I.

PATIENT’S PROFILE

Name: Ram Bahadur Basyal

Age: 49 years old
Sex: Male
Address: Unkown
Religion: Hindu
Marital Status: Married
Date of Admission: May 7, 2017

Chief Complain: Chest pain, shoulder pain, vomiting, shortness of breath

Diagnosis: Myocardial Infarction (anteroseptal)

II. HEALTH HISTORY

HISTORY OF PRESENT ILLNESS

Mr. Basyal claimed to be well one day before developing a central chest pain
radiating to his shoulder. He had an episode of non-projectile vomiting with no blood
composition. He also had a history of shortness of breathe

HISTORY OF PAST ILLNESS

Mr. Basyal had Diabetic Mellitus Type II, which he had been managing with
exercise and a diabetic diet.

FAMILY HEALTH HISTORY

 Nuclear family
 7 members in family
 Health: All members are healthy except client himself
PERSONAL HISTORY

Smoking : Smoker, smoke 12 sticks per day from 20 years

Alcohol: Alcoholic
Food habbit: Mixed diet , 2-3 times a day
Food allergy : not known
Drug allergy: Not Known
Bowel and Bladder: Regular
Sleeping pattern: Disturbed due to hospitalization
Hobbies: He likes to watch TV, listen radio

SOCIO-ECONOMIC HISTORY
Kitchen : separate
Type of drainage: open drainage
Type of toilet used: water seal
Sources of water: Hand pump and tap
Type of fuel: wood and gas
Adequate lighting: present
Facilities available in surrounding: medical shops, schools available
Monthly income: Rs 37000
Bread winner : Self, Son

LABORATORY RESULT

Test Value Remarks

Hemoglobin 10.2mg/dl Anemia

Total RBC count 3.74 million/cumm Anemia

Neutrophils 82% Neutrophilia

lymphocytes 15% Leukopenia

Total bilirubin 0.69 g/dl Jaundice

Conjugated bilirubin 1.61 mg/dl Indicate

 hepatobiliary

Unconjugated bilirubin 2.9 mg/dl Indicate blood or

liver problem

Alkaline phosphate 3.4 u/l Problem with gall

bladder

Echo

 Moderate MR
 Dilated LV
 Mild TR

MEDICATION

Name of Drug Dose Route Frequency Classification

Inj. Tazopip 4.5mg I/V TDS Antibiotic

Inj. Luponex 40mg Subcutaneous BD Low molecular weight

heparin group

Tab. clonaz 0.25mg P/O HS Benzodiazepine

Tab. Escospirin 150mg P/O BD Antiplatelet agent

Tab. Clopidet 75mg P/O BD NSAIDS

Tab. Lipicure 20mg P/O HS Lipid lowering agent

Tab. Pantocid 40mg P/O BD Proton pump inhibitor

PHYSICAL EXAMINATION
Findings

 Dull, ill looking

 Lean and thin body
 Physical hygiene not maintained well
 Self care deficit
 Oxygen supplementation 3L/m through nasal prong
 Neck vein visible
 Edema present at cannula site over right dorsal palm

NURSING DIAGNOSIS

1. Acute pain related to tissue ischemia as evidenced by patient reporting of chest

pain, facial grimacing.
2. Decreased cardiac output related to changes in myocardial contractility.
3. Impaired gas exchanges related to interruption of blood flow to pulmonary alveoli.
4. Imbalanced nutrition less than the body requirements related to inadequate
intake, anorexia.
5. Activity intolerance related to imbalance between myocardial oxygen supply and
needs
6. Anxiety related to hospitalization and fear of death
7. Risk of ineffective tissue perfusion related to reduction of blood flow