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Diagnosis "medical":
IHD ischemic heart disease : Unstable angina
Chief Complaints :
1. Exertional chest pain with radiation to the left side of the neck and down the left
arm
2. Shortness of breathing
3. Tired
Vital Signs
Pulse: 70 bpm ; regular in rhythm.
Temperature: 36.5 C Axillary
Respiration: 24 Breathing / min
Blood pressure: (130/80 mm Hg)
Nutritional history:
Now he eats three regular meals daily, and some snakes between meals.
As he said he eat various type of food include meat, vegetables and fruits.
He drinks some of tea and juice daily.
Allergies:
Un Known allergy to Drug, food or other Allergen.
General Appearance:
The patient awake, alert, and responsive, he hasn't healthy appearance, his facial
expression at pale and tired conversation, and during the physical examination, and
he Interact with others patient in room and with relative.
He has coordinated weakness movement, he is clean and neat.
Quality and speech: understand and clear tone.
Height 170 cm long
Weight 85 kg
BMI = 85/ (1.7)2 = 29
Skin:
He has light brown skin color, moisture present in some area and other less moist,
warm, and intact skin; with no lesions or nodules.
He has thick nails clubbing in shape, with poor capillary refill, rough in texture, no
lesions or fungus.
He has dry, soft in texture white in color hair with good distribution, no scalp
lesion.
Head:
He has normal rounded, symmetrical skull, with no masses or nodules, and he has
area with hear loss.
Face:
He has normal face with symmetrical facial movement, his facial expression at
pale and tired.
Neck:
He has head centered neck, muscle equal in size and coordinated smooth
movement normal in function with no discomfort.
Eyes:
He said Both eyes are normal vision, eye brows symmetrical and coordinated in
movement.
black in color, equal in size, round pupils.
Pink, smooth conjunctiva.
Hair of eyebrow evenly distributed.
Ears:
Nose:
Pink in color, soft, moist, smooth in texture of lips and gum and inner mucosa
Some teeth loss
The tongue central position, pink in color, slightly rough and move freely.
He has symmetrical chest, right and left shoulder and hips are at same height.
Chest wall intact, no tender ness or masses.
Bronchi breath sound audible in auscultation.
The anteroposterior (AP) diameter less than transverse diameter.
As patient said (Anxious patients may have episodic dyspnea during both rest and
exercise, and hyperventilation, or rapid, shallow breathing Cyanosis may also
appeared that's appeared when make an activity and some time in rest period.
Mild to moderate pain in Retrosternal or across the anterior chest, sometimes
radiating to the shoulders, arms, neck, lower jaw, or upper abdomen.
Sometimes perceived as discomfort rather than pain)
Abdomen:
Smooth and relaxed abdomen, counter is flat rounded shape and symmetrical.
The umbilicus in the middle.
Audible bowel sound.
Little fat accumulates in the lower abdomen and near the hips.
No any large dull areas.
No masses or nodules.
Musculoskeletal system:
The patient has equal size on both side of body and smooth coordinated movement.
But current disease affect his ability to do exercise and he spend most of time
relaxed.
Social environment:
The patient has many visitors some of them from his family and other from his
friends.
Also patient has good relation with other patient in room.
And he interacts with his visitor .
Laboratory data
Test
Patient
value
Normal
value
Meaning
of
abnormal
value
13.8 g/dl
4.70 million/mm3
5600 /mm3
230*103/mm3
13.8 16 g/dl
4.5 5.3 million/mm3
4500 11000/mm3
(150350)*103/mm3
Normal
Normal
Normal
Normal
Straw
Acid
Nil
Nil
Straw
Acid
Nil
Nil
Normal
Normal
Normal
Normal
18.7 mg/dl
1.3 mg/dl
10 20 mg/dl
0.7 1.4 mg/dl
Normal
Normal
18 U/l
26 U/l
4 36 U/l
4 36 U/l
Normal
Normal
CBC test
Hb%
RBC
WBC
PLTS
Urine
Color
PH
Sugar
Blood
Chemistry
BUN
Creatinine
work reagent
ALT (SGPT)
AST (SGOT)
Medication
Drug
Name
& Dose
isosorbide
dinitrate
Rational
Action
Side effect
(with pt)
T(Cordil)
20mg X 2
salicylic acid
to reduce the risk of recurrent
T(Baby aspirin) stroke
100 mg X 1
Rout :Po
Atenolol
Beta-blocker
T(Normatin)
blocking activity on
feeling light-headed
myocardial 1-receptors short of breath
tired feeling
Decreases amount of
HCl produced by
stomach by blocking
action of histamine on
histamine receptors of
parietal cells in the
stomach
headache, nausea,
fatigue, , dizziness,
Gastrointestinal:
Digestive, gastric or
intestinal disorders
(abdominal pain,
nausea, vomiting,
Skin Reactions:
Rashes, Pruritus,
urticaria or
photosensitivity
reactions.
100 mg X 1
Rout :Po
Ranitidine
hydrochloride
T(Ratidine)
50 mg X 3
Rout :IV
Fenofibrate
T(Lipidex)
40 mg X 3
Rout :Po
Pathophysiology of Angina:
Angina pectoris is the medical term for chest pain or discomfort
due to coronary heart disease. Angina is a symptom of a
condition called myocardial ischemia. It occurs when the heart
muscle (myocardium) doesn't get as much blood (hence as much
oxygen) as it needs. This usually happens because one or more
of the heart's arteries (blood vessels that supply blood to the
heart muscle) is narrowed or blocked.
Insufficient blood supply is called ischemia.
Angina also can occur in people with valvular heart disease,
hypertrophic
cardiomyopathy (this is an enlarged heart due to disease) or
uncontrolled high blood pressure. These cases are rare, though.
Typical angina is uncomfortable pressure, fullness, squeezing or
pain in the center of the chest. The discomfort also may be felt in
the neck, jaw, shoulder, back or arm. Many types of chest
discomfort aren't related to angina. Acid reflux (heartburn) and
lung infection or inflammation are examples.
What is unstable angina?
In people with unstable angina, the chest pain is unexpected and
usually occurs while at rest. The discomfort may be more severe
and prolonged than typical angina or be the first time a person
has angina. The most common cause is reduced blood flow to the
Nursing care
Nursing Priorities
Relieve/control pain.
Prevent/minimize development of myocardial complications.
Provide information about disease process/prognosis and
treatment.
Support patient/SO in initiating necessary lifestyle/behavioral
changes.
Nursing diagnosing:
Acute Pain
May be related to
Nursing intervention
ACTIONS/INTERVENTION
RATIONALE
Nursing diagnosing:
Risk for decreased Cardiac Output
May be related to
Nursing intervention
ACTIONS/INTERVENTION
Provide for adequate rest periods. Assist
with/perform
self-care activities, as indicated.
Stress importance of avoiding straining/
bearing down,
especially during defecation.
Assess for signs and symptoms of heart
failure.
RATIONALE
Conserves energy, reduces cardiac
workload.
Valsalva maneuver causes vagal
stimulation, reducing heart rate
(bradycardia), which may be followed
by rebound tachycardia, both of
which may impair cardiac output.
Angina is only a symptom of
underlying pathology causing
myocardial ischemia. Disease may
compromise cardiac function to point
of decompensation.
Peripheral circulation is reduced
when cardiac output falls, giving the
skin a pale or gray color (depending
on level of hypoxia) and diminishing
the strength of peripheral pulses.
Increases oxygen available for
myocardial uptake to improve
contractility, reduce ischemia, and
reduce lactic acid levels.
Nursing diagnosing:
Anxiety
May be related to
Situational crises
Threat to self-concept (altered image/abilities)
Underlying pathophysiological response
Threat to or change in health status (even death)
Negative self-talk
Nursing intervention
ACTIONS/INTERVENTION
RATIONALE
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Nursing diagnosing:
Knowledge, deficient [Learning Need] regarding condition, treatment needs,
self-care and discharge needs
May be related to
Lack of exposure
Inaccurate/misinterpretation of information
Unfamiliarity with information resources
Nursing intervention
ACTIONS/INTERVENTION
Discuss pathophysiology of condition.
Encourage avoidance of factors/situations
that may precipitate anginal episode
e.g., emotional stress, extensive or intense
physical exertion,
RATIONALE
Patients with angina need to learn
why it occurs and what they can do to
control it.
May reduce incidence/severity of
ischemic episodes.
Helps patient manage symptoms.
Knowledge of the significance of risk
factors provides patient with
opportunity to make needed
changes.
Patients with high cholesterol who
do not respond to 6- month program
of low-fat diet and regular exercise
will require medication.
Being prepared for an event takes
away the fear that patient will not
know what to do if attack occurs.
Knowledge of expectations can avoid
undue concern for insignificant
reasons or delay in treatment of
important symptoms.
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DISCHARGE GOALS
Achieves desired activity level; meets self-care needs with
minimal or no pain.
Free of complications.
Disease process/prognosis and therapeutic regimen
understood.
Participating in treatment program, behavioral changes.
Plan in place to meet needs after discharge.
References
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