Identification Data:
Name of the patient : Manju Naskar
Age : 54 years
Sex : Female
Bed No : SICU -538
Reg No : 232/20/1116
Ward : SICU
Date of Admission : 01.01.2020
Date of Operation : 03.01.2020
Under Doctor : Dr. Priyam Mukherjee
Address : C/o- Late Mohan Naskar ,
2/2 Nanda Gopal Mukherjee Road,
Sarsuna, Kolkata - 700061.
Diagnosis : HTN, DM , Congenital Ptosis,
TVCAD With OP CABG [3 graft]
Chief Complain : Severe chest pain since midnight of
31.12.19.
HISTORY
Present History
a) Medical History : Severe angina pain since midnight of
31.12.19. Stable angina since last 2yrs.
On CAG Sever TVCAD with DM and HTN.
b) Surgical History : OP CABG [3 graft]
→ LIMA → LAD
→ AO → RSVG → OM
→ PDA
Past History
a) Medical History : Stable angina since last 2yrs.
Type 2 DM & HTN
b) Surgical History : No
Personal History
a) Blood Group : B+
b) Activity : Depends on others for moving
c) Sleep : Insomnia
d) Elimination : Constipation (sometimes)
e) Allergy : No
f) Diet : Salt restricted Diabetic Diet
Family History
a) Type of Family : Nuclear Family
b) Nos. of Family Members : 5
c) Nos. of Child : 1
d) Health of Family Members : Good
Socio Economic History
a) Housing : Water Supply, Ventilation, Sanitation,
Electricity
b) Income : 8 L /year
Education History
a) Madhyamik : Class 8 (passed)
PHYSICAL EXAMINATION
General
a) Date & Time : 06.01.2020 and 10:30Hrs.
b) Vitals : Pulse – 90 beats/min
BP – 140/90 mm of Hg
Respiration – 20 breath/min
Temperature – 97.3° F
SPO2 – 98%
MAP – 84
CNS System
a) Level of consciousness : Alert
b) Orientation : Orientated to Person, Place and Situation
c) Speech : Normal
Respiratory System
a) Respiratory Pattern : Normal
b) Chest expansion : Bilateral equal
c) Breath sound : Normal
d) Cough : Present
e) Air Entry : O2 given by nasal canula
f) Chest Pain : Present
Cardiovascular System
a) Heart Rate : 90 beats/min
b) Blood Pressure : 140/90 mm of Hg
c) Peripheral Pulse : Present
d) Heart Sounds : S1 and S2 audible
e) Cyanosis : Absent
f) Clubbing of Finger : Not Present
Gastro Intestinal System
a) Mouth : Clean and Dry
b) Teeth : 5-6 teeth absent
c) Tongue : Dry
d) Lip : Crack marked
e) Peristalsis : Present
f) Nausea/ Vomiting : Absent
g) Nutritional route : Oral
h) Abdomen : Soft and Non tender, No organomegaly
i) Elimination : Constipation
Genito-Urinary System
a) Voids : Through Catheter
b) Urine Colour : Pale Yellow
Muscular Skeletal System
a) Joints : Normal
b) Fracture : Not Present
c) Ambulant/Bed Ridden : Bed ridden
Integumentary System
a) Skin : Normal
b) Texture : Less than normal
c) Cyanosis : Not Present
e) Capillary refill time : Less than 3 second
f) Temperature : Normal
Eye
a) Eye Brows : Normal
b) Eye Lash : Normal
c) Eye Ball : Movable
d) Eye Lid : Ptosis
e) Vision : Blurred (Spectacle user)
Ear
a) Size and Shape : Normal
b) External Ear : Normal
c) Growth : Not present
d) Discharge : Not Present
e) Hearing : Semi-conscious
Nose
a) Size and Shape : Normal
b) Patency : O2 given by nasal canula
c) Discharge : Absent
d) Septum : Normal
e) Bleeding : Not Present
INVESTIGATION
Laboratory Investigation
a) PT : 13.4 sec
b) INR : 1.09
c) Haemoglobin : 11.0 gm/dl
d) PCV : 34.0 %
e) TLC : 5.1 cells/μl
f) Neutrophil : 80%
g) Lymphocyte : 12%
h) Eosinophil : 0.5%
i) Basophil : 0.0%
j) Monocyte : 0.3%
k) Bilirubin :
l) Platelet : 1,80,000 per microliter
m) RBC : 4.15 million/mm3
n) MCV : 78.4 femtoliters
o) Sodium : 136 mEq/L
p) Potassium : 4.6 mEq/L
q) BUN : 38 mg/dl
r) Urea : 82 mg/dl
s) Creatinine : 2.10 mg/dl
Echo Report as on 02/01/2020
a) LVEF : 65% No RWMA
b) Grade :
c) PASP : 32 Mm of Hg
Treatment
a) Medication : Clopitab 150mg OD 2pm
Tab Atorva 40mg HS
Tab Nitrocontin 2.6mg 9am – 9pm
Tab Aldactone 50mg ODPC
Pyregesic – 8am, 2pm, 10pm
Tab Alprax 0.5mg HS
Syrup Duphalac 15ml HS 10pm
Tab A-Z once HS
Insulin Human Actrapid fixed dose (10unit before breakfast and 6unit before dinner)
b) Oxygen : 4 litres/min through nasal cannula
c) Application of Deep Vein Thrombosis (DVT) stocking done
d) Random blood sugar (RBS) was checked 6hourly
e) Oral intake only 2L/day.
NURSING PROCESS
DAY – 1 (06.01.2020)
Nursing Assessment Nursing Diagnosis Goal Planning Implementation Evaluation
Subjective data – Ineffective airway To maintain • Respiratory rate, breath • 1. Check respiratory rate, (24 • Respiratory rate
Breathing problem clearance related clear airway. sound, quality of respiration, br/min), breath sound and is 18 bt/min,
and cough with to excessive chest movement should be quality of respiration
mucous production. mucous production assessed.
as evidence by
Objective data – cough and SPO2 • SPO2 should be monitored.
Respiration 24 • Monitor SPO2 (90%) • Saturation
br/min, breathing • O2 should be administered. improved to
difficulty, cough and • O2 given with nasal cannula 98%,
mucous production, (4lts)
SPO2 (90%) without • Nebulization should be
O2. given. • Nebulization given with
duolin respule • Cough expelled
• Steam inhalation should be out after Chest
given. • Steam inhalation given. physiotherapy.
• Deep breathing and
coughing exercise should be • Encourage Deep breathing
encouraged. and coughing exercise.
• Advice should be given to
expel the cough.
• Chest Physiotherapy should • Chest Physiotherapy given.
be given.
Nursing Assessment Nursing Diagnosis Goal Planning Implementation Evaluation
Subjective Data – Pain related to To reduce • Type and location of the pain • Assess moderate pain in Patient feel
Pain in surgical and surgical procedure pain. should be assessed. grafting site and surgical site. comfortable after
grafting. as evidence by pain positioning and
score and • Assess facial expression. reassurance.
Objective Data – verbalization. • Facial expression and body
Pain in surgical site, gesture should be assessed.
Pain score -5, and • Advice given to patient to
verbalization. • Patient should be advice to rate on the pain scale.
rate on the pain scale.
• Monitor pulse (90 bt/min),
• Pulse, BP, Respiration should respiration (24 br/min) and
be monitor. BP (130/90)
• Calm and quite environment
• Calm and quite environment provided by curtain and
should be provided. deaminized light.
• Comfortable position should • Provided comfortable
be provided. position by supportive
pillow.
• Affected extremity should be • Gently handled grafting leg
gently handled. during position change.
• Emotional support is given.
• Emotional support should be
given.
Nursing Assessment Nursing Diagnosis Goal Planning Implementation Evaluation
Subjective Data – Anxiety related to To reduce • Verbal and non-verbal sign of • Observe Verbal and non- Patient is relaxed
Fear about lifestyle major surgery, anxiety. anxiety should be observed. verbal sign of anxiety by and anxiety level
change and major pain, possible interfering. got reduced.
surgery lifestyle changes as • Good interpersonal
Objective Data – evidence by relationship should be • Established good
Facial expression, restlessness, established. interpersonal relationship
pain, restlessness, agitation and by nursing care.
agitation and verbalization. • Explanation should be given
verbalization. about the disease condition • Proper explanation given
about the disease, its
• BP should be checked progress and recovery
• Verbalisation should be • BP checked (150/90)
encouraged about fear,
anxiety and feelings • Encourage for verbalisation
about fear, anxiety and
• Emotional support should be feelings
given.
• Emotional support is given.
• Calm and quite environment
should be provided. • Provided calm and quite
environment.
• Instruction should be given
about relaxation technique
• Instruction given about
relaxation technique
• Family members should be (Meditation, Deep breathing)
advice to give mental • Advice given to the family
support to the patient. members for giving support.
DAY – 2 (07.01.2020)
Nursing Assessment Nursing Diagnosis Goal Planning Implementation Evaluation
Subjective Data – Imbalance Maintenance • Nutritional status should be • Nutritional status is assessed Patient appetite
Complain loss of nutrition less than of adequate assessed. (Malnutrition dry skin and has increased to
Appetite and Nausea. body requirements nutrition mucous membrane some extent and
related anorexia, nausea has
Objective Data – nausea and dietary subsided.
Does not eat well and restrictions, • Dietary pattern and • Dietary pattern and
looks weak and contributing factor to alter contributing factors are
fatigue. nutritional intake should be assessed
assessed.
• Patient food preference • Dietary history taken and
within dietary restrictions preferable food given at
should be provided. meals.
• High protein and vitamin, • Provided High Calorie, salt
Low Fat and Carbohydrate, restricted diabetic diet.
Low salt diet to be provided.
• Rational for dietary • Explanation given about
restrictions should be dietary restrictions.
explained.
• Water should be provided as • Water is given.
per need.
• Daily weight should be • Weight is recorded. (73 kg)
checked.
Nursing Assessment Nursing Diagnosis Goal Planning Implementation Evaluation
Subjective Data – Activity intolerance To • Physical activity should be • Assess physical activity. Patient can
Unable to perform related to as participate in assessed. perform most of
daily activities. evidence by self-care the daily activity.
inability to perform activities • Schedule rest period should • Rest period provided as and
Objective Data – daily activities. within be provided. when required and after
Looks weak and tolerance. main meals.
fatigue, need assist to
perform daily • Independent self-care • Advised to perform self-care
activities. activity to be prompted. activity as tolerated and
assisted if fatigue.
• Passive and active range of • Demonstrate passive and
motion exercise should be active motion exercise
demonstrated.
• Proper positioning to be • Proper position done by
provided. pillow.
DAY – 3 (08.01.2020)
Nursing Assessment Nursing Diagnosis Goal Planning Implementation Evaluation
Subjective Data – Alter sleep related To induce • Calm and quite environment • Calm and quite environment Patient sleep well
In sufficient sleep. to hospitalization sleep should be provided. provided with curtain and and looks fresh.
as evidence by deaminized light.
Objective Data – sleeping pattern,
Drowsiness, facial drowsiness and • Comfortable atmosphere • Comfortable position done
expression and verbalization. should be provided. by pillow and Tab “Alprax”
verbalization. 0.5mg given before bed
time.
• Stress and anxiety should be • Stress and anxiety reduced
reduced. by proper explanation of the
surgery and its
improvement.
• Schedule nursing activity • Schedule nursing activity to
should be given when be given when conscious.
conscious.
• Medication should be • Medication provided as per
administered as per advice. advice (“Serenace” 15drops
BD)
• Bedtime rituals should be • Promote bedtime rituals by
promoted. taking with family members,
praying or reading books.
• Appropriate diet should be
given
• Light diet given and tea,
coffee avoided. Low Fluid
intake is advised.
Subjective Data – Risk for infection To minimize • Central line and peripheral • Central line and peripheral
In related to open possible risk line should be checked and line dressing checked every
heart surgery, of infection. dressing every day. day.
Objective Data – central line,
I arterial line and • Before and after each • Wash hand before and after
follis catheter. patient care, hand should be each activity with hand
washed. sanitizer.
• Systemic and localize sign • Assess Systemic and localize
and symptoms should be sign and symptoms of
assessed. infection (Redness, Swelling
and Tenderness at the site
and temperature checked)
• WBC and Differential count • Monitor WBC and
to be monitored. Differential count.
(neutrophil-60%,
• Follis catheter to be change lymphocyte-
every 3 days interval. 35%,enosonophil-01%,
monocyte-04%).
• Personal hygiene should be • Change Follis Catheter
maintained.
• Maintain personal hygiene
by given sponging, mouth
care.
PROGNOSIS
Day Temp Pulse Respiration BP CBG Weight Oxygen GCS Pain Shortness Sleep Remarks
(°F.) (bt/min) (br/min) (mm of Hg) (mg/dl) (Kg) (ltrs/min) score of breath
On 98.6 90 24 140/70 220 73.9 4 6 + Insomnia Severe angina
Admission pain, weakness
06.01.2020 98.2. 90 24 130/90 210 73.9 4 5 + Insomnia Pain in surgical
site, weakness
07.01.2020 97.3. 86 20 130/80 184 73.8 - 3 Absent Insomnia Pain reduced,
weakness
08.01.2020 98.4°F. 84 22 130/80 148 73.8 - 2 Absent Insomnia Slight pain,
weakness
