Ischemic heart disease (IHD)

10DIN0014

LEARNING OBJECTIVE

LEARNING OBJECTIVE
Outline of the Anatomy and Physiology of the heart State the Definition of Ischemic Heart Disease State the Etiology of Ischemic Heart Disease Explain the Pathophysiology of Ischemic Heart Disease List the Clinical Manifestation of Ischemic Heart Disease List the Complication of Ischemic Heart Disease List the Investigation of Ischemic Heart Disease Explain the Management of Ischemic Heart Disease Explain the Nursing Care Plan for Ischemic Heart Disease Provide Health Education for patient with Ischemic Heart Disease

INTRODUCTION

Mr. N ,48 years old accompany by his wife.

Clinic Dr . S 19/10/2010 @ 0940 hours c/o chest pain for 2 month, shortness of breath for 2 days.

Investigation -blood test -urine FEME -chest x-ray -ECG - stress test

Medical ward 19/10/2010 @ 1340 hours

PHYSICAL EXAMINATION

PATIENT PERSONAL DATA

Name : Mr. N MRN no. : 91XXX I/C no. : 63XXXX-XX-XXXX Date of birth : 1th February 1963 Age : 48 years old Sex : Male Race : Malay Religion : Muslim Status : Married Weight :84 kg Height :168 cm Body mass index : 29.8

 DATE / TIME OF ADMISSION : 19 October 2010 @ 1340hour REASON FOR ADMISSION : Complain of chest pain 2 month Complain of shortness of breath 2 days : Nil : Nil : Ischemia Heart Disease

PAST MEDICAL HISTORY PAST SURGICAL HISTORY PROVISIONAL DIOGNOSIS

FAMILY MEDICAL HISTORY : Nil CURRENT MEDICATION : Nil

VITAL SIGNS
Temperature : 36.3 C Pulse Respiration : 70 beat per minute : 22 breath per minute

Blood pressure : 145/109 mmHg spO2 : 94%

PHYSICAL EXAMINATION

INFORNT

BACK

ACTIVITY DAILY LIVING

ACTIVITY DAILY LIVING

-BREATHING*Mr. N had slightly breathing when exercise -EATING AND DRINKING-ELIMINATION BOWEL-BLADDER-SLEEPING-MOBILITY-PERSONAL HYGIENE-SAFE ENVIRONMENT-SPEECH-VISUAL-HEARING-SPRITUAL SUPPORT-

ORIENTATION
~ Named nurses/nurse work shift ~ Identification band ~ Room ~ Property ~ Bed ~ Toilet and Bathroom ~ Call bell ~ Doctor s Round ~ Meals

~ Television ~ Visiting hour s ~ Other s facilities ~ Smoking ~ Fire exit

ANATOMY & PHYSIOLOGY

HEART

ANATOMY OF THE HEART

The heart are roughly cone shape hollow muscular organ It is about 10 cm long and depend the of the owner fist. The heart is composed the three tissue layers :  Pericardium  Myocardium  Endocardium

The heart has four chambers two on the right and two on left  Atrium the two upper chambers that collects blood  Ventricles the two lower chambers that pump blood out the lungs and other parts of the body The heart has four types of valves ;  Tricuspid valve ( right artrioventricular valve ) has three cusps. this valve regulates blood flow between right atrium and right ventricle  Mitral valve (left artrioventricular valve ) has two cusps. this valve lets oxygenated blood pass from left atrium to left ventricle

 Pulmonary valve controls blood flow from the right ventricles into the pulmonary arteries  Aortic valve let the oxygenated blood to pass from the left ventricles into the aorta Valves are like doors that open and close. When valves open and close they make a lub DUB sound.

FLOW OF THE HEART

DEFINATION OF ISCHEMIA HEART DISEASE

Defination
Abnormal accumulation of lipid or fatty substances and fibrous tissue in the vessel wall that lead to changes in arterial structure and function and reduction of blood flow to the myocardium.
(Sandra M ,(2003),The Lippincott , p.365)

ETIOLOGY
Atherosclerosis An abnormal accumulation of lipid, or fatty, substances and fibrous tissue in the vessel wall. Vasospasm (sudden constriction or narrowing) of coronary artery Myocardial trauma (from internal or external forces) Structural disease Decreased oxygen supply (e.g. acute blood loss, anemia, or low blood pressure)

AGE SMOKING GENDER

HYPERTENSION

HEREDITARY DIABETIC

RISK FACTOR

HIGH BLOOD CHOLESTROL

PHYSICAL INACTIVITY OBESITY

PATHOPYHSIOLOGY

High cholesterol/Overweight Build up of cholesterol and fibrous tissue Plague formation Rupture of plague leads thrombus formation

Reduced coronary artery blood flows due to occlusion of an artery Increase oxygen consumption Cell are away completely of oxygen Ischemia Heart disease

 Nausea vomit

anxiety
Shortness of breath

Chest pain

fatigue

Clinical manifestation

syncope

palpitation

Nausea vomiting

Sudden cardiac death

Unstable angina

COMPLICATION

Acute myocardial infarction

Congestive cardiac failure

INVESTIGATION

During hospitalization, doctor had order a few investigation to be done:

    

Blood test Urine FEME Chest x-ray Electrocardiogram Stress test

FULL PROFILE (GP59E) DATE DONE: 19/10/10

HAEMATOLOGY Haemoglobin Red cell count Haematocrit (PCV) MCV MCH MCHC RDW Platelet count MPV ESR White blood cell count Result Unit 15.2 g/dl 5.6 10 /L 44 % 80 fl 27 pg 34 g/dl 12.6% 285 10/uL 8.7 fl 6 mm/hr 7.1 10/uL Reference Range 13.0-18.0 g/dl 4.5-5.9 41-53 % 76-103 fl 26-34 pg 31-36 g/dl 8.6-14.6 % 150-450 6.5-12.0 fl 0-20 mm/hr 4.3-10.5 10/uL

Result unit Serology -- Blood group -ABO group Rhesus group (D) -- thyroid function screen -Free T4

Reference range

B positive

20.3pmol/l

9.1 - 24.4pmol/l

-- rheumatoid factor screen -Rheumatoid factor --venereal disease screen -VDRL (RPF) -- AIDS screen -HIV I / II antibodies -- hepatitis B screen -HBs antigen * HBs antibody

12.2 IU/mL

< 15 IU/mL

non-reactive

non-reactive

non-reactive

non-reactive

non-reactive <2.0

non-reactive

WHITE BLOOD CELL DIFFERENT COUNT Neutrophil Lymphocyte Eosinophil Monocyte Basophil

Result Unit (%) 53.8 % 32.5 % 5.9% 6.4 % 0.3 %

Reference Range (%) 40 75 20 45 0 6 1 -11 0-2

RENAL FUNCTION TEST DATE DONE: 19/10/10

Result Unit (mmol/L) uric acid Creatinine Urea Sodium Potassium Chloride Calcium Phosphate 383mmol/L 75mmol/L 3.8mmol/L 142mmol/L 4.7mmol/L 100mmol/L 2.47mmol/L 1.32mmol/L Reference Range (mmol/L) 202 434mmol/L 51 124mmol/L 2.0 6.8mmol/L 135 -155mmol/L 3.5 5.5mmol/L 95 111mmol/L 2.14 2.55mmol/L 0.78 1.50mmol/L

LIPID PROFILE DATE DONE: 10/04/06

Result Unit (mmol/L) Total cholesterol triglycerides HDL cholesterol LDL cholesterol chol / HDL chol 5.1mmol/L 1.97mmol/L 0.90mmol/L 3.3mmol/L 5.7mmol/L Reference Range (mmol/L) <5.2mmol/L <1.71mmol/L >1.42mmol/L <2.6mmol/L Up to 4.0mmol/L

CHEST X-RAY
*Finding of chest radiograph The heart is in normal size. The lung is clear field.no enlarged hilar or mediastinal nodes.no ribs abnormalities noted.

ELECTROCARDIOGRAM

* Mr. N result shows sinus normal rythm.

STRESS TEST

*Mr. N resting electrocardiogram (ECG) normal. Functional capacity: normal. Blood pressure response to exercise: normal resting blood pressure. Chest pain : none. Arrhtymias : none ST changes : none .Normal stress test. Exercise stage 3.

MEDICATION

MEDICATION

DATE ON

DATE OFF

ROUTE

DOSAGE

Aceprin

19. 10. 2010

Continue at home

oral

300mg STAT & 100mg on

Methycobal

19. 10. 2010

21.10.2010

oral

500mg TDS

Glycerin trinitrate

19. 10. 2010

continue at home

sublingual

0.5 mg (PRN)

1. ACEPRIN
Generic name Group Indication : aspirin : anticoagulant,antiplatelets,fibrinolytics : prophylaxis of MI, transient ischemic attacks or stroke, thromboembolism & vascular occlusion Contraindication : bleeding ulcers, haemorrhagic states, haemophilia or other bleeding problem including coagulation or platelet function disorders, angioedema. Special precaution : dyspepsia or lesions of the gastric mucosa. asthma or allergic disorders, severe renal or hepatic impairment Adverse reaction : nausea, dyspepsia & vomiting Nursing responsibilities : -advice patient to take the medication with water -advice patient to rest in bed because it will cause patient to nausea, dyspepsia &vomiting.

2. METYHYCOBAL

Generic name Group Indication Contraindication Special precaution Adverse reaction

: mecobalamin : nootropics and neutronics : peripheral neuropathies : : discontinue if there is no response after taking orally for several month : Infrequently: anorexia, nausea, diarrhea, pain& induration at IM injection site. Rarely: skin rash, headache, sweating or hot sensation.

3. GLYCERIN TRINITRATE
: Nitroglycerin : anti-anginal drugs : Control of hypertension treatment of angina pectoris unresponsive to recommended doses of organic nitrates Contraindicated : Hypotension, increased intracranial pressure and idiosyncrasy to this drug, constrictive pericarditis and pericardial tamponade, severe anemia, arterial hypoxemia. Special precaution : Severe renal/hepatic impairment. Not for direct intravenous Adverse reaction : Headache, flushing, dizziness, palpation, orthostatic hypertension tachycardia, vertigo, confusion, weakness. Generic name Group Indication

Nursing responsibilities :- place medication under the tongue to dissolve - not to swallow the medication - no to take a drink until medication is completely dissolved -advise patient to completely rest in bed (CRIB) because the medication will cause patient feel headache, giddiness , nausea, vomiting

NURSING CARE PLAN

NURSING CARE PLAN 1. Altered in comfort : chest pain related to lack of oxygenated blood flow to the heart due to myocardial infarction/ischemia. 2. Alteration in breathing pattern : shortness of breath related to interruption of the blood supply to the heart due to ischemic. 3. Alteration in sleeping pattern: insomnia due to worries about health status. 4. Anxiety related to knowledge deficit of ischemia heart disease . 5. Knowledge deficit related to home care management

Nursing care plan 1

DATE : 19.10.2010 TIME : 1340hours NURSING DIAGNOSIS : Altered in comfort : chest pain related to lack of oxygenated blood flow to the heart due to myocardial infarction/ischemia . SUPPORTING DATA : - patient verbalize of having chest pain on and off since 2 month - patient complain chest pain during lying prone GOAL : patient will feel comfortable and relax by reducing his chest pain within 2 hours after nursing intervention applied during hospitalization

NURSING INTERVENTION : 1. Assess patient s location , characteristic, quality, time onset, and duration during chest pain occur. As a baseline data for further intervention. I :I ask Mr. N about his chest pain pattern such as location, characteristic, quality, time onset, and duration. 2. Monitor patient s vital sign especially blood pressure, pulse and oxygen saturation . Increase in blood pressure indicate patient having pain. I : Mr. N blood pressure is 145/107 mmHg and his pulse is 70 per minute ,spO2: 94% during admission. 3. Administer 0xygen 2L/min via nasal prong as doctor ordered. to supply an adequate oxygen supply to heart I: I had administer 2L/min oxygen via nasal prong to Mr. N.

4. Position patient s in comfortable position or patient s desire position. Example : semi fowlers position. For better lung expansion and easier breathing so that can reduce pain and feel more comfortable. I : I suggest Mr. N to position in semi-fowlers position and help him to prop up the bed. 5. Administer glycerin trinitrate sublingual as doctor ordered. To relieve chest pain I: I had administer glycerin trinitrate . I had instruct Mr. N to put the medication under his tongue. 6. Encourage patient to completely rest in bed (CRIB) . To reduce oxygen consumption and allow patient s to relax. I : I advise patient to rest in bed and placed the call bell near to the Mr. N and asked him to call the nurses by pressing the call bell whenever help or assistance needed.

7.Teach patient to do Deep Breathing Exercise (DBE). To relax the muscles and help to divert the attention from pain. This also can increase the oxygenation in our body. I : I had thought patient to do DBE. 8. Restrict the number of visitor by only allow them to visit during visiting hour. Patient will be able to rest more. It will reduce her activity and can prevent chest pain occur. I: I advice Mr. N family members do not stay long with patient and come on visiting hours because patient s need more rest. However, family member was allow to stay with patient to support patient emotionally. 9. Record patient s condition in nursing report As evidence for further intervention I: I had record patient s condition and Mr. N progress.

10. Inform to the doctor if patient s chest pain still persist. To plan for further treatment. I: I did not inform doctor because patient s pain has reduced and the chest pain is tolerable. However, there is still pain on and off. DATE : 19.10.2010 TIME : 1540hours EVALUATION : patient s chest pain reduced and patient able to tolerate the chest pain within 2 hours after nursing intervention given during hospitalization. EVIDENCE : - Mr. N verbalized he feels more comfortable. - Patient appears calm and comfortable

Nursing care plan 2 DATE : 19.10.2010 TIME : 1600HOURS NURSING DIAGNOSIS : Alteration in breathing pattern : shortness of breath related to interruption of the blood supply to heart due to ischemic. SUPPORTING DATA : - patient complain having shortness of breath for 2 days. - patient feel uncomfortable GOAL : patient shortness of breath will reduce within 2 hours after nursing intervention given during hospitalization.

NURSING INTERVENTION :

1. Assess patient s general condition (level of consciousness , breathing pattern) As baseline data for further intervention I : I observed patient breathing pattern and noted that he is tachypnoea. He looked restless and weak and her skin looked pale. 2. Monitor patient s vital sign (respiration rate, blood pressure, temperature, oxygen saturation (spo2) ). To determine whether patient had any alteration I : Mr. N respiration rate is 22 per min, blood pressure 145/107, temperature 36.3r, oxygen saturation 94%. 3. Encourage patient to completely rest in bed (CRIB). To reduce oxygen demand I : I advise Mr. N to completely rest in bed.

4. Position patient to semi-fowlers or fowlers position. To reduce the oxygen requirements. I : I positioning Mr. N to semi-fowlers 45r. 5. Teach patient Deep Breathing Exercise(DBE). To improve breathing pattern and help to increase oxygen level. I : I teach patient to do Deep Breathing Exercise and also advise him to do every morning. 6. Report patient condition to the doctor if dyspnea still persist. For further interventions. I : I did not report patient condition to the doctor because patient had no shortness of breath.

7. Inform to the doctor if patient s shortness of breath still occur To plan for further treatment. I: I did not inform doctor because patient s pain has reduced.

DATE : 19.10.2010 TIME : 1800hours EVLUATION : patient s had no shortness of breath and looks cheerful within 2 hours after intervention given EVIDENCE : - patient s verbalize had no shortness of breath and looks comfortable

Nursing intervention 3
DATE TIME : 20.10.2010 : 0830hours

NURSING DIAGNOSIS : Alteration in sleeping pattern: insomnia related to health status due to chest pain. SUPPORTING DATA : 1. Patient verbalize that she unable to sleep well last night. 2. Patient looked restless GOAL : Patient will be able to sleep well at least 6-8 hours per day after nursing intervention given and during hospitalization NURSING INTERVENTION: 1. Assess patient sleeping pattern as usual frequently As baseline data and for further intervention I : I ask Mr. N what time that he usually sleep at home and he said he sleep at 10pm and at the hospital he sleep at 12pm and cannot sleep at all.

2. Encourage patient to voice out his worries. To reduce his worries and to do nursing intervention according his worries. I : I asked Mr. N to tell me about his problems and he told me that he worried about his health status. 3. Encourage his family members to give him support and talk to him about his problems. To relax his mind. I: I asked his wife to talked to him to give emotional support and calm the patient.

4. Provide divertional theraphy. To divert his worries to something interesting. I : Since he loves to read book, I provide him with some books regarding his health status.

4. Position my patient to semi fowlers position. To promote good lung expansion and easier to breath and to make patient comfortable I:I prop up the head of the bed for Mr. N so that he can breath easily and comfortable.

5. Provide quite and conducive environment to the patient. To promote comfortable to the patient to get a well sleep I:I ensure the ventilation on her room is good by set the room temperature as desired by Mr. N . I also draw her curtain and advice the other patients to control their voice.

6.Restrict visitor except the patient wife & daughter. To ensure patient get adequate rest & relive her tension I: I tried to explain to patient relatives that he need a lot of rest and do not disturb him if not necessary.

7.Advice patient not to take any drinks that contain caffeine before sleep time To prevent patient from get difficulties to sleep I: I told to Mr. N that drinks that contain caffeine can make he can t sleep 8. Inform doctor if patient cannot sleep well after the nursing intervention given. To do further intervention. I : I did not inform the staff nurses because patient can sleep well after the nursing management.

EVALUATION : Patient able to slept well in 6-8 hours per day after nursing intervention given SUPPROTING DATA : - I saw Mr. N slept well when I m doing a ward round - Mr. N had no complaint of can t sleep well DATE: 19.10.2010 TIME: 8000hours

Nursing care plan 4

DATE: 20.10.10 TIME: 0900hours NURSING DIAGNOSIS: Anxiety related to knowledge deficit about ischemia heart disease. SUPPORTING DATA: -patient facial expression show he is in anxiety - patient verbalized that he worried about his condition -patient ask a lot of question regarding his disease GOAL: Patient s anxiety level will be reduce after 2 hours nursing intervention given and during hospitalization.

NURSING INTERVENTION: 1. Asses patient s general condition such as level of consciousness and facial expression. As a base line data I: I sit down and communicate with Mr. N with soft manner and listening to his problem. I also encourage Mr. N to express his feeling. 2. Monitor patient s vital sign such as blood pressure, respiration, temperature, and pulse To detect any abnormalities I : observation done to Mr. N and I had record in observation chart. 3. Inform the patient about the purpose of hospitalization, diagnostic test and medication in simple word. To increase patient level of confident and understanding I : I explain the purpose of treatment that had been done to Mr. N

4. Reinforce doctor explanation regarding the treatment which will carry out in simple word To increase the level of understanding and decrease anxiety I : I had explain again to Mr. N about treatment given by doctor by using printed document 5. Encourage family members and his friends to stay with patient and support and encouragement To reduce his anxiety and gave him moral support I : I advise Mr. N wife and son to stay along with Mr. N to give him support 6. Spent more time talking with my patient To know patient problem and establish relationship between nurse and patient I : During my spare time. I tried to had a talk with Mr. N.

7. Introduce other patient with same disease to my patient To share some experience and reduce his anxiety I : I had introduce Mr. A which is also had been diagnose with Ischemia Heart disease to Mr. N. 8.. Provide a therapeutic environment for patient example: eye contact To gain his confident level and his comfort to tell about his problem I: I use my eye contact everytime when I communicate with Mr. N.

9. Refer to the doctor if patient still anxiety about his disease. For further treatment I : I did not inform to doctor because Mr. N verbalize that he more confident now. EVALUATION : Patient s anxiety level will be reduce after 2 hours nursing intervention given and during hospitalization. SUPPORTING DATA: -Patient s facial expression not show he in anxiety. -Patient look cheerful DATE: 20.10.2010 TIME: 1100hours

NURSING CARE PLAN 5

DATE : 21.10.2010 TIME : 0830hours NURSING DIAGNOSIS: Knowledge deficit related to home care management SUPPORTING DATA: - Patient s asked how the chest pain occur -Patient verbalized Nurse, how I can manage myself at home? GOAL: Patient and family will be able to gain better understanding of Ischemia heart disease and lifestyle changes after explanation given before discharge.

NURSING INTERVENTION:

1. Assess level of patient s knowledge and understanding about the disease and self care at home. As a baseline data and to plan further nursing intervention. I :I assess Mr. N knowledge through answer that he gave to me whether he understand or not how the chest pain occur and how to manage him at home.

3. Provide patient information about management at home include diet To ensure patient take a good and balance diet to fasten recovery understand regarding his diet. I :I advised Mr. N to control his diet by take low fat, salt, and cholesterol food and eat a lot of fruit and vegetable. 4. Encourage patient to do light exercise at home. To promote blood circulation I :I advise my patient to walk around him house for 15-20 minutes a day 5. Advise patient to control his stress Stress will increase hormone epinephrine and norepinephrin in the body. I : I advice Mr. N to control him stress by doing outdoor activities such as picnic, gardening with family in the weekend

6. Explain to patient regarding the importance of the medications and the proper medication: Explain regarding all the medication and the indication of each medication and the side effect of each medication. Consume medication according to right medication, right dosage, right route, right time to prevent errors. In order for patient to understand regarding the importance of the medications and to administer accordingly and to prevent errors. I :I reexplain the staff nurse explanations regarding the important of medication

7. Give pamphlets about coronary artery disease to patient and his son. To gain more knowledge and better understanding I :I gave pamphlets to Mr. N and his family that I took from Dr .S clinic and gave simple explanation to them. 8. Encourage patient to ask any question regarding the disease (IHD) For clear and better understanding about disease happen I : I asked Mr. N whether he has any question .Mr. N so far don t have any question and he understands about his condition.

9. Inform Dr .S if patient still don t understand about his disease (IHD) For further explanation I : I didn t inform Dr.S because my patient understand and gain more knowledge DATE: 21.10.2010 TIME : 0930hours EVALUATION: Patient s and his wife gain better understanding of Ischemia heart disease and lifestyle changes after explanation given.

HEALTH EDUCATION
Advice on discharge

1. Diet control
 Avoid oily food example : fried chicken, fried noodle  Recommended to take low salt, low calories and low fat diet as recommended by dietician  Eat plenty of fresh fruit and vegetables as part of your diet example: papaya, spinach  Advise patient to avoid caffeine  Advise patient to eat in small amount but frequent  Take 1500-2000ml of water per day  Try to avoid fast food

2. Regular exercise  Exercise at least three times in a week, each time about 20-30 minutes 3. Stress management  Advise patient to remain calm, not to stress himself too much as stress can lead to coronary spasm.  To outdoor activity example: gardening  Spent more time with family  Take part in social activities to prevent loneliness 4. Smoking  Advise patient to avoid smoking .

5. Medication
 Patients have to take medication in right dosage, right time and right route.  Advice patient not to stop take their medication as their like, they must inform a doctor before they do it instead if the doctor ask him to stop take the medicine  Top up the medication before finish  Advise patient to consult the doctor if any adverse reaction of the medication. Further treatment can be giving to treat the complication  Provide instruction about the medication prescribed including the purpose and proper use and expected effect. I explain to Mr. N the important of medication especially glycerin trinitrate (GTN) tablet:-it must be taken during chest pain occur -he must carry everywhere he go -place the medication under his tongue until it dissolve -do not swallow the medication -do not drink the water when take medication

6 . Life style  Encourage patient to do light exercise such as gardening, walking and jogging to maintain good healthy.  Advise him don t forget to take rest between working and activity because more heart workload can cause chest pain.  Encourage him to discuss and get help from family members when facing problem  Encourage patient to carry out diversion therapy such as listen to the music, watching television and reading.

7. Follow up

 To come and follow up with doctor to check and adjust his medication. Advise patient to come to hospital immediately if any sign and symptoms of chest pain occur. Advise patient to come for follow up at the correct time and date. Explain to patient the important of follow up.

DISCHARGE

DISCHARGE
Mr. N was discharge by Dr. S on 21st October 2010 .He was accompanied by his wife . Mr. N was discharge after Dr S reviewed at 1210 hours .. I give health education on how to maintain blood pressure, take therapeutic diet an take medication as ordered by doctor .I also reminded him, his follow up was on 1 st Disember 2010 at 1000 hours at Dr S clinic. Observation before discharge;  Blood pressure : 138/60 mmHg  Temperature : 36 C  Pulse : 75 beat per minutes  Respiration : 18 breath per minutes

FOLLOW UP

FOLLOW UP
On 1th Disember 2010 at 1000 hours ,after six weeks from the date of discharge , Mr. N came to Dr .S clinic for his follow up ,he looked cheerful energetic and had no complaints of chest pain. His vital sign during the follow up are shown as bellowed: Blood Pressure Temperature Pulse Respiration : : : : 130/80 mmHg 37.0 C 76 beat per minute 20 breath per minute

*Dr .S decided to continue the same medication as discharge.

SUMMARY

SUMMARY
On 19 October 2010 @ 0940 hours, Mr. N 48 years old, , malay man was coming to specialist clinic at KSH with complaint of chest pain for almost 2 month and shortness of breath for 2 days without any treatment and medication . Dr. S ordered some diagnostic test and investigation for Mr. N such as blood test, chest x-ray, Electrocardiogram (ECG), and stress test . After Mr. N done the medical check up . Dr. S diagnosed as Ischemia Heart Disease (IHD). On 19 October 2010 @ 1340 hours, Mr. N admitted in Medical ward at room no 412B by walk in. During the interview Mr. N said he has no medical history and family history. Mr. N also has not done any operation. Mr. N has not any allergic to food and medication. During admission Mr. N fully conscious. After assessment done , Mr. N vital sign had taken and all the results was normal except blood pressure which was 145/107 mmHg, oxygen saturation:94%,and respiration is 22 per minute. Dr. S has prescribed few medication for Mr. N to be taken during hospitalization. During the follow up on 1 Disember 2010 @ 1000 hours. Mr. N looked cheerful energetic and had no complaint of chest pain . Dr. S decided to continue the same medication.

REFERENCE
A.McFerran T , (2005) , Dictionary of Nursing , Malaysian Edition , Oxford Fajar , p.315. Lemone P and Burke K , (2004) , The Medical Surgical Nurse, Medical Surgical Nursing, 3rd Edition ,Parson Education, New Jersey, p. 137. Marie T.O Toole , (2003) , Miller Keane Encyclopedia And Dictionary of Medicine Nursing And Allied Health , seventh Edition , p.115-116. Martin A.E ,(2003) , Oxford Dictionary of Nursing , Fourth Edition , p .40 Sandra M, (2003) , The Lippincott, Manual of Nursing Practice , seventh edition, Lippincott , p.3 Smeltzer S.C and Bare B , (2004) , Textbook of Medical Surgical Nursing ,Tenth Edition , Lippincott Williams and Wilkins , pp.76-85. Waugh A and Grant A , (2007), Anatomy and Physiology in Health and Illness, tenth edition, Churchill Livingstone Else , pp 85-93. Wilson B , Shannon M and Stange C , (2006) , Nurse s Drug Guide , Upper Saddle River , New Jersey , pp 315.

http: // www.myheart.net/conditions myocardial infraction , condition and diseases of ischemia heart disease http:// www.nml.nih.gov /Medline plus /ency / article / 000201.htm.medline.plus medical Encyclopedia; ischemia heart disease.

THANK YOU!!!!