BEE ENN COLLEGE OF NURSING

NURSING CARE PLAN

ON
ISCHEMIC HEART DISEASE

SUBMITTED TO SUBMITTED BY

SUBMITTED ON
IDENTIFICATION DATA OF PATIENT
Name of the patient : Mr. Bodh Raj

Age : 63 years

Sex : Male

Education : illiterate

Marital status : Married

Ward : Cardiac-Thoracic Ward

Bed no. : 10

Date of admission : /04/2024

Religion : Hindu

Occupation : Labour

Monthly family income : 25,000

Diagnosis : Ischemic Heart Disease

I.P.No. : 884967

II. CHIEF COMPLAINTS: 63 years old Mr. Bodh Raj was admitted in super
speciality hospital Jammu on /04/2024 with chief complaints of:-

 Chest pain-1 week Headache

 Cough -6 days
 Shortness of breath-3 days
 Loss of appetite
 Anxiety

III. HISTORY OF HEALTH STATUS

(a) Present Medical History: 63 yrs old Mr. Bodh Raj was admitted in super speciality
hospital Jammu on /04/2024 with chief complaints of chest pain since 1 week, cough since
6 days, shortness of breath since 3 days, headache,loss of appetite, anxiety and is on
medication aspirin, Lasix, inj.Monocef, inj.Aciloc.

(b) Past Medical History: No significant past medical history

(C)Present Surgical History: No significant present surgical history

(d)Past Surgical History: No significant past surgical history

IV. FAMILY HISTORY:

(a)Family Tree: female male

Bodh raj (63 yrs) Savita Devi (60yrs patient)

Surinder (28yrs) Rakesh (36yrs) Sushma(34)

Sakshi(10yrs)

s. Name of family Age Sex Relationshi Occupation Health Educatio

no Member p status n

1 Bodh Raj 63yrs Male Patient Labour unhealth illiterate

y
2 Savita Devi 60yrs Female Wife Housewife Healthy illiterate

3 Rakesh 36yrs Male Son Private Healthy 12th

employ
4 Surinder 28yrs Male Son Student Healthy B.ed

5 Sushma 34yrs Female Daughter- Housewife Healthy 10th

in-law
6 Sakshi 10yrs Female Grand School Healthy 5th class
daughter going

V. Personal History:

(a) Habits : Patient is vegetarian, non-smoker, non- alcoholic

(b) Sleep : Sleeping pattern is normal but get sometimes disturbed due to pain.

(c)Nutrition : Patient is well nourished

(d)Elimination pattern : Normal elimination.

VI. Socio Economic Status:

(a) Housing : Proper housing

(b) Ventilation : Proper ventilation

(c) Electricity : Good electricity

(d) Water supply : Tap water.

PHYSICAL ASSESSMENT/EXAMINATION

Vital signs

Temperature : 97.60 F Normal

Pulse : 110beats/minute

Resp. Rate : 26breaths/minute

B.P. : 140/90 mmhg

GENERAL APPEARANCE

Nourishment : Well Nourished

Body build : Normal

Activity : Patient performs the daily activities.

Consciousness : Patient is oriented to place, time and person

Look : Good looking

Body curves : Normal

Movement : Normal

Height : 5 feet 2 inches

Weight : 65 kg

Skin

Colour : Pale White

Texture : Eudermic

Temperature : 97.60F

Lesions : Absent

Lumps : Absent

Itching : Absent

Dryness : Absent

Moles : Absent

HEAD

Size : Normal

Shape : Normocephalic

Hair &Scalp/Skull/Face

Colour : Black

Distribution : Equally distributed

Hair loss : Absent

Dandruff : Absent

Lice : Absent

Eyes

Vision : 6/6 Normal

Glasses : Absent

Pain : Absent

Itching : Absent

Discharge : Absent
Eye lashes : Normal

Sclera : Normal

Diplopia : Absent

EARS

Hearing : Proper

Pain : Absent

Itching : Absent

Ringing : Absent

Vertigo : Absent

NOSE & SINUSES

Deviated nasal septum : Patient has no deviated nasal septum

Nostrils : Round

Discharge : Absent

Allergies : Absent

Obstruction : Absent

Pain : Absent

Epistaxis : Absent

MOUTH &THROAT

Tongue : Normal

Lesions : Absent

Lips : Hydrated

Bleeding : Absent
Dental care : Absent

Odour : No foul smell

NECK

Stiffness : Present

Lymph nodes : Normal

Swelling : Absent

Pain : Absent

Thyroid gland : Normal (4.0-6.0cm)

I. Respiratory System

H/O Smoking : No history of smoking

Sputum (Colour) : Present (yellowish)

Asthma : Absent

Wheezing : Present

Haemoptysis : Absent

Inspection : Bilateral symmetrical movement of chest wall

Palpation : No tenderness

Percussion : Absence of fluids

Auscultation : Lung sound is not normal

II. CARDIO VASCULAR SYSTEM

H/O Hypertension : 140/90mmhg

Varicose veins : Absent

Dyspnea : Present
Orthopnoea : Present

Chest pain : Present

Heart sound : S1 and S2 heard

Pulse : 110 beats/minute

Inspection : Normal shape

Palpation : Peripheral pulse is normal

Auscultation : Abnormal heart sounds are heard

III. GASTRO INTESTINAL SYSTEM.

Shape & symmetry : Normal

Pain : Absent

Anorexia : Present

Diarrhoea : Absent

Nausea : Absent

Constipation : Absent

Vomiting : Present

Inspection : Shape and size of abdomen is normal

Palpation : Tenderness is not present

Percussion : No abnormal fluid

Auscultation : Bowel sounds are heard

IV. GENITO URINARY SYSTEM

Nocturia : Absent

Dysuria : Absent

Incontinence : Absent
Infection : Absent

Inspection : Shape and size of kidneys is normal

Palpation : No supra pubic and bladder distention is found

Percussion : No edema

V. GENITO REPRODUCTIVE SYSTEM

MALE

Redness : Absent

Inflammation : Absent

Itching : Absent

Pain : Absent

Disharge : Absent

Swelling : Absent

VI. MUSCULO-SKELETAL SYSTEM

Posture : Normal

Muscular cramps : Absent

Range of motion : Proper

Swelling : Absent

Any deformities : Absent

Inspection : Normal musle structure

Palpation : No tenderness

VII. INTEGUMENTORY SYSTEM

Colour : Pale white

Texture : Eudermic

Bleeding : Absent

Discharge : Absent

Infection : Absent
VIII. HAEMATOLOGICAL SYSTEM

Hb% : 12.8gm/dl

Bleeding tendencies : No impaired bleeding tendencies

Any blood transfusion : Absent

IX. NEUROLOGICAL SYSTEM

Level of consciousness : Conscious

Activity : Active

Dizziness : Absent

Sensation of pain : Present

Tremors or seizures : Absent

Mental status : Patient is oriented to place, person and time

Reflexes : Normal

Cranial nerves function : Abnormal

GCS : E4 V4M3

INVESTIGATIONS:
S.No Name of Investigations Patient value Normal value Remarks

1 Haemoglobin 12.8gm/dl 12-14gm/dl Decreased

2 Blood sugar 141mg/dl 140-150mg/dl Normal

3 Sodium 135mg/dl 135-145mg/dl Normal

4 Serum creatinin 0.7mg/dl 0.8-1.5mg/dl Slightly

decreased
5 C-reactive protein 90 mg/l 10-100mg/dl increased

6 Potassium 4.5mg/dl 3.5-5.5mg/dl Normal

7 Serum urea 20mg/dl 15-50mg/dl Normal

MEDICATION CHART
S.no Name of Dose Route Frequency Action Side Nurses
drug Effects Responsibility
1 Aspirin 325 orally B.D Non- Upset Check
mg steroidal stomach, patient’s vital
anti- Heartburn signs before
inflammatory administering
drug the drug.

2 Injection 40mg I.V O.D Antacid Headache, Advice

pantop Nausea, patient
Vomiting without
consulting
doctor don’t
stop the
medication

3 Injection 20mg I.V B.D Loop diuretic Vomiting, Before giving

Lasix Hairloss, this
nausea medication
monitor
intake output
chart of
patient.

4 Injection 1 I.V B.D Antibiotic Skin rash, Assess vital

Monocef amp. Diarrhoea, signs before
Nausea administering
and this drug.
vomiting
NURSING DIAGNOSIS

PATIENT PROBLEM NURSING DIAGNOSIS

 Chest pain  Acute pain related to disease

condition (ischemic heart disease) as
evidenced by verbalization and pain
scale.

 Increased blood pressure

 Hypertension related to disease
condition as evidenced by checking
vitals of the patient.

 Impaired cardiac output

 Decreased cardiac output related to
increased peripheral vascular
resistance secondary to hypertension
as evidenced by vital signs.

 Loss of appetite
 Imbalanced nutritional pattern less
than body requirement related to
hospitalization as evidenced by intake
output chart.

 Knowledge deficit
 Knowledge deficit related to disease
condition as evidenced by frequent
questioning by patient.
 NURSING CARE PLAN:
Assessment Diagnosis Goal Planning Implementat Rationale Evaluatio
ion n

Subjective Acute pain To Check the General To get the Patient is

Data:-Patient related to reduce general condition of baseline comfortabl
complaints disease the chest condition of patient was data. e and
that he is condition pain Patient. checked. stable up
having chest (ischemic Expecte to some
pain. Heart d Check the Pain level of To check extent.
Objective Disease) Outcom pain level of patient was the
Data:- as e patient. checked by intensity
Observation evidenced Patient’s pain scale of pain.
Verbalization by chest
Pain scale verbalizatin pain will Check the Vitals of To know
Acute pain in and pain be vitals of patient were the vitals
Myocardium scale. reduced patient. checked. of patient.
Of heart. upto 0
Temp.-97.6 F
Dull facial some Pulse-110b/m
expression. extent. Bp-
140/80mmhg

Provide Provided the To divert

divertional divertional the mind
therapy to therapy to of patient
patient patient. from pain.

Provide Provided To reduce

medication if medication as the pain
prescribed by prescribed by
doctor doctor.
e.g. Aspirin
Assessment Diagnosis Goal Planning Implementat Rationale Evaluatio
ion n

Subjective Hypertensio To Assess the Condition of To get the Patient is

Data:-Patient n related to reduce condition of patient was baseline feeling
says that he is disease the blood patient. assessed. data. Comfortab
having condition Pressure le
headache. (ischemic of and is able
Objective Heart patient. Check the Vital signs of To know to attain
data:- Disease ) as Expecte vital signs of patient was the blood normal
Observation evidenced d patient checked pressure of blood
Vital signs by checking outcome Bp:-140/90 patient. pressure as
vitals :-Patient evidenced
will by vitals.
attain Provide salt Salt restricted To
normal restricted diet diet was maintain
blood to patient. provided to the blood
pressure patient. pressure of
with in patient.
3-4
hours.
Provide more More fluids To
fluids to the were decrease
patient. provided to the
patient that increased
are juices etc. bp of
patient.

Administer Administered For

medication medication as therapeuti
(loop diuretic prescribed by c purpose
lasix) to doctor.
patient as
prescribed
Assessment Diagnosis Goal Planning Implementati Rational Evaluatio
on e n

Subjective Decreased To Assess the Assessed the To get Patient

data:-Patient cardiac increase condition of condition of the feels
says that he output cardiac patient. patient by baseline comfortabl
feels related output. observation. data. e upto
restlessness, increased some
breathing peripheral Provide Adequate rest To extent and
difficulty and vascular adequate rest was provided provide is able to
chest pain. resistance to patient. to patient. comfort attain
Objective Secondary to patient normal
data to cardiac
Observation hypertensio output.
Inadequate n as
Oxygen evidenced Provide Provided To
Supply by vital cardiac table to cardiac table to improve
Facial signs. patient. patient the
Expression. breathin
g pattern
of
patient.

Administer Oxygen To
oxygen therapy was reduce
therapy to provided to the
patient patient breathin
g
difficulty

Elevate the Head of bed To

head of bed. was elevated. increase
the
cardiac
output of
patient.
HEALTH EDUCATION
Patients Name: - Bodh Raj

MRD No.:- 943612

TOPIC CONTENT REMARKS

DIET(calcium Advice patient to take calcium rich diet Patient and family members
rich diet) such as cheese, milk etc. well co-operated with us.

PERSONAL Advice patient to follow following Patient and family members

HYGIENE.  Hand washing. well co-operated with us.
 Nail cutting and other measures.

MEDICATION Advice patient to take proper medication Patient and co-operated well.
on proper time

POSITIONING Advice patient’s family members to Patients family members

change the position of patient on regular Co-operated well.
time.

CARE OF Provide passive exercises to patient. Patient co-operated with us

PATIENT Advice patient about advantages of well.
WITH exercises.
PHYSICAL Advice patient about passive exercises
MOBILITY. such as abduction,adduction,flexion.

FOLLOW UP Advice patient for follow up care Patient co-operate with us

well.
PROGNOSIS
The prognosis for patients with Ischaemic Heart Disease varies greatly in function of the
disease’s progression and extension. When an acute infarction occurs, the prognosis primarily
depends on the presence of arrhythmias and how quickly treatment is established and so it is
essential that you seek healthcare advice without delay for the best possible prognosis.

Prognosis depends on which area of the heart is affected and the chances of repairing
damaged arteries. A large proportion of patients can, with appropriate treatment, eliminate
the symptoms forever; whereas others may see their life expectancy reduced.

CONCLUSION
In conclusion, ischemic heart disease is a significant and potentially life-threatening condition
that requires comprehensive management and prevention strategies. Understanding the risk
factors, symptoms, diagnosis, and treatment options is essential for both healthcare
professionals and individuals to reduce the burden of this disease and improve cardiovascular
health. Additionally, ongoing research and advancements in medical science hold promise for
better outcomes and innovative treatments for ischemic heart disease in the future.
BIBLIOGRAPHY

 Monga Poonam; “Text book of Anatomy and Physiology”; Jay Pee Publishers edition
13th page no 240-245.

 Brunner and Sidharth; “Text book of medical surgical nursing”;12th edition volume
2,page no 415-422.

 Wilson and Ross: “Anatomy and Physiology in Health and illness”13th edition
;Elsevier Publishers,page no-149-155.
 https://enm.wikipedia.org/wiki/heartdisease.
 https://mayafieldclinic.com/pe.anat.hearthtm