SUBMITTED TO Ms. Sucheta Yangad Asso. Prof.

(med-surg)

SUBMITTED BYMr. Sanvar mal soni Msc. final year (med-surg)

Submitted on- 2nd feb. 2013

HISTORY OF THE PATIENT

IDENTIFICATION DATA Name of the patient Age Gender Bed No. Ward IPD No. OPD No. Date of admission Educational status Occupation Monthly income Religion Mother tongue Marital status Address Diagnosis : : : : : : : : : : : : : : : : Mrs. Svitri Bai Chavan 77 years Female 01 Intensive coronary care unit 1178 14919 01/03/2013 10th standard House wife Appox. Rs. 8000/ month Hindu Marathi Married Mahatma fulle Nagar, dapodi, pune. Anterior wall MI with DM

CHIEF COMPLAINTS AND PRESENT MEDICAL HISTORY Patient was apparently asymptomatic before 1 month of admission and after then She started left sided chest pain, dyspnea on exertion and sweating but since 2 days of admission she started to having severe chest pain and shortness of breathing. PAST MEDICAL HISTORY The client had the history of diabetes mellitus since 5 years. Client Had the history of pain in chest infrequently . Pt had no history of other major disease. PAST SURGICAL HISTORY Client has undergone the surgery of hysterectomy 25yrs ago.

FAMILY HISTORY Family tree:

Patient

husband

Daughter FAMILY INFROMATION

son

son

Sr. No 1 2 3 4

Name of Family Members Mr. pandurang chavan Ms. Khusi vitkar Mr. Sunil chavan Mr. sanjay chavan

Relationship with patient Husband daughter Son Son

Age (yrs.) 80 46 45 42

Educatio n th 8 pass 10th pass Graduate 10th pass

Occupation Worker House wife Teacher worker

Marital Status Married Married Married Married

Health status Healthy Diabetes Healthy Healthy

Family income per year Family interpersonal relationship

: Rs.1 lakh approximately. : All the family members have good IPR. No disharmony.

Family history of illness

: patient`s mother had the history of diabetes mellitus.

The family members of the patient were healthy except daughter. Daughter of the patient having diabetes mellitus. There was no family history of any other illness like cancer, arthritis or neurological disorders were not found. DIETARY HISTORYPatient used to take mixveg diet. She used to take chicken once in a week. She also used to take green leafy vegetables and other veg diet. She used to take meals in lunch time and dinner. She did not use to take breakfast in morning. She used to take tea four times in a day. SOCIOECONOMIC STATUS A) HOUSING Type of house - Small house with 2 rooms made up of bricks. Lighting Lack of proper lighting facility. Ventilation 1 window and 2 doors for ventilation. Water facility once a day. Sanitation Lack of sanitation and hygiene.

B) FOOD HYGIENE PRACTICES Lack of food hygiene. Not washing hands before cooking and not washing vegetables also before cooking food. Cook food in unhygienic condition. C) PERSONAL HYGIENE PRACTICES Not maintaining personal hygiene. Not taking bath daily. Not washing hands and cutting nails etc. D) COMMUNITY RESOURCES Resources like transportation are available by bus and train. Educational resources are available up to higher education. E) RELIGIOUS PRACTICES Client and his family strongly believe in the god and they worship regularly. They visit temple sometimes. F) FAMILY INCOME & EXPENDITURE Food Rs.2000 per month Clothing Rs.500 per month Education Nil Health Rs.1000 per month ALLERGIES AND MEDICATIONS Client doesnt have any allergies from medicines, food, dyes etc.

PHYSICAL ASSESSMENT GENERAL APPEARANCE Level of Consciousness: Orientation: Activity: Body Built: Breath odour Sign of distress Hygiene and groomingConscious Oriented to time, place and person. patient is less active Moderate foul smell patient is confused and asking again and again about her disease. patient does not use to groom independently.

ANTHROPOMETRIC MEASUREMENT 1. Height: 55 VITAL SIGNS 1. Temperature: 99.8F 2. Pulse: 80/min 3. Respiration: 28/min 2. Weight: 50 kg

4. Blood Pressure: 120/86 mmHg INTEGUMENTORY SYSTEM Skin color Dermatitis Allergies Lesions/Abrasions Tenderness /Redness Surgical scar Abnormal growth Cyanosis Jaundice HyperpigmentationBrown No skin infections No skin allergies non healing diabetic wound present on left leg at ankle joint. No redness and tenderness. Surgical scar present at lower abdomen. No abnormal growth. paleness present at face and finger tips. not present. present over the upper limbs.

HEAD Hair: Color of Hair: Scalp: Pediculosis: Sinus areaEqually Distributed Grey Clean, No Dandruff Absent no inflammation.

 Nodes-

not present.

FACE Face: Facial Puffiness: Symmetrical Present

EYES Eye Brows: Eye Lid/Lashes: Eye Ball: Conjunctiva: Sclera: Puncta: Cornea: Iris: Eye Discharge Use of glasses Pupils Visual AcuitySINUS Maxillary sinus infection Frontal sinus infection EARS Size & shape Position And Alignment Redness Discharge Cerumen Lesions Foreign Body Hearing Acuity Use of Hearing AidsNormal & symmetrical. Normal. Absent Absent Present Absent Absent Normal No No No Symmetrical No Redness/ Swelling/Discharge/Lesions Normal Normal/ No Lesions White Red and not swollen Regular Ridges Flat Absent No Equally Reacting To Light and normal size Not proper patient not able to see the far objects.

NOSE Nasal Septum Nasal Polyps Nasal DischargeORAL CAVITY LIPS Cleft Lips Stomatitis Number of Teeth Dentures Dental Carries Odour of Mouth Gums Palate and uvula Taste NECK General structure Trachea Thyroid Nodes Muscles normal normal not palpable. not palpable, absent normal strength No Crack/ Healthy lips. No cleft lips. Absent 28 teeth. Absent Present Foul Smell Weak no inflammation. Patients able to identify the taste. Not deviated Absent Absent

CHEST AND RESPIRATORY SYSTEM Respiratory Rate Thoracic Cage POSTERIOR THORAX Inspection Shape and Summetry Skin Color and ConditionNormal shape. Anterioposterior to transverse diameter in ratio of 1:2 Normal 28 per min. Normal shape. Anterioposterior to transverse diameter in ratio of 1:2

Exaggerated spine curvature, slight kyphosis present. palpation Skin is intact, uniform temperature. Chest wall intact, tenderness absent. No presence of masses.

 Chest expansion FremitusPercussion Resonance-

decreased chest expansion (2 cm) increased fremitus.

Normal restricted lung excurtion (2 cm).

Diaphragmatic ExcursionAuscultation Breathing Sound Respiratory PatternANTERIOR THORAX

Rales crackles at inspiration Rapid breathing with effort.

Costal angle is 50 degree. Skin is intact on anterior chest side. Rales crackles at inspiration. Reasonance sound present on percussion.

CARDIO VASCULAR SYSTEM PulsePrecordium No heaves or lift present on palpation. Aortic pulsation absent. Point of maximal impulse Heart Sound Abnormal Heart Sound Murmurs Carotid Pulse Rate Blood Pressure5th intercostal space, midclavicular line S1 , S2 Heard S3 sound present. Absent 80/min 120/86 mmHg 80/min

Chest pain, radiationPositive chest pain at the left side that radiates to the left shoulder, palpitations noted at some times Carotid pulse Decrease pulsation, asymmetric volume. No sound present on auscultation. Jugular vein Visible distended. Peripheral pulses Symmetric volume, rate and rhythm.

ABDOMEN AND INGUINAL AREA Abdominal Girth Diarrhea / Constipation Counter and tone Scar marks Liver Spleen Kidneys Bladder Hernias MassesInspection Size Symmetry Scar Lesions and rednessPalpation Tenderness Fluid Collection Mass/SoftNo tenderness Absent No palpable mass. Protuberant Flat Normal No scar present surgical scar marks present over lower abdomen area. 76 cm Absent. symmetric. surgical scar marks present over lower abdomen area. not palpable. not palpable. not palpable, normal. normal. absent. absent.

No enlargement of liver, spleen. Percussion Ascitis / Peritonitis No Gas /Fluid Collection Tympanic sound present over the stomach area. Dullness sound over the liver. Auscultation Bowel SoundsGENITO URINARY Frequency of Urination ColorNormal Pale yellow. properly heard. Absent

No complaints of Anuria / Hematuria / Dysuria / Incontinence. Catheter PresentNo

 Urethral Discharge-

No

MUSCULO SKELETAL SYSTEM Range of Motion Joint Swelling / Pain Weakness Extrimity strength EdemaNERVOUS SYSTEM Level of consciousness Orientation Emotional state Language Motor coordination Reflexes Conscious, coherent and responsive Oriented to time, place and person Calm, but upon exertion she feels dizzy and answers questions inappropriately. Marathi Normal coordination. Normal Normal ROM. no inflammation. Complaint of pain at the time of walking. No weakness. Equal extremity strength. edema present over lower exterimities.

INVESTIGATIONS . DIAGNOSTIC STUDIES

SR NAME OF NO. INVESTIGATION 1. Haemoglobin 2. WBC count

NORMAL VALUE 12-16 gm% 400011000/cumm 40-75 % 20-45 % 0-5 % 0-5% 0-2% 70-120 mg% ----135-145 mEq/L

PATIENT VALUE 12.3 gm% 12000/cumm

REMARK Normal Elevated

3.

Neutrophils Lymphocytes Eosinophil Monocytes Basophils

60 % 35 % 04 % 02% 00 % 140 mg% A positive Negative 135 mEq/L Elevated ----Normal Normal

4. 5. 6. 7.

Random blood sugar Blood group HIV Serum sodium

8. 9. 10. 11.

Serum potassium Serum creatinine Serum chloride CK-MB

3.5-4.5 mEq/L 0.8-1.4 mg/dl 96-106 mEq/L 0-3 ng/Ml

4.2 mEq/L 1.8 mg/dl 105 mEq/L 48ng/dl

Normal Normal Normal Elevated

Others Laboratory Examinations

ECG ST segment elevation CAG LAD- type III mid segmental 30% stenosis. LCX- non dominating artery with 90% mid segmental stenosis. RCA dominating artery. Ostial 50% stenosis. 2D ECHO Left ventricular ejection fraction 45% Grade 1st diastolic dysfunction Mitral annular calcification.

HEALTH EDUCATION AND DISCHARGE PLANNING Client was given health education on various aspects of health, disease condition, its diagnosis, treatment and follow-up during his stay in the hospital and at the time of discharge. 1) DISEASE CONDITION Client was explained about the causes of the myocardial infarction. She was explained about the severity of the disease. She was guided for the prevention of the same condition in the future and maintains food hygiene at home. Special instructions were given on food hygiene.

2) MEDICATIONS Patient was explained about the importance of medications. She was explained about the route, time and dosage of medications. Side effects were told to be reported to the doctor. Follow-up of the treatment was advised. She was advised not to give any medications without doctors order. Reinforced the importance of having blood sugar checked every day. In patients with self-administer insulin, demonstrate patient the appropriate preparation and administration techniques.

3) NUTRITIONAL THERAPY Eat a variety of foods as recommended in the Diabetes Food Pyramid to get a balanced intake of the nutrients your body needs - carbohydrates, proteins, fats, vitamins, and minerals. Reduce the amount of fat you eat by choosing fewer high-fat foods and cooking with less fat. Eat more fiber by eating at least 5 servings of fruits and vegetables every day. Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks, sodas, and tea or coffee sweetened with sugar. Use less salt in cooking and at the table. Eat fewer foods that are high in salt, like canned and packaged soups, pickles, and processed meats 4) HEALTH TEACHING Encouraged client to do at least 30 minutes of walking a day as a form of exercise. Instructed to monitor blood sugar regularly. Adjustments in diet, medication and exercise can be made accordingly.

Encouraged to stick to the monitoring protocol prescribed by the doctor. Generally, blood is monitored before meals and at bedtime. Safety precaution should be maintained to prevent foot injury such as do not wear open shoes or walk barefoot Teach to the patient signs and symptoms of diabetic neuropathy and emphasize the need for safety precautions because neuropathy decreased sensation can hide sense injuries. Adjust of activities to avoid over exertion and fatigue, allow rest periods

BIBLIOGRAPHY 1. Brunner & Suddarth, Textbook of Medical Surgical Nursing, 11th edition, Lippincott Williams & Wilkins, pp:896-897. 2. Gulanick Myers, Nursing Care Plans, 6th edition, Mosby publication, pp:54-57. 3. Holloway Nancy M., Medical Surgical Care Planning, 3rd edition, Springhouse publication, pp:891-894. 4. http://en.wikipedia.org/wiki/Miocardial infarction.

5. http://www.emedicinehealth.com/miocardial infarction/page6_em.htm 6. http://www.wrongdiagnosis.com/g/miocardial infarction/treatments.htm 7. Lewis, Medical Surgical Nursing, 6th edition, Mosby publication; pp:1020-1023. 8. Lippincott, A Proffessional Guide to Pathophysiology, 1st edition, Lippincott Williams & Wilkins, pp:686-688. 9. Skidmore-Roth Linda, Nursing Drug Reference, 22nd edition, Mosby & Elsevier, pp:21-23; 42-44. 10. Tortora, Principles of Anatomy & Physiology, 10th edition, Jhon Wiley & Sons, pp:851-858. 11. Patients file.

NURSING CARE PLAN

NURSES NOTES

DISCHARGE PLANNING

HISTORY COLLECTION

PHYSICAL ASSESSMENT