msn

1. TIME SPECIFIC
OBJECTIVE
CONTENT TEACHING
LEARNING
ACTIVITY
AV
AIDS
EVALUATIO
N
1min
1min
2 min
Introduce about
the patient
Introduce the
patient
identification
data
Describe the
history of
patient
INTRODUCTION
As a part of Medical & Surgical Nursing I came across the patient, Mr. Balram Das
65yrs old. who came to the hospital with the alleged history of shortness of breath on
exertion for last 4 months. Doctor has seen him in the causality and advised
hospitalization and advised for lab investigation like complete blood count,
hemoglobin, total blood count etc. I thought that he needs special care. I took his case
as my case study patient from 12/01/2023 to 16/01/2023. with the history of
occasional increase BP (irregular mods) presented with above complaints to EST
maintain- diagnosed as Coronary Artery Disease with Hypertension and Type2 DM
he was looking so weak and very poor condition. I felt that he needs care and I have
taken this case for my case study.
IDENTIFICATION DATA
Name - Mr. Balaram
Age - 65 years
Sex - Male
Education - Graduate
Religion - Hindu
Address - surajpur Chhattisgarh
Ward - Medical ward
Bed No. – 20
IP. NO. –
Date of admission - 12-01-2023
Diagnosis - CAD+ DM2+HTN
Treating Doctor - Dr.
A. SHORT MEDICAL HISTORY OF PATIENT
1. PRESENT MEDICAL HISTORY
Mr. Balram Das brought to the hospital with the alleged history of shortness of breath
on exertion for last 4 months (retained by rest) on 12/01/2023, at 10 am. After the
thorough examinations like history collection, physical examination and complete
blood test in the CPC, Dr. admitted him for emergency treatment.
Explanation
Understandin
g
Lecture
Listening
Lecture
What are the
identification
data of
patient.?
What are the
health history
of patient.?

2. PAST MEDICAL HISTORY
Mr. Balram Das was with Hypertension and Type2 DM and very often gets sickness,
like fever, cold and cough before one month. He was on the antihypertensive
medications and Insulin therapy since 20 years.
PRESENT SURGICAL HISTORY - Planning for Coronary Angiography
PAST SURGICAL HISTORY – Nil significant
B. SHORT PERSONAL HISTORY
Family History
Mr. Balram Das belongs to a joint family. His family constitutes of his wife, two son,
and two daughter, he is a head of the family, and he is a retired teacher. They are not
having any hereditary disease.
Family tree
Mr. Balram Das (65 years) Mrs. Bimla Das (60 years)
Mr. Sani(30yr) Mr. Rajeshwar (28 yr)
Key points
-Male
- Female
-Patient
Married

3. FAMILY ROSTER
S.N. Name Age Gender Relationship
with the
patient
Education Occupation Health
status
1. Mr. Bilram
Das
65yrs Male Himself Graduate Retired
teacher
Unhealthy
2. Mrs. Bimla
Das
60 yrs Female Wife 10th
Pass Housewife Healthy
3. Mr. Sani 30yrs Male Son Graduate Engineer Healthy
4. Mr.
Raeshwar
28 yrs Male Son Graduate Teacher Healthy
SOCIO ECONOMIC STATUS
Mr. Balram Das belongs to a middle class family. He is the head of the family and he
is a retired teacher and getting pension per month. With this only they manage their
other expenses. This is sufficient for their family living.
PERSONAL HISTORY
Mr. Balram Das maintains his personal hygiene well. He use to take bath daily and
change his cloths daily. He does not have any bad habits like chewing tobacco, alcohol
consumption etc.
NUTRITIONAL HISTORY
Mr. Balram Das is of thin body built. He is non – vegetarian. He takes meal 3 times a
day, in the morning for breakfast he usually takes chapatti with curry, in the noon rice,
dal and vegetables, in the night also he takes Diabetic Diet, chapatti, dal and vegetables.
He also takes meat, fish, and egg in his meal occasionally. He is not having any allergic
reaction with food items.
ENVIRONMENTAL HISTORY
Ventilation: They are having pakka house with 08 rooms, 8 windows but well
ventilated with separate kitchen.
Lighting: They have the electricity connection in their home. Some time they use oil
lamp and candle too.
Refuse disposal: They are disposing waste far from the house facility available like
Nagar nigam Kachara Gadi.

4. 5 min Explain physical
examination of
patient
Savage system & toilet facilities: They have toilet facilities inside and as well as
outside of the house. Well drainage system is there house. Waste water goes to the
kitchen garden.
Water supply: They don’t have their own water supply. They are using public bore
well water for all the purposes.
HEALTH HABITS:- Mr. Blram Das is a thin body built. He doesn’t have any bad
habits of drinking alcohol or cigarette etc.
SPECIAL INTEREST:- Mr. Balram has specific interest to singing , and he also likes
news paper reading and gardening .
PSYCHOSOCIAL HISTORY:- Mr. Balram maintains good interpersonal
relationships with their family members and also with the health care members in the
hospital.
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Mr. Balram Das conscious and well oriented. He is thin body built, looks very weak
and drowsy and mild disoriented, he was with the support of oxygen and attached
cardiac monitor .
A. Height and weight
Height – 156 cm.
Weight – Not measured
BMI- Weight (kg) =
Height (m) 2
VITAL SIGNS:-
Parameters Normal values Patient value.
Temperature 98.6 F 104F
Pulse 72-80 / mt 90/minute
Respiration 20- 22/ mt 24b/mt
Blood pressure 120/ 80mmHg 140/90 mmHg
Lecture
Explanation.
What are the
physical
examination of
patient.?

5. INTEGUMENTRY SYSTEM:-
 Inspection- On inspection Mr. Balram Das skin is fare in color skin looks
unhealthy, dry and no lessons and scars are not present, Has no specific complaints
regarding skin.
 Palpation- On palpation skin is warm. Returns not quickly to its original shape
when pulled up between two fingers and released, has slightly wrinkled skin due to
aging. No abnormality felt on palpation.
HEAD:-
 Inspection – His head is normocephalic has white hair on his scalp. Scalp is clean
and free from dandruff.
 Palpation- On head scalp palpation abnormal growth not felt and had not specific
complaints of head Injury. There was not found any abnormal focal spots of
hemorrhagic contusion.
EYES AND VISIONS:-
 Inspection- Eyebrows and eyelashes are placed symmetrical and with equal
distribution of hair. Eyeballs are well fixed in orbits no protrution seen no lesions
are focused on eye lids colour of sclera is white is conjunctiva is in light pink color
and cornea is centrally located with pupil on its center. Pupil shows positive
papillary reflex when bright light is passed through.
 Palpation- On palpation there is no tenderness and no any abnormal growth is
found had complaints of mild pain during palpation of eyeball and surrounding
structure.
EAR AND HEARING:-
 Inspection- Both ears are placed symmetrically structure of pinna is normal ear
wax is present in both ears no abnormal discharge seen from ears and has not
proper hearing capacity from right ear.
 Palpation- On palpation of ear pinna and external ear no any abnormality is felt.

6. NOSE AND SINUSES
 Inspection- On observation of nasal septum is normally straight and not perforated.
There is not having deformity; airway is not patent and had more secretions.
Patient has on mechanical ventilatory support.
 Palpation- On palpation of external nose abnormality is not felt.
MOUTH AND PHARYNX:-
 Inspection- Lips are symmetrically placed and pink tongue is present in midline
uvula is in midline, no any sign of infection like redness is present in the pharynx.
No mass or ulceration is present in mouth dental carries are present.
 Palpation- On palpation no abnormal growth and tenderness found in equal cavity
NECK:-
 Inspection- Mr. Balram Das neck muscle is symmetry. passive Range of motion is
possible, no lymph node enlargement is seen, thyroid glands are not enlarged
 Palpation- On palpation neck muscles are palpated without any abnormal growth,
lymph nodes are not palpable thyroid gland is not enlarged.
LYMPH NODE:-
 Inspection- Lymph nodes are not enlarged on inspection
 Palpation- On palpation intraclavicular nodes are normal axillary lymph nodes
are not palpable represents its normal structure.
RESPIRATORY SYSTEM:
 Inspection: - On inspection chest is symmetrical, chest expansion and recoil is
equal respiratory rate is about 24 breaths/mint no abnormal respiratory pattern is
seen in patient and she was stable with mechanical ventilator support.
 Palpation:-On palpation of her chest no abnormal growth is found, no tender and
deformity is found
 Percussion- Dull sounds are heard over the sternum over the ribs.
 Auscultation-
i.Tracheal sounds are heard over the trachea it is high pitched and hars air entry
sound.

7. ii.Bronchovesicular sounds are heard between 1st
and 2nd
intercostals spaces on the
anterior chest. Sounds in softer than bronchial sounds.
iii.Bronchial sounds are heard over the body of the sternum. Bronchial sounds are
loud and high in pitch.
iv.Vesicular sounds are heard over most of the lungs fields vesicular sounds are soft,
blowing sound heard throughout inspiration and felt away about one third of the
way about one third of the way through expiration.
CARDIOVASCULAR SYSTEM:-
 Inspection: - Chest size shape is normal. Chest heart beats can’t be observed on
inspection of chest.
 Auscultation; On auscultation over the chest between sternum and left 3rd
- 5th
intercostals space heart lub dub sound is heard. Heart rate is found 78 beats/mint
 Palpation- For superficial palpation heart beats are felt over the left side of chest
between 3rd
– 5th
intercostals space.
GI SYSTEM:-
 Inspection: - On inspection Mr. Blaram Das abdomen is flat, umbilicus is clean
and there is no any lesion found over abdomen.
 Auscultation: - On auscultation peristaltic movement is heard had 4-5 bowel
sounds per minute.
 Percussion- On percussion dull sound is heard over the abdomen
 Palpation: - On superficial and deep palpation abdominal structures are soft
structure and tumor growth is not felt. During the palpation doesn’t feel pain over
the abdomen region.
MUSCULOSKELETAL SYSTEM:- Mr. Balram Das upper and lower extremities
are symmetrical in size not having neck and back tenderness. Strength of the muscle
is not present in patient.
CENTRAL NERVOUS SYSTEM: - Sensory, motor and cerebellar function is
normal. Memory and reasoning abilities are mild Normal. Looks lethargic and very
poor.

8. G.U. SYSTEM: - On observation there are no any abnormalities in external genital
and not having any bad odor and discharge. Mr. Balram Das is with urinary catheter.
Her urine output is 1500 ml in 24 hrs.
RECTUM AND ANUS: -. Rectus is patent. No hemorrhoid are present. Has no
difficulty in elimination. Has abnormal bowel pattern. He is Not passing motion.
IMPRESSION- Mr. Balram Das general condition looks very weak & lethargy,
initially having breathing difficulty mild disoriented blood pressure is 140/90 mmHg
, she is having hearing problem on right ear.
Investigation Normal value Patient’s value Remark
Hemoglobulin
TC
Eosin
Neutron
Platelet count
HBs Ag
Anti HCV
A HIV (1 & 2)
antibody to HIV
LVEF
12-15 gm/dl
5000-10000
cell/cumm
1-6%
45%-65%
1.5-2.5 lakh/dl
>1.0 (Reactive)
>1.0(Reactive)
<1.0 (Non reactive)
>1.0 (Reactive)
60%
11.2gm/dl
26,100
cell/cumm
2-6%
80%
157X 103
lakh/dl
Non reactive (0.27)
Non reactive (0.05)
Nonreactive (0.05)
Decreased
Increased
Normal
Increased
Normal
OTHER DIAGNOSTIVC TEST
 Echocardiography; Infero posterior wall and other walls, hypokinetic, LVEF
30-35%, and enlarged Grade III MR found.

9.  CAG:- LMCA- free of disease, LAD- 80% stenosis in ostial multiple septal
filling PDA, PLB and the distal RCA retrogradly. LCX- proximal total 1/L
collaterals. RCA- total occlusion in ostium filling retrogradly from L septals.
Advice:- surgical consultaion for Revascularization
 X-ray:- infection found on the chest x-ray report
 ECG- Abnormal ECG collected.
 Impression;- Severe TVD (Triple Vessel Disease

10. DISEASE CONDITION

11. TIME SPECIFIC
OBJECTIVE
CONTENT TEACHING
LEARNING
ACTIVITY
AV
AIDS
EVALUATION
1min
2 min
5 min
Introduce the
coronary
artery
disease.
Define
coronary
artery
disease.
Explain the
incidence of
CAD.
INTRODUCTION
Coronary artery disease is the narrowing or blockage of the coronary arteries, usually
caused by atherosclerosis. Atherosclerosis (sometimes called "hardening" or "clogging"
of the arteries) is the buildup of cholesterol and fatty deposits (called plaques) on the
inner walls of the arteries. These plaques can restrict blood flow to the heart muscle by
physically clogging the artery or by causing abnormal artery tone and function.Without
an adequate blood supply, the heart becomes starved of oxygen and the vital nutrients it
needs to work properly. This can cause chest pain called angina. If the blood supply to a
portion of the heart muscle is cut off entirely, or if the energy demands of the heart
become much greater than its blood supply, a heart attack (injury to the heart muscle)
may occur.
DEFINITION:-A narrowing of the coronary arteries that prevents adequate blood
supply t the heart muscle is called coronary artery disease. Usually caused by
atherosclerosis, it may progress to the point where the heart muscle is damaged due to
lack of blood supply. Such damage may result in infarction, arrhythmias, and heart
failure.
INCIDENCE
Heart disease is the leading cause of death among men and women in the United States.
Coronary artery disease affects 16.5 million Americans. The American Heart
Association (AHA) estimates that someone in the US has a heart attack about every 40
seconds. In addition, for patients with no risk factors for heart disease, the lifetime risk
of having cardiovascular disease is 3.6% for men and less than 1% for women. Having
2 or more risk factors increase the lifetime risk of cardiovascular disease to 37.5% for
men and 18.3% in women.
(Heart Disease and Stroke Statistics 2017 Update: A Report from the American Heart
Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2017,
January 25,)
Lecture
Discussion
Lecture
Lecture
What is
coronary artery
disease.?
Define the
CAD?
What are the
incidence of
CAD.?

12. 5 min
5 min
Enumerate
types of acute
coronary
syndrome.
Enlist the risk
factor of
CAD.
TYPES OF ACUTE CORONARY SYNDROME
According to Book In patient
1. Unstable angina: This may be a new
symptom or a change from stable angina.
The angina may occur more frequently,
occur more easily at rest, feel more severe,
or last longer. Although this can often be
relieved with oral medications (such as
nitroglycerin), it is unstable and may
progress to a heart attack. Usually, more
intense medical treatment or a procedure is
required to treat unstable angina.
2. Non-ST segment elevation myocardial
infarction (NSTEMI): This type of heart
attack, or MI, does not cause major changes
on an electrocardiogram (ECG). However,
chemical markers in the blood indicate that
damage has occurred to the heart muscle.
In NSTEMI, the blockage may be partial or
temporary, so the extent of the damage is
usually relatively small.
3. ST segment elevation myocardial
infarction (STEMI): This type of heart
attack, or MI, is caused by a sudden
blockage in blood supply. It affects a large
area of the heart muscle and causes changes
on the ECG as well as in blood levels of key
chemical markers.
Patient’s have unstable
angina
RISK FACTORS
According to Book Seen in Patient
Non-modifiable risk factors (those that cannot
be changed) include:
This may be one of the cause for
patient being male .
Lecture
Discussion
Lecture
discussion
Chart
Chart
Discuss the
types of acute
coronary
syndrome.?
What are the
risk factors of
CAD.?

13.  Male gender. Men have a greater risk of
heart attack than women do, and men
have heart attacks earlier in life than
women. However, beginning at age 70,
the risk is equal for men and women.
 Advanced age. Coronary artery disease
is more likely to occur as person get
older, especially after Age 65.
Family history of heart disease. an increased
risk of developing heart disease if have a parent
with a history of heart disease, especially if they
were diagnosed before Age 50.
Race. African Americans have more severe high
blood pressure than Caucasians and, therefore,
have a higher risk of heart disease. The risk of
heart disease is also higher among Mexican
Americans, American Indians, native
Hawaiians, and some Asian Americans. This is
partly due to higher rates of obesity and diabetes
in these populations.
Modifiable risk factors (those you can treat or
control) include:
 Cigarette smoking and exposure to
tobacco smoke
 High blood cholesterol and high
triglycerides – especially high LDL
("bad") cholesterol over 100 mg/dL and
low HDL ("good") cholesterol under 40
mg/dL. Some patients who have existing
heart or blood vessel disease, and other
patients who have a very high risk,
should aim for an LDL level less than 70
mg/dL.
In his family no history of
cardiac diseases.
This may be the cause for
Mr. Balram Das

14. 5 min
Discuss the
causes of
CAD
 High blood pressure (140/90 mmHg or
higher)
 Uncontrolled diabetes (HbA1c >7.0)
 Physical inactivity
 Being overweight (body mass index
[BMI] 25–29 kg/m2) or being obese
(BMI higher than 30 kg/m2)
 Uncontrolled stress or anger
 Unhealthy Diet
CAUSATIVE FACTORS:
According to book picture Patient picture
The exact cause of myocardial hypoxia and ischemia
is probably a combination of the following variables.
1. Decrease in oxygen supply to the myocardium
(delivery by the coronary arteries)
a) Vessel factors
 Atherosclerosis narrowing of the lumen of
coronary vessels, causes the majority of
anginal attacks.
 Arterial spasm and reflexive narrowing of
coronary vessels, resulting from cold,
emotional stress, and smoking.
 Coronary arteritis or inflammation of the
coronary arteries, due to infections or
autoimmune disease.
b) Circulatory factors
 Hypotension due to spinal anesthesia, potent
antihypertensive drugs, blood loss, or other
Mr. Balram Das exact cause is
unknown he is not having any
of this problem.
Lecture
Discussion
Explanation
Hand
out
Explain the
causative
factors of
CAD.?

15. factors, resulting in decreased blood return to
the heart.
 Aortic stenosis or aortic insufficiency, due to
congenital anomalies infectious processes, resulting
in decreased filling pressure of the coronary
arteries.
c) Blood factors
 Anemia and hypoxemia, resulting in
decreased oxygen flow to the myocardium.
 Polycythemia, causing increased blood
viscosity, which shows blood flow through the
coronary arteries.
1.Need for an increased cardiac output, which may
overwork the heart.
a) Physiologic factors: exercise, emotion,
digestion of a large meal.
b) Pathologic factors: anemia, hyperthyroidism.
2. Increased myocardial need for oxygen
a) Damaged myocardium unable to properly
utilize oxygen.
b) Hypertrophied myocardium that has
“outgrown” its normal blood supply and requires
added supplies of oxygen.
c) Aortic stenosis or insufficiency and diastolic
hypertension, causing heart to work harder.
d) Thyrotoxicosis, increasing oxygen
consumption.
e) Strong emotion or heavy exertion, increasing
heart’s and body’s need for oxygen.
My patient was on the
antihypertensive drug therapy
since 3 years
Not found in patient’s history
These may be the causes of my
patient.
Not found in patient.

16. 4 min
4 min
Describe the
pathophysiol
gy of head
injury.
Discuss the
clinical
manifestation
of CAD
PATHOPHYSIOLOGY OF ANGINA PECTORIS-
Atherosclerosis Arterial spasm Atherosclerosis+Plaque
split+Thrombus
Sudden not usually reversible
Gradual Sudden reversible Occlusion
Obstruction Obstruction
ISCHEMIA
HYPOXIA
Reduced oxygen supply Angina
Thrombolysis Unstable Angina
SIGN AND SYMPTOMS:-
Book Picture Patient Picture
Ischemia of the heart muscle may produce pain or
other symptoms, varying in severity from a felling
of indigestion to a chocking or heavy sensation in
the upper chest that ranges from discomfort to
Explanation
Discussion
Lecture
Explanation
Chart
Chart
Explain the
pathophysiolog
y of CAD.?
What are the
sign and
symptoms of
CAD.?

17. 3 min Enlist the
diagnostic
evaluation of
CAD
agonizing pain accompanied by severe
apprehension and a feeling of impending death.
 The pain is often felt deep in the chest
behind the upper or middle third of the
sternum (retrosternal area).
 Typically, the pain or discomfort is poorly
localized and may radiate to the neck, jaw,
shoulders, and inner aspects of the upper
arms, usually the left arm.
 The patient often feels tightness or a heavy,
choking, or strangling sensation that has a
viselike, insistent quality.
 The patient with diabetes mellitus may not
have severe pain with angina because the
neuropathy that accompanies diabetes can
interfere with neuroreceptors, dulling the
patient’s perception of pain.
 A feeling of weakness or numbness in the
arms, wrists, and hands may accompany the
pain, as may shortness of breath, pallor,
diaphoresis, dizziness or light headedness
and nausea and vomiting.
When these symptoms appear alone, they are called
angina – like symptoms. Anxiety may accompany
angina. An important characteristic of angina is that
it abates or subsides with rest or nitroglycerin.
Mr. Balram Das
having a left sided
chest pain and mild
sternal chest pain.
DIAGNOSTIC EVALUATION:-
Book Picture Patient Picture
Lecture Chart What are the
diagnostic
evaluation of
CAD.?

18. 1. History taking – PQRST assessment of
Angina:-
 P- Precipitating events – what event or activities
precipitated the pain (e.g., argument, exercise,
resting)?
 Q- Quality of pain – what does the pain feel like
(e.g., pressure, dull, aching, tight, squeezing,
heaviness)?
 R- Radiation of pain – where is the pain located?
Does the pain radiate to other areas (e.g., back,
neck, arms, jaw, shoulder, elbow)?
 S- Severity of pain – on a scale of 0 to 10 with 0
indicating no pain and 10 being the most severe
pain you could imagine, what number would
you give the pain?
 T- Timing – when did the pain begin? Has the
pain changed since this time? Have you had
pain like this before?
1.Characteristic of chest pain and clinical
history.
2.Nitroglycerin test – relief of pain with
nitroglycerin.
3.Blood test.
 Cardiac markers, creatine kinase (CK)
and its isoenzyme CK-MB, and troponin-I to
determine the presence and severity if acute
cardiac insult is suspected.
 HbA1c and fasting lipid panel to rule out
modifiable risk factors for CAD.
 Coagulation studies, homocysteine, and
lipoprotein, (increased levels are associated with
a two-fold risk in developing CAD).
Complete history was taken from
Mr. Balram Das he told his pain is
arising from the neck and shoulder.
History has taken by the patient as
well as family members in that there
is patient is already diagnosed with
Hypertension and Diabetes Mellitus
and he is taking antihypertensive
medicines and insulin injection.
There is no family history of heart
diseases in his family.
This test is performed for the Mr.
Balram Das and he did not get
relieve from chest pain after taking
this medicine.
Trop-t test is positive seen in patient
HbA1c test is done for patient it
found 5% and patient is non
diabetic.
Coagulation studies done for the
patient.
Hb test also done and it found 12%

19.  Hemoglobin to rule out anemia, which
may reduce myocardial oxygen supply.
2. 12-lead ECG-may show LVH, ST-T wave
changes, arrhythmias, and Q waves.
3. ECG stress testing- progressive increase
the workload of the heart. ST-Y wave
changes occur if myocardial ischemia is
induced.
4. Radionuclide imaging- a radioisotope,
thallium 201, injected during exercise is
imaged by camera. Low uptake of the
isotope by heart muscle indicates regions
of ischemia induced by exercise. Images
taken during rest show a reversal of
ischemia in those regions affected.
5. Radionuclide ventriculography (gated
blood pool scanning) – red blood cells
tagged with a radioisotope are imaged by
camera during exercise and at rest. Wall
motion abnormalities of the heart can be
detected and ejection fraction estimated.
6. Cardiac catheterization- coronary
angiography performed during the
procedure determines the presence,
location, and extent of coronary lesions.
7. Positron-emission tomography (PET) –
cardiac perfusion imaging with high
resolution to detect very small perfusion
differences caused by stenotic arteries.
Not available in all settings.
8. Electron-beam computed tomography
(CT) – detects coronary calcium, which is
found in most, but not all, atherosclerotic
plaque. It is not routinely used due to its
ECG done for the patient and it
shows the abnormality rhythm on
the ECG graph.
This is not done for patient.
Not done for the Mr. Balram Das.
Cardiac catheterization is done for
the patient and lesions found in the
coronary artery.
PET- scan done for the patient and
decreased perfusion seen due to
stenosis in the coronary artery.
Not performed for my patient.

20. 12
Min
Describe the
management
of CAD.
MANAGEMENT-
Objectives of management- the treatment of angina aims to decrease oxygen demand
and/or increase oxygen supply.
BOOK PICTURE PATIENT PICTURE
Immediate Management-
 Patient with angina pectoris relax, rest or lie
down to alleviate the pain.
 Calm and focusing on breathing. Breathe in
through the nose and breathe out slowly from
the mouth.
 Administration of oxygen- oxygen therapy is
usually initiated at the onset of chest pain in
an attempt to increase the amount of oxygen
delivered to the myocardium and to decrease
pain. The therapeutic effectiveness of oxygen
is determined by observing the rate and
rhythm of respirations and the color or skin
and mucous membranes. Blood oxygen
saturation is monitored by pulse oximetry;
the normal oxygen saturation (SpO2) level is
greater than 90%.
 Take Nitroglycerin.
 If the pain or discomfort does not stop a few
minutes after taking nitroglycerin or if
symptoms become more severe, call 911 or
let someone know that need immediate
medical assistance.
Pharmacological management-
1. Nitroglycerin- (Nitrostat, Nitro-Bid),
Oxygen administration dione
for the patient 6 liter per minute
Mr. Balram Das got
nitroglycerin
but not relived chest pain.
low specificity for identifying significant
CAD.
Lecture
Discussion
Chart
What are the
management of
CAD.?

21.  Nitroglycerin may be given by
several routes: sublingual tablet or
spray, oral capsule, topical agent, and
intravenous (IV) administration.
 Nitrates are a standard treatment for
angina pectoris.
 Nitroglycerin is a potent vasodilator
that improves blood flow to the heart
muscle and relieves pain.
 Nitroglycerin dilates primarily the
veins and, to a lesser extent, the
arteries.
 Dilation of the veins causes venous
pooling of blood throughout the
body. As a result, less blood returns
to the heart, and filling pressure
(preload) is reduced.
Sublingual Nitroglycerin- is generally placed under
the tongue or in the cheek (buccal pouch) and ideally
alleviates the pain of ischemia within 3 minutes.
With sublingual nitroglycerin, the nurse should
check the patient’s medication history for drugs that
may lead to dry mouth and mucous membranes and
thus impair the absorption of the drug.
A continuous or intermittent IV infusion of
nitroglycerin may be administered to the
hospitalized patient with recurring sign and
symptoms of ischemia or after a revacularization
procedure. The rate of infusion is titrated to the
patient’s pain level and blood pressure. It usually is
not administered if the systolic blood pressure is less
than 90 mm Hg.
Self-Administration of Nitroglycerine-
 Instruct the patient to make sure the mouth is
moist, the tongue is still, and saliva is not
swallowed until thenitroglycerin tablet

22. dissolves. If the pain is hasten sublingual
absorption.
 Advise the patient to carry the medication at
all times as a precaution.
 Explain that nitroglycerine is volatile and is
inactivated by heat, moisture, air, light, and
time. Instruct the patient to renew the
nitroglycerin supply every 6 months.
 Inform the patient that the medication should
be taken in anticipation of any activity that
may produce pain. Because nitroglycerin
increases tolerance for exercise and stress
when taken prophylactically (i.e., before
angina-producing activity, such as exercise,
stair-climbing, or sexual intercourse), it is
best taken before pain develops.
 Discuss possible side effects of nitroglycerin,
including flushing, throbbing headache,
hypotension, and tachycardia.
 Advise the patient to sit down for a few
minutes when taking nitroglycerin to avoid
hypotension and syncope.
2. Beta-Adrenergic Blocking Agents-
[Metoprolol(Lopressor, Toprol)]
[Atenolol(Temormin)]
 Beta-blockers reduce myocardial oxygen
consumption by blocking beta-adrenergic
sympathetic stimulation to the heart.
 The result is a reduction in heart rate, slowed
conduction of impulses through the
conduction system, decreased blood
pressure, and reduced myocardial
contractility (force of contraction).
 Because of these effects, beta-blockers
balance the myocardial oxygen needs
Patient is getting Metaprolol.

23. (demands) and the amount of oxygen
available (supply).
 This helps control chest pain and delays the
onset of ischemia during work or exercise.
 Beta-blockers reduce the incidence of
recurrent angina, infarction, and cardiac
mortality.
 The dose can be titrated to achieve a resting
heart rate of 50 to 60 b/m.
 Side effects including depressed mood,
fatigue, decreased libido, and dizziness.
3. Calcium Channel Blocking
Agents[Amlodipine(Norvasc)][Diltiazem(Car
dizem, Tiazac) Nifedipine(Procardia),
Verapamil, Felodipine, Nicardipine]
 Calcium channel blockers have a variety
of effects on the ischemic myocardium.
 These agents decrease sinoatrial node
automaticity and artioventricular node
conduction, resulting in a slower heart
rate and a decrease in the strength of
myocardial contraction.
 Hypotension may occur after the
administration of any of the calcium
channel blockers, particularly when
administered IV.
 Side effect may include atrioventricular
block, bradycardia, and constipation.
 Prevent calcium entry into vascular
smooth muscle cells and myocytes
(cardiac cells).
4. Antiplatelet Medications- [Aspirin,
Clopidagrel (Plavix), Prasugrel (Effient),
Mr. Balram Das is getting
Nicardia

24. Glycoprotein IIb/IIIa agents:,
Abciximab(ReoPro), Eptifibatide (Integrilin)]
Antiplatelet medications are administered to prevent
platelet aggregation and subsequent thrombosis,
which impedes blood flow through the coronary
arteries.
 Aspirin prevents platelet aggregation
and reduces the incidence of MI and
death in patients with CAD.
 A 162-325 mg dose of aspirin should be
given to the patient with a new diagnosis
of angina and then continued with 81 to
325 mg daily.
 Clopidogrel and Ticlopidine-
Clopidogrel (Plavix) or Ticlopidine
(Ticlid) is given to patients who are
allergic to aspirin or given in addition to
aspirin in patients at high risk for MI.
 Unlike aspirin, these medication take a
few days to achieve their antiplatelet
effect.
 They also cause gastrointestinal upset,
including nausea, vomiting, and diarrhea,
and they decrease the neutrophil level.
 Thienopyridines- these medications act
on different pathways than aspirin to
block platelet activation.
 However, unlike aspirin, these agents
may take a few days to achieve
antiplatelet effects. Clopidogrel (plavix)
is commonly prescribed in addition to
aspirin in patients at high risk for MI.
Mr. Balram Das getting aspirin

25.  Glycoprotein IIb/IIIa Agents- IV
administration of glycoprotein (GP)
IIb/IIIa agents, such as abciximab
(ReoPro) or eptifibatide (Integrilin), is
indicated for hospitalized patients with
unstable angina and as adjunct therapy
for PCL.
 These agents prevent platelet aggregation
by blocking the GP IIb/IIIa receptor on
the platelets,
 Preventing adhesion of fibrinogen and
other factors that crosslink platelets to
each other and thus from intracoronary
clots.
 As with heparin, bleeding is the major
side effect, and bleeding preventions
should be initiated.
5. Anticoagulant Medications-
 Heparin- unfractionated IV heparin
prevents the formulation of new blood
clots. Treating patients with unstable
angina with heparin reduces the
occurrence of MI.
 If the patient’s sign and symptoms
indicate a significant risk for a cardiac
event, the patient is hospitalized and may
be given an IV bolus of heparin and
started on a continuous infusion.
 The amount of heparin administered is
based on the results of the activated
partial thromboplastin time.
Opioid Analgesics-
Morphine-
 Functions as an analgesic and sedative.
 Acts as a vasodilator to reduce preload and
myocardial O2 consumption.
Mr. Balram Das getting heparin
He is getting inj. Tramadol

26. 2 min
4 min
Discuss the
complication
oc CAD.?
Explain the
nursing
management
of CAD.?
COMPLICATIONS
Seen in the Book picture Seen in Patient
 Myocardial infarction
 Dysrhythmias and cardiac arrest
 Heart failure
 Cardiogenic shock
 Acute pulmonary edema
 Congestive heart failure
 Myocardial rupture
 Pericardial effusion and cardiac
tamponade.
Seen in Mr. Balram Das
Nursing Management-
Assessment
1. Ask patient to describe angina attacks.
(a) When do attacks tend to occur? After a meal? After engaging in certain activities?
After physical activities in general? After visits of family/others?
(b) Where is the pain located? Does it radiate?
(c) Was the onset of pain sudden? Gradual?
(d) How long did it last- seconds? Minutes? Hours?
(e) How is the pain relieved? How long does it take for pain relief?
Nursing interventions for a patient with angina pectoris include:
1. Treating angina- if the patient reports pain, the nurse takes immediate action.
Lecture
Explanation
Explanation
Chart
Chart
What are the
complication of
CAD.?
What are the
nursing
management of
CAD.?

27.  The nurse should instruct the patient to stop all activities and sit or rest in bed
in a semi-Fowler’s position to reduce the oxygen requirements of the
ischemic myocardium.
 The nurse then continues to assess the patient, measuring vital signs and
observing for signs of respiratory distress.
 If the patient is in the hospital, a 12-lead ECG is usually obtained and
scrutinized for ST-segment and T-wave changes.
 If the patient has been placed on cardiac monitoring with continuous ST-
segment monitoring, the ST- segment is assessed for changes.
 Nitroglycerin is administered sublingually, and the patient’s response is
assessed. If the chest pain is unchanged or is lessened but still present,
nitroglycerin administration is repeated up to three doses.
 The nurse administers oxygen therapy if the patient’s respiratory rate is
increased or the oxygen saturation level is decreased.
2. Reducing anxiety- patients with angina often fear loss of their roles within society
and the family.
 They may also be fearful that the pain may lead to an MI or death.
 Various stress reduction methods should be explored with the patient. For
example, music therapy.
 Addressing the spiritual needs of the patient and family may also assist in
allaying anxieties and fears.
3. Preventing pain- The nurse reviews the assessment findings, identifies the level of
activity that causes the patient’s pain, and plans the patient’s activities accordingly.
 If the patient has pain frequently or with minimal activity, the nurse
alternates the patient’s activities with rest periods.
Home Care Guidelines

28. The goals of education ate to reduce the frequency and severity of anginal attacks, to
delay the progress of the underlying disease if possible, and to prevent complications.
 Reduce anginal attacks. Activities should be planned to minimize the occurrence
of angina episodes.
 Follow-up monitoring. The patient may need reminders about follow-up
monitoring, including periodic blood laboratory testing and ECGs.
 Adherence. The home care nurse may monitor the patient’s adherence to dietary
restrictions and to prescribed antianginal medications.
Client Teaching- The client must be knowledgeable in the care of episodes of angina and
how to reduce the risk factors that exacerbate the process.
The nurse should provide the client with the following instructions:
 Avoid known activities that precipitate angina (e.g., eating large meals, smoking,
strenuous exercise, extremes in weather, increased humidity, excess stress.)
 If angina occurs, stop the activity, sit down and rest, and take nitroglycerin if
prescribed (three tablets taken 5-10 minutes apart).
 If the pain does not subside, worsens, or radiates, Notify the physician or go to
the emergency room. Do not drive yourself.

29. NURSING DIAGNOSIS
NURSING DIAGNOSIS
 Acute Pain related to Increased cardiac workload/oxygen consumption blood flow evidenced by reports of pain varying in frequency, duration, and
intensity (especially as condition worsens).
 Activity Intolerance related to Imbalance between oxygen supply and demand evidenced by fatigue, feeling weak Abnormal blood pressure/heart rate in
response to activity Exertional dyspnea
 Fear and anxiety related to hospitalization and procedure as evidenced by increased tension.
 Knowledge deficient related to unfamiliarly with resources as evidenced by statement of misconception.
 Impaired skin integrity related to decreased sensation and circulation to lower extremities as characterized by patient verbalization.
 Self-care deficit related to neuromuscular impairment, decreased strength and endurance, loss of muscle control coordination as evidenced by impaired
ability to perform.
 Knowledge deficit related to disease process and its treatment as evidenced by many queries by family members.
 Imbalanced nutrition less than body requirement related to protein catabolism as evidenced by decrease in total body weight
 Impaired physical mobility related to pain and discomfort as evidenced by reluctance to move
Short term goal
1. The patient will be able to maintain normal fluid volume as evidenced by maintaining, normal vital signs and adequate urine output.
2. The patient will be relieved from pain as evidenced by verbalization and by his pleasant facial expression.
3. The patient will have normal body temperature as evidenced by thermometer reading.
4. The patient will resume normal sleep pattern as evidenced by facial expression.
5. The patient will regain proper nutritional status as evidenced by observation and increase intake of food.
6. Patient will be relieved from anxiety as evidenced by verbalization.
7. The patient and family members will be gain proper knowledge about the burn and management as evidenced by verbalization.
Long term goal
1. Mr. Balram Das will be prevented from recurrent infection.
2. Mr. Balram Das will be prevent from complications .
3. Mr. Balram Das will be prepared for early discharge.

30. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective data:-
Patient told that he is
having pain
Objective data:- by
observation he is having
pain rated by pain score
scale.
Acute Pain related to
Increased cardiac
workload/oxygen
consumption blood
flow evidenced by
Reports of pain varying
in frequency, duration,
and intensity (especially
as condition worsens).
The patient
will relief of
pain as
evidenced
by stable
vital signs,
absence of
muscle
tension and
restlessness
Assess the condition
of the patient
Instruct patient to
notify nurse
immediately when
chest pain occurs
Assess and
document patient
response
to medication.
Observe for
associated
symptoms:
dyspnea, nausea and
vomiting, dizziness,
palpitations, desire
to micturate.
Place patient at
complete rest during
anginal episodes
Provide light meals.
Have patient rest for
1 hr after meals
To collect the
baseline data.
To minimize the
chest pain.
To give the early
treatment and
minimize the
symptoms
Reduces myocardial
oxygen demand to
minimize risk of
tissue injury.
Decreases
myocardial workload
associated with work
of digestion,
reducing risk of
anginal attack.
Assessed the
condition of the
patient
Instructed patient to
notify nurse
immediately when
chest pain occurs
Assess and document
patient response
to medication.
Observed for
associated symptoms:
dyspnea, nausea and v
omiting, dizziness,
palpitations, desire to
micturate.
Placed patient at
complete rest during
anginal episodes
Provided light meals.
Have patient rest for 1
hour after meals.
Mr. Balram
complain of
chest pain is
relief

31. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective data:- He is having
itching around the wound
Objective data:- skin
excoriation is present around
the wound
Activity
Intolerance related
To Imbalance
between oxygen
supply and demand
evidenced By
Reports fatigue,
feeling weak
Abnormal blood
pressure/heart rate
in response to
activity Exertional
dyspnea
The patient
will
Achieve
measurable
increase in
activity
tolerance,
evidenced
by reduced
fatigue and
weakness
and by vital
signs within
acceptable
limits
during
activity.
.-Check vital signs
before and
immediately after
activity during acute
episode or
exacerbation of HF.
-Assess level of
fatigue, and evaluate
for other
precipitators and
causes of fatigue, for
example, HF
treatments, pain.
-Evaluated
accelerating activity
intolerance.
 Orthostatic
hypotension can
occur with activity
because of
medication effect.
Fatigue because of
advanced HF can be
profound and is
related to
hemodynamic,
respiratory, and
peripheral muscle.
May denote
increasing cardiac
decompensation
rather than
overactivity
Checked vital signs
before and immediately
after activity during acute
episode or exacerbation
of HF.
Assessed level of fatigue,
and evaluate for other
precipitators and causes
of fatigue, for example,
HF treatments, pain.
Evaluated accelerating
activity intolerance.
Mr. Balram
Das have
normal skin
integrity.

32. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective Data:-
Patient’s relative said that ‘I
have itching on the body and
cracking heel’.
Objective Data:- based on
observation patient have dry
skin due to this causing
itching and crack heel.
Impaired skin integrity
related to decreased
sensation and circulation
to lower extremities as
characterized by patient
verbalization.
Maintain
skin
integrity
Instruct patient in
foot care guidelines
Closely monitor
blood glucose
levels to detect
hypoglycemia
.Instruct, patient in
the importance of
accuracy in insulin
preparation and
meal timing to
avoid
hypoglycemia
Assessment
provides baseline
data for better
intervention.
Prevention from
the skin breakdown
To keep moisture
to the skin and
prevent cracking
and fissures
Prevent from the
wound.
Smoking-cessation
reduces
vasoconstriction
and enhances
peripheral blood
flow.
Instruct patient in
foot care guidelines
Closely monitor
blood glucose levels
to detect
hypoglycemia
Instruct, patient in
the importance of
accuracy in insulin
preparation and meal
timing to avoid
hypoglycemia
These
interventions
help in
promoting
sensation and
circulation to
lower
extremities and
maintaining
skin skin
integrity

33. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective Data:-
patient’s relative
said that “he is
having one side
body weakness
because of that he
is unable care of
himself ”.
Objective data:-
based on
observation “
patient is unable to
do work. he is on
bed.
Self care deficit
related to
neuromuscular
impairment, decreased
strength and
endurance, loss of
muscle control
coordination as
evidenced by impaired
ability to perform.
Maintain
patient care
Assess abilities and level
of deficit(0-4)
Avoid doing things for
patient that patient can do
for self, but provide
assistance as necessary
Maintain supportive, firm
attitude.
Provide self care device
(button, zipper hook) assist
and encourage good
grooming.
Planning for meeting
individual needs
These patients may
become fearful and
dependent, and although
assistance is helpful in
preventing frustration.
Patient need empathy and
to know caregivers will
be consistent in their
assistance.
Enables patient to
manage for self,
enhancing independence
and self esteem, reduces
reliance on others for
meeting own need.
Assessed abilities
and level of
deficit(0-4)
Avoid doing things
for patient that
patient can do for
self, but provide
assistance as
necessary
Maintained
supportive, firm
attitude.
Provided self care
device (button,
zipper hook) assist
and encourage
good grooming.
Family
member have
understood the
difficulty to
maintain self
care.

34. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective
Data:-
patient’s
relative said
that “I am
very anxious
about how to
handle this
situation”.
Objective
data:- based
on
observation “
patient have
not proper
knowledge
about disease
condition and
its treatment
regimen”.
Knowledge deficit
(family) related to
disease process and
its treatment as
evidenced by many
queries.
Improve the
knowledge of
family
members.
Provide some information to
the client about disease
condition.
Instruct about the what type
symptoms you will be faced
such as sweating, palpitation
etc.
Assess the hydration condition
of the client.
To provide adequate amount of
fluid to the client.
To know the knowledge
level of the client.
Improve the knowledge
level of client.
To aware about the
symptoms regarding
disease and help to cope
up with condition.
To maintain the normal
health status
Provided some
information to the
client about
disease condition.
Instruct about the
what type
symptoms you
will be faced such
as sweating,
palpitation etc.
Assessed the
hydration
condition of the
client.
To provided
adequate amount
of fluid to the
client.
Mr. Balram
family members
improved
knowledge
regarding
disease
condition and its
treatment
regimen.

35. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective
Data:-
Family told
that patient
extremities
gradually
become
cold and
decrease
pulse rate.
Objective
Data:-
I observe
patient
extremities
cold and
decrease
pulse rate
Decreased Cardiac Output
related to Structural factors
of congenital heart defect
as evidence by Murmur,
Decreased peripheral
pulses
Maintain the
cardiac
output
-Assess heart rate
and blood pressure.
-Note skin color,
temperature, and
moisture.
-Check for peripheral
pulses, including
capillary refill.
-Assess heart sounds for
gallops (S3, S4).
-Monitor
electrocardiogram (ECG)
-Most patients have
compensatory tachycardia and
significantly low blood
pressure in response to reduced
cardiac output.
-Cold, clammy, and pale skin
is secondary to a compensatory
increase in
sympathetic nervous
system stimulation and low
cardiac output and oxygen
desaturation.
-Weak pulses are present in
reduced stroke volume and
cardiac output. Capillary refill
is sometimes slow or absent.
-S3 indicates reduced left
ventricular ejection and is a
class sign of left ventricular
failure. S4 occurs with reduced
compliance of the
left ventricle, which impairs
diastolic filling.
-Cardiac dysrhythmias may
occur from low perfusion,
acidosis, or hypoxia.
-Rest decreases metabolic rate,
decreasing myocardial and
oxygen demand.
-Assess heart rate
and blood pressure.
-Note skin color,
temperature, and
moisture.
-Check for
peripheral pulses,
including capillary
refill.
-Assess heart
sounds for gallops
(S3, S4).
Patient cardiac
output
maintained

36. for rate, rhythm, and
ectopy.
-Provide adequate rest
periods
-Position in semi-
Fowler’s position.
-Administer oxygen
therapy as prescribed.
- Administer (Lanoxin)
Digoxin
-Administer
Furosemide (Lasix);
spironolactone
(Aldactone).
-Rest decreases metabolic rate,
decreasing myocardial and
oxygen demand.
-The failing heart may not be
able to respond to increased
oxygen demands. Oxygen
saturation need to be greater
than 90%.
-Increases contractility of the
heart and force of contraction.
-Decreases edema formation
and diminish afterload.
-Monitor
electrocardiogram
(ECG) for rate,
rhythm, and
ectopy.
-Provide adequate
rest periods
-Position in semi-
Fowler’s position.
-Administer
oxygen therapy as
prescribed.
- Administer
(Lanoxin) Digoxin
-Administer
Furosemide (Lasix)
;
spironolactone
(Aldactone).

37. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective
data:-
Family told
that patient
and they are
unable to
cope with
current
situation.
Objective
data:-
I observe
the family
having
coping
difficulty
due to
surgical
procedure
to the
patient
Compromised Family
Coping related to
Situational and
developmental crises as
evidence by
Chronic anxiety and
possible hospitalization
and surgery
Family will
cope more
effectively.
-Observe for erratic
behaviors (anger,
tension, disorganization),
perception of crisis
situation.
-Encourage expression of
feelings and provide
factual information about
patient.
-Assess usual family
coping methods and
effectiveness.
-Assess need for
information and support.
-Clarify any
misinformation
and answer questions
regarding disease
process.
-Suggest and reinforce
appropriate
coping behaviors,
support family
decisions.
-Information affecting the
ability of the family to cope
with patient cardiac condition.
-Reduces anxiety and
enhances family’s
understanding of the condition.
-Identifies need to develop
new coping skills
-Provides information about
need for interventions to
relieve anxiety and concern.
-Prevents unnecessary
anxiety resulting
-Promotes behavior change
and adaptation to care for
patient.
-Observe for
erratic
behaviors (anger,
tension, disorgani
zation),
perception of
crisis situation.
-Encourage
expression of
feelings and
provide factual
information about
patient.
-Assess usual
family coping
methods and
effectiveness.
-Assess need for
information
and support.
-Clarify any
misinformation
and answer
questions
regarding disease
process.
-Suggest and
reinforce
appropriate
coping behaviors,
support family
decisions.
Family is coping
effectively
towards the
surgical
procedure and
treatment

38. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective
Data:-
Mr. Balram
said that “I
m feeling
difficulty
during the
time of
respiration”.
Objective
Data:-
Patient had
Labor
breathing,
Decrease
respiratory
rate.
Infective breathing
pattern related to
decreased energy, fatigue
as evidence by decrease
respiratory rate.
Client will be
improve the
breathing
pattern as
evidence by
decrease
labor
breathing.
1.Monitor respiratory
rate, depth & effort.
2.Investigate change
in level of
consciousness.
3. Keep head of bed
elevated.
4.Encourage frequent
reposition and deep
breathing exercises.
5.Monitor
temperature.
6.Monitor serial
ABGs, pulse
oximetry, vital
capacity
measurements, chest
x-rays.
7. Provide
supplemental 02 as
indicated.
-Rapid shallow respiration
are presence of dyspnea.
-Changes I mention may
reflect hypoxemis and
respiratory failure.
-Facilitates breathing by
reducing pressure on the
diaphragm.
-Aids in lung expansion
and mobilizing secretions.
-Indicative of onset of
infection.
-Reveals changes in
respiratory status,
developing pulmonary
complications.
-To treat or prevent
hypoxia.
1.Monitored
respiratory rate, depth
& effort.
2.Investigated change
in level of
consciousness.
3. Keep head of bed
elevated.
4.Encourage frequent
reposition and deep
breathing exercises.
5.Monitor temperature.
6.Monitor serial
ABGs, pulse oximetry,
vital capacity
measurements, chest
x-rays.
7. Provide supplemental
02 as indicated.
Client has
regained normal
health pattern

39. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective
data:-
Mr. Balram
said that “I
am not feeling
well am
felling like
fever”.
Objective
data:-
Patient had
increased body
temperature
i.e. 1000
F
Hyperthermia related
invasion of micro
organism as evidence
thermometer reading
1000
F
Client body
temperature
will reduced
as evidence
by
thermometer
reading e.g.
98.6 0
F
1.Check the vital
sign.
2. Give the clean
environment to the
patient.
3.Give the non-
pharmacological
management tapid
sponging to patient.
4.Give the antipyretic
paracetamol injection.
1.To know the patient
vital condition specially
body temperature.
2. To prevent from
invasion of microorganisn
3.To decrease the body
tempreture.
4.To reduce the body
temperature.
1.Checked the vital
sign.
2. Given the clean
environment to the
patient.
3.Given the non-
pharmacological
management tapid
sponging to patient.
4.Given the antipyretic
paracetamol injection
Patient body
temperature is
normal 98.60
F

40. Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective
data:-
Mr. Balram
said that “I
m not
feeling to
eat anything
feeling very
weakness”.
Objective
data:-
Patient had
weakness,
weight loss,
loose
increase
skin
integrity.
Imbalanced
Nutrition Less
Than Body
Requirements
related to
Altered
absorption of
nutrients as
evidence by
Weight loss,
muscle mass,
poor muscle
tone
Client will be
able to
maintain the
nutrition in the
body as
evidence by
increase body
weight
34-40kg
-Monitor Weigh
daily.
- Encourage bed rest
and limited activity.
- Recommend rest
before meals.
- Serve foods in
well-ventilated,
pleasant
surroundings.
- Limit foods that
might cause or
exacerbate abdominal
cramping.
- Record intake and
changes in
symptomatology.
-Aadvance diet as
indicated (clear
liquids progressing
to bland, low
residue; then high-
protein, high-calorie.
Provides information about dietary
needs and effectiveness of therapy.
- Decreasing metabolic.
-Quiets peristalsis and increases
available energy for eating.
- Pleasant environment aids in
reducing .
- Depending on stage of disease and
area of bowel affected.
- Useful in identifying specific
deficiencies and determining GI response
to foods.
-Allows the intestinal tract to readjust
to the digestive process
-Monitored Weigh daily.
- Encouraged bed rest
and limited activity.
- Recommend rest before
meals.
- Served foods in well-
ventilated, pleasant
surroundings.
- Limited foods that might
cause or exacerbate
abdominal cramping.
- Recorded intake and
changes in
symptomatology.
-Aadvanced diet as
indicated (clear liquids
progressing to bland, low
residue; then high-protein,
high-calorie.
Client body
weight is
increased 6
kg

41. THEORY APPLICATION

42. THEORY APPLICATION FOR Mr. BALRAM DAS
Introduction
“Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time.”
Nursing: Need Theory. Henderson's theory stresses the priority of patient self-determination so the patient will continue doing well after being released from the
hospital. ... The role of the nurse helps the patient become an individual again. She arranged nursing tasks into 14 different components based on personal needs...
The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peace
full death) that he would perform unaided if he had the necessary strength, will or knowledge.
Definition
Virginia Henderson defines nursing as ‘assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a
peaceful death and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge’
Henderson’s Theory and the Four Major concept
Henderson viewed human being, health, environment and Nursing as follows:
Human being: The patient as an individual who requires assistance to achieve health and independence or peaceful death. The mind and body are inseparable.
The patient and his family are viewed as a unit.
Health: She views health in terms of the patient’s ability to perform unaided the 14 components of nursing care. She says it is “the quality of health rather than
life itself, that margin of mental physical vigor that allows a person to work most effectively and to reach his highest potential of satisfaction in life. She does not
state her own definition of health.
Environment: She used Webster Dictionary, which defines environment as “the aggregate of all the external conditions and influences affecting the life and
development of an organism.
Nursing:In 1966, Henderson’s ultimate statements in the definition of nursing were published of her ideas. It reads as follows:
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or
to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this, in such a way as to help him gain
independence as rapidly as possible.”
Henderson needs theory:
The Nature of nursing Model
1922 she conceptualized the role of the nurse as assisting sick or healthy individuals to gain independence in meeting the 14 fundamental needs.

43. Henderson’s Basic needs
Henderson does not give any definition of need. Her focuses on individual care is evident in that she stressed assisting individuals with essential activities to
maintain health, to recover, or to achieve peaceful death. She proposed 14 basic needs of patients. For basic Nursing care to augment her definitions, which
comprise the components of nursing care, these include the need to:
1. Breathe normally.
2. Eat and drink adequately
3. Eliminate body wastes.
4. Move and maintain desirable position.
5. Sleep and rest.
6. Select suitable clothes—dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and modifying the environment
8. Keep the body clean and well grange by groomed and protect integument.
9. Avoid dangers in environment and avoid injuring others.
10. Communicate with others in expressing emotions, need, and fears of options.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishments.
13. Play or participate in various forms of recreations.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities
These needs were considers on basic principles of nursing care.
Henderson’s on Nursing Process
Henderson views the nursing process as “really the application of the logical approach to the solution of a problem. The steps are those of the scientific method.”
“Nursing process stresses the science of nursing rather than the mixture of science and art on which it seems effective health care service of any kind is based.”
A. Nursing Assessment
Assess needs of human being based in the 14 components of basic nursing care.
 Breathe normally.
 Eat and drink adequately
 Eliminate body wastes.
 Move and maintain.
 Sleep and rest.
 Suitable clothing, dress and uniform.
 Maintain body temperature.
 Keep body clean and well grange by groomed.

44.  Avoid dangers in environment..
 Communicate.
 Worship according to one’s faith.
 Recreation.
 Learn, discover of satisfy curiosity.
Analysis: compare data to knowledge base of health and disease.
B. Nursing Diagnosis
 Identify individuals ability to meet own needs with or without assistance, taking into consideration strength will or knowledge.
C. Nursing Plan
 Document how the nurse can assist the individual sick or well.
D. Nursing Implementation
 Assist the sick or well individual in the performance of activities in meeting human needs to maintain health, recover from illness or to aid in peaceful
death. Implementation based on principles age, culture background, emotional balance and intellectual capacities carry out treatment prescribed by the
Doctor.
E. Nursing evaluation
Use the acceptable definition of nursing and appropriate laws related to the practice of nursing. The quality of care distinctly of the nursing personnel rather than
the amount of care. Successful outcome of Nursing care is based on the speed with then which the patient performs indendently ADL.

45. HENDERSON 14
COMPONENT
NURSING
ASSESSMENT
POSSIBLE NURSING
DIAGNOSIS
PLANNING INTERVENTION
1. Breath normally He was experiencing
difficulty in breathing.
Respiratory rate is 16
irregular, oxygen
saturation 87%
Activity intolerance related
to dyspnea
Address all the physiological
needs provide respective nursing
care.
Observe for strengths such as
the ability to relate the facts and
to recognize the source of
stressors.
14. Learn, discover, or satisfy
the curiosity that leads to
normal development and
health and use the available
health facilities.
Finding difficult to
cope with her stress
and present illness
Ineffective coping related
to situational crisis and
inadequate psychological
resources.
Discuss effective coping
strategies and impulse control
like talking, drawing any
pictures, asking questions for
exploring her stress factors.
Help client set realistic goals
and identify personal skills and
knowledge
8.Keep the body clean and
well groomed and protect the
integument.
Son reported that he
was very conscious of
his physical
appearance and
hygiene but was not
well groomed at that
time.
Self –care deficit related to
stress and fatigue
Encourage client to identify her
strengths and limitations, share
her concerns, and participate in
activities of daily living
Encourage client to make
choices and participants in
planning of care and scheduled
activities

46. DAY TO DAY PROGNOSIS
First day: - 12/01/2023
This is the first day of my case study, I have visited Mr. Balram Das. He was looking very weak. Assisted his to take the breakfast by giving good position.
Arranged the patient unit clean and tidy. Checked the vital signs, his blood pressure was high up to 130/90 mmHg. Then I’ve given the entire medical regimen.
I’ve informed all my care to ward in charge, reported and recorded all care and condition of the patient. General condition looks weak.
Vital signs Value
Temperature
Pulse
Respiration
Blood pressure
Output
98.60
F
80/mint
20/mint
130/90 mmhg
200ml
Second day: - 13/1/23
Today, I went and wished the patient. Mr. Balram Das also wished me. I have taken the vitals and recorded. He has 99.40
f . He has taken the food and passed
motion. Administered all the medications. Today I’ve collected the history and done the physical examination. I’ve recorded all the care, medications which I’ve
given and the condition of the patient and informed it into the ward in charge. Mr. Balram Das is improving his status, resting at present general condition looks
weak.
Vital signs Value
Temperature
Pulse
98.40
F
1oo/mint

47. Respiration
Blood pressure
Output
22/mint
150/70 mmHg
250ml
Third day: - 14/1/2023
As same today also I went and wished the patient. He was looking good. He wished me. Then i gave catheter care. I‘ve done the bed making and patient unit tidy.
He has taken food and passed motion. I’ve carried out all the medications. I have given health education regarding Coronary artery disease its causes, clinical
manifestation and management as well as prevention, he understood the topic and he cleared his doubts. He has mild pain. Vitals checked and recorded. General
condition looks better. Resting at present. Informed the condition to ward in charge.
Vital sign Value
Temperature
Pulse
Respiration
Blood pressure
Output
98̊̊̊ F
11o/mint
24/mint
130/80 mmhg
100ml
Fourth day: - 15/1/2023
He had no fever since last evening. Rice water 100ml are given. And he was passing motion 2 times. His appetite was good. His drain output was 50ml in 24
hours. All medication, injection are administered. All the vital sign were checked and was stabilized. There was no fresh complaint.
Vital sign Value
Temperature
Pulse
Respiration
98.20
F
9o/mint
26/mint

48. Blood pressure
Output
130/90 mm Hg
50ml
Fifth day: - 16/1/2023
Mr. Balram looked ungroomed. I have given back care to the patient, catheter care is also given, all the injection were given, today he got the discharge and were
ready to go home. Proper explanation was given to take low protein diet, increase fiber intake in the diet, and perform the range of motion adequately I’ve
explained about follow up medicine. I’ve checked the vitals and it was stable patient’scondition is bette
Vital sign Value
Temperature
Pulse
Respiration
Blood pressure
98.00
F
11o/ mint
22/mint
110/80 mm Hg

49. HEALTH EDUCATION

50. INTRODUCTION:- Coronary artery disease develops when the major blood vessels that supply to heart become damaged or diseased. Cholesterol-containing
deposits (plaques) in the coronary arteries and inflammation are usually to blame for coronary artery disease.
DEFINITION:- “A narrowing of the coronary arteries that prevents adequate blood supply t the heart muscle is called coronary artery disease. Usually caused
by atherosclerosis, it may progress to the point where the heart muscle is damaged due to lack of blood supply. Such damage may result in infarction,
arrhythmias, and heart failure”.
CAUSES:-
Development of atherosclerosis Open pop-up dialog box
Coronary artery disease is thought to begin with damage or injury to the inner layer of a coronary artery, sometimes as early as childhood. The damage may
be caused by various factors, including:
 Smoking
 High blood pressure
 High cholesterol
 Diabetes or insulin resistance
 Not being active (sedentary lifestyle)
Once the inner wall of an artery is damaged, fatty deposits (plaque) made of cholesterol and other cellular waste products tend to collect at the site of injury.
This process is called atherosclerosis. If the plaque surface breaks or ruptures, blood cells called platelets clump together at the site to try to repair the artery.
This clump can block the artery, leading to a heart attack.
RISK FACTORS
Risk factors for coronary artery disease include:
 Age. Getting older increases your risk of damaged and narrowed arteries.
 Sex. Men are generally at greater risk of coronary artery disease. However, the risk for women increases after menopause.
 Family history. A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a close relative developed heart
disease at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before age 55 or if your mother or a sister developed
it before age 65.
 Smoking. People who smoke have a significantly increased risk of heart disease. Breathing in secondhand smoke also increases a person's risk of coronary
artery disease.
 High blood pressure. Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the channel through which
blood can flow.

51.  High blood cholesterol levels. High levels of cholesterol in your blood can increase the risk of formation of plaque and atherosclerosis. High cholesterol
can be caused by a high level of low-density lipoprotein (LDL) cholesterol, known as the "bad" cholesterol. A low level of high-density lipoprotein (HDL)
cholesterol, known as the "good" cholesterol, can also contribute to the development of atherosclerosis.
 Diabetes. Diabetes is associated with an increased risk of coronary artery disease. Type 2 diabetes and coronary artery disease share similar risk factors,
such as obesity and high blood pressure.
 Overweight or obesity. Excess weight typically worsens other risk factors.
 Physical inactivity. Lack of exercise also is associated with coronary artery disease and some of its risk factors, as well.
 High stress. Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for coronary artery disease.
 Unhealthy diet. Eating too much food that has high amounts of saturated fat, trans fat, salt and sugar can increase your risk of coronary artery disease.
 leep apnea. This disorder causes you to repeatedly stop and start breathing while you're sleeping. Sudden drops in blood oxygen levels that occur during
sleep apnea increase blood pressure and strain the cardiovascular system, possibly leading to coronary artery disease.
 High-sensitivity C-reactive protein (hs-CRP). This protein appears in higher-than-normal amounts when there's inflammation somewhere in your body.
High hs-CRP levels may be a risk factor for heart disease. It's thought that as coronary arteries narrow, you'll have more hs-CRP in your blood.
 High triglycerides. This is a type of fat (lipid) in your blood. High levels may raise the risk of coronary artery disease, especially for women.
 Homocysteine. Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. But high levels of homocysteine may
increase your risk of coronary artery disease.
 Preeclampsia. This condition that can develop in women during pregnancy causes high blood pressure and a higher amount of protein in urine. It can
lead to a higher risk of heart disease later in life.
 Alcohol use. Heavy alcohol use can lead to heart muscle damage. It can also worsen other risk factors of coronary artery disease.
 Autoimmune diseases. People who have conditions such as rheumatoid arthritis and lupus (and other inflammatory conditions) have an increased risk of
atherosclerosis.
SYMPTOMS
 Chest pain (angina). You may feel pressure or tightness in your chest, as if someone were standing on your chest. This pain, called angina, usually occurs
on the middle or left side of the chest. Angina is generally triggered by physical or emotional stress. The pain usually goes away within minutes after stopping
the stressful activity. In some people, especially women, the pain may be brief or sharp and felt in the neck, arm or back.
 Shortness of breath. If your heart can't pump enough blood to meet your body's needs, you may develop shortness of breath or extreme fatigue with
activity.
 Heart attack. A completely blocked coronary artery will cause a heart attack. The classic signs and symptoms of a heart attack include crushing pressure
in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating.
Women are somewhat more likely than men are to have less typical signs and symptoms of a heart attack, such as neck or jaw pain. And they may have other
symptoms such as shortness of breath, fatigue and nausea.

52. Sometimes a heart attack occurs without any apparent signs or symptoms.
DIAGNOSIS:-
 Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. An ECG can often reveal evidence of a
previous heart attack or one that's in progress.
 Echocardiogram. An echocardiogram uses sound waves to produce images of your heart. During an echocardiogram, your doctor can determine whether
all parts of the heart wall are contributing normally to your heart's pumping activity.
Parts that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may be a sign of coronary artery disease or other
conditions.
 Exercise stress test. If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary
bike during an ECG. Sometimes, an echocardiogram is also done while you do these exercises. This is called a stress echo. In some cases, medication to
stimulate your heart may be used instead of exercise.
 Nuclear stress test. This test is similar to an exercise stress test but adds images to the ECG recordings. It measures blood flow to your heart muscle at
rest and during stress. A tracer is injected into your bloodstream, and special cameras can detect areas in your heart that receive less blood flow.
 Cardiac catheterization and angiogram. During cardiac catheterization, a doctor gently inserts a catheter into an artery or vein in your groin, neck or
arm and up to your heart. X-rays are used to guide the catheter to the correct position. Sometimes, dye is injected through the catheter. The dye helps blood
vessels show up better on the images and outlines any blockages.
 Cardiac CT scan. A CT scan of the heart can help your doctor see calcium deposits in your arteries that can narrow the arteries. If a substantial amount
of calcium is discovered, coronary artery disease may be likely.
TREATMENT:-
Treatment for coronary artery disease usually involves lifestyle changes and, if necessary, drugs and certain medical procedures.
Lifestyle changes
Making a commitment to the following healthy lifestyle changes can go a long way toward promoting healthier arteries:

53.  Quit smoking.
 Eat healthy foods.
 Exercise regularly.
 Lose excess weight.
 Reduce stress.
Drugs
Various drugs can be used to treat coronary artery disease, including:
 Cholesterol-modifying medications. These medications reduce (or modify) the primary material that deposits on the coronary arteries. As a result,
cholesterol levels — especially low-density lipoprotein (LDL, or the "bad") cholesterol — decrease. Your doctor can choose from a range of medications,
including statins, niacin, fibrates and bile acid sequestrants.
 Aspirin. Doctor may recommend taking a daily aspirin or other blood thinner. This can reduce the tendency of your blood to clot, which may help prevent
obstruction of coronary arteries.
 Beta blockers. These drugs slow heart rate and decrease blood pressure, which decreases heart's demand for oxygen. Beta blockers reduce the risk of
future attacks.
 Calcium channel blockers. These drugs may be used with beta blockers if beta blockers alone aren't effective or instead of beta blockers if not able to
take them. These drugs can help improve symptoms of chest pain.
 Ranolazine. This medication may help people with chest pain (angina). It may be prescribed with a beta blocker or instead of a beta blocker if you can't
take it.
 Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by temporarily dilating coronary arteries and reducing your heart's demand
for blood.
 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). These similar drugs decrease blood pressure and
may help prevent progression of coronary artery disease.

54. COMPLICATIONS
Coronary artery disease can lead to:
 Chest pain (angina). When Doctor coronary arteries narrow, heart may not receive enough blood when demand is greatest — particularly during physical
activity. This can cause chest pain (angina) or shortness of breath.
 Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete blockage of your heart artery may trigger a heart attack. The lack of blood
flow to heart may damage your heart muscle. The amount of damage depends in part on how quickly you receive treatment.
 Heart failure. If some areas of your heart are chronically deprived of oxygen and nutrients because of reduced blood flow, or heart has been damaged by
a heart attack, heart may become too weak to pump enough blood to meet your body's needs. This condition is known as heart failure.
 Abnormal heart rhythm (arrhythmia). Inadequate blood supply to the heart or damage to heart tissue can interfere with your heart's electrical impulses,
causing abnormal heart rhythms.
PREVENTION:-
The same lifestyle habits used to help treat coronary artery disease can also help prevent it. A healthy lifestyle can help keep your arteries strong and clear of
plaque. To improve your heart health, follow these tips:
 Quit smoking.
 Control conditions such as high blood pressure, high cholesterol and diabetes.
 Stay physically active.
 Eat a low-fat, low-salt diet that's rich in fruits, vegetables and whole grains.
 Maintain a healthy weight.
 Reduce and manage stress.
CONCLUSION:-
As a part of Medical & Surgical Nursing I came across the patient, Mr. Balram 65yrs old. who came to the hospital with the alleged history of shortness of breath
on exertion for last 4 months. Doctor has seen him and advised hospitalization and advised for lab investigation like complete blood count, hemoglobin, total
blood count etc. I thought that he needs special care. I took his case as my case study patient from 12/01/2023 to 16/01/2023 with the history of occasional
increase BP (irregular mods) presented with above complaints to EST maintain- diagnosed as Coronary Artery Disease with Hypertension and Type2 DM he
was looking so weak and very poor condition. I felt that he needs care and I have taken this case for my case study.
I would like to give thanks to Miss Vandana Dubey MSc Nursing Lecturer institute of nursing research centre surajpur for her guidance and support during my
Surgical Case study.

55. BIBLIOGRAPHY
 Lewis, Medical Surgical Nursing Assessment and Management of Clinical Problems, 5th
Edition, 2000, United states of America, Pg. no. 841-880.
 Lippincott, Manual of Nursing Practice, 10th
Edition, 2014, Wolters Kluwer, Pg. no. 380-394.
 Brunner & Suddarth’s, Textbook of Medical-Surgical Nursing, 12 Edition, 2011, volume 1, Wolters Kluwer (India) Pvt. Ltd., Pg. no. 756-776.
 Linda D. Urden, Critical Care Nursing Diagnosis and Management, 6th
edition, 2010, Mosby(ELSEVIER), page no. 451.
Net reference:-
 https://www.bhf.org.uk>publications
 https://www.webmd.com>understa.....
 https://www.healthline.com>health

56. INSTITUTE OF NURSING RESEARCH CENTRE SURAPUR CG
SUBJECT-MEDICAL SURGICAL NURSING
MEDICAL CASE STUDY OF BALRAM DAS
ON
CORONARY ARTERY DISEASE
SUMBITTED TO:- SUBMITTED
BY:-
MISS VANDANA DUBEY SMRITIKA
SHIBA DAS MSc NURSING LECTURER
MSc NURSING 1ST YEAR INSTITUTE OF NURSING RESEARCH
CENTRE , SURAJPUR CG

57. INSTITUTE OF NURSING RESEARCH CENTRE, SURAJPUR CG
Name of the supervisor → Miss vandana Dubey
Name of the student teacher → Smritika Shiba Das
Name of the subject → Medical surgical nursing
Topic → Coronary artery disease
No. of student →
Class → MSc nursing 1st Year
Date and time → 24/01/2023, 11 am
Duration → 45 min
Venue → Institute of nursing and research center surajpur cg
A.V. aids → LCD, , chart, , handout.
Method of teaching → lecture, discussion .
Resources → Books, net, journals.
Previous knowledge of the student → Student had some knowledge about CAD.

58. GENERAL OBJECTIVE:-
At the end of the case study the student will be able to explain the CAD.
SPECIFIC OBJECTIVE:-
At the end of the class the student will be able to -
1. give introduction of CAD.
2. define the term of CAD.
3. explain the incidence of CAD.
4. descibe the types of CAD.
5. enlist the causes of CAD.
6. explain the diagnostic investigation of CAD.
7. discuss the management of CAD.
8. discuss the nursing management.
9. discuss the complication of CAD.