CHOITHRAM COLLEGE OF NURSING
SUBJECT- MEDICAL SURGICAL NURSING
TOPIC- NURSING PROCESS
ON
CORONARY ARTERY DISEASE (CAD)
SUBMITTED TO- SUBMITTED BY-
PROFESSOR SHWETA PATTNAIK
MISS Shreya Bisen
H.O.D
[Link] NURSING 1ST YEAR
MEDICAL SURGICAL
DEPARTMENT
CCON
CCON
IDENTIFICATION DATA
NAME : Mr Majid khan
AGE :45 years
GENDER : Male
MARITAL STATUS : Married
ADRESSESS :Hasalpur, Mhow, Indore
IPD NO. : 22-23-1435
MRN NO. : 230200244
WARD/BED NO. : ICU / Bed no. 5
RELIGION : Muslim
EDUCATION : 12th
OCCUPATION : Worker
CONSULTANT : Dr Deepesh Kothari
DIAGNOSIS : CAD, DVD
DATE OF ADMISSION : 07/02/23
ALLERGIES : Not Known
CHIEF COMPLAINTS OF ADMISSION WITH DURATION:
My patient Mr. Majid Khan admitted in Vone under Dr.
Deepesh kothari with the complaint of chest pain for 2 days.
HISTORY OF PRESENT ILLNESS:
Mr. Majid admitted in ICU under Dr. Arun Bisnar. Patient is
diagnosed CLD on 11/4/22 after investigations. Presently patient is having difficulty in
breathing and Fever.
HISTORY OF PAST ILLNESS:
Patient was having CLD diagnosed in 2022.
FAMILY HISTROY:
Type Of family :Joint
No. of members : 6 members
Support person : himself and his son
Any diseases : No specific disease
FAMILY TREE:
Mr. majid Khan Mrs. Sahina Khan
Age- 45 year Age- 40 year
Patient Wife
Mr. Atik Khan
Miss Najma Khan Miss Salma Khan
Age- 26 years
Age- 22 years Age- 18 years
Son
Daughter
Daughter
HEALTH FACILITY
Type: Hospital
Transportation: available
HOUSING
Type : Pucca
Number of rooms : 4 Rooms
Toilet : Indian
Electricity : Available
Drinking Water : Bore water
PERSONAL HYGIENE:
Oral Hygiene : Once a day using tooth brush and paste.
Bath : Once a day with using soap and water
Diet : Vegetarian
No. of meals per day : Twice a day
Fluid : approx. 2 liters
Tea/coffee : 2-3 cups
ELIMINATION HISTORY:
Bowel pattern : Normal, passes stool once in a day
Bladder pattern : 5-6 times in a day.
MOBILITY AND EXERCISES
Walking habit : No
Exercise : No
SEXUAL AND MARITAL HISTORY
Spouse general health: Good
Occupation of spouse : selfworker
Relationship : Good
Staying together : yes
No. of children’s : No
ANY DEFICIENCY/ IMPAIREMENT/AIDS
No such findings
SUBSTANCE ABUSE AND DRUG ADDICTION
My patient is not having habit of substance abuse.
PHYSICAL EXAMINATION
Temperature : 100.7℉
Pulse : 120 b/min
Respiration : 26 breath/min
Blood pressure : 140/70 mmhg
Height: 178 cm
Weight: 78 kg
General Appearance:
Nourishment: Not well nourished
Health: Ectomorphic
Activity:
Mental status:
Consciousness: Conscious
Look: Anxious
Head:
Pediculosis: Not Present
Scalp: Dandruff Present
Hair- Brittle
Eye:
Color: Brown
Reaction to light: Reactive
Discharges: No secretions
Nose:
Obstruction: No obstruction in nasal canal
Mucus: Present
Nasal Hair: Present
EAR:
Clean and no wax present
ORAL CAVITY:
Teeth: Yellow discoloration but bleeding not present
Gums: Healthy
Neck- No enlargements of lymph nodes.
CHEST
Breath sound: Normal
Shape: Normal
Breathing pattern: somewhat labored
ABDOMEN
Shape: Normal
Distension: Not present
Pain: Not present
Bowel Sound: Present
Inspection: Scars present on abdomen
Auscultation: Normal
Palpation: Tenderness absent
SKIN:
Color: Normal
Temperature: 100.7℉
Ecchymosis: Present
LIMBS:
Shape: Normal
Toes and Nails: Normal
POSTURE: Normal
GAIT: Not able to walk without support. Patient is having weakness
GLANDS: Normal
EXTREMITIES: Not able to perform full range of motion exercises
Dependency level of patient: Dependent as of now.
CORDINATION TEST: Patient is able to perform coordination
INVESTIGATION
BLOOD EXAMINATION
TEST RESULT NORMAL VALUES
Hemoglobin 10.5 13-17gm/dl
MCV 77.2 81-101 5milli per
cumm
Platelets 5.27 1.5-4.5 lac per cumm
Total Leucocyte count 13930 4,000-10,000
Neutrophils 75% 40-80%
Lymphocytes 10% 20-40%
Monocytes 2% 2-8%
Eosinophils 1% 1-6%
BIOCHEMICAL EXAMINATION
TEST RESULT NORMAL VALUES
Creatinine 0.75 0.6-1.4 mg%
Sodium 140 136-144 mEq/L
Potassium 4.5 3.5-5.05mEq/L
Chloride 102 98-1085mEq/L
S.G.O.T 32U 10-40U/L
S.G.P.T 17 10-40U/L
HCO3 32 22-29mEq/L
ALBUMIN 3.1 3.3-4.4 g/dl
NURSING
PROCESS
ASSESSMENT NURSING GOAL PLANNING IMPLENETATION EVALUATION THEORY
APPLICATION
DIAGNOSIS
SUBJECTIVE Patient is To reduce To assess General condition Pain reduced to
DATA: having pain in chest pain general assessed patient some extend
My patient said chest related to and provide condition of looks anxious and 2/10
that “ I am ischemia as comfort to patient. dull.
having chest evidenced by patient
pain pain score To assess level Assessed pain score
4/10, patient of pain, i.e., 4/10 pain in
verbalization characteristics chest, continuous
and fascial and type pain
expressions
OBJECTIVE To provide Provided semi fowler
DATA : proper position position to patient or
I observed that to patient as per patient need
my patient is
having pain
through pain Psychological
score, patient To give support given to
verbalization psychological patient and
and fascial support to maintained IPR with
expressions patient patient
Lanol ER 650 mg
To administer given to patient
analgesics to
patient
Diversional therapy
To give given through
knowledge providing knowledge
regarding and involve patient
disease in other activity.
process in a
form of
diversional
therapy
ASSESSMENT NURSING GOAL PLANNING IMPLENETATION EVALUATIO THEORY
DIAGNOSIS N APPLICATION
SUBJECTIVE Decreased To To assess vital Assessed vital signs Patient will be
DATA: cardiac output increase signs and and characteristics of able to maintain
My patient related to cardiac characteristics heartbeat at the least adequate cardiac
attender said disease output to of heartbeat every 4 hours. output.
that patient is condition some, Assessed heart
not able to CAD as extend sounds via
breath properly. evidenced by To administer auscultation
fatigue and supplemental
inability to do oxygen as Provided o2 therapy
daily activity. needed by NRBM 6-7 liter.
OBJECTIVE
DATA: To elevate bed
I observed that of patient
my patient is Provided semi fowler
using accessory position to patient
muscles to To maintain
breath. fluid
restriction and Fluid restriction
sodium maintained through
restriction restricted fluid to 1lit
in a day and sodium
restricted diet given
to patient
To give
prescribed
medication to Medication given to
patient patient
Betaloc 25
Ecosprin 75
Tonact 80mg
ASSESSMEN NURSING GOAL PLANNING IMPLENETATION EVALUATION THEORY
T DIAGNOSIS APPLICATIO
SUBJECTIVE Imbalance To maintain To assess Assessed general
DATA: Nutritional less nutritional general condition of patient,
My patient said than body status of condition of patient looks dull
that I am not requirements patient patient and weak.
able to eat food related to loss
of appetite and To check Checked intake and
hospitalization intake and output charting
OBJECTIVE output of patient not taking
DATA: patient. proper meal
I observed that
my patient is To do Nutritional
looking dull, nutritional assessment done.
weak because assessment
of improper through
intake of food history
To ask for like Likes and dislikes
and dislike of asked, patient likes
patient mutton and khichdi
To give small Give nutritive
and frequent khichdi to patient in
diet a decorative manner
to increase appetite
ASSESSMENT
ASSESSMEN NURSING
NURSING GOAL
GOAL PLANNING
PLANNING IMPLENETATION
IMPLENETATIO EVALUATIO
EVALUATIO THEORY
THEORY
T DIAGNOSIS
DIAGNOSIS N NN APPLICATION
APPLICATION
SUBJECTIVE Constipation To To assess Assessed I/O charting Patient bowel
DATA:\
SUBJECTIVE related to low maintain
Activity To intake
To and
assess patient
Assessed not general
passed Patient
pattern activity
will be
My Patient said
DATA:\ dietary intake normal
intolerance maintain output
general of motion from
condition 2days.
of patient normal
level after
that
MyI am not said and
Patient related to bowel
daily patient
condition of Patient interventions to
needs maintained
able to pass
that I am not immobilizatio
decreased pattern
activityof patient support in activity. some extend
motion
able tofrom
pass2 n cardiac
as evidenced
output patient
of To assess diet Assessed diet chart
days
motion from 2 byas intake and patient
evidenced chart
To of
assist Basic care done
days output
by fatigue and patient
patient in needed assistance
charting
not able toand
do daily living Bowel
providedsound present
to patient
OBJECTIVE attender
daily activity To
activity assess and abdominal is
DATA:
OBJECTIVE verbalization bowel sound slightly
Explaineddistended on
patient
I DATA:
observed that and
To abdominal
restrict palpation call bell
regarding
myI observed
patient not
that distension
heavy activity and ask for help
passed motion
my patient not fiber rich diet given
from 2 days
passed as
motion To give fiber to patient andpatient
Explained milk
observed
from 2 daysbyas rich diet and given
about as a natural
exercise of
output chartingby
observed natural
To explain laxative
hands and leg to
and
output patient
charting laxative
patient to maintain circulation
verbalization
and patient patient
regarding and prevent stiffness
verbalization light activity of muscles.
To
by herself give Syrup cremaffin 30
laxatives to ml given to patient.
patient
To give enema Enema can be given
to patient when patient is not
able to pass motion
after giving cremaffin
syrup
