Care plan

1. Introduction: Why I'm choosing this case?

 Meet professional standards of practice to deal with same cases
 Identify strengths, problems, and needs for me to deal with pt.
 Apply what we study in theory on practice.
 This case has critical type of care in CCU department.
⇒ So this case has clinical manifestation and data that allow me to achieve of
previous goals.

Information & Identifying Data

Mr. A.N, an 57--year--old client, was admitted to the hospital (CCU ward) on
1/2/2011 with Retrosternal chest pain . This construction worker, a married, 3-4
weeks he has had increasing fatigue and chest pain. He visited his doctor two weeks
ago, and he order for catheterization, the result show 80% blockage in LAD and 75%
in Circumflex coronary artery and in OM3 blockage 70%.> So CABG is order.
His preferred foods are fresh fruits and vegetables, rice, meat . Mr. Rodriguez lives
with his wife with 4boys and 2 daughters.
He smoked two packs per day x 35 years.
His medical history includes mild peptic ulcer x 10 years, asthma.

Patient's No : 215292 Date : 6 / 11 / 2009

Patient age : 57 Bed No : 11
Sex : Male Date Admitted : 1 / 2 /
2011
Marital status : Married Have 4 sons and 2 girls

Diagnosis "medical":
IHD ischemic heart disease

Chief Complaints :
1. Retrosternal 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: (100/56 mm Hg)

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History of present illness:
1 month ago patient has chest pain with radiation to the left side of the neck and
down the left arm especially when tired and this symptom developed and become
more sever
This diseases affect the patient life by decrease the activity and as he said he stop
smoking, he try to be quite and not anger because it affect them , the disease also
decrease his sexual function
He said : Some time he has anorexia (loss of appetite)
Heartburn may be produced by heavy meals.

Past medical history:

As he said he has peptic ulcer and take medication for it.
The patient has free medical surgical history
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 relative.
He has coordinated weakness movement, he is clean and neat.
Quality and speech: understand and clear tone.
Height 165 cm long
Weight 100 kg
BMI = 100/ (1.65)2 = 36

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 good capillary refill, smooth 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:
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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:
He has symmetrical, same as facial in color.
Able to hear in both ears as he said; Normal voice tones audible.
No abnormal discharge
Nose:
Symmetrical and straight, nasal septum midline, pink mucosa.
He said "he can smell good in both nostrils".
Mouth and Throat:
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.
Chest and Lungs:
He has symmetrical chest, right and left shoulder and hips are at same height.
He has line of wound because chest open due to CABG.
The anteroposterior (AP) diameter less than transverse diameter.
patients have episodic dyspnea during, and hyperventilation, or rapid, shallow
breathing
tired appeared when make an activity and some time in rest period.
Mild to moderate pain in Retrosternal or across the anterior chest deu to surgery.
Sometimes perceived as discomfort rather than pain.
Heart and Circulatory system:
Heart rate is 70 beat per minute.
Blood pressure: (100/56 mm Hg)
Pulse detected in pulse palpated place as carotid, radial, and apical.
Dysrhythmia and palpitation may some time present as in his history and as he said.
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.
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No masses or nodules.

Musculoskeletal system:
The patient has equal size on both side of body and smooth coordinated movement.
But current surgery 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 Normal Meaning of
value value abnormal
value
CBC test
Hb% 9.0 g/dl 13.8 – 16 g/dl Due to blood loss in
surgery
RBC 3.17 million/mm3 4.5 – 5.3 Due to blood loss in
million/mm3 surgery
WBC 4600 /mm3 4500 – Normal
11000/mm3
PLTS 187*103/mm3 (150– Normal
350)*103/mm3
Urine
Color Straw Straw Normal
PH Acid Acid Normal
Sugar Nil Nil Normal
Blood Nil Nil Normal
Chemistry
BUN 18.7 mg/dl 10 – 20 Normal
mg/dl
Creatinine 1.3 mg/dl 0.7 – 1.4 Normal
work mg/dl
reagent
INR 1.1 1 – 1.3 Normal
ABO AB+
CPK 512 U/l 25 – 190 U/l Increase due to
muscle damage
Tropnin_1 21.6 mg/dl 0.5 ng/ml Increase due to
heart muscle
damage
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 Medication
Drug Rational Action Side effect
Name (with pt)
& Dose
ceftazidime used to treat infections caused Antibiotics are used to Swelling of eyelids,
pentahydrate by one germ, a mixture of kill the bacteria or face or lips.
germs and also severe “germs” that cause Skin lumps or hives.
T(Fortum) infections in general. infections. Skin rash.
1g X 3
Rout :IV
salicylic acid to reduce the risk of recurrent aspirin inhibits the Vertigo
T(Baby aspirin) stroke action of blood clotting weakness
element (platelets) dizziness
100 mg X 1

Rout :Po
paracetamol Decrease pain caused by is an analgesic, or pain constipation,
and tramadol surgery. reliever, and is used to sleepiness, diarrhea,
T(Zaldiar) treat pain that is nausea.
moderate to severe.
100 mg X 1

Rout :Po
Ranitidine Decreases the heart pain cause Decreases amount of headache, nausea,
hydrochloride by high amount of HCl HCl produced by fatigue, , dizziness,
stomach by blocking
T(Ratidine) action of histamine on
histamine receptors of
50 mg X 3 parietal cells in the
stomach
Rout :IV

Fenofibrate Decrease amount of LDL and For use as adjunctive Gastrointestinal:

for reduce therapy to diet to reduce Digestive, gastric or
T(Lipidex) hypercholesterolemia elevated LDL-C, Total- intestinal disorders
C,Triglycerides and Apo (abdominal pain,
40 mg X 3 B, and to increase HDL- nausea, vomiting,
C in adult patients with Skin Reactions:
Rout :Po primary Rashes, Pruritus,
hypercholesterolemia or urticaria or
mixed dyslipidemia photosensitivity
reactions.

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 Pathophysiology of the current
disease.
Coronary artery bypass graft (CABG) surgery
Coronary artery bypass graft surgery is an operation that bypasses a
narrowed or blocked segment of a coronary artery using a graft.
Usually, this graft is taken from either the leg (saphenous vein) or
the chest wall (internal mammary artery). Alternatively, an artery
from the arm (radial artery) is used as a graft. It is quite normal to
need two, three or even four grafts, otherwise known as a double,
triple or quadruple bypass.
The grafts taken from the leg and/or forearm are connected to the
aorta, with the other end attached to the coronary artery. This
bypasses the blockage or narrowing, providing a new channel that
allows blood to flow to the heart muscle.
If the internal mammary artery is used as a graft, it remains
attached to its own blood supply with the free end sewn onto the
coronary artery, bypassing the blockage or narrowing.
As a result of the coronary artery bypass graft surgery; there will be
an improvement in blood flow and relief from angina symptoms.

The benefits of coronary artery bypass graft surgery

Coronary artery bypass graft surgery is performed primarily to
relieve angina symptoms. By improving the blood flow to the heart
muscle, surgery can result in a more active and better quality of life,
with less or no angina and less requirement for medication.
Choosing and maintaining positive lifestyle changes can significantly
help prevent a recurrence

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 Nursing care
The goal of treatment for heart disease is to maximize cardiac
output. Surgically this may be done by improving myocardial muscle
function and blood flow through procedures such as the traditional
CABG (or via less invasive procedures such as MIDCAB,
percutaneous transmyocardial revascularization [PTMR],and/or
repair or replacement of defective valves. Of the three types of
cardiac surgery—(1) reparative (e.g., closure of atrial or ventricular
septal defect, repair of mitral stenosis), (2) reconstructive (e.g.,
CABG, reconstruction of an incompetent valve), and (3)
substitutional (e.g., valve replacement, cardiac transplant)—
reparative surgeries are more likely to produce cure or prolonged
improvement.

Nursing Priorities
 Support hemodynamic stability/ventilatory function.
 Promote relief of pain/discomfort.
 Promote healing.
 Provide information about postoperative expectations and
treatment regimen.

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Nursing diagnosing:
Risk for decreased Cardiac Output
May be related to
 Decreased myocardial contractility secondary to temporary factors
(e.g., ventricular wall surgery
 Decreased preload (hypovolemia)
 Alterations in electrical conduction (dysrhythmias)
Planning and Goals
Patient goal include Hemodynamic Regulation.
Nursing intervention
ACTIONS/INTERVENTION
Monitor/document trends in heart rate and
BP, especially noting hypertension.
Monitor/document cardiac dysrhythmias.
Observe patient response to dysrhythmias
Record skin temperature/color and
quality/equality of peripheral pulses
Measure/document I&O and fluid balance.
RATIONALE
sustained tachycardia
increases cardiac workload and
can decrease effective cardiac
output. Hypertension can occur
(fluid excess or preexisting
condition),
Life-threatening dysrhythmias can
occur because of electrolyte
imbalance, myocardial ischemia, or
alterations in the heart’s electrical
conduction. Atrial fibrillation/flutter
are the most common dysrhythmias
occurring around the second or
third day post-CABG older patients
or presence of right coronary
artery disease increases risk).
Warm, pink skin and strong, equal
pulses are general Indicators of
adequate cardiac output.
Useful in determining fluid needs
or identifying fluid excesses, which
can compromise cardiac output
/oxygen consumption.
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 Schedule uninterrupted rest/sleep periods.
Assist with self-care activities as needed.
Evaluate presence/degree of
anxiety/emotional duress.
Encourage the use of relaxation
techniques, e.g., deep breathing,
diversional activities.
Prevents fatigue/overexhaustion
and excessive cardiovascular
stress.
Excessive/escalating emotional
reactions can affect vital signs and
SVR, eventually affecting cardiac
function.

Evaluation (Expected Patient Outcomes)

 Report/display decreased episodes of angina and dysrhythmias.
 Demonstrate an increase in activity tolerance.
 Participate in activities that maximize/enhance cardiac function.
Nursing diagnosing:
Acute Pain or Discomfort
May be related to
Sternotomy (mediastinal incision) and/or donor site (leg/arm incision)
Myocardial ischemia (acute MI, angina)
Tissue inflammation/edema formation
Intraoperative nerve trauma
Planning and Goals
patient goal include decrease or relive pain or discomfort.
Nursing intervention
ACTIONS/INTERVENTION RATIONALE
Encourage patient to report type, location, Pain is perceived, manifested, and
and intensity of pain, rating on a scale of tolerated individually. It is
0–10. Note associated symptoms. Ask the important for patient to differentiate
patient how this compares with incisional pain from other types of
preoperative chest pain. chest pain, such as angina or
discomfort from chest tubes.
Observe for anxiety, irritability, crying, These nonverbal cues may
restlessness, sleep disturbances. indicate the presence/degree of
pain being experienced.
Identify/promote position of comfort, using Pillows/blanket rolls are useful in
adjuncts as necessary. supporting extremities, maintaining
body alignment, and splinting
incisions to reduce muscle
tension/promote comfort.
Identify/encourage use of behaviors such Relaxation techniques aid in
as guided imagery, distractions, management of stress, promote sense
visualizations, deep breathing of well-being, may reduce analgesic
needs, and promote healing.
Administer medications as indicated Usually provides for adequate
control of pain and inflammation,
and reduces muscle tension, which
improves patient comfort and
promotes healing.
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Evaluation (Expected Patient Outcomes)
Verbalize relief/absence of pain.
Demonstrate relaxed body posture, ability to rest/sleep appropriately.
Nursing diagnosing:
Risk for ineffective Breathing Pattern,
May be related to
Inadequate ventilation (pain/muscular weakness)
Diminished oxygen-carrying capacity (blood loss)
Decreased lung expansion (atelectasis or pneumothorax/hemothorax)
Planning and Goals
Patient goal include effective Breathing Pattern
Nursing intervention
ACTIONS/INTERVENTION
Evaluate respiratory rate and depth. Note
respiratory effort, e.g., presence of
dyspnea, use of accessory muscles, nasal
flaring.
Auscultate breath sounds. Note areas of
diminished/absent breath sounds and
presence of adventitious sounds, e.g.,
crackles or rhonchi.
Observe chest excursion. Investigate
decreased expansion or lack of symmetry
in chest movement.
Encourage patient participation/
responsibility for deep-breathing exercises,
use of adjuncts, and coughing, as
indicated.
Evaluation (Expected Patient Outcomes)
RATIONALE
Patient responses are variable.
Rate and effort may be increased
by pain, fear, fever, diminished
circulating volume (blood or fluid
loss), accumulation of secretions,
hypoxia, or gastric distension
Breath sounds are often
diminished in lung bases for a
period of time after surgery
because of normally occurring
atelectasis.
Air or fluid in the pleural space
prevents complete expansion
(usually on one side) and requires
further assessment of ventilation
status.
Aids in reexpansion/maintaining
patency of small airways,
especially after removal of chest
tubes. Coughing is not necessary
unless wheezes/rhonchi are
present, indicating retention of
secretions.
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Maintain a normal/effective respiratory pattern free of cyanosis and other
signs/symptoms of hypoxia with breath sounds equal bilaterally, lung fields
clearing.
Display complete reexpansion of lungs with absence of pneumothorax or
hemothorax.

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
Planning and Goals
Patient goal include awareness of the disease process and understanding of
the prescribed care, adherence to the self-care program,
Nursing intervention
ACTIONS/INTERVENTION RATIONALE
Discuss pathophysiology of condition Patients with angina need to learn
why it occurs and what they can do
to control it.
Encourage avoidance of factors/situations May reduce incidence/severity of
that may precipitate anginal episode ischemic episodes.
e.g., emotional stress, extensive or Helps patient manage symptoms.
intense physical exertion,
Review importance of weight control, Knowledge of the significance of
cessation of smoking, dietary risk factors provides patient with
opportunity to make needed
changes, and exercise.
changes.
Patients with high cholesterol who
do not respond to 6- month
program of low-fat diet and regular
exercise will require medication.
Discuss steps to take when anginal Being prepared for an event takes
attacks occur, away the fear that patient will not
know what to do if attack occurs.
Review symptoms to be reported to Knowledge of expectations can
physician, e.g., increase in avoid undue concern for
insignificant reasons or delay in
frequency/duration of attacks,
treatment of important symptoms.
changes in response to medications.

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Evaluation (Expected Patient Outcomes)
 Participate in learning process.
 Assume responsibility for own learning, looking for information and asking
questions.

DISCHARGE GOALS
 Activity tolerance adequate to meet self-care needs.
 Pain alleviated/managed.
 Complications prevented/minimized.
 Incisions healing.
 Post discharge medications, exercise, diet, therapy understood.
 Plan in place to meet needs after discharge.

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References
1.Brunner & Suddarth's Textbook of Medical - Surgical Nursing (11th
edition) Philadelphia: Lippincott Williams & Wilkins(2008).
2.Kozier & Erb's Fundamentals of Nursing Concepts, Process, and
Practice (7th edition) (2007)
3.Amy M. Karch lippincott's nursing drug guide: Lippincott Williams &
Wilkins (2009).
4.Bates’ Instructors Manual Guide to Physical Exam and History
Taking (8 th edition) Philadelphia: Lippincott Williams & Wilkins(2006).
5.Meg Gulanick, Judith L. Myers Nursing Care Plans : Nursing
Diagnosis and Intervention (6th edition) : Elsevier Health Sciences
(2006)
6. Client profile – No: 28412

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