NURSING care plan on mi

7/29/2019 NURSING care plan on mi

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SUBMITTED TO - SUBMITTED BY-

Ms. Sucheta Yangad Mr. Sanvar mal soni

Asso. Prof.(med-surg) Msc. final year (med-surg)

Submitted on- 2nd

feb. 2013


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HISTORY OF THE PATIENT

IDENTIFICATION DATA

Name of the patient : Mrs. Svitri Bai Chavan

Age : 77 years

Gender : Female

Bed No. : 01

Ward : Intensive coronary care unit

IPD No. : 1178

OPD No. : 14919

Date of admission : 01/03/2013

Educational status : 10th standard

Occupation : House wife

Monthly income : Appox. Rs. 8000/ month

Religion : Hindu

Mother tongue : Marathi

Marital status : Married

Address : Mahatma fulle Nagar, dapodi, pune.

Diagnosis : Anterior wall MI with DM

CHIEF COMPLAINTS AND PRESENT MEDICAL HISTORY

Patient was apparently asymptomatic before 1 month of admission and after then She started left sided

chest pain, dyspnea on exertion and sweating but since 2 days of admission she started to having severe

chest pain and shortness of breathing.

PAST MEDICAL HISTORY

The client had the history of diabetes mellitus since 5 years. Client Had the history of pain in chest

infrequently .

Pt had no history of other major disease.

PAST SURGICAL HISTORY

Client has undergone the surgery of hysterectomy 25yrs ago.


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FAMILY HISTORY

Family tree:

Patient husband

Daughter son son

FAMILY INFROMATION

Sr.No

Name of FamilyMembers

Relationshipwith patient

Age(yrs.)

Education

Occupation MaritalStatus

Healthstatus

1 Mr. pandurang chavan Husband 80 8t pass Worker Married Healthy

2 Ms. Khusi vitkar daughter 46 10t pass House wife Married Diabetes

3 Mr. Sunil chavan Son 45 Graduate Teacher Married Healthy

4 Mr. sanjay chavan Son 42 10t pass worker Married Healthy

Family income per year : Rs.1 lakh approximately.

Family interpersonal relationship : All the family members have good IPR.

No disharmony.

Family history of illness : patient`s mother had the history of diabetes mellitus.

The family members of the patient were healthy except daughter. Daughter of the patient having diabetes

mellitus. There was no family history of any other illness like cancer, arthritis or neurological disorders

were not found.

DIETARY HISTORY-

Patient used to take mixveg diet. She used to take chicken once in a week. She also used to take green

leafy vegetables and other veg diet. She used to take meals in lunch time and dinner. She did not use to

take breakfast in morning. She used to take tea four times in a day.

SOCIOECONOMIC STATUS

A) HOUSING Type of house - Small house with 2 rooms made up of bricks. Lighting Lack of proper lighting facility. Ventilation1 window and 2 doors for ventilation. Water facilityonce a day. SanitationLack of sanitation and hygiene.


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B) FOOD HYGIENE PRACTICESLack of food hygiene. Not washing hands before cooking and not washing vegetables also before

cooking food. Cook food in unhygienic condition.

C) PERSONAL HYGIENE PRACTICESNot maintaining personal hygiene. Not taking bath daily. Not washing hands and cutting nails etc.

D) COMMUNITY RESOURCESResources like transportation are available by bus and train.

Educational resources are available up to higher education.

E) RELIGIOUS PRACTICESClient and his family strongly believe in the god and they worship regularly. They visit temple

sometimes.

F) FAMILY INCOME & EXPENDITUREFood Rs.2000 per monthClothing Rs.500 per month

Education Nil

Health Rs.1000 per month

ALLERGIES AND MEDICATIONS

Client doesnt have any allergies from medicines, food, dyes etc.


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PHYSICAL ASSESSMENT

GENERAL APPEARANCE

Level of Consciousness: - Conscious Orientation: - Oriented to time, place and person. Activity: - patient is less active Body Built: - Moderate Breath odour- foul smell Sign of distress- patient is confused and asking again and again about her disease. Hygiene and grooming- patient does not use to groom independently.

ANTHROPOMETRIC MEASUREMENT

1. Height: 55 2. Weight: 50 kg

VITAL SIGNS

1. Temperature: 99.8F 2. Pulse: 80/min 3. Respiration: 28/min4. Blood Pressure: 120/86 mmHg

INTEGUMENTORY SYSTEM

Skin color- Brown Dermatitis- No skin infections Allergies- No skin allergies Lesions/Abrasions- non healing diabetic wound present on left leg at ankle joint. Tenderness /Redness- No redness and tenderness. Surgical scar- Surgical scar present at lower abdomen. Abnormal growth- No abnormal growth. Cyanosis - paleness present at face and finger tips. Jaundice - not present. Hyperpigmentation- present over the upper limbs.

HEAD

Hair: - Equally Distributed Color of Hair: - Grey Scalp: - Clean, No Dandruff Pediculosis: - Absent Sinus area- no inflammation.


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Nodes- not present.

FACE

Face: - Symmetrical Facial Puffiness: - Present

EYES

Eye Brows: - Symmetrical Eye Lid/Lashes: - No Redness/ Swelling/Discharge/Lesions Eye Ball: - Normal Conjunctiva: - Normal/ No Lesions Sclera: - White Puncta: - Red and not swollen Cornea: - Regular Ridges Iris: - Flat Eye Discharge - Absent Use of glasses - No Pupils- Equally Reacting To Light and normal size Visual Acuity- Not proper patient not able to see the far objects.

SINUS

Maxillary sinus infection - No Frontal sinus infection - No

EARS

Size & shape- Normal & symmetrical. Position And Alignment- Normal. Redness- Absent Discharge - Absent Cerumen- Present Lesions- Absent Foreign Body - Absent Hearing Acuity- Normal Use of Hearing Aids- No


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NOSE

Nasal Septum- Not deviated Nasal Polyps- Absent Nasal Discharge- Absent

ORAL CAVITY

LIPS- No Crack/ Healthy lips. Cleft Lips- No cleft lips. Stomatitis- Absent Number of Teeth- 28 teeth. Dentures - Absent Dental Carries- Present Odour of Mouth- Foul Smell Gums Weak Palate and uvula- no inflammation. Taste - Patients able to identify the taste.

NECK

General structure- normal Trachea - normal Thyroid - not palpable. Nodes - not palpable, absent Muscles - normal strength

CHEST AND RESPIRATORY SYSTEM

Respiratory Rate- 28 per min. Thoracic Cage - Normal shape. Anterioposterior to transverse diameter in ratio of 1:2

POSTERIOR THORAX

Inspection

Shape and Summetry Normal shape. Anterioposterior to transverse diameter in ratio of 1:2 Skin Color and Condition- Normal Exaggerated spine curvature, slight kyphosis present.

palpation

Skin is intact, uniform temperature. Chest wall intact, tenderness absent. No presence of masses.


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Chest expansion- decreased chest expansion (2 cm) Fremitus- increased fremitus.

Percussion

Resonance- Normal Diaphragmatic Excursion- restricted lung excurtion (2 cm).

Auscultation

Breathing Sound- Rales crackles at inspiration Respiratory Pattern- Rapid breathing with effort.

ANTERIOR THORAX

Costal angle is 50 degree. Skin is intact on anterior chest side. Rales crackles at inspiration. Reasonance sound present on percussion.

CARDIO VASCULAR SYSTEM

Pulse- 80/minPrecordium

No heaves or lift present on palpation. Aortic pulsation absent. Point of maximal impulse 5t intercostal space, midclavicular line Heart Sound S1 , S2 Heard Abnormal Heart Sound S3 sound present. Murmurs Absent Carotid Pulse Rate - 80/min Blood Pressure- 120/86 mmHg Chest pain, radiation- Positive chest pain at the left side that radiates to the left shoulder,

palpitations noted at some times

Carotid pulse

Decrease pulsation, asymmetric volume.No sound present on auscultation.

Jugular vein

Visible distended.Peripheral pulses-

Symmetric volume, rate and rhythm.


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ABDOMEN AND INGUINAL AREA

Abdominal Girth- 76 cm Diarrhea / Constipation- Absent. Counter and tone- symmetric. Scar marks- surgical scar marks present over lower abdomen area. Liver- not palpable. Spleen- not palpable. Kidneys- not palpable, normal. Bladder- normal. Hernias- absent. Masses- absent.

Inspection

Size- Protuberant Flat Symmetry Normal Scar- No scar present Lesions and redness- surgical scar marks present over lower abdomen area.

Palpation

Tenderness- No tenderness Fluid Collection- Absent Mass/Soft- No palpable mass. No enlargement of liver, spleen.

Percussion

Ascitis / Peritonitis- Absent No Gas /Fluid Collection Tympanic sound present over the stomach area. Dullness sound over the liver.

Auscultation

Bowel Sounds- properly heard.GENITO URINARY

Frequency of Urination- Normal Color- Pale yellow. No complaints of Anuria / Hematuria / Dysuria / Incontinence. Catheter Present- No


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Urethral Discharge- NoMUSCULO SKELETAL SYSTEM

Range of Motion- Normal ROM. Joint Swelling / Pain- no inflammation. Complaint of pain at the time of walking. Weakness- No weakness. Extrimity strength- Equal extremity strength. Edema- edema present over lower exterimities.

NERVOUS SYSTEM

Level of consciousness Conscious, coherent and responsive Orientation Oriented to time, place and person Emotional state Calm, but upon exertion she feels dizzy and answers

questions inappropriately. Language Marathi Motor coordination Reflexes

Normal coordination.

Normal


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INVESTIGATIONS .

DIAGNOSTIC STUDIES

SR

NO.

NAME OF

INVESTIGATION

NORMAL

VALUE

PATIENT

VALUE

REMARK

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Haemoglobin

WBC count

Neutrophils

Lymphocytes

Eosinophil

Monocytes

Basophils

Random blood sugar

Blood group

HIV

Serum sodium

Serum potassium

Serum creatinine

Serum chloride

CK-MB

12-16 gm%

4000-

11000/cumm

40-75 %

20-45 %

0-5 %

0-5%

0-2%

70-120 mg%

---

---

135-145 mEq/L

3.5-4.5 mEq/L

0.8-1.4 mg/dl

96-106 mEq/L

0-3 ng/Ml

12.3 gm%

12000/cumm

60 %

35 %

04 %

02%

00 %

140 mg%

A positive

Negative

135 mEq/L

4.2 mEq/L

1.8 mg/dl

105 mEq/L

48ng/dl

Normal

Elevated

Normal

Elevated

---

---

Normal

Normal

Normal

Normal

Elevated


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Others Laboratory Examinations

ECG

ST segment elevation

CAG

LAD- type III mid segmental 30% stenosis.

LCX- non dominating artery with 90% mid segmental stenosis.

RCAdominating artery. Ostial 50% stenosis.

2D ECHO

Left ventricular ejection fraction45%

Grade 1

st

diastolic dysfunction

Mitral annular calcification.


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HEALTH EDUCATION AND DISCHARGE PLANNING

Client was given health education on various aspects of health, disease condition, its diagnosis, treatment

and follow-up during his stay in the hospital and at the time of discharge.

1) DISEASE CONDITION

Client was explained about the causes of the myocardial infarction. She was explained about the severity of the disease. She was guided for the prevention of the same condition in the future and maintains food hygiene

at home.

Special instructions were given on food hygiene.2) MEDICATIONS

Patient was explained about the importance of medications. She was explained about the route, time and dosage of medications. Side effects were told to be reported to the doctor. Follow-up of the treatment was advised. She was advised not to give any medications without doctors order. Reinforced the importance of having blood sugar checked every day. In patients with self-administer insulin, demonstrate patient the appropriate preparation and

administration techniques.

3) NUTRITIONAL THERAPY

Eat a variety of foods as recommended in the Diabetes Food Pyramid to get a balanced intake ofthe nutrients your body needs - carbohydrates, proteins, fats, vitamins, and minerals.

Reduce the amount of fat you eat by choosing fewer high-fat foods and cooking with less fat. Eat more fiber by eating at least 5 servings of fruits and vegetables every day. Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks, sodas, and tea or

coffee sweetened with sugar.

Use less salt in cooking and at the table. Eat fewer foods that are high in salt, like canned andpackaged soups, pickles, and processed meats

4) HEALTH TEACHING

Encouraged client to do at least 30 minutes of walking a day as a form of exercise. Instructed to monitor blood sugar regularly. Adjustments in diet, medication and exercise can be

made accordingly.


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Encouraged to stick to the monitoring protocol prescribed by the doctor. Generally, blood ismonitored before meals and at bedtime.

Safety precaution should be maintained to prevent foot injury such as do not wear open shoes orwalk barefoot

Teach to the patient signs and symptoms of diabetic neuropathy and emphasize the need for safetyprecautions because neuropathy decreased sensation can hide sense injuries.

Adjust of activities to avoid over exertion and fatigue, allow rest periods


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BIBLIOGRAPHY

1. Brunner & Suddarth, Textbook of Medical Surgical Nursing, 11 th edition, Lippincott Williams &Wilkins, pp:896-897.

2. Gulanick Myers, Nursing Care Plans, 6th edition, Mosby publication, pp:54-57.3. Holloway Nancy M., Medical Surgical Care Planning, 3 rd edition, Springhouse publication,

pp:891-894.

4. http://en.wikipedia.org/wiki/Miocardialinfarction.5. http://www.emedicinehealth.com/miocardial infarction/page6_em.htm6. http://www.wrongdiagnosis.com/g/miocardial infarction/treatments.htm7.

Lewis, Medical Surgical Nursing, 6

th

edition, Mosby publication; pp:1020-1023.

8. Lippincott, A Proffessional Guide to Pathophysiology, 1st edition, Lippincott Williams & Wilkins,pp:686-688.

9. Skidmore-Roth Linda, Nursing Drug Reference, 22nd edition, Mosby & Elsevier, pp:21-23; 42-44.10.Tortora, Principles of Anatomy & Physiology, 10th edition, Jhon Wiley & Sons, pp:851-858.11.Patients file.
http://en.wikipedia.org/wiki/Miocardialhttp://en.wikipedia.org/wiki/Miocardialhttp://www.emedicinehealth.com/miocardial%20infarction/page6_em.htmhttp://www.emedicinehealth.com/miocardial%20infarction/page6_em.htmhttp://www.wrongdiagnosis.com/g/miocardial%20infarction/treatments.htmhttp://www.wrongdiagnosis.com/g/miocardial%20infarction/treatments.htmhttp://www.wrongdiagnosis.com/g/miocardial%20infarction/treatments.htmhttp://www.emedicinehealth.com/miocardial%20infarction/page6_em.htmhttp://en.wikipedia.org/wiki/Miocardial


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NURSING CARE

PLAN


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NURSES NOTES


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DISCHARGE

PLANNING


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HISTORY

COLLECTION


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PHYSICAL

ASSESSMENT

NURSING care plan on mi

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