Introduction

As a part of my clinical requirement when I had been posted to Columbia Asia

Hospital, I selected a patient by name Mr.Rakesh who is been diagnosed as IHD with
Double Vessel Disease to provide complete nursing care by using a nursing theory. I
provided him care from 10-11-08 to 12-11-2008.

A. Demographic data

Name : Mr. Rakesh

Age : 50yrs

Date : 10-11-2008

Time of arrival to unit : 10:30:45am

Mode of admission :-

Hospital No. : 113890

Contact phone no. : 984573214

Admission from : House

Admission medical diagnosis : IHD, Double vessel diseases

Surgical Procedure : Percutaneous transluminal Coronary

Angioplasty

B. Health Pattern Assessment

1. Health perception/ Management
At present patient is been admitted to the hospital with complaints of severe chest
pain, weakness.
Previous Hospitalisation
Previous patient was quite healthy. He didn’t admit to any hospital for treatment.
But he use to go for general check up in his native.
Statement of the patient’s general appearance
 Patient is moderately built and nourished. Patient looks very weak, and tired. His
skin condition is quite normal. Hair distribution is normal.
Personal history
Patient is non-vegetarian. He uses to take alcohol twice in a week. He is having
habit like smoking, and takes half pack a day.

2. Nutrition/ Metabolic
Patient is non-vegetarian. His appetite is good. His G.I functioning is good. There
is no loss of weight. He is having dental caries.

3. Elimination
Patient’s bowel and bladder pattern is normal. His bowel movement is regular and
no history of constipation. Bladder patterns are regular, voids approximately 5 times a
day. No history of disuria, haematuria.

4. Cardiovascular status
On inspection the size and shape of the chest is with in normal limit; surgical scar
present over the sternum. No sign of infection. Healing well. C/o pain over the surgical
wound. On palpation carotid pulse and peripheral pulses which is regular; normal sinus
rhythm; rate 94b/m. cardiac borders well with in normal limits. S1 and S2 heard well.
Respiratory status
On inspection size and shape normal, chest expansion equal in both side and
respiration are normal. On palpation no local swelling, no lymphnode enlarge. On
percussion normal resonance in both lungs. On auscultation breath sounds are irregular
high pitched in both side.

5. Activities of daily living/ Mobility status

Patient is moderately active. He can’t able to do his activities without any
assistance. At present because of postoperative period he needs assistance for few
activities like bathing, dressing, grooming, toileting and all.
6. Level of consciousness
Patient’s conscious level is good. He is oriented for place, time and person.
Patient doesn’t have any complaints of Epilepsy/ Seizures/ Parkinson’s.

7. Cognitive and Perception

Reflexes: Patient’s reflexes are good and he can react well to the stimulus.
Pupillary reaction is good for lighting. Grasping capacity of hands is good, but because of
postoperative weakness it’s been reduced. Movements of the extremities are good.
Sensorium: He can able to see well, no problem with vision. No abnormalities
found in hearing capacity of the patient. Patient’s sense of smell and taste are found to be
normal. Patient will react to touch. But he has got numbness and dizziness in the body
and extremities.
Pain: He is suffering from pain in the operated site, which is disturbing his daily
activities and disturbs his resting periods.
8. Sleep/Rest
Patient gets much sleep disturbance because of pain and dyspnoea. He cannot able
to take rest completely because of pain. Medications will relieve pain for some time and
provide rest and sleep.

9. Self Perception/ Self Concept

Patient feels very sad and depressed for his unhealthy condition. He is much
disturbed from his condition. Patient says because of his illness family members are
much disturbed.

10. Role/ Relationship

He is father of two children. Wife supports and takes care of him a lot. He has
good relationship with all family members.

11. Sexuality/ Reproduction

 Patient doesn’t have any problem related to this.

12. Coping/ Stress

At present patient is under much stress and tension because of his disease
condition. Because of his family members support he can able to cope up with the
situation and forget his pain for little extent.

13. Value/ Belief

Patient is more religious, when he find time hospital he pray, and he says his wife
and children are praying for him which makes him to feel much relaxed and happy.

C. Orientation to unit

Patient is been oriented to:

 The proposed care has been explained to the patient/ family members
 The expected results have been explained to the patient/family members
 The possible complications have been explained to the patient/ family members

D. Vital signs

Height - 155cms

Weight - 56kgs

Temperature - 99.2

Pulse - 88 b/m

Respiration - 22/m

B.P. – 120/60 mm hg
Investigations

Sl.No Investigations Patient’s Value Normal Value

1 Blood
 Heamoglobin 11.6 gm/dl 14-16
 Red blood cell 4.47 milcmm 4.5-6.51

 PCV 39.9% 20-54

 Platelets 3.43 lacs 1.5-4.5

8400 cu/mm 5000-11000
 Total WBC different count
74% 40-75
 Neutrophil
19% 20-45
 Lymphocytes
06% 1-6
 Esinophills
01% 1-6
 Monocytes
83fl 80-99
 MCV
28pg 27-33
 MCH
33.7g/dl 32-37
 MCHC 20mm/hr 0-20
 ESR
Routine Investigation
 RBS 142 mgs/dl < 150
 Blood urea 19 mg/dl 20-45
 S. Creatinine 1.2mgs/dl 0.7-1.2
 S. Sodium 142 meq/l 135-145
 S. Potassium 5.0 meq/l 3.5-4.5

LFT
 S. Bilirubin 1.2 mgs/dl 1

 S. total protein 8.1 gm/dl 6-8

4.7 gm/dl 3-5
 S. Albumin
3.4 gm/dl 1.8-3.6
 S. Globulin
1.4
  A/G ratio 32 u/l 2-20
 SGOT 28 u/l 2-22

 SGPT 64 IU/l 80-120

 Alkaline phosphate

Echo Cardiography
 LMCA normal
 LAD short segment lesion of 95-99%
 LCX thin vessels
 RCA proximately 90-95% lesions.

Medication

Sl. Name of Route Dose Freq Action Side effects

No Medication
1 Inj. I.V 1 mg bd Antibiotic Skin rash, red neck,
Vancomycin flushing, fever.
2 Tab. PCT Oral 500mg bd Antipyretic, Liver damage
Analgesic
3 Tab. Pan-40 Oral 40mg bd Proton Pump Headache, skin
Inhibitor rashes, pruritis,
dizziness.
4 Tab. Ecosprin Oral 150mg Od Antiplatelet, Vertigo, visual
NSAID impairment, tinnitus.
5 Tab. Cardarone Oral 50mg Od Vitamin Vitamin toxicity
supplementary
6 Tab. Amifru Oral 40mg Od Diuretics Vertigo, visual
impairment, nausea.
7 Tab. Diataclor Oral 750mg Od Antibiotics Nausea, vomiting,
 oesonophillia,
pruritis.

APPLICATION OF THEORY

Name : Mr. Rakesh

Age : 50yrs
Sex : Male
Ward : Post operative ward
Present complaints : Chest pain and Dyspnoea on exertion
Diagnosis : Ischemic Heart Disease

Theories applicable
1. Dorothy E. Johnson Behavioral System Model
2. sister Callista Roy Adaptation Model
3. Orem Self Care Deficit theory
4. SELYE’s stress-adaptation theory

In this case I am going to provide care according to Roy’s adaptation model

Sister Roy focus on the individual as biophysical adaptive system and describe
nursing as a humanistic discipline that places emphasis on the person own coping
abilities the individual and the environment as the resources of stimuli that require
modification to promote adaptation. The nurse promotes adaptation by modifying
external stimuli.
The individual is in constant interaction with a changing environment and to respond
positively to environment changes that person only can adapt.

The Major Concept of Roy’s Model are briefly presented here

These are the stressor from internal and external environment that act upon a
person, and person respond to the stimuli as a man is an adaptive person. The three major
stimuli described here
1. Focal stimuli: Immediate confronting stimuli demanding attention/relief
2. Contextual stimuli: All other situation or surrounding stimuli contributing to the
effect of focal stimuli
3. Residual stimuli: Ambiguous factors that may affect the person.

Adaptation level
 Adaptation level of an individual is the ability to cope constantly and positively
with the changing environment, stimuli, falling out of the adaptive zone produce
ineffective response, coping skills can be taught or learned through experience.

Coping mechanism
These may be in the form of routine behavior. The two types of coping
mechanism described
1. Regular or physiological coping mechanism
2. Non regular or psychological coping mechanism

Adaptive modes
An individual adopts by four modes in response to changing environment
1. Physiological mode: involve body basic needs and way of adapting regard to fluid
and electrolytes, oxygen, nutrition, activity, rest, elimination etc.
2. Self concept mode: is an adaptation to ones own self perception that may be
personal or physical.
3. Role function mode: or adapting to a new role and behavior associated with a role
performance requirement associated with a role in order to maintain social
integrity.
4. Inter dependence mode: or social adaptive mode is a patient’s dependence on a
nurse in varying degree. It involves ones relation with a significant others and
support system that provide help affection and attention.

Assessment of Mr. Prakash with Roy’s Adaptation Model

Assessment behavior
Physiological adaptive mode
  Oxygenation: Chest size and shape normal, Chest expansion equal in both side
and respiration are normal. Palpation reveals no swelling or palpable lymph
nodes. Percussion revealed low resonance and moderate intensity in the right lung
field and mild intensity in the left lung field. Cardiac border well and in equal
limits.
 Nutrition: Has no problem in eating or digestion. He is on 3 rd day post-operative
day. He is tolerating soft diet.
 Elimination: Normal voiding pattern, voiding about 5-6 times a day, no disuria.
Passes stool everyday morning, and have no complaints of constipation and
diarrhea.
 Activity and Rest: At present he is taking bed rest.
 Protection: Wound present in the chest region, have no sign of infection.
 Senses: Has no abnormalities detected.
 Fluid and Electrolyte: The skin is generally moist and turgor is fair; has no
edema noted.
 Neurological function: Conscious, orientation to time, place and person is good;
insight and judgment are good, speech is fluent; comprehension is good; reflexes
present in both extremities; coordination is not impaired.

Assessment of Stimuli
Focal: pain in the site of surgery, he is bit discomfort because of his postoperative state.
Contextual: tissue trauma resulting from the surgical procedure.
Residual: he expressed anxiety as residual status.

Conclusion

After providing care to the patient by using nursing theory, better changes can be seen in
patient both physically and mentally. Now patient can understand his condition and better
cope up with the situation.