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NAVPREET KAUR MSC nursing 1st year Medical surgical nursing

Department of Medical Surgical Nursing



















NAME AGE SEX MARITAL STATES ADDERS RELIGION ADMISSION DATE DIAGNOSIS OCCUPATION MONTHLY INCOME WEIGHT HEIGHT CHIEF COMPLAINS Clicking pain on left side of chest Anxiety Pain radiate to shoulder &beck Gurjit Singh 56 years Male Married Raipur ball an, Punjab BA. Bed 7-Feb 2012 ANGINA PECTORIS Teacher 40,000 98 kg 5 10

PATIENTS PRESENT HISTORY Mr. Gurjit singh admitted in PIMS on 7 Feb. 2012 with the complain of pain in chest anxiety etc. PATIENT PAST MEDICAL HISTORY Mr. Gurjit singh is suffering from hypertension. He has diagnosed as hypertension patient in 2004 PATIENTS SURGICAL HISTORY Mr. Gurjit singh has not under gone any surgery FAMILY HISTORY Type Joint No of members 9 Any illness Asthma

HEALTH FACILITY NEAR HOME Type Doctors clinic Distance 1-2 km Transportation No HOUSING Type puce No of rooms 8 Toilets - Present Electricity Present Drinking water filtered water PERSONAL HISTORY ORAL HYGIENE Frequency 1 time/day Agent Toothpaste BATH Frequency 1 time/day Agent Soap DIET No of meals / days 3-4 meals /days Food preference Both veg & non veg FLUID Tea or coffee 3-4 cups/days SLEEP AND REST 7-8 hrs /day ELIMINATION Bowel /day Frequency 1-2 times /day Urine Frequency 5-6 times /day Drinking habits Not proper Exercise Not proper

S no 1 2 3 4 GENERAL APPEARANCE Nourishment Well nourished Body build Obese Health Healthy Activity Dull MENTAL STATUS Consciousness conscious Look Anxious POSTURE Body curves Normal Movement Dull HEIGHT & WEIGHT Height 5 10 Weight 98 kg Skin condition Color Flushed Texture Exercise moisture Temperature Cold Lesion Absent HEAD AND FACE Scalp cleanliness Face Flushed Vital sing Temperature Pulse Respiration Blood pressure Patients value 98.8 F 88 Beats /mint 24 /mint 140/100minof hg Normal value 98.6 F 72/min 22/min 120/80mm hg

EYE Eye brows Normal Eye lashes Absent of infection Eye lids Normal Vision Normal EARS External ear No abnormal discharge Hearing Normal NOSE External nars No abnormal discharge Nostrils Normal MOUTH & PHARYNX Lips Crusts Odor of the mouth No bad odor Tongue Normal NECK Lymph nodes No enlargement Thyroid gland No enlargement CHEST Breath sounds No abnormal Heart sound Faster than normal ABDOMEN Observation Normal Auscultation Normal Palpation Normal

DEFINITION Angina pectoris is a clinical syndrome usually characterized by episode or paroxysms of pain or pressure in the anterior chest. CAUSE The cause is insufficient coronary blood flow Resulting in a decreased for oxygen supply when there is Increased myocardial demand for oxygen in response to physical examination or emotional stress PATH PHYSIOLOGY

Due to any cause

Destruction of major coronary artery


Angina pain TYPE OF ANGINA Stable angina: Predictable and consistent pain that char occurs on exertion and is relieved by rest Unstable angina: Symptoms occur more frequency and last longer than stable angina the threshold for pain is lower and pain may occur at rest Intractable or refractory angina: Severe incapacitating chest pain Variant angina: Pain at rest with reversible ST segment elevation thought to be caused by coronary artery vasospasm Silent ischemia: Objective evidence of ischemia but patient reports no symptoms

CLINICAL MANIFESTATION Ischemia of the heart muscle Pain Choking Heavy sensation in the upper chest Discomfort to agonizing pain accompanied by severe apprehension Feeling of impending death The pain is often felt deep in the chest behind the sternum May radiate to the neck jaw shoulders and inner aspects of the upper arms usually the left arm Tightness Heavy choking or strangling Viselike



Subjective data Patient says I am having pain Objective data On observation it is evidence by facial expression as pulse & discomfort

NURSING GOAL DIAGNOSI S Pain related To reduce to imbalance pain reduce pain & demand

PLANNIN G Assess the general condition of the patient Assess severity location of the pain To provide the comfortable position to the patient Check the vital signs of the patient Provide O2 therapy Abstain ECG during pain as prescribed Assess the respiratory rate of the patient as well as pulse To administer Iv fluids Monitor wine output of the patient Administer vasodilator & anti platelet drugs to the patient Check the B.P of the patient every 2hours.

RATIONAL E Helps to know & plan about the needs of safe patient. Helps to know the nature of pain. To reduce pain. To assess any change in TPR & B.P To prevent Ischemia To know the cardiac.

EVALUATI ON Pain is reliever to some extend

Subjective data Patient says that I am feeling difficulty in breathing. Objective data On observation patient having dyspnoea & shallow repaired breathing tachycardia

Decreased cardiac output related to decreased contraction

To improve cardiac output

To know about the rates rhythm To maintain electrolyte balance To know about kidney function To improve the blood supply to the myocardiam To know about the hypertension

Cardiac output breathing activities to some extend

Subjective data Patient complaints about the chest tightness & breathing difficulty

Ineffective airway exchange related to fluid overload and pain

To maintain the normal breathing pattern

Objective data On observation patient Is restlessness & having discomfort cyanosis is present

Check the breath pattern of the patient Ventilate the air properly Administer 02 if needed Provide comfortable position to the patient Provide a humidified 02 to the patient Avoid no of visitors around the patient

Subjective data Patient says that he has feeling of anorexia & nausea Objective data On observation patient is having decreased gut movement & fear of hospitalization.

Imbalance nutritional status of the patient related to restlessness restricted diet fatigue.

To maintain the normal nutritional status of the patient

To asses the patient habit about food. To provide semisolid light diet of patient choice. Advised the patient to take food by himself.

To assess for any abnormal sound To meet the 02 demand of the body To smoothen the dry throat and eradicate dyspnea. To maintain the urine flow To relieve prevent any damage to mucus membrane. To maintain calm environment around the patient . as to relive discomfort and restlessness To plan menu accordingly To stimulate the hunger To improve the actives of the patient as it give sense of well being To prevent the vomiting

Airway is maintained &breathing is improved

Nutritional status is maintained up to some extent.

Provide anti emetics drugs of necessary or prescribed

Regarding medication Encourage the patient to take regular medication without disorder Tough about the side effects of the drug

Regarding exercise Teach the patient about active & passive exercise Advice the patient to avoid heavy exertion or activities. Provide psychological support to the patient restart the physical activity

Regarding diet Instruct the patient to take food rich in carbohydrates &low fat cholesterol & protein. Instruct him to take vegetarian and avoid animal fat Advise the patient to consume more fluid amount in diet Advise the patient to take complete bed rest. Regarding personal hygiene Advice the patient to maintain his personnel hygiene properly Prevent the patient from further complication


In this case study of APPENDICITIS have explained about the Introduction of disease Cause , factorsphysiology signs & symptoms diagnosis evaluation management .


Anthonys text book of anatomy and physiology, jaypee publication 11th edition. Brunners and suddarths, medical nursing 11th edition. Jaypee m. black, jane hokanson hawks medical surgical nursing 7th edition.