Power Point IHD

8/11/2019 Power Point IHD

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Ischemic Heart Disease

29(2/2005)

1686


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Learning objective Learn about the anatomy and physiologyof the

cardiovascular system State the definitionof the ischemic heart disease State the predisposinngfactor Explain the pathophysiologyof the ischemic heart

disease

Sate the clinical manifestationof the ischemic heartdisease List up the complicationof the ischemic heart disease Explain all the investigationgiven to the patient with

ischemic heart disease Carry out the nursing care planfor patient with

ischemic heart disease List the medicationgiven to patient with ischemic

hear disease Provide health educationfor patient about self care

at home


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Introduction


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AdmissionName: Mr. S

Registered number: 93***

Date of birth: **-**-****

Age/Sex: 57 years old/Male

Marital status: Married

I/c No.: 4909********

Race/Religion: Chinese/BuddhistOccupation: Laboratory supervisor

Consultant: Dr. T

Date of admission: 6thJune 2006


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Reason of admission: complained ofchest pain (on & off) & S.O.B 2/52

Diagnosis: Ischemic Heart DiseaseMedical history: Diabetes Melitus,

hypertension

Surgical history: angiography and PTCAon 30thMarch 2006

Family history: Nil

Allergies: NilCurrent medication: Imdur, dormicum,

betaloc, plavix, cardiprin,


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Condition of admission

Vital sign

Temperature: 36oC

Pulse: 47bpm

Respiration: 20bpm

Blood pressure:112/68mmHg

Weight: 50kg Height: 161cm

Mode of admission: walk

in

Level of consciousness:conscious

Mental status: orientated

Emotional status: calm Skin Condition: dry


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Activity daily living

Breathing

He has difficulty in breathing when he is walking inlong distance

Cough

Mr. S does not has any cough Smoke

Mr. S does not smoking

Eating/drinking

Mr. S does not having problem in eating.

He does not take cold water, seafood

He likes to eat red meat especially mutton and durian.

He used to has supper with fried mee frequently

His favourite drink is coffee


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Elimination-bowel

He has his bowel movement daily.

He does not has problem in passing motionElimination-bladder

He does not has problem in passing urine

He used to get up at night to pass urine twice, noturia

SleepingHe does not has any problem in sleeping

Mobility

Mr. S is able to ambulate

Personal HygieneHe able to has self hygiene

Safe environment

Siderails is needed to promote safety


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Physical examination


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Orientation

During the admission on Mr. S, a orientation wasgiven according to the checklist as below:

1. Ward

Room no./bed no.

Television Call bell

Bed chair

2. Staff

Unit manager Staff nurse/assistant nurse

Care assistance

Student nurse

Ward clerk

3. Routine

doctors rounds

Nurses rounds Meal times

4. Hospital policies

Visiting hours

Companion Property/valueable


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Anatomy


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Layers of the heartPericardium

Pericardium is a strong, non-distensible sac which loosely enclosesthe heart and attaches to the large blood vessels at the base of theheart and to the diaphragm at the apex.

The walls of the heart composed of three layers of tissue:

1. epicardium outer layer of the heart

visceral layer of the pericardium

2. myocardium middle layer of the tissuecomposed of the invonluntary striated muscle fibres

which interlace, branch and anastomose

responsible for the hearts contractile force

3. Endocardium thin layer of endothelial cells lining the inferiorsurface of the hearts chambers which covers the

heartcreate a smooth surface, reducing friction between

moving blood and the walls of heart


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Anatomy of the heart


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Anatomy of the heart


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Circulation of the heart


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DEFINITION


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Definition

Coronary artery disease or ischemic heartdisease affect three major coronary arteries(right coronary artery, left anterior descendingartery and left circumflex artery) that provide

oxygen and nutrient to myocardium. When blood flow through these major vessel

becomes partially or completely blocked,ischemia and infarction of the myocardium mayresult. Ischemia occurs when the balancebetween oxygen supply and demand becomesdisproportionate.

(Medical Surgical Nursing, Page 2149)


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Etiology


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Etiology1. Decrease aortic pressure

2. Increased intravascular pressure andmyocardial infarction

3. Coronary artery stenosis

Atheroscleros is

Fixed coronary stenosis

Acute plague change(rupture,hemmorhage)

Coronary artery thrombosis

Vasoconstricion4. Aortic valve stenosis

5. Aortic regurgitation

6. Increased right artrial pressure


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What is atherosclerosis

Coronary artery disease (CAD) is caused

by atherosclerosis (the thickening and

hardening of the inside walls of arteries).

Some hardening of the arteries occursnormally as a person grows older.


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Atherosclerosis1) In atherosclerosis, plaque

deposits build up in thearteries. Plaque is made up offat, cholesterol, calcium, andother substances from theblood. Plaque buildup in thearteries often begins inchildhood. Over time, plaque

buildup in the coronary arteriescan:

Narrow the arteries. Thisreduces the amount of bloodand oxygen that reaches theheart muscle.

Completely block the arteries.This stops the flow of blood tothe heart muscle.

Cause blood clots to form. Thiscan block the arteries thatsupply blood to the heart

muscle.


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Risk factor

Modified risk factor

Hyperl ip idemia

Hypertension

Diabetes Mel i tus Physical act iv i ty

Cigarette smoking

Obesity

High alcohol intake

Personality characterics


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Pathophysiology

ageing hypertension Diabetes melitus

atherosclerosishyperlipidemia

Inflammatory process

T-lymphocytes & monocytes(become macrophages)ingest the lipids & die

Degeneration of smooth muscle cells(vessel)

Fibrous capis form(over fatty core(called plague/atheromas


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Disturbance

Insuffiency of oxygen & nutrient demand to myocardium

Myocardila ischemia

Narrow & obstruct blood flow


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Clinical manifestationBreathlessness, sho rtness of breath or dyspnea.

Lack of oxygen supply to myocardium because of thenarrowing of the right coronary artery.

Chest pain

The volume of oxygenation blood deliver to themyocardium is lesser due to the occlusion artery causethe workload of heart increase lead angina attack.

Palpitation

The workload of heart is increasing and pump harder tomeet the oxygen demand.

FatigueIt is because patient use accessory muscle to help inincrease breathing process to inhale more oxygen


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Syncope

The symptom of syncope is happen in a sudden,transient loss of consciousness due to

inadequate cerebral blood flow

Diaphoresis

Anxiety

Mr. S is always anxiety during chest pain.

Patient might be fear an anxious during the

chest pain as they are afraid of dying Nausea and vomiting

Lightheadedness

Pallor


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Complication


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complication

Myocardial infarction Congestive heart failure

Congestive heart failure

Myocardial rupture Cardiogenic shock

Dysrhythimias

Acute heart failure (pulmonary oedema)

Pericardial effusion and cardiac

tamponade


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Investigation


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Investigation

List of investigation

done:

Diagnostic test:

Chest x-ray

Electocardiogram

Angiography

Stress test

Laboratory test:

1. Haematology-value of

haemoglobin

2.

Total white blood countand WBC differential

count

3. Random blood sugar

(RBS)

4. Urea electrolyte (BUSE)

5. Lipid profile

6. Blood coagulant test


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Result of Chest x-ray

Report:

Heart size normal

Lung fields clearNo hilar abnormality seen


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Electrocardiogram


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Result of the

electrocardiogram

ST segment depression of 0.6mm in lead

I, II and V5V6. According to the


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Result of blood test

[Total white blood count & WBC differential count]

Examination Result/unit Normal range

Total white blood

count

White blood cell 7.8/uL 4.3-10.5

WBC differential

count

NeutrophilLymphocyte

Eosinophil

Monocyte

Basophil

66.7%

20.6%6.1%

4.7%

1.1%

40-75

20-450-6

1-11

0-2


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Result of random blood

sugar


Glucose 6.2mmolL

111mg/dL

3.9-6.1

70-110


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Angiography

Selective coronary angiography is the only

method currently available for accurately

delineating human coronary anatomy as wellas for locating and quantitating obstruction

in large-caliber coronary arteries.


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Occlusion coronary arteries of

Mr. S


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Result of angioraphy

Report: Left Main Stem, LMS: Normal

Left anterior descending artery, CAD: Normal

First Diagonal of the CAD: 90%Tight stenosis (donePTCA with balloon)

Left circumflex artery, LCX: 90% Tightstenosis(done PTCA with stent)

Right coronary artery, RCA: 60%-70% distal stenous

mild stenous with posteriordescending artery, PDA


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Result of stress test

Summary of the treadmill stress test Total of exercise time: 06:23

Maximum heart rate:144bpm 87% of maximum

predicted 164bpm

Maximum ST level :-2.90mm in lead III in Stage3

is 6:23

Reason for termination: Fatigue,chest discomfort

Conclusion: Positive stress test


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Phase &

time

Position time Speed

(km/h)

Grade

(%)

B/P

(mmHg)

HR

(bpm)

Workload RPP

(100)

VE

(1min)

ST

levelII

(mm)

Comment

Pretest supine 00:39 0.00 0.00 130/70 100 1.0 130 0 -0.99

standing 00.31 1.60 0.00 100 1.0 0 -0.95

Warm

up

00.31 1.60 0.00 97 1.1 0 -0.70

Exercise Stage 1 03.00 2.70 12.00 170/80 127 4.6 215 0 -1.65

Stage 2 03.01 4.00 12.00 200/80 147 7.2 284 0 -2.70

Stage 3 00.23 5.50 14.00 147 7.5 0 -2.90 6.10

chest

pain

Recovery 06.13 0.00 0.00 180/80 93 1.0 167 0 -1.75


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Result of lipid profileExamination Result/unit Normal range

Total cholesterol 7.4mmol/L

2.87mg/dL


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Result of the blood testaPartial thromboplastin time & aPTT control


aPartial

thromboplastin

time

>180 sec

(prolonged)

30-40

aPTT control 33.0sec 28-36

Result of blood studies


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Result of blood studies(Activated clotting time, ACT)

Date/time Examination Result/unit Normal range

6/6/06 at

10.00p.m

Activated

clotting time,ACT

337sec


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Treatment

Invasive procerdure


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Invasive procerdure,Percutaneuos Transluminal

Coronary Artery (PTCA)PTCA is an invasive procedure where

narrow coronary artery that are block by

the plague on the arterial wall is dilate by

balloon or stent. This procedure is carriedout in the cardiac catheterization

laboratory.

A preparation will be done before sendpatient for PTCA


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Pre-PTCA, checklist

1. Patient name,M.R.N2. Consent

3. Patients height/weighttaken

4. Allergy to contrast5. Allergy todrugs/elastroplast

6. Present medication

7. Pre-medication

8. Last meal or drinktaken

9. Fever

1. Asthma2. Chest x-ray

accompanying patient

3. ECG recordsaccompanying patient

4. HB,B.U.S.E,RBS

5. VRDL/HEPATITSB/AIDS

6. Dentures removed

7. Shaving done8. Patient passed urine

9. Nittoderm in place onthe right chest

10. Venofix inserted

11. others

Invasive procerdure


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Invasive procerdure,Percutaneuos Transluminal

Coronary Artery (PTCA)

Balloon is deflated

AngiographyDiagnose theocclusion coronaryartery byintroduced using

femoral artery

Atheroma areverified

A ballooncatheter are

inserted into thedistal of the RCA

Ballooninflated toexpand thestent

Catheter idremoved, stentis hold to openthe artery


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Coronary stent


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The patient might return to ward with a large peripheral

vascular access sheath in place. The sheath areremoved after blood studied (e.g activated clotting time)indicate that the clotting time is within an acceptablerange.

The patient must remain flat in the bed and keep the

affected leg straight until the sheath are removed andthen for few hours to maintain hemostasis.

After hemostasis is achieved, patient usually can beweaned from intravenous medications, resumed self-care, ambulate unassist within 1 to 12 hours in the

procedure The nurses teachers the patient to monitor the site for

bleeding or development of hard lump that is larger thana walnut.

Post-PTCA


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Medication


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Aspirin, aspirin 100mg,glycine 45mg

Group name: Anticoagulant drug

Date on: 6th June 2006

Date off: Continue at home

Route: Oral

Dosage: 150mg

Frequency: BD

Indication: Transient

ischem ic attacks, secondary preventionof MI, vascular occlus ion and deep veinthrombos is


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Plavix, Clopidrogel hydrogen sulfate

Group name: Anticoagulant drug



Route: oral

Dosage: 75mg

Frequency: BD

Indication:Prevention of atherothrombotic events

H b Dilti h d hl id


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Herbresser, Diltiazem hydrochloride

Group name: Calcium antagonist

Date on: 6th June 2006 Date off: 6th June 2006

Route: Oral

Dosage: 30mg

Frequency: BD

Indication: Mild and

moderatehypertension, angina

pectoris,variant angina pectoris


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Lipitor,Astrovastatin Calcium

Group name: Antihyperlipidaemicagent

Date on: 6th June2006


Route: Oral

Dosage: 10mg

Frequency: Daily

Indication: Reduct ion o felevated to tal and LDL cho lesterol

I d I bid 5 it t


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Imdur, Isosorbide-5-mononitrate

Group name: Antianginal

Date on: 6th June2006


Route: oral

Dosage: 30mg

Frequency: Daily

Indication: Prophylactictreatment of angina pectoris


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Nitroderm Nitroglycerin


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Nitroderm, Nitroglycerin

Group name: Antianginal


Route: topical

Dose: 10 mg

Frequency: stat

Indication:

Prevent ion o f theang ina pecto r is

Ativan Lorazepam


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Ativan, Lorazepam

Group name: Sedative


Route: oral

Dose: 0.5mg Frequency: daily

Indication:

Management of anx ietydisordersoranxiety associatedwithdepressive

symptoms


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Valium,Benzodiazepine

Group name: Antianxiety


Date off: 6th June 2006

Route: oral

Dose: 5mg

Frequency: stat

Indication:preoperatively as arelaxation


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Heparin,Heparin Leo Group name: Anticoagulant agent


Date off: 7th June 2006

Dosage: 1000u per hour in 8hours Frequency: Stat

Indication:

Deep-vein thrombosis, prevent ion ofDVT/PE

Controloc, Pantoprazole sodium


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, p

sesquihydrate


Date off: 6th June 2006 Route: oral

Dose: 40mg

Frequency: stat Indication:

long term management and prevention of

relapse of reflux oesophagus,

Glyceryl Trinitrate DBL Glyceryl Trinitrate


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Glyceryl Trinitrate DBL,Glyceryl Trinitrate

Group: Antianginal drug

Date on: 6th June 2006 Date off: continue at home

Dosage: 25mg

Route: Sublingual Frequency: Stat

Indication:

Control of hypertension treatment ofangina pectoris unresponsive torecommended doses of organicnitrates


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Nursing Care Plan

Nursing care plan


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r r1. Alteration in emotional status: anxiety related to invasive

procedure, Percutaneous Transluminal Coronary Angioplasty

2 .Potential of bleeding associated with arterial puncture after

invasive procedure after invasive procedure, PTCA

3. Potential of chest pain related to decrease myocardial

oxygenation and ischemia (angina attack)

4. Alteration in sleeping pattern discomfort relate to new

hospital environment

5.Knowledge deficit related to home care management of

Ischemic heart disease


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Nursing Care Plan

1

Dateon: 6thJune 2006Time: 12 00 noon


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Time:12.00 noon

Problem identi f ied:

Alteration emotion status: Anxiety related to invasiveprocedure, Percutaneous Transluminal Coronary Artery,PTCA

Suppo rt ing data:

Patient verbalized that he worry about the severity of hisdisease and chance to recover

Patient appear fear, and anxious when he was informthe PTCA will be done on 4.00pm

Expected ou tcome: Patient will has manageable level of his anxiety and

become more relaxed, less anxious, fear and ready to gofor PTCA within 1 hour of the nursing interventions given

Nursing interventions:


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1) Assess patient general condition: level of

the anxiety (facial expression) and hisundestanding regarding to the invasive

procedure, PTCA

Rationale: to act as baseline data and toplan an appropriate nursing intervention

Implementation:I assess his point of

view towards the PTCA, he replied thatalthough he had done PTCA once on

March, he still anxious because he

confuse about it

2) Provide conducive environment to rest


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2) Provide conducive environment to rest,expression of fears

Rationale: determine his feeling andproblem regarding the PTCA. Rest andexpression of fears may promoterelaxation at the same time.

Implementat ion: I encourage him to restand express feeling his own feeling abouthis real problem and I explain it isimportant to my knowledge to help himanswer

3) Encourage patient to ask questions and


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3) Encourage patient to ask questions and

do not avoid questions

Rationale:enable patient feel free to askquestions and promote confidence in

patient to staff nurse by not avoiding

questionsImplementation:I encourage Mr. S to ask

any questions he feel confuse and I try to

answer it and some of the question, I get

answer from Staff nurse N

4)Reinforce doctors explaination regarding to the PTCA


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4)Reinforce doctor s explaination regarding to the PTCA

in clearly and accurate way, plus give him a phamplet

about the PTCA. Then evaluate his understanding

beside obtain his consent on behalf of the doctor afterDr. T had given the explaination to him

Rationale: Increase of his knowledge of the PTCA

may enable patient to sign the consent confidentlyImplementat ion: I explain to the patient about PTCA

briefly and clear plus given him a phamplet regarding

the PTCA. I evaluate the understanding of the

explaination I given and he signed the consent underthe observation by the Staff nurse A

5) Inform the reason of asking for allergy to


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5) Inform the reason of asking for allergy to

contrast, drugs or elastroplast before the

PTCARationale: enable Mr. S to know the

reasons allergies being assess

Implementation: I explain to the patientthat if he allergy to certain matter, it will

affect the progress of the PTCA since the

dye contain iodine

6) Provide explaination that the staff nurse


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6) Provide explaination that the staff nurse

obtained the when he taken his last meal

or drink is because prevent aspiration offood into lung if the patient collapse

Rationale:allay his anxiety since he might

curious because he is order to nil bymouth

Implementat ion: I tell Mr. S that he need

to fasting to prevent aspiration of food into

lung

7) Assess his reaction when he being assess for


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7) Assess his reaction when he being assess for

having fever or asthma and comfort him by

briefly explaination that fever indicate infection

whereas asthma may cause patient to have

difficulty in breathing so that the health

personnel will take precaution

Rationale: evaluate his anxiety status for beingassess having fever or asthma

Implementat ion: I observe his reaction: facial

expression when the staff is assess his

temperature and asthma. He look confuse but

he just answer he has asthma since 4 year ago.

I tell the patient is it an precaution for the PTCA

8)R i f th t d bt i


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8)Reinforce that assess and obtain

VRDL/HEPATITIS B /AIDS test is act for

precaution to the health personnel careand enable them to perform it in excel

Rationale:enable not to angry or worry

that the tests being investigate to promoteco-operative environment between nurse-

patient

Implementation: I tell him the tests isassess for precaution and future

references

9)Assure the patient dentures is removed


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9)Assure the patient dentures is removed

and it is because the dentures might

cause complication; obstruction of airwayRationale:allay patient curiosity and

reinforce the explaination so that patient

can be co-operate wellImplementation: Mr. S asked me that

purpose for the dentures need to be take

out. I answer the dentures may causeobstruction of airway during the procedure

10) Provide information that the nitroderm in


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10) Provide information that the nitroderm in

place on the right chest

Rationale:enable patient to know thepatchess purpose so that he would not

confuse

Implementation: I tell him not to worryabout the patches being stick on the right

chest, its just for precaution

Date: 6th June 2006


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Time:1.00p.m

Evaluat ion:Patients anxiety status is reduced,

calm and ready to do the PTCA after one of

nursing intervention given.

Suppo rt ing data:

Patient verbalized that he is more confident to face the

PTCA

He thank you me for me giving him a briefly view of thePTCA for the second time

Init iated by: STN Low,1686


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Nursing Care Plan

Date:6thJune 2006


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Time: 7.40p.m

Problem identi f ied: Potential of bleeding associated with arterial puncture

after invasive procedure after invasive procedure, PTCA

Suppo rt ing data: Patient is administer with intravenous heparin from

12.00a.m until 5.00a.m

Patient has done the PTCA

Expected outcomes:

Patient will has intact and dry at the arterial puncture asit monitor during the nursing intervention given within 8hours



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1) Assess patient general condition: facial

expression e.g pale, fatigue and his complaint is

taking seriously

Rationale:Fatigue and pale is a signs of

prolonged bleeding or large volume of blood is

loss from the large artery, femoral artery. Besidepatients complaint is important to be pay

attention to detect any abnormalities

Implementat ion: I assess patients facial

expression and ask for his concern, he looked

pinkish, tired and he has no complaint

2) Monitor vital sign and oxygen saturation


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) g yg

hourly

Rationale:Act as baseline data and thechanges in blood pressure indicate pain

or decrease of blood volume

Implementat ion: I monitor hourly in first4 hours for once with the observation by

the staff nurse in-charge and the

following of the monitoring I do not do as

my shift is end on that day

3) Monitor the puncture site hourly and record the


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) p y

color, movement, sensation, warm or cold in the

circulation chart

Rationale: Potential of bleeding may occurafter PTCA since large artery being puncturedby determine the circulation in the right groin isintact as the sign and symptom of the bleedingis mentioned as above

Implementat ion: The monitoring of the groinis done by the staff nurse in-charge and Iobserve once. The patient groin appearedpinkish, able to move a bit of the right leg,sensation is felt and it felt warm

4) Obtain the coagulant studies as order by


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4) Obtain the coagulant studies as order by

doctor e.g Activated coagulant test,ACT

Rationale: help to determine thetendency to bleed

Implementat ion: The staff nurse in-

charge obtain the patients blood for ACTtwice an the 1st result is prolong and the

2nd result is in acceptable range

5) Inspect all the body fluid for presence of


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5) Inspect all the body fluid for presence of

the blood e.g urine, sputum, stool,

vomitus Rationale:Internal bleeding may be

manifested in urine, sputum and

gastrointestinal drainage Implementat ion:I inspect all the body

fluid which belonged to Mr. S frequently

and I inform him if he notices the

presence of blood the body fluid to report

to the nurses immediately

6) Avoid intramuscular injection


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6) Avoid intramuscular injection

Rationale: Intramuscular injection may

have potential to cause bleeding sincethe needle being inject to the muscle

Implementat ion:All the staff nurse have

ensure the injection not given throughmuscle

7)Keep and ensure intravenous line on the


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7)Keep and ensure intravenous line on the

other hand which not giving the heparin is

patentRationale:A patent intravenous line may

be needed during complication occur such

as active bleedingImplementation :I ensure the intravenous

line is patent and tell him the importance

of keeping the line is intact

8) Ensure one pint of whole blood is


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8) Ensure one pint of whole blood is

reserved

Rationale:patient may has risk ofbleeding, thus the blood transfusion may

be treat at once

Implementat ion: The staff nurse ensureone pint whole blood is reserved and

prepare it if blood transfusion is needed

9) Advise the patient to lie flat on the bed


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) p

for 6 hours and provide explanation

Rationale: If patient sit up the groin isflex and the femoral sheath apply

pressure is decrease plus the high

pressure from the femoral artery mayhave tendency to bleed

Implementat ion: I tell him lie on the bed

flat for 6 hours to prevent the puncture

site from bleeding

10)Ensure the other anticoagulant drug is


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10)Ensure the other anticoagulant drug is

not administer to patient

Rationale:Assure the risk of bleedingincrease as the prevention of blood

clotting is enhance

Implementat ion:the staff nurse assurethat there are no others anticoagulant

drug is given as ordered as doctor

Date:8th June 2006Time: 8.00a.m


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Time:8.00a.m

Evaluat ion: The potential of bleeding is monitor and no

bleeding occur during the nursing interventiongiven and during hospitalization

Suppo rt ing data:

The arterial puncture site is intact

Patient appeared pinkish and not fatigue butcomplain a little pain at the groin when moving

In i t iated by:STN Low,1686


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Nursing care plan 3

Date: 6th June 2006


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Time: 12noon

Problem identified: Potential of chest pain related to decrease myocardial

oxygenation and ischemia (angina

Attack)

Supporting data: Patient having is diagnose has single vessel disease-

40% of mild stenosis of RCA from previous angiogram

Patient verbalized he experienced chest pain on and offlast 2 last 2 weeks

Expected outcome:

Patient will has absent of chest pain after 1 day of thenursing interventions given and hospitalization



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1)Assess the characteristic of the chest pain such asquality, location, severity of pain (scale pain:0-absent of

pain till 10-severe pain), time onset and duration,determine it occurs at rest or during exertion, strongemotion, or during exposure to temperature extreme

Rationale:to obtain as baseline data, symptoms andcauses associated with angina usually precipitated by

exertion or emotion and can occur on during the day andnight or both

Implementat ion:I interviewed the patient and his wiferegarding the characteristic of pain. They described tome that his chest pain occur is like squeezing around thearea of the chest and he chosen 6-7 rate of rate of thescale pain. The duration is lasting not more than 30minute and it occur during the minimal exertion and rest.

2) Provide patient to rest in bed in calm,i t i t id t f l


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quiet environment, avoid stressfulsituations

Rationale: to reduce oxygenconsumption and excessive used ofenergy to have balance between oxygen

supply and demand by resting. Stressfulenvironment may not promote relaxation.

Implementat ion:I advised rest in bed ifhe having chest pain and will ensure the

environment is quiet and suitable for himto rest



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by pulse oxymeter 4 hourly

Rationale:Detect any abnormalitiesespecially dyrhsthimas and high blood

pressure

Implementat ion: I monitor vital sign andoxygen saturation 4 hourly.

4) Provide assistance aids to complete his


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) p

ADL e.g bath

Rationale: reduced used of excessiveenergy that will increase workload of the

heart

Implementat ion:I offer my help toassist him to bath in the bathroom

5) Provide certain equipment which enable


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)

patient to complete his ADL on bed e.g

urinal Rationale:reduce metabolic rate to

decrease energy to complete ADL on

bed. Hence myocardial oxygenation may

be adequately supply to the heart

Implementat ion: I offer a urinal to Mr. S

and tell him to pass urine in it

6) Inform patient to report to health


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6) Inform patient to report to health

personnel care immediately sign and

symptom of chest pain occur e.g Short ofbreath, palpitation, syncope

Rationale:to be notified and further

treatment is given immediately.Implementation: I tell the patient to report

to nurse if about sign and symptom of

chest pain occur


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7) Do the nurses round frequently and


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) q y

assess patients general condition

complain at the sane time Rationale: Enable detectation of any

abnormalities especially chest pain and

assessing patients general condition andcomplaint as well

Implementation: Always do the ward

round to the patient frequently on my freetime and assess his complaint.

8) Restrict visitors and inform the visiting


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time such as 12 noon-2 pm; 4 pm-9 pm

Rationale: Enable patient to have restand reduce over-emotional status such as

happy.

Implementat ion:I tell the patient to let

the amount visitor reduce to one or two

and inform the visitor about the

visiting time.

Date: 6th June 2006

Time: 1 p m


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Time: 1 p.m

Evaluation: Patient verbalized he did not experience chestpain or sign and symptom of chest discomfort after 1hour the nursing intervention given and duringhospitalization.

Supporting data:

Patient verbalized that no sign and symptom of chestpain

Patients vital sign is in normal range as below:

TO: 36.7OC

P : 70 bpmR : 20 bpm

BP : 100/60 mmHg

Init iated by:STN Low,1686


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Nursing care plan 4

Date:6th June2006

Time: 12 00 noon


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Time:12.00 noon

Problem identified: Alteration in sleeping pattern discomfort relate to new

hospital environment

Supporting data:

He complain of chest pain occur on and off at night

since last two weeks

He seem fatigue, weak

Expected outcomes:

Patient will have undisturbance of sleep at night within 1

day of nursing interventions



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g

1) Assess patient general condition:

lethargic signs e.g fatigue, weak, dizzinessRationale:determine sleeping pattern

level to act as baseline data and plan

appropriated nursing interventionImplementation: I interview the Mr. S

about is problem in sleeping disturbance

and assess sign of lack of sleep

2) Provide warm drink at night, 2 hours


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earlier before he sleep

Rationale: warm drink to induce thepatient to have good sleep and given 2

hours earlier is to prevent patient wake

up to pass urine

Implementat ion:I provide a cup of

warm Milo to Mr. S 2 hours before he

sleep and ask him to pass urine before

sleep

3) Provide conducive environment which is


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quiet, calm and peaceful

Rationale: enable patient to have goodrest because the noisy environment may

produce stressful feeling

Implementat ion: I ensure theenvironment is quiet, peaceful and calm

as all the patients in the six bedded room

are sleeping as well

4) Advise the patient not to having nap


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) p g p

during the day or a short period of nap

may be acceptable since patient mightfeel tired

Rationale: Having nap produce excessive

rest and might change the habit to sleepvery late at night

Implementat ion:I advise the patient may

have short period of nap or not to do so ifhe able to manage and admit this one of

the reason he having difficulty in sleeping

5) Encourage patient to express his feelingdi t hi bl


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according to his problem

Rationale: Express feeling of problemhelp to relieve stress and might promote avery peaceful sleep

Implementation:I encourage Mr. S to

voice out his problem and he said healways have chest pain at home duringsleeping, he also anxious about the effectof PTCA since he done the PTCA ispurposely to live longer to take care of hisfamily

6) Teach patient to use diversional therapy

l ti th


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or relaxation therapy

Rationale: promote relaxation and divertpatient problem to others matters so that

patient able to sleep well

Implementation: I teach patient about the

relaxation therapy such as listening to the

peaceful songs while patient go to bed

7) Allow one companion to stay in the


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7) Allow one companion to stay in the

hospital at night with the patient e.g family

memberRationale:Allay patient anxiety and

promote comfort as family member is with

patientImplementation:I tell Mr. S may has one

companion is allow to accompany him at

night so that he can feel more comfortable

8) Administer medication as ordered by


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) y

doctor to enable he sleep well e.g ativan

0.5mg dailyRationale: Ativan assist in relieve

depression and promote relaxation

Implementation: The staff nurseadminister ativan as prescribed by doctor

and follow the 5R, right patient, right drug,

right route, right dose, right time and tellhim it help to induce sleeping

Date:8th June2006


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Time: 12 noon

Evaluation: Patients sleeping pattern has improved within 1

day after the nursing intervention given and

during hospitalization.

Supporting data:

Patient verbalised he is able to sleep well

Initated by: STN Low


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Nursing plan 5

Date : 8th June 2006

Time:9.00a.m


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Problem identified:

Knowledge deficit related to home care management ofIschemic heart disease

Support data:

Mr. S ask me about method of prevention as hedischarge

Mr. S seem to ask me a lot of question about his disease

He seem anxious of home care as he go home

Expected outcome: Patients knowledge about home care will be improved

within 1 hour as the nursing interventions given

Nursing intervention:


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1) Assess patients general condition: facial

expression and patients complaintRationale: Obtain general information fro

patient due to his problem of home care

deficitImplementation: I assess patients

general condition: Facial expression, ask

for his concern. He complain he is worryabout the name care at home.

2) Assess patients level of knowledge or

d t di f hi di d th d


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understanding of his disease and method

of care should be taken

Rationale: Determine patients

knowledge of his disease and step of

care for himself at home

Implementat ion: I assess his education

level by ask for his occupation,

knowledge of medical term or any

information in ischemic heart disease

3)Inform the sources or causes, sign andt f hi h t i h


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symptom of his chest pain such as

palpitation and short of breath, fatigueRationale:enable patient to has

awareness over the cause of chestdiscomfort so that he can avoid these

sources

Implementation:I inform the patient thatthe cause that triggers the chest pain e.g

exertion activity and it normally will occurfatigue and short of breath as symptoms


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5) Encourage patient to do regularly

exercise start with gradually exercise


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exercise start with gradually exercise

Rationale:Gradually exercise is aneffective may burn the fat being store

and enable heart workload increase

slowly in acceptable range

Implementat ion:I always encourage the

patient to do gradual exercise by

walking for short distance and gradually

increase to jogging if persist

6) Advise patient to have rest between the


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stressful activity e.g exercise or even

after meal Rationale: reduce oxygen demand in

stressful environment to prevent chest

pain occur because cardiac workloadincrease

Implementat ion: I advise Mr. S to rest

as he feel stress or tired to relive chestdiscomfort

7) Advise patient to change his eating habitby changing not to take supper


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by changing not to take supperespecially oily food and reduce eating of

red meat e.g mutton as well as consumecaffeine drink

Rationale:reduce the risk factor of

increase atherosclerosis by modify theeating unhealthy habit

Implementat ion: I advise him to changehis unhealthy eating habit: not to take

supper, can has 1/2 of mutton and do notconsume coffee

8)Maintain the level of blood glucose by

d l di t t k di ti


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reduce low sugar diet, take medication

prescribed by doctorRationale:to monitor the glucose in blood

to reduce risk of complication occur from

ischemic heart disease such asmyocardial infarction

Implementation: I reinforce patient to

maintain the level of blood glucose by

taken right mediaction and reduce sugar

intake, fruit e.g durian

9)Advise patient ot do self-administer mediaction

as orderd by doctor e g Lipitor Aspirin Herbresser


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as orderd by doctor e.g Lipitor, Aspirin, Herbresser

,Imdur

Rationale:Lipitor user to maintain cholesterol

level whereas aspirin is assist in prevent blood

clot formation in the coronary artery stent.

Hebresser may reduce hypertension andangina pain as well as Imdur. Overall patients

condition is controlled by these medication

Implementat ion: I advise patient to take the

medication on time, to maintain his severity of

his disease become worse.

Date: 8th June 2006

Time: 10 00a m


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Time:10.00a.m

Evaluat ion: Patients has improving his knowledgeregarding to the home care deficit in management of the

ischemic hear disease after 1 hour the nursing

intervention given.

Suppo rt ing data:

Patient verbalized that he is more confident to take care

of himself at home

Patient appreciated my lessons on him and he evenwish to try the steps as soon as possible.

Init iated by:STN Low,1686


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Health education

On 8th June2006, I have teach Mr. S about

the health education in the morning before


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the health education in the morning before

he proceed his discharged. I given thehealth education as stated below:

Diet

Medication Exercise

Risk factor

Life style


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Discharge

Date:8thJune 2006

Ti 12


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Time:12noon

TTA: Aspirin 150mg, BD

Plavix 1/1 BD

Lipitor 1omg dailyImdur 90mg daily

Herbresser 30mg

daily

Diamicron 40mg daily


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Follow up

Date: 20thJune 2006 Dr. S has seen Mr. S. Doctor evaluate his

condition that it is now improving of recovery


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condition that it is now improving of recovery.

Dr. S also stated the patient his is showing agood sign after post PTCA and no complicationof the PTCA is identified.

Dr. S also had assess his blood pressure andthe result is 110/80 mmHg

TTA: Zocor 40mg, Daily

Aspirin 150 mg, BDPlavix 1/1, BD

Herbresser 30mg, Daily

Imdur 30mg, Daily


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Summary

Mr. S was admitted to JSH for PTCA. Actually, he hasdeveloped chest pain on and off after 2 years ago. Thenhe felt chest pain is became severe and intolerance.


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p

Hence a few investigation was done when he admittedon 30/O6/06. An angiogram is performed, the findingsare single vessel disease of right coronary artery 40%mild stenosis, 90% thigh stenosis of left circumflex arteryand thigh 90% of the first diagonal of left anteriordescending artery. He had done a PTCA on 3O/6/O6

However he still experience chest pain after the PTCA,thus he decreased to do second PTCA to dilate thenarrow distal of the right coronary artery.

During his admission, he came from Dr. Ts clinic to the

ward, he looked fatigue. He complained of chest pain on

and off since two weeks ago He had normal Dr T had


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and off since two weeks ago. He had normal Dr. T had

decided to perform the PTCA on4.00p.m

Value of haemodynamic accept his heart rate was

bradycardia, 47beats per minute. Dr. T seen had him

and decided to perform the PTCA on 4.00 pm. Doctor

also had prescribed the drugs for him as below:Aspirin 150mg, BD

Plavix 1/1, BD

Lipitor 10mg, Daily

Ativan 0.5mg Daily

After the PTCA was completed, the patient

was sent to the High Dependcence Unit


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was sent to the High Dependcence Unit,

HDU on 7.40p.m for close monitoring. Hecame out from the cardiac catheterization

laboratory with femoral dressing is dry and

intact. Close observation is and potential

of bleeding was monitored beside assessfor complication


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Reference

1)C. Smeltzer S. ,Bare B.July2003(tenth edition) Brunner and

Suddarths Medical Surgical Nursing, Coronary Artery Disease


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Suddarth sMedical Surgical Nursing, Coronary Artery Disease

2) Wange A,Grant A 2001 (ninth edition)Ross and Wilson, anatomy and

Physiology Inhealth and Illness, Cardiovascular System3) Ignatavicius D.D, Bayne M.V, Medical Surgical Nursing Coronary

Artery Disease)

4) Walsh W. 2006 (Sixth Edition)Watsons Clinical Nursing and

Related Sciences, Disorders of myocardial blood supply

5) Lemone P, Burke K, (Third edition), Medical Surgical Nursing,

Coronary Heart Disease6) Skidmore-roth L., (2004), Mosbys Nursing Drug Reference

(102nd Edition 2005), MIMS

8) Martin E.A, (2005), Dictionary Nursing Malaysian Edition

9) http://www.nhlbi.nih.gov/nhlb/contact/index.htm

10) www.heart.com11) www.heartonline.com

12) www.healthcentral.com
http://www.nhlbi.nih.gov/nhlb/contact/index.htmhttp://www.heart.com/http://www.heartonline.com/http://www.healthcentral.com/http://www.healthcentral.com/http://www.heartonline.com/http://www.heart.com/http://www.nhlbi.nih.gov/nhlb/contact/index.htm


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