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Ischemic Heart Disease
29(2/2005)
1686
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Learning objective Learn about the anatomy and physiologyof the
cardiovascular system State the definitionof the ischemic heart disease State the predisposinngfactor Explain the pathophysiologyof the ischemic heart
disease
Sate the clinical manifestationof the ischemic heartdisease List up the complicationof the ischemic heart disease Explain all the investigationgiven to the patient with
ischemic heart disease Carry out the nursing care planfor patient with
ischemic heart disease List the medicationgiven to patient with ischemic
hear disease Provide health educationfor patient about self care
at home
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Introduction
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AdmissionName: Mr. S
Registered number: 93***
Date of birth: **-**-****
Age/Sex: 57 years old/Male
Marital status: Married
I/c No.: 4909********
Race/Religion: Chinese/BuddhistOccupation: Laboratory supervisor
Consultant: Dr. T
Date of admission: 6thJune 2006
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Reason of admission: complained ofchest pain (on & off) & S.O.B 2/52
Diagnosis: Ischemic Heart DiseaseMedical history: Diabetes Melitus,
hypertension
Surgical history: angiography and PTCAon 30thMarch 2006
Family history: Nil
Allergies: NilCurrent medication: Imdur, dormicum,
betaloc, plavix, cardiprin,
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Condition of admission
Vital sign
Temperature: 36oC
Pulse: 47bpm
Respiration: 20bpm
Blood pressure:112/68mmHg
Weight: 50kg Height: 161cm
Mode of admission: walk
in
Level of consciousness:conscious
Mental status: orientated
Emotional status: calm Skin Condition: dry
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Activity daily living
Breathing
He has difficulty in breathing when he is walking inlong distance
Cough
Mr. S does not has any cough Smoke
Mr. S does not smoking
Eating/drinking
Mr. S does not having problem in eating.
He does not take cold water, seafood
He likes to eat red meat especially mutton and durian.
He used to has supper with fried mee frequently
His favourite drink is coffee
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Elimination-bowel
He has his bowel movement daily.
He does not has problem in passing motionElimination-bladder
He does not has problem in passing urine
He used to get up at night to pass urine twice, noturia
SleepingHe does not has any problem in sleeping
Mobility
Mr. S is able to ambulate
Personal HygieneHe able to has self hygiene
Safe environment
Siderails is needed to promote safety
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Physical examination
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Orientation
During the admission on Mr. S, a orientation wasgiven according to the checklist as below:
1. Ward
Room no./bed no.
Television Call bell
Bed chair
2. Staff
Unit manager Staff nurse/assistant nurse
Care assistance
Student nurse
Ward clerk
3. Routine
doctors rounds
Nurses rounds Meal times
4. Hospital policies
Visiting hours
Companion Property/valueable
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Anatomy
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Layers of the heartPericardium
Pericardium is a strong, non-distensible sac which loosely enclosesthe heart and attaches to the large blood vessels at the base of theheart and to the diaphragm at the apex.
The walls of the heart composed of three layers of tissue:
1. epicardium outer layer of the heart
visceral layer of the pericardium
2. myocardium middle layer of the tissuecomposed of the invonluntary striated muscle fibres
which interlace, branch and anastomose
responsible for the hearts contractile force
3. Endocardium thin layer of endothelial cells lining the inferiorsurface of the hearts chambers which covers the
heartcreate a smooth surface, reducing friction between
moving blood and the walls of heart
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Anatomy of the heart
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Anatomy of the heart
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Circulation of the heart
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DEFINITION
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Definition
Coronary artery disease or ischemic heartdisease affect three major coronary arteries(right coronary artery, left anterior descendingartery and left circumflex artery) that provide
oxygen and nutrient to myocardium. When blood flow through these major vessel
becomes partially or completely blocked,ischemia and infarction of the myocardium mayresult. Ischemia occurs when the balancebetween oxygen supply and demand becomesdisproportionate.
(Medical Surgical Nursing, Page 2149)
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Etiology
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Etiology1. Decrease aortic pressure
2. Increased intravascular pressure andmyocardial infarction
3. Coronary artery stenosis
Atheroscleros is
Fixed coronary stenosis
Acute plague change(rupture,hemmorhage)
Coronary artery thrombosis
Vasoconstricion4. Aortic valve stenosis
5. Aortic regurgitation
6. Increased right artrial pressure
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What is atherosclerosis
Coronary artery disease (CAD) is caused
by atherosclerosis (the thickening and
hardening of the inside walls of arteries).
Some hardening of the arteries occursnormally as a person grows older.
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Atherosclerosis1) In atherosclerosis, plaque
deposits build up in thearteries. Plaque is made up offat, cholesterol, calcium, andother substances from theblood. Plaque buildup in thearteries often begins inchildhood. Over time, plaque
buildup in the coronary arteriescan:
Narrow the arteries. Thisreduces the amount of bloodand oxygen that reaches theheart muscle.
Completely block the arteries.This stops the flow of blood tothe heart muscle.
Cause blood clots to form. Thiscan block the arteries thatsupply blood to the heart
muscle.
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Risk factor
Modified risk factor
Hyperl ip idemia
Hypertension
Diabetes Mel i tus Physical act iv i ty
Cigarette smoking
Obesity
High alcohol intake
Personality characterics
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Pathophysiology
ageing hypertension Diabetes melitus
atherosclerosishyperlipidemia
Inflammatory process
T-lymphocytes & monocytes(become macrophages)ingest the lipids & die
Degeneration of smooth muscle cells(vessel)
Fibrous capis form(over fatty core(called plague/atheromas
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Disturbance
Insuffiency of oxygen & nutrient demand to myocardium
Myocardila ischemia
Narrow & obstruct blood flow
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Clinical manifestationBreathlessness, sho rtness of breath or dyspnea.
Lack of oxygen supply to myocardium because of thenarrowing of the right coronary artery.
Chest pain
The volume of oxygenation blood deliver to themyocardium is lesser due to the occlusion artery causethe workload of heart increase lead angina attack.
Palpitation
The workload of heart is increasing and pump harder tomeet the oxygen demand.
FatigueIt is because patient use accessory muscle to help inincrease breathing process to inhale more oxygen
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Syncope
The symptom of syncope is happen in a sudden,transient loss of consciousness due to
inadequate cerebral blood flow
Diaphoresis
Anxiety
Mr. S is always anxiety during chest pain.
Patient might be fear an anxious during the
chest pain as they are afraid of dying Nausea and vomiting
Lightheadedness
Pallor
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Complication
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complication
Myocardial infarction Congestive heart failure
Congestive heart failure
Myocardial rupture Cardiogenic shock
Dysrhythimias
Acute heart failure (pulmonary oedema)
Pericardial effusion and cardiac
tamponade
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Investigation
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Investigation
List of investigation
done:
Diagnostic test:
Chest x-ray
Electocardiogram
Angiography
Stress test
Laboratory test:
1. Haematology-value of
haemoglobin
2.
Total white blood countand WBC differential
count
3. Random blood sugar
(RBS)
4. Urea electrolyte (BUSE)
5. Lipid profile
6. Blood coagulant test
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Result of Chest x-ray
Report:
Heart size normal
Lung fields clearNo hilar abnormality seen
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Electrocardiogram
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Result of the
electrocardiogram
ST segment depression of 0.6mm in lead
I, II and V5V6. According to the
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Result of blood test
[Total white blood count & WBC differential count]
Examination Result/unit Normal range
Total white blood
count
White blood cell 7.8/uL 4.3-10.5
WBC differential
count
NeutrophilLymphocyte
Eosinophil
Monocyte
Basophil
66.7%
20.6%6.1%
4.7%
1.1%
40-75
20-450-6
1-11
0-2
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Result of random blood
sugar
Examination Result/unit Normal range
Glucose 6.2mmolL
111mg/dL
3.9-6.1
70-110
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Angiography
Selective coronary angiography is the only
method currently available for accurately
delineating human coronary anatomy as wellas for locating and quantitating obstruction
in large-caliber coronary arteries.
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Occlusion coronary arteries of
Mr. S
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Result of angioraphy
Report: Left Main Stem, LMS: Normal
Left anterior descending artery, CAD: Normal
First Diagonal of the CAD: 90%Tight stenosis (donePTCA with balloon)
Left circumflex artery, LCX: 90% Tightstenosis(done PTCA with stent)
Right coronary artery, RCA: 60%-70% distal stenous
mild stenous with posteriordescending artery, PDA
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Result of stress test
Summary of the treadmill stress test Total of exercise time: 06:23
Maximum heart rate:144bpm 87% of maximum
predicted 164bpm
Maximum ST level :-2.90mm in lead III in Stage3
is 6:23
Reason for termination: Fatigue,chest discomfort
Conclusion: Positive stress test
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Phase &
time
Position time Speed
(km/h)
Grade
(%)
B/P
(mmHg)
HR
(bpm)
Workload RPP
(100)
VE
(1min)
ST
levelII
(mm)
Comment
Pretest supine 00:39 0.00 0.00 130/70 100 1.0 130 0 -0.99
standing 00.31 1.60 0.00 100 1.0 0 -0.95
Warm
up
00.31 1.60 0.00 97 1.1 0 -0.70
Exercise Stage 1 03.00 2.70 12.00 170/80 127 4.6 215 0 -1.65
Stage 2 03.01 4.00 12.00 200/80 147 7.2 284 0 -2.70
Stage 3 00.23 5.50 14.00 147 7.5 0 -2.90 6.10
chest
pain
Recovery 06.13 0.00 0.00 180/80 93 1.0 167 0 -1.75
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Result of lipid profileExamination Result/unit Normal range
Total cholesterol 7.4mmol/L
2.87mg/dL
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Result of the blood testaPartial thromboplastin time & aPTT control
Examination Result/unit Normal range
aPartial
thromboplastin
time
>180 sec
(prolonged)
30-40
aPTT control 33.0sec 28-36
Result of blood studies
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Result of blood studies(Activated clotting time, ACT)
Date/time Examination Result/unit Normal range
6/6/06 at
10.00p.m
Activated
clotting time,ACT
337sec
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Treatment
Invasive procerdure
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Invasive procerdure,Percutaneuos Transluminal
Coronary Artery (PTCA)PTCA is an invasive procedure where
narrow coronary artery that are block by
the plague on the arterial wall is dilate by
balloon or stent. This procedure is carriedout in the cardiac catheterization
laboratory.
A preparation will be done before sendpatient for PTCA
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Pre-PTCA, checklist
1. Patient name,M.R.N2. Consent
3. Patients height/weighttaken
4. Allergy to contrast5. Allergy todrugs/elastroplast
6. Present medication
7. Pre-medication
8. Last meal or drinktaken
9. Fever
1. Asthma2. Chest x-ray
accompanying patient
3. ECG recordsaccompanying patient
4. HB,B.U.S.E,RBS
5. VRDL/HEPATITSB/AIDS
6. Dentures removed
7. Shaving done8. Patient passed urine
9. Nittoderm in place onthe right chest
10. Venofix inserted
11. others
Invasive procerdure
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Invasive procerdure,Percutaneuos Transluminal
Coronary Artery (PTCA)
Balloon is deflated
AngiographyDiagnose theocclusion coronaryartery byintroduced using
femoral artery
Atheroma areverified
A ballooncatheter are
inserted into thedistal of the RCA
Ballooninflated toexpand thestent
Catheter idremoved, stentis hold to openthe artery
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Coronary stent
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The patient might return to ward with a large peripheral
vascular access sheath in place. The sheath areremoved after blood studied (e.g activated clotting time)indicate that the clotting time is within an acceptablerange.
The patient must remain flat in the bed and keep the
affected leg straight until the sheath are removed andthen for few hours to maintain hemostasis.
After hemostasis is achieved, patient usually can beweaned from intravenous medications, resumed self-care, ambulate unassist within 1 to 12 hours in the
procedure The nurses teachers the patient to monitor the site for
bleeding or development of hard lump that is larger thana walnut.
Post-PTCA
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Medication
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Aspirin, aspirin 100mg,glycine 45mg
Group name: Anticoagulant drug
Date on: 6th June 2006
Date off: Continue at home
Route: Oral
Dosage: 150mg
Frequency: BD
Indication: Transient
ischem ic attacks, secondary preventionof MI, vascular occlus ion and deep veinthrombos is
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Plavix, Clopidrogel hydrogen sulfate
Group name: Anticoagulant drug
Date on: 6th June 2006
Date off: Continue at home
Route: oral
Dosage: 75mg
Frequency: BD
Indication:Prevention of atherothrombotic events
H b Dilti h d hl id
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Herbresser, Diltiazem hydrochloride
Group name: Calcium antagonist
Date on: 6th June 2006 Date off: 6th June 2006
Route: Oral
Dosage: 30mg
Frequency: BD
Indication: Mild and
moderatehypertension, angina
pectoris,variant angina pectoris
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Lipitor,Astrovastatin Calcium
Group name: Antihyperlipidaemicagent
Date on: 6th June2006
Date off: Continue at home
Route: Oral
Dosage: 10mg
Frequency: Daily
Indication: Reduct ion o felevated to tal and LDL cho lesterol
I d I bid 5 it t
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Imdur, Isosorbide-5-mononitrate
Group name: Antianginal
Date on: 6th June2006
Date off: Continue at home
Route: oral
Dosage: 30mg
Frequency: Daily
Indication: Prophylactictreatment of angina pectoris
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Nitroderm Nitroglycerin
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Nitroderm, Nitroglycerin
Group name: Antianginal
Date on: 6th June 2006 Date off: 6th June 2006
Route: topical
Dose: 10 mg
Frequency: stat
Indication:
Prevent ion o f theang ina pecto r is
Ativan Lorazepam
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Ativan, Lorazepam
Group name: Sedative
Date on: 6th June 2006 Date off: 8th June 2006
Route: oral
Dose: 0.5mg Frequency: daily
Indication:
Management of anx ietydisordersoranxiety associatedwithdepressive
symptoms
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Valium,Benzodiazepine
Group name: Antianxiety
Date on: 6th June 2006
Date off: 6th June 2006
Route: oral
Dose: 5mg
Frequency: stat
Indication:preoperatively as arelaxation
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Heparin,Heparin Leo Group name: Anticoagulant agent
Date on: 7th June 2006
Date off: 7th June 2006
Dosage: 1000u per hour in 8hours Frequency: Stat
Indication:
Deep-vein thrombosis, prevent ion ofDVT/PE
Controloc, Pantoprazole sodium
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, p
sesquihydrate
Date on: 6th June 2006
Date off: 6th June 2006 Route: oral
Dose: 40mg
Frequency: stat Indication:
long term management and prevention of
relapse of reflux oesophagus,
Glyceryl Trinitrate DBL Glyceryl Trinitrate
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Glyceryl Trinitrate DBL,Glyceryl Trinitrate
Group: Antianginal drug
Date on: 6th June 2006 Date off: continue at home
Dosage: 25mg
Route: Sublingual Frequency: Stat
Indication:
Control of hypertension treatment ofangina pectoris unresponsive torecommended doses of organicnitrates
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Nursing Care Plan
Nursing care plan
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r r1. Alteration in emotional status: anxiety related to invasive
procedure, Percutaneous Transluminal Coronary Angioplasty
2 .Potential of bleeding associated with arterial puncture after
invasive procedure after invasive procedure, PTCA
3. Potential of chest pain related to decrease myocardial
oxygenation and ischemia (angina attack)
4. Alteration in sleeping pattern discomfort relate to new
hospital environment
5.Knowledge deficit related to home care management of
Ischemic heart disease
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Nursing Care Plan
1
Dateon: 6thJune 2006Time: 12 00 noon
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Time:12.00 noon
Problem identi f ied:
Alteration emotion status: Anxiety related to invasiveprocedure, Percutaneous Transluminal Coronary Artery,PTCA
Suppo rt ing data:
Patient verbalized that he worry about the severity of hisdisease and chance to recover
Patient appear fear, and anxious when he was informthe PTCA will be done on 4.00pm
Expected ou tcome: Patient will has manageable level of his anxiety and
become more relaxed, less anxious, fear and ready to gofor PTCA within 1 hour of the nursing interventions given
Nursing interventions:
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Nursing interventions:
1) Assess patient general condition: level of
the anxiety (facial expression) and hisundestanding regarding to the invasive
procedure, PTCA
Rationale: to act as baseline data and toplan an appropriate nursing intervention
Implementation:I assess his point of
view towards the PTCA, he replied thatalthough he had done PTCA once on
March, he still anxious because he
confuse about it
2) Provide conducive environment to rest
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2) Provide conducive environment to rest,expression of fears
Rationale: determine his feeling andproblem regarding the PTCA. Rest andexpression of fears may promoterelaxation at the same time.
Implementat ion: I encourage him to restand express feeling his own feeling abouthis real problem and I explain it isimportant to my knowledge to help himanswer
3) Encourage patient to ask questions and
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3) Encourage patient to ask questions and
do not avoid questions
Rationale:enable patient feel free to askquestions and promote confidence in
patient to staff nurse by not avoiding
questionsImplementation:I encourage Mr. S to ask
any questions he feel confuse and I try to
answer it and some of the question, I get
answer from Staff nurse N
4)Reinforce doctors explaination regarding to the PTCA
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4)Reinforce doctor s explaination regarding to the PTCA
in clearly and accurate way, plus give him a phamplet
about the PTCA. Then evaluate his understanding
beside obtain his consent on behalf of the doctor afterDr. T had given the explaination to him
Rationale: Increase of his knowledge of the PTCA
may enable patient to sign the consent confidentlyImplementat ion: I explain to the patient about PTCA
briefly and clear plus given him a phamplet regarding
the PTCA. I evaluate the understanding of the
explaination I given and he signed the consent underthe observation by the Staff nurse A
5) Inform the reason of asking for allergy to
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5) Inform the reason of asking for allergy to
contrast, drugs or elastroplast before the
PTCARationale: enable Mr. S to know the
reasons allergies being assess
Implementation: I explain to the patientthat if he allergy to certain matter, it will
affect the progress of the PTCA since the
dye contain iodine
6) Provide explaination that the staff nurse
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6) Provide explaination that the staff nurse
obtained the when he taken his last meal
or drink is because prevent aspiration offood into lung if the patient collapse
Rationale:allay his anxiety since he might
curious because he is order to nil bymouth
Implementat ion: I tell Mr. S that he need
to fasting to prevent aspiration of food into
lung
7) Assess his reaction when he being assess for
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7) Assess his reaction when he being assess for
having fever or asthma and comfort him by
briefly explaination that fever indicate infection
whereas asthma may cause patient to have
difficulty in breathing so that the health
personnel will take precaution
Rationale: evaluate his anxiety status for beingassess having fever or asthma
Implementat ion: I observe his reaction: facial
expression when the staff is assess his
temperature and asthma. He look confuse but
he just answer he has asthma since 4 year ago.
I tell the patient is it an precaution for the PTCA
8)R i f th t d bt i
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8)Reinforce that assess and obtain
VRDL/HEPATITIS B /AIDS test is act for
precaution to the health personnel careand enable them to perform it in excel
Rationale:enable not to angry or worry
that the tests being investigate to promoteco-operative environment between nurse-
patient
Implementation: I tell him the tests isassess for precaution and future
references
9)Assure the patient dentures is removed
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9)Assure the patient dentures is removed
and it is because the dentures might
cause complication; obstruction of airwayRationale:allay patient curiosity and
reinforce the explaination so that patient
can be co-operate wellImplementation: Mr. S asked me that
purpose for the dentures need to be take
out. I answer the dentures may causeobstruction of airway during the procedure
10) Provide information that the nitroderm in
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10) Provide information that the nitroderm in
place on the right chest
Rationale:enable patient to know thepatchess purpose so that he would not
confuse
Implementation: I tell him not to worryabout the patches being stick on the right
chest, its just for precaution
Date: 6th June 2006
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Time:1.00p.m
Evaluat ion:Patients anxiety status is reduced,
calm and ready to do the PTCA after one of
nursing intervention given.
Suppo rt ing data:
Patient verbalized that he is more confident to face the
PTCA
He thank you me for me giving him a briefly view of thePTCA for the second time
Init iated by: STN Low,1686
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Nursing Care Plan
Date:6thJune 2006
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Time: 7.40p.m
Problem identi f ied: Potential of bleeding associated with arterial puncture
after invasive procedure after invasive procedure, PTCA
Suppo rt ing data: Patient is administer with intravenous heparin from
12.00a.m until 5.00a.m
Patient has done the PTCA
Expected outcomes:
Patient will has intact and dry at the arterial puncture asit monitor during the nursing intervention given within 8hours
Nursing interventions:
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Nursing interventions:
1) Assess patient general condition: facial
expression e.g pale, fatigue and his complaint is
taking seriously
Rationale:Fatigue and pale is a signs of
prolonged bleeding or large volume of blood is
loss from the large artery, femoral artery. Besidepatients complaint is important to be pay
attention to detect any abnormalities
Implementat ion: I assess patients facial
expression and ask for his concern, he looked
pinkish, tired and he has no complaint
2) Monitor vital sign and oxygen saturation
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) g yg
hourly
Rationale:Act as baseline data and thechanges in blood pressure indicate pain
or decrease of blood volume
Implementat ion: I monitor hourly in first4 hours for once with the observation by
the staff nurse in-charge and the
following of the monitoring I do not do as
my shift is end on that day
3) Monitor the puncture site hourly and record the
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) p y
color, movement, sensation, warm or cold in the
circulation chart
Rationale: Potential of bleeding may occurafter PTCA since large artery being puncturedby determine the circulation in the right groin isintact as the sign and symptom of the bleedingis mentioned as above
Implementat ion: The monitoring of the groinis done by the staff nurse in-charge and Iobserve once. The patient groin appearedpinkish, able to move a bit of the right leg,sensation is felt and it felt warm
4) Obtain the coagulant studies as order by
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4) Obtain the coagulant studies as order by
doctor e.g Activated coagulant test,ACT
Rationale: help to determine thetendency to bleed
Implementat ion: The staff nurse in-
charge obtain the patients blood for ACTtwice an the 1st result is prolong and the
2nd result is in acceptable range
5) Inspect all the body fluid for presence of
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5) Inspect all the body fluid for presence of
the blood e.g urine, sputum, stool,
vomitus Rationale:Internal bleeding may be
manifested in urine, sputum and
gastrointestinal drainage Implementat ion:I inspect all the body
fluid which belonged to Mr. S frequently
and I inform him if he notices the
presence of blood the body fluid to report
to the nurses immediately
6) Avoid intramuscular injection
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6) Avoid intramuscular injection
Rationale: Intramuscular injection may
have potential to cause bleeding sincethe needle being inject to the muscle
Implementat ion:All the staff nurse have
ensure the injection not given throughmuscle
7)Keep and ensure intravenous line on the
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7)Keep and ensure intravenous line on the
other hand which not giving the heparin is
patentRationale:A patent intravenous line may
be needed during complication occur such
as active bleedingImplementation :I ensure the intravenous
line is patent and tell him the importance
of keeping the line is intact
8) Ensure one pint of whole blood is
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8) Ensure one pint of whole blood is
reserved
Rationale:patient may has risk ofbleeding, thus the blood transfusion may
be treat at once
Implementat ion: The staff nurse ensureone pint whole blood is reserved and
prepare it if blood transfusion is needed
9) Advise the patient to lie flat on the bed
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) p
for 6 hours and provide explanation
Rationale: If patient sit up the groin isflex and the femoral sheath apply
pressure is decrease plus the high
pressure from the femoral artery mayhave tendency to bleed
Implementat ion: I tell him lie on the bed
flat for 6 hours to prevent the puncture
site from bleeding
10)Ensure the other anticoagulant drug is
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10)Ensure the other anticoagulant drug is
not administer to patient
Rationale:Assure the risk of bleedingincrease as the prevention of blood
clotting is enhance
Implementat ion:the staff nurse assurethat there are no others anticoagulant
drug is given as ordered as doctor
Date:8th June 2006Time: 8.00a.m
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Time:8.00a.m
Evaluat ion: The potential of bleeding is monitor and no
bleeding occur during the nursing interventiongiven and during hospitalization
Suppo rt ing data:
The arterial puncture site is intact
Patient appeared pinkish and not fatigue butcomplain a little pain at the groin when moving
In i t iated by:STN Low,1686
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Nursing care plan 3
Date: 6th June 2006
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Time: 12noon
Problem identified: Potential of chest pain related to decrease myocardial
oxygenation and ischemia (angina
Attack)
Supporting data: Patient having is diagnose has single vessel disease-
40% of mild stenosis of RCA from previous angiogram
Patient verbalized he experienced chest pain on and offlast 2 last 2 weeks
Expected outcome:
Patient will has absent of chest pain after 1 day of thenursing interventions given and hospitalization
Nursing interventions:
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1)Assess the characteristic of the chest pain such asquality, location, severity of pain (scale pain:0-absent of
pain till 10-severe pain), time onset and duration,determine it occurs at rest or during exertion, strongemotion, or during exposure to temperature extreme
Rationale:to obtain as baseline data, symptoms andcauses associated with angina usually precipitated by
exertion or emotion and can occur on during the day andnight or both
Implementat ion:I interviewed the patient and his wiferegarding the characteristic of pain. They described tome that his chest pain occur is like squeezing around thearea of the chest and he chosen 6-7 rate of rate of thescale pain. The duration is lasting not more than 30minute and it occur during the minimal exertion and rest.
2) Provide patient to rest in bed in calm,i t i t id t f l
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quiet environment, avoid stressfulsituations
Rationale: to reduce oxygenconsumption and excessive used ofenergy to have balance between oxygen
supply and demand by resting. Stressfulenvironment may not promote relaxation.
Implementat ion:I advised rest in bed ifhe having chest pain and will ensure the
environment is quiet and suitable for himto rest
3) Monitor vital sign and oxygen saturation
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3) Monitor vital sign and oxygen saturation
by pulse oxymeter 4 hourly
Rationale:Detect any abnormalitiesespecially dyrhsthimas and high blood
pressure
Implementat ion: I monitor vital sign andoxygen saturation 4 hourly.
4) Provide assistance aids to complete his
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) p
ADL e.g bath
Rationale: reduced used of excessiveenergy that will increase workload of the
heart
Implementat ion:I offer my help toassist him to bath in the bathroom
5) Provide certain equipment which enable
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)
patient to complete his ADL on bed e.g
urinal Rationale:reduce metabolic rate to
decrease energy to complete ADL on
bed. Hence myocardial oxygenation may
be adequately supply to the heart
Implementat ion: I offer a urinal to Mr. S
and tell him to pass urine in it
6) Inform patient to report to health
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6) Inform patient to report to health
personnel care immediately sign and
symptom of chest pain occur e.g Short ofbreath, palpitation, syncope
Rationale:to be notified and further
treatment is given immediately.Implementation: I tell the patient to report
to nurse if about sign and symptom of
chest pain occur
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7) Do the nurses round frequently and
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) q y
assess patients general condition
complain at the sane time Rationale: Enable detectation of any
abnormalities especially chest pain and
assessing patients general condition andcomplaint as well
Implementation: Always do the ward
round to the patient frequently on my freetime and assess his complaint.
8) Restrict visitors and inform the visiting
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time such as 12 noon-2 pm; 4 pm-9 pm
Rationale: Enable patient to have restand reduce over-emotional status such as
happy.
Implementat ion:I tell the patient to let
the amount visitor reduce to one or two
and inform the visitor about the
visiting time.
Date: 6th June 2006
Time: 1 p m
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Time: 1 p.m
Evaluation: Patient verbalized he did not experience chestpain or sign and symptom of chest discomfort after 1hour the nursing intervention given and duringhospitalization.
Supporting data:
Patient verbalized that no sign and symptom of chestpain
Patients vital sign is in normal range as below:
TO: 36.7OC
P : 70 bpmR : 20 bpm
BP : 100/60 mmHg
Init iated by:STN Low,1686
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Nursing care plan 4
Date:6th June2006
Time: 12 00 noon
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Time:12.00 noon
Problem identified: Alteration in sleeping pattern discomfort relate to new
hospital environment
Supporting data:
He complain of chest pain occur on and off at night
since last two weeks
He seem fatigue, weak
Expected outcomes:
Patient will have undisturbance of sleep at night within 1
day of nursing interventions
Nursing interventions:
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g
1) Assess patient general condition:
lethargic signs e.g fatigue, weak, dizzinessRationale:determine sleeping pattern
level to act as baseline data and plan
appropriated nursing interventionImplementation: I interview the Mr. S
about is problem in sleeping disturbance
and assess sign of lack of sleep
2) Provide warm drink at night, 2 hours
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earlier before he sleep
Rationale: warm drink to induce thepatient to have good sleep and given 2
hours earlier is to prevent patient wake
up to pass urine
Implementat ion:I provide a cup of
warm Milo to Mr. S 2 hours before he
sleep and ask him to pass urine before
sleep
3) Provide conducive environment which is
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quiet, calm and peaceful
Rationale: enable patient to have goodrest because the noisy environment may
produce stressful feeling
Implementat ion: I ensure theenvironment is quiet, peaceful and calm
as all the patients in the six bedded room
are sleeping as well
4) Advise the patient not to having nap
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) p g p
during the day or a short period of nap
may be acceptable since patient mightfeel tired
Rationale: Having nap produce excessive
rest and might change the habit to sleepvery late at night
Implementat ion:I advise the patient may
have short period of nap or not to do so ifhe able to manage and admit this one of
the reason he having difficulty in sleeping
5) Encourage patient to express his feelingdi t hi bl
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according to his problem
Rationale: Express feeling of problemhelp to relieve stress and might promote avery peaceful sleep
Implementation:I encourage Mr. S to
voice out his problem and he said healways have chest pain at home duringsleeping, he also anxious about the effectof PTCA since he done the PTCA ispurposely to live longer to take care of hisfamily
6) Teach patient to use diversional therapy
l ti th
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or relaxation therapy
Rationale: promote relaxation and divertpatient problem to others matters so that
patient able to sleep well
Implementation: I teach patient about the
relaxation therapy such as listening to the
peaceful songs while patient go to bed
7) Allow one companion to stay in the
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7) Allow one companion to stay in the
hospital at night with the patient e.g family
memberRationale:Allay patient anxiety and
promote comfort as family member is with
patientImplementation:I tell Mr. S may has one
companion is allow to accompany him at
night so that he can feel more comfortable
8) Administer medication as ordered by
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) y
doctor to enable he sleep well e.g ativan
0.5mg dailyRationale: Ativan assist in relieve
depression and promote relaxation
Implementation: The staff nurseadminister ativan as prescribed by doctor
and follow the 5R, right patient, right drug,
right route, right dose, right time and tellhim it help to induce sleeping
Date:8th June2006
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Time: 12 noon
Evaluation: Patients sleeping pattern has improved within 1
day after the nursing intervention given and
during hospitalization.
Supporting data:
Patient verbalised he is able to sleep well
Initated by: STN Low
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Nursing plan 5
Date : 8th June 2006
Time:9.00a.m
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Problem identified:
Knowledge deficit related to home care management ofIschemic heart disease
Support data:
Mr. S ask me about method of prevention as hedischarge
Mr. S seem to ask me a lot of question about his disease
He seem anxious of home care as he go home
Expected outcome: Patients knowledge about home care will be improved
within 1 hour as the nursing interventions given
Nursing intervention:
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1) Assess patients general condition: facial
expression and patients complaintRationale: Obtain general information fro
patient due to his problem of home care
deficitImplementation: I assess patients
general condition: Facial expression, ask
for his concern. He complain he is worryabout the name care at home.
2) Assess patients level of knowledge or
d t di f hi di d th d
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understanding of his disease and method
of care should be taken
Rationale: Determine patients
knowledge of his disease and step of
care for himself at home
Implementat ion: I assess his education
level by ask for his occupation,
knowledge of medical term or any
information in ischemic heart disease
3)Inform the sources or causes, sign andt f hi h t i h
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symptom of his chest pain such as
palpitation and short of breath, fatigueRationale:enable patient to has
awareness over the cause of chestdiscomfort so that he can avoid these
sources
Implementation:I inform the patient thatthe cause that triggers the chest pain e.g
exertion activity and it normally will occurfatigue and short of breath as symptoms
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5) Encourage patient to do regularly
exercise start with gradually exercise
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exercise start with gradually exercise
Rationale:Gradually exercise is aneffective may burn the fat being store
and enable heart workload increase
slowly in acceptable range
Implementat ion:I always encourage the
patient to do gradual exercise by
walking for short distance and gradually
increase to jogging if persist
6) Advise patient to have rest between the
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stressful activity e.g exercise or even
after meal Rationale: reduce oxygen demand in
stressful environment to prevent chest
pain occur because cardiac workloadincrease
Implementat ion: I advise Mr. S to rest
as he feel stress or tired to relive chestdiscomfort
7) Advise patient to change his eating habitby changing not to take supper
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by changing not to take supperespecially oily food and reduce eating of
red meat e.g mutton as well as consumecaffeine drink
Rationale:reduce the risk factor of
increase atherosclerosis by modify theeating unhealthy habit
Implementat ion: I advise him to changehis unhealthy eating habit: not to take
supper, can has 1/2 of mutton and do notconsume coffee
8)Maintain the level of blood glucose by
d l di t t k di ti
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reduce low sugar diet, take medication
prescribed by doctorRationale:to monitor the glucose in blood
to reduce risk of complication occur from
ischemic heart disease such asmyocardial infarction
Implementation: I reinforce patient to
maintain the level of blood glucose by
taken right mediaction and reduce sugar
intake, fruit e.g durian
9)Advise patient ot do self-administer mediaction
as orderd by doctor e g Lipitor Aspirin Herbresser
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as orderd by doctor e.g Lipitor, Aspirin, Herbresser
,Imdur
Rationale:Lipitor user to maintain cholesterol
level whereas aspirin is assist in prevent blood
clot formation in the coronary artery stent.
Hebresser may reduce hypertension andangina pain as well as Imdur. Overall patients
condition is controlled by these medication
Implementat ion: I advise patient to take the
medication on time, to maintain his severity of
his disease become worse.
Date: 8th June 2006
Time: 10 00a m
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Time:10.00a.m
Evaluat ion: Patients has improving his knowledgeregarding to the home care deficit in management of the
ischemic hear disease after 1 hour the nursing
intervention given.
Suppo rt ing data:
Patient verbalized that he is more confident to take care
of himself at home
Patient appreciated my lessons on him and he evenwish to try the steps as soon as possible.
Init iated by:STN Low,1686
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Health education
On 8th June2006, I have teach Mr. S about
the health education in the morning before
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the health education in the morning before
he proceed his discharged. I given thehealth education as stated below:
Diet
Medication Exercise
Risk factor
Life style
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Discharge
Date:8thJune 2006
Ti 12
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Time:12noon
TTA: Aspirin 150mg, BD
Plavix 1/1 BD
Lipitor 1omg dailyImdur 90mg daily
Herbresser 30mg
daily
Diamicron 40mg daily
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Follow up
Date: 20thJune 2006 Dr. S has seen Mr. S. Doctor evaluate his
condition that it is now improving of recovery
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condition that it is now improving of recovery.
Dr. S also stated the patient his is showing agood sign after post PTCA and no complicationof the PTCA is identified.
Dr. S also had assess his blood pressure andthe result is 110/80 mmHg
TTA: Zocor 40mg, Daily
Aspirin 150 mg, BDPlavix 1/1, BD
Herbresser 30mg, Daily
Imdur 30mg, Daily
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Summary
Mr. S was admitted to JSH for PTCA. Actually, he hasdeveloped chest pain on and off after 2 years ago. Thenhe felt chest pain is became severe and intolerance.
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p
Hence a few investigation was done when he admittedon 30/O6/06. An angiogram is performed, the findingsare single vessel disease of right coronary artery 40%mild stenosis, 90% thigh stenosis of left circumflex arteryand thigh 90% of the first diagonal of left anteriordescending artery. He had done a PTCA on 3O/6/O6
However he still experience chest pain after the PTCA,thus he decreased to do second PTCA to dilate thenarrow distal of the right coronary artery.
During his admission, he came from Dr. Ts clinic to the
ward, he looked fatigue. He complained of chest pain on
and off since two weeks ago He had normal Dr T had
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and off since two weeks ago. He had normal Dr. T had
decided to perform the PTCA on4.00p.m
Value of haemodynamic accept his heart rate was
bradycardia, 47beats per minute. Dr. T seen had him
and decided to perform the PTCA on 4.00 pm. Doctor
also had prescribed the drugs for him as below:Aspirin 150mg, BD
Plavix 1/1, BD
Lipitor 10mg, Daily
Ativan 0.5mg Daily
After the PTCA was completed, the patient
was sent to the High Dependcence Unit
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was sent to the High Dependcence Unit,
HDU on 7.40p.m for close monitoring. Hecame out from the cardiac catheterization
laboratory with femoral dressing is dry and
intact. Close observation is and potential
of bleeding was monitored beside assessfor complication
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Reference
1)C. Smeltzer S. ,Bare B.July2003(tenth edition) Brunner and
Suddarths Medical Surgical Nursing, Coronary Artery Disease
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Suddarth sMedical Surgical Nursing, Coronary Artery Disease
2) Wange A,Grant A 2001 (ninth edition)Ross and Wilson, anatomy and
Physiology Inhealth and Illness, Cardiovascular System3) Ignatavicius D.D, Bayne M.V, Medical Surgical Nursing Coronary
Artery Disease)
4) Walsh W. 2006 (Sixth Edition)Watsons Clinical Nursing and
Related Sciences, Disorders of myocardial blood supply
5) Lemone P, Burke K, (Third edition), Medical Surgical Nursing,
Coronary Heart Disease6) Skidmore-roth L., (2004), Mosbys Nursing Drug Reference
(102nd Edition 2005), MIMS
8) Martin E.A, (2005), Dictionary Nursing Malaysian Edition
9) http://www.nhlbi.nih.gov/nhlb/contact/index.htm
10) www.heart.com11) www.heartonline.com
12) www.healthcentral.com
http://www.nhlbi.nih.gov/nhlb/contact/index.htmhttp://www.heart.com/http://www.heartonline.com/http://www.healthcentral.com/http://www.healthcentral.com/http://www.heartonline.com/http://www.heart.com/http://www.nhlbi.nih.gov/nhlb/contact/index.htm -
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Thank You