory Rate : 26 breaths per minute
❖ Type of Respiration : tachypneac
❖ Thoracic Expansion : symmetrical
❖ Palpation : ribs are palpable and normal
❖ Percussion : resonant sounds

Nervous system:

❖ Language : clear and understandable

❖ Mental status : sound mental health
❖ Orientation : well oriented
❖ Memory Attention span : long term memory
❖ Level of Consciousness (GCS) : 14
❖ Cranial Nerves : normal function
❖ Deep Tendon Reflex : present
❖ Gross and Fine motor function of UE and LE: normal
❖ Sensory function : normal
❖ Light touch : sensible to light touch
❖ Pain : sensitive to pain
❖ Temperature : normal body temperature
❖ Position : normal

Respiratory system

❖ Respiratory Rate:- 26 breaths per minute

Inspect the Chest

5
 ❖ Thoracic Cage- Shape:- Barrel Chest/Scoliosis/ Kyphosis/ Normal
❖ Configuration:- Pectus Excavatum/Pectus Carrinatum/Normal
❖ Skin Colour and Condition:- Normal/ Cyanosis/ Pallor
❖ Chest Expansion:- Symmetric/ Asymmetric

Percussion

❖ Lung Field:- Clear/congestion present

❖ Resonance:- Hyper Resonance/ Dull/ normal
❖ Diaphragmatic Excursion:- Dull/ Normal

Auscultation

❖ Breathing Sound:- Broncho/ Broncho Vesicular/ Vesicular/normal

❖ Adventitious Sound:- Crackles/ Wheeze/ Ronchi
❖ Respiratory Pattern:- Normal/Tachypnea/ Bradypnea/ Cheyne Stokes/
Hypo/ Hyper/ Ventilation

Cardiovascular system:

❖ Pulse :- 76 beats/min
❖ Heart Sound:- S1, S2 Heard
❖ Abnormal Heart Sound:- S3 or S4 Present / Absent
❖ Murmurs:- Present / Absent
❖ Carotid Pulse Rate : 74/min
❖ Blood Pressure: 160/86 mmHg

Central and peripheral lymphatic system

❖ Inspect and Palpate the Leg:- Cyanosis / Uni / Bilateral Edema/nil

❖ Carotid arteries : palpable
❖ Peripheral pulses : palpable
❖ Radial : palpable
❖ Femoral : palpable
❖ Popliteal : palpable
❖ Posterior Tibial Pulse:- : palpable
❖ Dorsalis Pedis Pulse:- :palpable
❖ Edema:- Present /Absent
❖ Type of Edema:- Pitting / Pretibial Generalize
❖ Lymph Edema:- Present / Absent
❖ Varicose Veins:- Present / Absent
❖ Venous Ulcer:- Present / Absent

❖ Capillary Refill : 3seconds

Digestive system
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❖ Abdominal Girth:- 62
❖ Diarrhea / Constipation:-nil

Inspection

❖ Size:- Flat Rounded

❖ Symmetry:- no Bulges Masses or Hernia
❖ Scar:- absent
❖ Lesions:- absent
❖ Redness:- absent

Palpation

❖ Tenderness:- Present / Absent

❖ Fluid Collection:- Present / Absent
❖ Mass / Soft :- soft

Percussion

❖ Ascites / Peritonitis: nil

❖ No Gas / Fluid Collection

Auscultation

❖ Bowel Sound:- Normal / Borborygmus / Absent

Musculoskeletal system:

❖ Gait : no significant spinal abnormalities and gait

disturbances
❖ Upper Extremities : swelling present
❖ Lower extremities : swelling present
❖ Muscle strength : no musle weakness
❖ Range of Motion : normal
❖ Spine : absence of lordosis, kyphosis or scoliosis
❖ Joint Swelling / Pain / Other- :absent
❖ Weakness / Paralysis / Contracture : weakness present

Genito urinary system:

❖ Frequency of Urination:- 5 to 6 times a day

❖ Colour of the urine:- pale yellowish coloured
❖ Normal / Anuria / Hematuria / Dysuria/ Incontinence / Any Other:- not present
❖ Catheter Present:- Yes / No
❖ Urethral Discharge:- Yes / No

Integumentory system :

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 ❖ Skin Colour - Normal Brown
❖ Dermatitis - No
❖ Allergies - No
❖ Cause :Nil
❖ Reaction -Nil
❖ Lesions / Abrasions No
❖ Tenderness / Redness -No
❖ Surgical scar -No
❖ Secretion - No

Mental status :

❖ Memory : Good
❖ Knowledge : Good
❖ Thinking : Good
❖ Judgement : Good
❖ Insight : Yes

Neurological assessment :- (Level of consciousness)

GCS (Glasgow coma scale)

Content Normal Patient score

score

Eye opening response

Spontaneous 4 4

To Voice 3

To pain 2

No response 1

Best motor response

Obeys verbal command 6 6

Localize pain 5

Flexion 4

Flexion abnormal 3

Extension abnormal 2
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No response 1

Best verbal response

Oriented to place & person 5 5

Conversation with confused 4

Inappropriate words 3

Incomprehensive Sounds 2

No response 1

TOTAL 15 15

Notes :

Record if eyes closed by swelling - C

Record if Endotracheal tube in place - E

Record if Tracheostomy tube is placed - T

Motor function :
Reflexes

Sr. No. NAME OF THE REFLEX REMARK

1. Biceps Normal
2. Triceps Normal
3. Patellar Normal
4. Achilles Normal
5. Plantar Normal
6. Gluteal Normal

Cranial nerve function :-

Sr. Name of Cranial

Functions Remarks
No. Nerve
1 Olfactory Identify familiar odour Normal
2 Optic Check the visual acuity and field Normal
Check the pupilary reflex
3 Oculomotor Extra ocular muscle movement Normal
4 Trochlear Extra ocular muscle movement Normal
5 Trigeminal Clench teeth Normal
6 Abducens Extra ocular muscle movement to Normal
right and left side
7 Facial Smile/Puff cheeks/ Identify tasks Normal

5
 8 Acaustic Hearing acuity(Weber and rinne test) Normal
9 Glossopharyngeal Gag reflex Normal
10 Vagus Swallowing Normal
11 Spinal Accessory Turn head Normal
Shrug shoulders again resistance
12 Hypoglossal Protrude tongue Normal
Wiggle tongue from side to side

FINAL IMPRESSION :- All the cranial nerves function are normal.

COMPARISON OF THE PATIENT’S DISEASE WITH BOOK

PICTURE.
ANATOMY AND PHYSIOLOGY OF HEART:

The heart is the pump responsible for maintaining adequate circulation of oxygenated blood
around the vascular network of the body. It is a four-chamber pump, with the right side
receiving deoxygenated blood from the body at low presure and pumping it to the lungs (the
pulmonary circulation) and the left side receiving oxygenated blood from the lungs and
pumping it at high pressure around the body (the systemic circulation).

The myocardium (cardiac muscle) is a specialised form of muscle, consisting of individual

cells joined by electrical connections. The contraction of each cell is produced by a rise in
intracellular calcium concentration leading to spontaneous depolarisation, and as each cell is
electrically connected to its neighbour, contraction of one cell leads to a wave of depolarisation
and contraction across the myocardium.
17 | P a g e

This depolarisation and contraction of the heart is controlled by a specialised group of cells
localised in the sino-atrial node in the right atrium- the pacemaker cells.

1. These cells generate a rhythmical depolarisation, which then spreads out over the atria
to the atrio-ventricular node.

2. The atria then contract, pushing blood into the ventricles.

3. The electrical conduction passes via the Atrio-ventricular node to the bundle of His,
which divides into right and left branches and then spreads out from the base of the
ventricles across the myocardium.

4. This leads to a 'bottom-up' contraction of the ventricles, forcing blood up and out into
the pulmonary artery (right) and aorta (left).

5. The atria then re-fill as the myocardium relaxes.

The 'squeeze' is called systole and normally lasts for about 250ms. The relaxation period, when
the atria and ventricles re-fill, is called diastole; the time given for diastole depends on the
heart rate.

The ECG

The Electrocardiograph (ECG) is clinically very useful, as it shows the electrical activity within
the heart, simply by placing electrodes at various points on the body surface. This enables
clinicians to determine the state of the conducting system and of the myocardium itself, as
damage to the myocardium alters the way the impulses travel through it.

When looking at an ECG, it is often helpful to remember that an upward deflection on the ECG
represents depolarisation moving towards the viewing electrode, and a downward deflection
represents depolarisation moving away from the viewing electrode. Below is a normal lead II
ECG.

• The P wave represents atrial depolarisation- there is little muscle in the atrium so the
deflection is small.

• The Q wave represents depolarisation at the bundle of His; again, this is small as there
is little muscle there.

• The R wave represents the main spread of depolarisation, from the inside out, through
the base of the ventricles. This involves large ammounts of muscle so the deflection is
large.

• The S wave shows the subsequent depolarisation of the rest of the ventricles upwards
from the base of the ventricles.

5
 • The T wave represents repolarisation of the myocardium after systole is complete.
This is a relatively slow process- hence the smooth curved deflection.

The Coronary Circulation

The heart needs its own reliable blood supply in order to keep beating- the coronary circulation.
There are two main coronary arteries, the left and right coronary arteries, and these branch
further to form several major branches (see image). The coronary arteries lie in grooves (sulci)
running over the surface of the myocardium, covered over by the epicardium, and have many
branches which terminate in arterioles supplying the vast capillary network of the myocardium.
Even though these vessels have multiple anastomoses, significant obstruction to one or other
of the main branches will lead to ischaemia in the area supplied by that branch.

DISEASE CONDITION:CORONARY ARTERY DISEASE:-

Coronary Heart Disease (CHD) is a heart disease that is mainly caused by narrowing of the
coronary arteries due to atherosclerosis or spasm or a combination of both. CHD is a disease
that is very scary. It is recognized that the recent developments in the field of heart disease
found many new facts about CHD. However, control of traditional risk factors, particularly
dyslipidemia, obesity, smoking, and hypertension is still quite relevant in reducing morbidity
and mortality of CHD and other cardiovascular diseases.

Definition

Coronary Heart Disease (CHD) is the circumstances in which there is an imbalance between
the needs of the heart muscle with oxygen supply that is provided by the coronary arteries
(Mila, 2010).
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Incidence

Atherosclerosis, causes about 98% of cases of CHD.

Etiology

Coronary heart disease can be caused by several things:

Narrowing (stenosis) and contraction (spasm) of coronary arteries, but gradually narrowing
will allow the development of adequate collateral as a replacement.

1. Smoking

Smoking can stimulate the process of atherosclerosis due to a direct effect on the arterial wall,
carbon monoxide causes arterial hypoxia, nicotine causes mobilization of catecholamines that
cause platelet reaction, glycoprotein tobacco can cause hypersensitivity reactions arterial wall.

2. Hyperlipoproteinemia

Diabetes Mellitus, obesity and hyperlipoproteinemia associated with fat deposition.

3. Hypercholesterolemia

Cholesterol, fat and other substances can cause thickening of the artery walls, so that the lumen
of the blood vessels constrict and the process is called atherosclerosis.

4. Hypertension

Increased blood pressure is a heavy burden to the heart, causing left ventricular hypertrophy or
enlargement of the left ventricle. As well as high blood pressure which cause direct trauma to
the coronary arteries, thus facilitating the occurrence of coronary atherosclerosis (coronary
factor).

5. Diabetes mellitus

Intolerance to glucose, known as vascular disease predisposition.

6. Obesity and metabolic syndrome

Obesity is the excess amount of body fat is more than 19% in men, and more than 21% in
women. Obesity can also increase levels of cholesterol and LDL cholesterol. Risk of Coronary
Heart Disease will obviously increase when the weight began to exceed 20% of ideal body
weight.

Pathophysiology:-

If too many foods that contain cholesterol, the cholesterol levels in the blood can be excessive
(called hypercholesterolemia). Excess cholesterol in the blood will be stored in the lining of
the arteries, known as plaque, or atheroma (plaque major source, derived from LDL-

5
cholesterol. While HDL carry excess cholesterol back to the liver, thus reducing the buildup of
cholesterol in the vessel wall blood).

If the longer plaque increases, there will be a thickening of the artery walls, causing narrowing
of the arteries. This incident is referred to as atherosclerosis (aterom presence in arterial walls,
contains cholesterol and other fatty substances). This leads to atherosclerosis (thickening of the
arterial wall and loss of flexibility of the artery walls). If the atheroma, which formed the
thicker, can tear the artery wall lining, and a blood clot occurs (thrombus) that can block blood
flow in the arteries.
This can lead to reduced blood flow and the supply of essential substances, such as oxygen to
a particular area or organ, like the heart. When the coronary arteries, which supply blood to the
functioning heart muscle (myocardium medical term), then the blood supply is reduced and
causes of death in the region (known as a myocardial infarction).

The consequence is the occurrence of heart attacks and cause symptoms such as severe chest
pain (known as angina pectoris). This condition is called coronary heart disease (CHD).

Clinical Manifestations

Book picture Patient picture

Symptoms of CHD:
A few days or weeks, before the body was present
not powered,

chest feels uncomfortable during exercise or

move hard heart beat, present

shortness of breath, present

nausea vomiting, sometimes present

a lot of body sweat. present

Chest pain. Left chest pain (angina) and felt present

pain coming from inside. Patients felt chest
pain, also an assortment of tingling, burning,
crushed by heavy objects, slashed, hot. Chest
pain is felt in the left chest with spreading to
the left arm, pain in the pit of the stomach,
right chest, chest pain which penetrates to the
back, even to the jaw and neck.

Heart palpitations (rapid pulse). -

cold sweat -

Energy and mind become weak, fear no

reason, feeling wanted to die. -
21 | P a g e

Low blood pressure or stroke. -

Signs of CHD:
Usually high fat content, does not cause
symptoms. Sometimes, if the level is very
high, fatty deposits will form a buildup of fat,
called xanthomas in the tendons and in the
skin.

Fever, body temperature is usually around 38 -

° C.
Nausea and vomiting, present

upper abdominal bloating and pain. -

Pale face. -

Skin becomes wet and cold, sweaty bodies. -

Movements became sluggish (less present

enthusiasm).

Shortness of breath. present

Anxious and restless. present

Fainting. -

Diagnostic Tests

Book picture Patient picture

Depending on the needs, various types of

checks can be performed to establish the
diagnosis and determine the degree of CHD.
From the simple to the invasive.
• Chest x-ray done

• CT scan of the heart done

• Echocardiogram done
• ECG (electrocardiogram) done
• MRI of the heart
done
• Transesophageal echocardiogram
done
(TEE)

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INVESTIGATIONS:-

SR NAME OF NORMAL PATIENT REMARK

NO. INVESTIGATION VALUE VALUE
1. Haemoglobin 12-16 gm% 12.3 gm% Normal

2. WBC count 4000- 12000/cumm Slightly elevated

11000/cumm

3. Neutrophils 40-75 % 60 %

Lymphocytes 20-45 % 35 %

Eosinophil 0-5 % 04 % Normal

Monocytes 0-5% 02%

Basophils 0-2% 00 %
Normal
4. Random blood sugar 70-120 mg% 110 mg%
---
5. Blood group --- A positive
---
6. HIV --- Negative
Hypernatremia
7. Serum sodium 135-145 150 mEq/L
mEq/L Hypokalemia
8. Serum potassium 2.4 mEq/L
3.5-4.5 mEq/L Normal
9. Serum creatinine 1.4 mg/dl
0.8-1.4 mg/dl Normal
10. Serum chloride 105 mEq/L
96-106 mEq/L Normal
11. Erythrocyte 10mm
Sedimentation 5-15mm
Rate(ESR)
12. <200mg/dl 340mg/dl hypercholestrolemia
Total cholestrol

Complications

Coronary artery disease can lead to:

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• Chest pain (angina). When your coronary arteries narrow, your heart may not receive
enough blood when demand is greatest — particularly during physical activity. This
can cause chest pain (angina) or shortness of breath.

• Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete
blockage of your heart artery may trigger a heart attack. The lack of blood flow to your
heart may damage your heart muscle. The amount of damage depends in part on how
quickly you receive treatment.

• Heart failure. If some areas of your heart are chronically deprived of oxygen and
nutrients because of reduced blood flow, or if your heart has been damaged by a heart
attack, your heart may become too weak to pump enough blood to meet your body's
needs. This condition is known as heart failure.

• Abnormal heart rhythm (arrhythmia). Inadequate blood supply to the heart or

damage to heart tissue can interfere with your heart's electrical impulses, causing
abnormal heart rhythms.

Outlook (Prognosis)

The outcome varies. The disorder may be mild, without symptoms, or may be more severe and
become disabling over time. Complications may be severe or life-threatening. In most cases, it
can be controlled with treatment and improved with surgery.

MANAGEMENT:-

Medical and Surgical management:-

Book picture Patient picture

Treatment for coronary artery disease usually
involves lifestyle changes and, if necessary,
drugs and certain medical procedures.
➢ Lifestyle changes
Making a commitment to the following
healthy lifestyle changes can go a long way
toward promoting healthier arteries:
• Quit smoking.
• Eat healthy foods.
• Exercise regularly.
• Lose excess weight.
• Reduce stress.
➢ Drugs Patient is on pharmacological management
Various drugs can be used to treat coronary of the mentioned drugs.
artery disease, including:
• Cholesterol-modifying
medications. By decreasing the
amount of cholesterol in the blood,

5
 especially low-density lipoprotein
(LDL, or the "bad") cholesterol, these
drugs decrease the primary material
that deposits on the coronary arteries.
Your doctor can choose from a range
of medications, including statins,
niacin, fibrates and bile acid
sequestrants.
• Aspirin. Your doctor may
recommend taking a daily aspirin or
other blood thinner. This can reduce
the tendency of your blood to clot,
which may help prevent obstruction
of your coronary arteries.
If you've had a heart attack, aspirin can help
prevent future attacks. There are some cases
where aspirin isn't appropriate, such as if you
have a bleeding disorder or you're already
taking another blood thinner, so ask your
doctor before starting to take aspirin.
• Beta blockers. These drugs slow
your heart rate and decrease your
blood pressure, which decreases your
heart's demand for oxygen. If you've
had a heart attack, beta blockers
reduce the risk of future attacks.
• Nitroglycerin. Nitroglycerin tablets,
sprays and patches can control chest
pain by temporarily dilating your
coronary arteries and reducing your
heart's demand for blood.
• Angiotensin-converting enzyme
(ACE) inhibitors and angiotensin II
receptor blockers (ARBs). These
similar drugs decrease blood pressure
and may help prevent progression of
coronary artery disease.
Procedures to restore and improve blood
flow
Coronary artery stent
Sometimes more aggressive treatment is
needed. Here are some options:
• Angioplasty and stent placement
(percutaneous coronary
revascularization).Your doctor
inserts a long, thin tube (catheter) into
the narrowed part of your artery. A
wire with a deflated balloon is passed
through the catheter to the narrowed
area. The balloon is then inflated,
25 | P a g e

compressing the deposits against your

artery walls.
A stent is often left in the artery to help keep
the artery open. Some stents slowly release
medication to help keep the artery open.
• Coronary artery bypass surgery. A
surgeon creates a graft to bypass
blocked coronary arteries using a
vessel from another part of your body.
This allows blood to flow around the
blocked or narrowed coronary artery.
Because this requires open-heart
surgery, it's most often reserved for
cases of multiple narrowed coronary
arteries.
Alternative medicine
Omega-3 fatty acids are a type of unsaturated
fatty acid that's thought to reduce
inflammation throughout the body, a
contributing factor to coronary artery disease.
However, recent studies have not shown them
to be beneficial. More research is needed.
• Fish and fish oil. Fish and fish oil are
the most effective sources of omega-3
fatty acids. Fatty fish — such as
salmon, herring and light canned tuna
— contain the most omega-3 fatty
acids and, therefore, the most benefit.
Fish oil supplements may offer
benefit, but the evidence is strongest
for eating fish.
• Flax and flaxseed oil. Flax and
flaxseed oil also contain beneficial
omega-3 fatty acids, though studies
have not found these sources to be as
effective as fish. The shell on raw
flaxseeds also contains soluble fiber,
which can help lower blood
cholesterol.
• Other dietary sources of omega-3
fatty acids. Other dietary sources of
omega-3 fatty acids include canola
oil, soybeans and soybean oil. These
foods contain smaller amounts of
omega-3 fatty acids than do fish and
fish oil, and evidence for their benefit
to heart health isn't as strong.
Other supplements may help reduce your
blood pressure or cholesterol level, two

5
contributing factors to coronary artery
disease. These include:
• Alpha-linolenic acid (ALA)
• Artichoke
• Barley
• Beta-sitosterol (found in oral
supplements and some margarines,
such as Promise Activ)
• Blond psyllium
• Cocoa
• Coenzyme Q10
• Garlic
• Oat bran (found in oatmeal and whole
oats)
• Sitostanol (found in oral supplements
and some margarines, such as
Benecol)
27 | P a g e

PHARMACOLOGICAL MANAGEMENT

S.n Trade name and generic dose Route frequency Mode of action Side effects Nurses
o name of the drug responsibility

1. Inj. Nitroglycerine 2ml IV BD It is a coronary vasodilator used Hypotension, rashes, -Check the vitals
to reduce preload and afterload. allergic reactions, -provide complete
dizziness, weakness, bed rest.
restlessness, pallor. -Monitor intake and
output chart
2. Inj. Heparin 2ml IV BD It is an anticoagulant. It Haemorrhagic shock, Check the vitals
2000IU prevents the conversion of vasospasm, fever, -provide complete
fibrinogen to fibrin. It also headache, chills, bed rest.
stimulates release of purpura,nausea, -provide calm and
lipoprotein lipase. vomiting, quiet environment.
constipation, gum -provide fibre rich
bleeding etc. diet.
3. Inj.Dopamine 15mg IV BD Produce cardiac stimulation Tissue necrosis, -provide
and renal vasodilation. It also acute renal failure, comfortable
reduces high B.P. cardiac arrhythmias. position.
-provide adequate
fluid.
-check B.P.
frequently.
4. Inj.Dobutamine 2ampoul IV BD To decrease the high blood Nausea and vomiting -must be diluted
e in pressure.(sympathomimetic prior to use.
5%Dextr vasopressor) -check the vitals
ose -provide adequqte
rest

5
5 Inj.Diazepam 10-20mg IV SOS It acts by enhancing Acute narrow angle -donot mix with
presynaptic/post synaptic glaucoma, other solutions
inhibition through a specific myasthenia gravis, -it should be
BZD receptor which is an vertigo, nausea, injected slowly
integral part of the GABA diarrhoea, increased
receptor. appetite, anorexia.
(sedative)
6. Inj. Furosemide(Lasix) 40mg IV BD It affects the entire nephron Hypotension, -serum electrolytes
affecting sodium and water hypokalemia, should be regularly
excretion. It also lowers arterial nausea, vomiting, monitored
B.P. ototoxicity with -Cardiac arrest onIV
tinnitus, deafness and and sudden death on
vertigo, IM use are possible.
hyperuricemia and
allergic disorders.
29 | P a g e

LIST OF NURSING DIAGNOSES AND NURSING CARE PLANS

1. Ineffective individual coping related to :Situational crisis; Inadequate support systems;

Ineffective coping methods.

2. Deficient Knowledge (learning needs) related to : Lack of knowledge; Misinterpretation of

information; Cognitive limitations; Deny the diagnosis.

3. Risk for Fluid Volume Excess related to : The displacement of the pressure on the congestive
pulmonary vein; Decrease in perfusion organ (kidney); Increased retention of sodium / water;
Increased hydrostatic pressure, or decreased plasma protein (absorbs liquid in the interstitial
area / tissue).

4. Risk for Impaired gas exchange related to : Alveolar - capillary membrane changes
(displacement of fluid into the interstitial area / alveoli).

5. Ineffective breathing pattern related to: decreased lung expansion.

6. Anxiety related to: Threat of loss / death; Situational crisis; Threats to self-concept (self-
image).

7. Ineffective Tissue perfusion related to: Decrease in peripheral blood circulation; Cessation
of arterial-venous flow; Decrease in activity.

8. Decreased cardiac output related to: Obstruction of blood flow from the left atrium into the
left ventricle,Presence of ventricular tachycardia,Shortening of the diastolic phase.

9. Imbalanced Nutrition: less than body requirements related to: Shortness of breath.

10. Impaired Urinary Elimination related to: Decreased glomerular perfusion; Decrease in
cardiac output.

11. Risk for Fluid Volume Deficit related to: Decrease in cardiac output; Decline in glomerular
filtration.

12. Activity intolerance related to: Decreased cardiac output, Congestive pulmunal.

5
 Nursing Nursing Expected Out Interventions Rationale Evaluation
Assessment Diagnosis Come

Subjective data: Activity Patient -Document heart rate and - Trends determine patient’s Expected outcome
Patient says that intolerance demonstrates rhythm and changes in BP response to activity and may is partially met as
she is feeling very related to measurable/progres before, during, and after indicate myocardial oxygen evidenced by
much weak and sive increase in activity. Correlate with deprivation that may require patient reports of
decreased cardiac
tired. tolerance for reports of chest pain or decrease in activity level absence of angina
output activity with heart shortness of breath. and/or return to bedrest, with activity.
Objective data : rate/rhythm and BP changes in medication
-Alterations in within patient’s regimen, or use of
heart rate and BP normal limits and supplemental oxygen.
with activity skin warm, pink,
-Development of dry -Encourage rest initially. - Reduces myocardial
dysrhythmias Thereafter, limit activity on workload and oxygen
-Changes in skin basis of pain and/or adverse consumption, reducing risk
color/moisture cardiac response. Provide of complications.
-Exertional nonstress diversional
angina activities.
-Generalized
weakness -Instruct patient to avoid - Activities that require
increasing abdominal holding the breath and
pressure (straining during bearing down (Valsalva
defecation). maneuver) can result in
bradycardia (temporarily
reduced cardiac output) and
rebound tachycardia with
elevated BP.
-Explain pattern of graded - Progressive activity
increase of activity level: provides a controlled
getting up to commode or demand on the heart,
sitting in chair, progressive increasing strength and
ambulation, and resting after preventing overexertion.
meals.
31 | P a g e

-Review signs and symptoms - Palpitations, pulse

reflecting intolerance of irregularities, development
present activity level or of chest pain, or dyspnea
requiring notification of may indicate need for
nurse or physician. changes in exercise regimen
or medication.
-Refer to cardiac - Provides continued support
rehabilitation program. and/or additional supervision
and participation in recovery
and wellness process.

5
 Nursing Nursing Expected Out Interventions Rationale Evaluation
Assessment Diagnosis Come

Subjective data: Fear/Anxiety Demonstrate -Identify and acknowledge - Coping with the pain and Expected outcome
Patient says that related to patient’s perception of threat emotional trauma of an MI is is partially met as
she is feeling like threat of loss / positive problem- and situation. Encourage difficult. Patient may fear evidenced bypatient
restless, uncertain death; situational solving skills. expressions of, and do not death and/or be anxious
verbalize of
and fearful. crisis; threats to deny feelings of, anger, grief, about immediate
Objective data : sadness, fear. environment. Ongoing reduction in
self-concept (self- anxiety/fear..
-Fearful attitude anxiety (related to concerns
-Apprehension, image). about impact of heart attack
increased tension, on future lifestyle, matters
restlessness, left unattended or
facial tension unresolved, and effects of
-Uncertainty, illness on family) may be
feelings of present in varying degrees
inadequacy for some time and may be
-Somatic manifested by symptoms of
complaints/sympa depression.
thetic stimulation
-Focus on self, -Note presence of hostility, - Research into survival rates
expressions of withdrawal, and/or denial between type A and type B
concern about (inappropriate affect or individuals and the impact of
current and future refusal to comply with denial has been ambiguous;
events medical regimen). however, studies show some
-Fight (e.g., correlation between degree
belligerent or expression of anger or
attitude) or flight hostility and an increased
behavior risk for MI.

-Maintain confident manner - Patient and SO can be

(without false reassurance). affected by the
anxiety/uneasiness displayed
by health team members.
33 | P a g e
-Observe for verbal and
nonverbal signs of anxiety
(restlessness, changes in vital
signs), and stay with patient.
Intervene if patient displays
destructive behavior.
-Accept but do not reinforce
use of denial. Avoid
confrontations.
-Orient patient and/or SO to
routine procedures and
expected activities. Promote
participation when possible.
-Answer all questions
factually. Provide consistent
information; repeat as
indicated.
5
Honest explanations can
alleviate anxiety
-Patient may not express
concern directly, but words
and actions may convey
sense of agitation,
aggression, and hostility.
Intervention can help patient
regain control of own
behavior.
- Denial can be beneficial in
decreasing anxiety but can
postpone dealing with the
reality of the current
situation. Confrontation can
promote anger and increase
use of denial, reducing
cooperation and possibly
impeding recovery.
- Predictability and
information can decrease
anxiety for patient.
- Accurate information about
the situation reduces fear,
strengthens nurse-patient
relationship, and assists
patient and SO to deal

-Encourage patient and SO to
communicate with one
another, sharing questions
and concerns.
- Provide privacy for patient
and SO.
-Provide rest periods and/or
uninterrupted sleep time,
quiet surroundings, with
patient controlling type,
amount of external stimuli.
-Support normality of
grieving process, including
time necessary for resolution. that feelings are normal
-Encourage independence,
self-care, and decision
making within accepted
treatment plan.
realistically with situation.
Attention span may be short,
and repetition of information
helps with retention.
- Sharing information elicits
support and comfort and can
relieve tension of
unexpressed worries.
- Allows needed time for
personal expression of
feelings; may enhance
mutual support and promote
more adaptive behaviors.
- Conserves energy and
enhances coping abilities.
-Can provide reassurance
response to situation and/or
perceived changes.
- Increased independence
from staff promotes self-
confidence and reduces
feelings of abandonment that
can accompany transfer from
35 | P a g e
-Encourage discussion about
postdischarge expectations
-Administer anti anxiety and
hypnotics as indicated:
alprazolam (Xanax),
diazepam (Valium),
lorazepam (Ativan),
flurazepam (Dalmane).
5
coronary unit and/or
discharge from hospital.
- Helps patient and/or SO
identify realistic goals,
thereby reducing risk of
discouragement in face of the
reality of limitations of
condition and/or pace of
recuperation.
-Promotes relaxation and rest
and reduces feelings of
anxiety.
 Nursing Nursing Expected Out Interventions Rationale Evaluation
Assessment Diagnosis Come

Subjective data: Decreased Maintain -Auscultate BP. Compare - Hypotension may occur Expected outcome
Patient says that Cardiac Output hemodynamic both arms and obtain lying, related to ventricular is partially met as
she is having related to stability, e.g., BP, sitting, and standing dysfunction, hypoperfusion evidenced by
chest pain. obstruction of cardiac output pressures when able. of the myocardium, and
patient-Display
blood flow from within normal vagal stimulation. However,
Objective data : the left atrium range, adequate hypertension is also a vital signs within
into the left urinary output, common phenomenon, acceptable limits,
increased heart ventricle decreased possibly related to pain, dysrhythmias
rate (tachycardia), frequency/absence anxiety, catecholamine absent/controlled,
dysrhythmias, of dysrhythmias. release, and/or preexisting and no symptoms
vascular problems. of failure (e.g.,
ECG changes Orthostatic (postural)
hemodynamic
hypotension may be
Changes in BP associated with parameters within
(hypotension/hyp complications of infarct acceptable limits,
ertension) (heart failure). urinary output
Evaluate quality of pulses on adequate).
Extra heart both pulse points.
sounds (S3, S4) -Report decreased
-Decreased cardiac output - Irregularities suggest episodes of
Decreased output results in diminished weak or dysrhythmias, which may dyspnea, angina.
thready pulses. require further evaluation -Participate in
Diminished and monitoring. activities that
peripheral pulses reduce cardiac
workload.
Cool, ashen skin;
-Auscultate heart sounds:
Diaphoresis - S3 is usually associated
-Note development of S3 with HF, but it may also be
Orthopnea, noted with the mitral
crackles, JVD, insufficiency (regurgitation)
and left ventricular overload
 37 | P a g e

Edema that can accompany severe

infarction.
Chest pain
- S4 may be associated with
-S4 myocardial ischemia,
ventricular stiffening, and
pulmonary or systemic
hypertension.

- Indicates disturbances of
-Presence of murmurs or normal blood flow within the
friction rubs. heart: incompetent valve,
septal defect, or vibration of
papillary muscle and/or
chordae tendineae
(complication of MI).
Presence of rub with an
infarction is also associated
with inflammation:
pericardial effusion and
pericarditis.

- Crackles reflecting
-Auscultate breath sounds. pulmonary congestion may
develop because of
depressed myocardial
function.

5
-Monitor heart rate and
rhythm. Document
dysrhythmias via telemetry.
-Note response to activity
and promote rest
appropriately.
- Provide small and easily
digested meals. Limit
caffeine intake and caffeine-
containing products.
-Heart rate and rhythm
respond to medication,
activity, and developing
complications. Dysrhythmias
(especially premature
ventricular contractions or
progressive heart blocks) can
compromise cardiac function
or increase ischemic damage.
Acute or chronic atrial flutter
may be seen with coronary
artery or valvular
involvement and may or may
not be pathological.
- Overexertion increases
oxygen consumption and
demand and can compromise
myocardial function.
- Large meals may increase
myocardial workload and
cause vagal stimulation,
resulting in bradycardia or
ectopic beats. Caffeine is a
direct cardiac stimulant that
can increase heart rate. Note:
New guidelines suggest no
39 | P a g e
-Have emergency equipment
and/or medications available.
-Administer supplemental
oxygen, as indicated.
-Measure cardiac output and
other functional parameters
as appropriate.
5
need to restrict caffeine in
regular coffee drinkers.
- Sudden coronary occlusion,
lethal dysrhythmias,
extension of infarct, and
unrelenting pain are
situations that may
precipitate cardiac arrest,
requiring immediate life-
saving therapies and/or
transfer to CCU.
- Increases amount of oxygen
available for myocardial
uptake, reducing ischemia
and resultant cellular
irritation and/or
dysrhythmias.
- Cardiac index, preload,
afterload, contractility, and
cardiac work can be
measured noninvasively with
thoracic electrical
bioimpedance (TEB)
technique. Useful in
evaluating response to
therapeutic interventions and
 identifying need for more
aggressive and/or emergency
care.
-Maintain IV or Hep-Lock - Patent line is important for
access as indicated. administration of emergency
drugs in presence of
persistent lethal
dysrhythmias or chest pain.

-Review serial ECGs.

- Provides information
regarding progression or
resolution of infarction,
status of ventricular function,
electrolyte balance, and
effects of drug therapies.
-Review chest x-ray.
- May reflect pulmonary
edema related to ventricular
dysfunction.
-Monitor laboratory data:
cardiac enzymes, ABGs, - Enzymes monitor
electrolytes. resolution or extension of
infarction. Presence of
hypoxia indicates need for
supplemental oxygen.
Electrolyte imbalances:
hypokalemia or
hyperkalemia, adversely
41 | P a g e
-Administer antidysrhythmic
drugs as indicated.
-Assist with insertion and
maintenance of pacemaker,
when used.
5
affects cardiac rhythm and
contractility.
- Dysrhythmias are usually
treated symptomatically,
except for PVCs, which are
often treated
prophylactically. Early
inclusion of ACE inhibitor
therapy (especially in
presence of large anterior
MI, ventricular aneurysm, or
HF) enhances ventricular
output, increases survival,
and may slow progression of
HF. Note: Use of routine
lidocaine is no longer
recommended.
- Pacing may be a temporary
support measure during acute
phase or may be needed
permanently if infarction
severely damages conduction
system, impairing systolic
function. Evaluation is based
on echocardiography or
radionuclide
ventriculography.
 Nursing Nursing Expected Out Interventions Rationale Evaluation
Assessment Diagnosis Come

Subjective data: Risk for Excess -Maintain fluid -Auscultate breath sounds for - May indicate pulmonary Not applicable as
Fluid Volume balance as presence of crackles. edema secondary to cardiac the patient is at risk,
Not applicable as related to evidenced by BP decompensation. it is not an actual
the patient is at increased within patient’s nursing diagnosis.
risk, it is not an sodium/water normal limits. -Note JVD, development of - Suggests developing
actual nursing retention -Be free of dependent edema. congestive heart failure or
diagnosis. peripheral/venous fluid volume excess.
Objective data : distension and Measure I&O, noting
dependent edema, decrease in output,
Not applicable. A with lungs clear and concentrated appearance.
risk diagnosis is weight stable.
not evidenced by -Calculate fluid balance. - Decreased cardiac output
signs and results in impaired kidney
symptoms, as the perfusion, sodium and water
problem has not retention, and reduced urine
occurred and output.
nursing
interventions are -Weigh daily. - Sudden changes in
directed at weight reflect alterations in
prevention. fluid balance.

-Maintain total fluid intake at - Meets normal adult body

2000 mL/24 hr within fluid requirements, but may
cardiovascular tolerance. require alteration or
restriction in presence of
cardiac decompensation.

-Provide low-sodium - Sodium enhances fluid

diet/beverages. retention and should
therefore be restricted during
active MI phase and/or if
heart failure is present.
43 | P a g e

-Administer diuretics: - May be necessary to correct

furosemide (Lasix), fluid overload. Drug choice
spironolactone with is usually dependent on acute
hydrochlorothiazide or chronic nature of
(Aldactazide), hydralazine symptoms.
(Apresoline).

-Monitor potassium as - Hypokalemia can limit

indicated. effectiveness of therapy and
can occur with use of
potassium-depleting
diuretics.

5
 Nursing Nursing Expected Out Interventions Rationale Evaluation
Assessment Diagnosis Come

Subjective data: Risk for impaired Maintain skin Inspect skin, noting skeletal Skin is at risk because of Not applicable as
Skin Integrity integrity. prominences, presence of impaired peripheral the patient is at risk,
Not applicable as related to Demonstrate edema, areas of altered circulation, physical it is not an actual
the patient is at prolonged bedrest behaviors/technique circulation, or obesity and/or immobility, and alterations in nursing diagnosis.
risk, it is not an edema, decreased s to prevent skin emanciation. nutritional status.
actual nursing tissue perfusion breakdown.
diagnosis. Provide gentle massage Improves blood flow,
Objective data : around reddened or blanched minimizing tissue hypoxia.
areas. Note: Direct massage of
Not applicable. A compromised area may cause
risk diagnosis is tissue injury.
not evidenced by
signs and Encourage frequent position Reduces pressure on tissues,
symptoms, as the changes, assist with active improving circulation and
problem has not and passive range of motion reducing time any one area is
occurred and (ROM) exercises. deprived of full blood flow.
nursing
interventions are
directed at Provide frequent skin care: Excessive dryness or moisture
prevention. minimize contact with damages skin and hastens
moisture and excretions. breakdown.
. Dependent edema may cause
Check fit of shoes and shoes to fit poorly, increasing
slippers and change as risk of pressure and skin
needed. breakdown on feet.
Interstitial edema and
impaired circulation impede
Avoid intramuscular route for drug absorption and
medication. predispose to tissue
breakdown and development
of infection.
45 | P a g e

5
 NURSES NOTES - 1
Name of the Patient - Mr.harish malav Diagnosis - coronary artery disease
Age / Sex - 40 years / male Name of Surgery - nil
Date of Admission - 12/05/2017 Date of Surgery -nil
Ward / Bed No. - CCU
Nursing
Observation,
Date Diet Medication Time Sign.
Intervention and
Remark

12/05/17 Break fast : -Inj.Nitroglycerine 8.00am Patient is sleeping in

Upma -1 plate 2ml IV BD supine position. She
Banana - 1 -Inj. Heparin 2ml has an IV cannula on
Water – 150cc 2000IU IV BD right hand.
-Inj.Dopamine
Lunch : 15mg IV BD 8.30am She is talking with
Roti – 3 -Inj.Dobutamine her relatives.
Dal – 1wati 2ampoule in
Mix veg. -1 wati 5%Dextrose IV BD 9.00am Bed looks unclean
Water – 150cc -Inj.Diazepam 10- and untidy. So bed
20mg IV SOS making done.
Inj.Furosemide(Lasix)
40mg IV BD 9.30am Patient had Break
fast.

9.45am Patients vital signs

are checked and
recorded
Temperature :
98.6’F
Pulse : 88b/m.
47 | P a g e

Respiration :
24b/m.
Blood pressure
: 150/90 mm of hg.
10.00am
Medications given as
per doctors order.
11.00am
Incentive spirometry
done by the patient.
11.30am
Patient history was
taken in all the
aspects of history
taking format.
12:00pm
Advised and
encouraged the
patient to do
coughing and
breathing exercises.

5
 NURSES NOTES– 2
Name of the Patient - Mr.harish malav Diagnosis - coronary artery disease
Age / Sex - 40 years / male Name of Surgery - nil
Date of Admission - 12/05/2017 Date of Surgery -nil
Ward / Bed No. - CCU

Nursing
Observation,
Date Diet Medication Time Sign.
Intervention and
Remark

13/05/17 Break fast : -Inj.Nitroglycerine 8.00am Patient is sleeping in

Upma -1 plate 2ml IV BD supine position. She
Banana - 1 -Inj. Heparin 2ml has an IV cannula on
Water – 150cc 2000IU IV BD right hand.
-Inj.Dopamine
Lunch : 15mg IV BD 8.30am She is talking with
Roti – 3 -Inj.Dobutamine her relatives.
Dal – 1wati 2ampoule in
Mix veg. -1 wati 5%Dextrose IV BD 9.00am Bed looks unclean
Water – 150cc -Inj.Diazepam 10- and untidy. So bed
20mg IV SOS making done.
Inj.Furosemide(Lasix)
40mg IV BD 9.30am Patient had Break
fast.

9.45am Patients vital signs

are checked and
recorded
49 | P a g e

Temperature :
98.6’F
Pulse : 88b/m.
Respiration :
24b/m.
Blood pressure
: 150/90 mm of hg.
10.00am
Medications given as
per doctors order.
11.00am
Incentive spirometry
done by the patient.
11.30am
Advised and
encouraged the
patient to do
coughing and
breathing exercises.
12:00pm
Discussed with the
patient the need for
activity. Planned
schedule with patient
and identified
activities that lead to
fatigue.

5
 NURSES NOTES - 3
Name of the Patient - Mr.harish malav Diagnosis - coronary artery disease
Age / Sex - 40 years / male Name of Surgery -
Date of Admission - 12/05/2017 Date of Surgery -
Ward / Bed No. - CCU

Nursing
Observation,
Date Diet Medication Time Sign.
Intervention and
Remark

14/05/17 Break fast : -Inj.Nitroglycerine 8.00am Patient is sleeping in

Banana - 1 2ml IV BD supine position. She
Water – 150cc -Inj. Heparin 2ml has an IV cannula on
2000IU IV BD right hand.
Lunch : -Inj.Dopamine
Roti – 3 15mg IV BD 8.30am She is talking with
Dal – 1wati -Inj.Dobutamine her relatives.
Mix veg. -1 wati 2ampoule in
Water – 150cc 5%Dextrose IV BD 9.00am Bed looks unclean
-Inj.Diazepam 10- and untidy. So bed
20mg IV SOS making done.
Inj.Furosemide(Lasix)
40mg IV BD 9.30am Patient had Break
fast.

9:45am
51 | P a g e

Patients vital signs

are checked and
recorded
Temperature :
98.6’F
Pulse : 88b/m.
Respiration :
24b/m.
Blood pressure
10.00am : 140/90 mm of hg.

Medications given as
11.00am per doctors order.

Incentive spirometry
11.30am done by the patient.

Provided back care

nail care to the
12:00pm patient.

Encouraged the
patient to verbalize
12:30pm her feelings

Provided
psychological
support.
.

5
Health Education:

Prevention

Follow your health care provider's recommendations for treating conditions that can cause
valve disease. Treat strep infections promptly to prevent rheumatic fever. Tell your health care
provider if you have a family history of congenital heart diseases.

Mitral stenosis itself often cannot be prevented, but complications can be prevented. Tell your
health care provider about your heart valve disease before you receive any medical treatment.
Discuss whether you need preventive antibiotics.

Heart Healthy Tips

Although cardiovascular disease remains the number one cause of death and disability in the
United States, there are a number of things you can do to keep your heart healthy and reduce
your risk of heart disease.

Eat Right

Healthy food habits can help you reduce three of the major risk factors for heart attack: high
cholesterol, high blood pressure and excess body weight. The best way to help lower your
blood cholesterol level is to eat less saturated fat, avoid cholesterol and control your weight.
Here are some other nutrition tips:

• Eat a variety of fruits, vegetables and grain products, especially whole grains.

• Consume fat-free and low-fat dairy products, fish, beans, skinless poultry and lean
meats.

• Limit foods high in saturated fat, trans fat and cholesterol.

• Eat less than 6 grams of salt a day.

• Have no more than one alcoholic drink (no more than 1/2 ounce of pure alcohol) per
day if you're a woman and no more than two drinks if you're a man.

Be Active

Physical activity is good for your entire body, especially your heart. While getting into a regular
exercise routine is great, there are a number of quick ways to easily add more physical activity
into your days:

• Take the stairs — Get in the habit of taking the stairs instead of the elevator. If you
are going to a high floor, take the elevator part of the way — either walk up a few flights
and then catch the elevator, or get off early and walk the rest of the way.

• Go for a walk — Even a short walk around the block or through your office can help
get your heart rate up and invigorate your body.
53 | P a g e

• Clean the house — Vacuuming, dusting and even doing laundry gets you up and
moving around.

• Garden — Raking leaves, mowing the lawn and pruning plants all get you outside and
active.

• Shop — When running errands or going to the mall, park farther away and walk the
extra distance. Wear your walking shoes and take an extra lap or two around the mall.

• Talk on the phone — Stand up while talking on the phone or, better yet, walk around
when using a cordless or cellular phone.

• Play — Play and recreation are important for good health. Look for opportunities to be
active and have fun at the same time.

• Find a buddy — For many, it is easier to be active with a partner. Make a date with a
friend to enjoy your favorite physical activities and try to get into a regular routine of
being active together.

• Go dancing — Both fun and physical, dancing is a great way to enjoy moving and
grooving.

CONCLUSION:-

Mr.harish malav a 40 year old male patient, who had come to the hospital with
complaints of chest discomfort, breathing difficulty, fatigue and swelling of feet and ankles.
He got admitted to New Medical college & Hospital on 08/07/2019. He was admitted to the
CCU of the hospital Various laboratory investigations were performed and treatment was
prescribed accordingly. He was diagnosed as a case of Coronary artery disease. I have selected
this patient for my case study and providing appropriate nursing care.I have collected history
of the patient and have given health education on hygienic practices. I have even maintained
good interpersonal relationship with the patient and her family and have rendered a need based
nursing care. As a result, the client’s health status and level of self esteem improved.

BIBLIOGRAPHY:-

• Brunner and Sugharths, Text book of Medical Surgical Nursing, 10th Edition,
Lippincott Williams and Wilkins publications
• Lewis Heitkemper,Dirksen(2004), Text book of Medical – Surgical Nursing, 6th
edition, Mosby Publications.
• Joyce M Black, Jane Hawkanson Haurles(2005),Text book of Medical – Surgical
Nursing, 10th edition, Volume 2, Haeseor Publications.
• Ross & Wilson(2006), Text Book of Anatomy & Physiology, 10th edition, Elseveier
publications, Philadelphia, USA
• Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS.
Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic
review and meta-analysis. Journal of the American College of Cardiology. 2016 Jan
5;67(1):1-2.
• http://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/diagnosis-
treatment/treatment/txc-20165340
• https://www.nlm.nih.gov/medlineplus/ency/article/000175.htm
• http://www.le.ac.uk/pa/teach/va/anatomy/case1/frmst1.html
• http://emedicine.medscape.com/article/155724-overview#a6
• http://nurseslabs.com/6-heart-failure-nursing-care-plans/
• https://www.ucsfhealth.org/education/heart_healthy_tips/