AMITY COLLEGE OF NURSING

NURSING CARE PLAN

ON
HEART FAILURE

Presented To: Presented By:

Ms. Parul Saini Jyoti punia
Assistant Professor M.Sc Nursing IInd Semester
ACON ACON
 CASE PRESENTATION
PART -1: HISTORY COLLECTION
1. Bio Demographic Data of Patient:
Name : XYZ
Age : 56 years
Sex : Female
Religion : Hindu
Marital Status : Married
Qualification : Illiterate
Occupation : Housewife
Address : Gurgaon, Haryana
Date of admission : 21/ 03/ 2020
IPD NO. : 17/12294
Ward : MICU
Bed No. : 05
Date of discharge : Not yet
Provisional Diagnosis : Heart failure
Consultant name : Dr. Vishal Agarwal

2. Chief Complaints (At the time Of Admission): As per patient,

 C/O breathlessness on exertion for 5 days

 palpitation and edematous limbs for 1 month

 cyanosis on hand and foot fingertips for 1 month

 breathing difficulty for 5 days

 fatigue and restlessness for about a month now.

 cough and blood tited sputum for 2 days now

 confusion seen by family members at times

3. History of Present Illness:

Patient, Mrs. XYZ, 50yrs, female known case of MI 12 months back was present with following
complaints of breathlessness on exertion, palpitation, swelling in foot. Then she is admitted in ABC
hospital for further evaluation and management. She has shifted in CCU ICU for further
management and undergone with blood investigations, ECG, 2-D Echo. After all these
investigations, Dr. Vishal Agarwal diagnosed her with Congestive heart failure and she is receiving
the treatment as per now

4. History of Past Medical & Surgical Illness:

 Past medical history of MI , Is on medications as per now.
 No past surgical history

5. Family History:
Mrs. XYZ is living in nuclear family. There are total 6 members in her family. There is no history of
any heredity or genetic disease/ communicable or non communicable disease among her family.

S.NO. Name of Age Relation Health condition

family member with patient
1. Mr. DEF 505 yrs Husband Healthy
2. Mrs. XYZ 48 yrs. Self Unhealthy/ patient
3. Mr. GHI 22 yrs Elder son Healthy
4. Mrs. JKL 20 yrs Elder daughter in law Healthy
5. Master MNO 01yr Grandson Healthy
6. Miss PQR 17 yrs Daughter Healthy

Family tree:

KEYS
Mr. DEF Mrs. XYZ
(55yrs) (50 yrs) Patient

Female

Male
Mr. GHI Mrs. JKL Miss PQR
(22yrs) (20 yrs) (17 yrs)

Master MNO
(01yr)
6. Personal History:
 Diet: She is vegetarian, is not allergic to any food,
 Habit: no such bad habit of smoking/drinking alcohol/tobacco/drugs.
 Exercise: doing daily farming
 Activity pattern: active life
 Allergies: not known
 Sleep pattern: not appropriate due to disease related breathlessness and edema .
 Elimination history: appropriate bowel and bladder habit.
 Drug history: poor drug compliance but not known about drug allergies.

7. Socio – Economic Status: Patient belongs to middle class family. They have good interpersonal
relationship with their family members and also with their neighbours. She lives in her own Pucca
house in clean environment with proper sanitation. Her family monthly income is nearly rupees
40,000/ month.

PART- 2: PHYSICAL EXAMINATION

1. General Appearance:
 Level of consciousness: conscious to time, person, place, event and follow command
 Grooming : well groomed
 Nourishment : malnourished.
 Body build : patient is thin.
 Body posture : flexed
 Activity : bed rest
 Mood : anxious.
2. Vital Signs:
S.NO. Vital signs Normal Values Patient’s finding on 23/03/20
1 Temperature 98.40 F 96..50 F
2 Pulse 72-80 b/min 42 b/min
3 Respiration 16-20/min 28 / min
4 B.P. 120/80 mm of Hg 100/60 mm of Hg
5 SPO2 100% 100% on face mask

3. Anthropometric Measurement:
Height : 140 cm Weight : 40 kg
4. Head to Toe examinations:
 Skin : Cool and clammy skin, poor elasticity, diaphoresis,peripheral line present
 Mouth : dry mucus membrane and lips
 Neck : elevated jugular venous pressures
 Chest : B/L Air entry present
 Extremity : edema present on foot
5. Systemic Physical Examination:
Neurological System:
 Level of consciousness: patient was conscious and oriented to time, person, place and event
 G.C.S. : Eye opening –E4; Verbal response –V5; Motor response –M6. Total scoring is 15
 Reflexes : superficial and deep tendon reflexes are present.
 Sensory system: in touch, pinch and pressure, pain sensory is intact.
Respiratory System:
 Chest shape : symmetrical
 Inspection : Fast and heavy breathing with hyperventilation at times.RR= 28
 Auscultation : crackles ,coughs and wheezing sounds present B/L,Orthopnea present.
Cardiovascular system:
 Cardiac pattern : heart rate is 42 beat/ min and B.P. is 010/60 mm of Hg
 Rhythm & Regulation: irregular S3 and S4 heart sound present without splitting.
 Capillary refill : capillary refill time is 3.5 sec.
 Auscultation : Murmurs
Gastrointestinal system:
 Palpation : abdomen is soft to touch
 Auscultation : bowel sound is present
 Feeding pattern : orally
 Elimination pattern : urinate through Foley’s catheter
Renal (urinary) system
 Urinate /day : 860ml/day
 Color : light yellow
Integumentary system:
 Color :pale
 Texture & turgor : Dry & poor elasticity , cool and clammy
 Edema : present in leg
Musculoskeletal system:
  Activity level : bed rest , restless and activity intolerance
 Joints : no range of motion
 Muscles : No muscle stiffness

PART-3: INVESTIGATIONS:
Name of lab Investigations Normal values Patient’s finding on 11/08/19
Hematological profile
Hemoglobin (gm %) 13-17 gm 12.7 gm
TLC 5-11 K/mm3 11.58
Polymorphs (%) 40-80% 45
Lymphocytes 20-40% 45
Eosinophil 1-6% 1
Monocytes 2-10% 7
Basophil 0-1% 0
PC/cmm 1.5-4.1 lakh 24.4
P.C.V (%) 40-50 40.8
RBC (Count/cmm) 4.5-5.5 4.70
Metabolic profile
Urea 15-36 mg/dl 25
Creatinine 0.6-1.4 mg/dl 1.9
Sodium 135-148 meq/lt 139
Potassium 3.5-5.3 meq/lt 3.6
Calcium 9.1
Phosphorus 3.8
Hepatic
S. Bill 0.0-0.3 mg/dl 0.07
SGOT 5-34 IU/lt 32
SGPT 0-40 IU/lt 28
Protein Total 6-8.3 gm/dl 7.71
ALB 3.2-5 gm/dl 4.26
GLOB 1.5-3.6 gm/dl 3.45
Alk. Phosphate 35-104 U/lt 95
Coagulation profile
INR 0.75-1.05 6.19
Special test
HIV Non- reactive Non- reactive
HBsAG Negative Negative
Anti HCV Negative Negative
Bl. Sugar 108mg/dl
CRP 6.8
ECG ECG reveals ventricular
hypertrophy
2 D Echo Dilated LA, LVEF<45%, very
severe MS
Chest xray Chest radiography reveals
cardiomegaly and pulmonary
congestion

PART-4: DRUG MANAGEMENT

S. Drug’s name Dose Route Frequency Action

No.
1 Inj Monocef 1gm IV BD Antibiotics
2 Tab Pan 40mg PO BD Proton pump inhibitor
3 Tab Zental 400 mg PO STAT Anti-worm
4 Tab Dytor plus 10 mg PO OD Digitalis
5 Chlorhexidine mouth wash 1 cap PO BD
6 Neb Salbair 0.63 PN TDS Bronchodilator
7 Neb Budecort 0.5 PN BD Corticosteroids
8 Neb Mucomix 2cc PN TDS Mucus thinner
9 Inj. Digoxin 5 mg IV SOS Cardiac glycoside
CARDIAC PROBLEMS WITH RHEUMATIC HEART DISEASE

Given in book Present in patient

 Arrhythmias—Atrial fibrillation; ventricular  Muscle wasting
arrhythmias (ventricular tachycardia,  Bradyarrhythmias
ventricular fibrillation); bradyarrhythmias  Pulmonary congestion
 Thromboembolism—Stroke; peripheral  respiratory muscle weakness
embolism; deep venous thrombosis;
pulmonary embolism
 Gastrointestinal—Hepatic congestion and
hepatic dysfunction; malabsorption
 Musculoskeletal— Muscle wasting
 Respiratory—Pulmonary congestion;
respiratory muscle weakness; pulmonary
hypertension (rare
 Atrial Fibrillation especially if the mitral
valve is involved.

SIGN & SYMPTOMS:

Given in book Present in patient

 Chest pain & Heart palpitations  Heart palpitations
 Breathlessness on exertion  Breathlessness on exertion
 Breathing problems when lying down (orthopnoea)  orthopnea
 Waking from sleep with the need to sit or stand up  Swelling in foot
(paroxysmal nocturnal Dyspnea)
 Swelling (edema)
 Fainting (syncope) & Stroke
 Fever associated with infection

OTHER DIAGNOSTIC EVALUATION:

Given in book Done for the patient
 History collection & Physical examination  History collection
 Chest x-ray  Physical examination
 Electrocardiogram (ECG)  Cxray
 Echocardiogram  ECG
 Throat culture  2D Echo
 Blood investigation  Complete blood count

MEDICAL AND SURGICAL MANAGEMENT:

Given in book Given to patient

Pharmacological Intervention PHARMACOLOGICAL INTERVENTION
 Hospital admission to treat heart failure  Antibiotics
 Antibiotics therapy  Proton pump inhibitor
 Blood-thinning medicine  Anti-worm
 diuretics  Digitalis
 Ace inhibitors  Bronchodilators
 Digoxin  Corticosteroids
 beta blockers
 ace inhibitors
Surgical intervention Surgical intervention
CABG No surgical intervention has been yet
ICD (implantable cardioverter defibrilator) suggested by the consultant.
LVAD
CRT
Heart transplant

NURSING MANAGEMENT:
Nursing assessment

Problems Need
Ineffective breathing Maintaining effective breathing
Impaired gas exchange Improve ventilation and oxygenation
Decreased cardiac output Maintenance of adequate cardiac output
Edema Resolve edema
Risk for impaired skin integrity Maintenance of skin integrity
Activity intolerance Maintain activity tolerance
LIST OF NURSING DIAGNOSIS
 Ineffective breathing pattern related to decreased lung expansion and pulmonary congestion as
manifested by Dyspnea, restlessness
 Impaired gas exchange related to fluid shifting in the pleural space secondary to pulmonary
congestion as manifested by use of accessory muscle and Crackles
 Decreased cardiac output related to altered myocardial contractility as manifested by cold
clammy skin, 4 sec. Capillary refill time
 Excess fluid volume related to increased ADH production and sodium/water retention as
manifested by Orthopnoea, Oliguria, edema, JVD,
 Risk for impaired Skin Integrity related to decreased tissue perfusion as manifested by prolonged
bedrest, Edema.
 Activity intolerance related to decreased cardiac output, oxygen supply and demand imbalance as
manifested by weakness, dyspnea.

HEALTH EDUCATION:
Diet: Encourage patient to eat nutritious foods, limiting intake of sodium containing food.
Follow – up: Instruct the patient to have a follow-up visit after 1 week at her doctor’s clinic.
Especially every 21 days, for treatment maintenance.
Activity level:
 Encourage activity with restrictions, resuming activity gradually, and resting whenever tired.
 Advice patient to have assistance and support as tolerated when ambulating and to perform
ADL’s involving hygiene and self-care, with support if needed

Treatment:
 Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and
continuous therapy to prevent further damage to herat.
 Explain the patients of continuing home medications as prescribe by the Doctors.

Discharge plan:
 Explain to the patient and family the disease process and its treatment to promote understanding
of acute and lifelong prophylactic treatment.
 Teach the patient and family to prevent further streptococcal infections by good hand washing
and avoiding people with sore throat and contact the physician if a sore throat occurs.
 Encourage patient to take frequent naps and rest periods.
 Encourage for using relaxation techniques, listening to music and quiet activities
 Teach patients and family about the importance in keeping their environment clean and
practicing proper food handling and sterilizing kitchen utensils.

Medications: Instruct patient and family to strictly follow the orders for taking home medications as
prescribed the physician.

BIBLIOGRAPHY:
 Black M. Joyce et.al. Medical surgical nursing. 6 th edition (2010), volume 2.W.B.Saunders
publishers: 1685-1691
 Cintamani .Lewis’s Medical surgical nursing assessment and management of clinical problems;
2nd edition (2013) ; Elsevier publishers: 781-783
 Nettina M. Sandra . Lippincott manual of nursing practice. 9 thedition (2010). Lippincott Williams
& Wilkins: 460-462.
 Smeltzer C.Suzanne, Bare G.Brenda. Bruner & Siddharth’s textbook of medical surgical nursing;
12th edition (2010); Lippincot Williams & Wilkins publishers: 620-630
 www.nanda-books.com/.../priority-nu...sis-for.html
 www.registerednursern.com/...
 NURSING CARE PLAN
ASSESSMENT NURSING PLANNING NURSING ACTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Cues: Decreased Cardiac STG:  Assess for abnormal  Rationale: Allows At the end of 8-hour
N/A Output related to At the end of 30-min heart and lung sounds. detection of left-sided heart failure Nursing Interventions, the
altered heart rate Nursing Interventions, the that may occur with chronic renal goal was partially met as
Objective Cues: and Inadequate client will be able to: failure patients due to fluid volume evidenced by:
 Generalized blood pumped by  Demonstrate excess as the diseased kidneys are ----Patient will
paleness noted the heart to meet hemodynamic stability unable to excrete water. S1 and S2 demonstrate adequate
 Irregular rhythm metabolic (blood pressure and may be weak because of cardiac output as
of pulse noted demands of the cardiac output) by 20% diminished pumping action. evidenced by vital signs
 PR =42/min body. – 30% as revealed in within acceptable limits,
 Pale the cardiac monitor dysrhythmias
conjunctiva,  Monitor blood  Rationale: Patients with absent/controlled, and no
nail beds, and LTG: pressure and pulse. renal failure are most often symptoms of failure (e.g.,
buccal mucosa At the end of 8-hour hypertensive, which is hemodynamic parameters
 irregular Nursing Interventions, the attributable to excess fluid and within acceptable limits,
rhythm of pulse client will be able to: the initiation of the RAS. urinary output adequate).
 bradycardia  Demonstrate -----Patient will report
 generalized hemodynamic stability decreased episodes of
weakness (Blood pressure and  Assess mental status  Rationale: The dyspnea, angina.
cardiac output) by and level of accumulation of waste products Patient will participate in
31%-80% as revealed consciousness. in the bloodstream impairs activities that reduce
in the cardiac monitor oxygen transport and intake by cardiac workload.
 Manifest absence of cerebral tissues, which may
angina manifest itself as confusion,
lethargy, and altered Endorsed to the next shift
consciousness. NOD for further
interventions and
revisions of NCP for
 Rationale: Decreased continuity of care
 Assess patient’s skin perfusion and oxygenation of
temperature and tissues secondary to anemia and
peripheral pulses. pump ineffectiveness may lead
to decreased in temperature and
peripheral pulses that are
diminished and difficult to
 palpate.

 Monitor results of  Rationale: Provides

laboratory and diagnostic information regarding the
tests. heart’s ability to perfuse distal
tissues with oxygenated blood

 Monitor oxygen  Implement strategies to treat fluid

saturation and ABGs and and electrolyte imbalances.
peripheral
perfusion,Give oxygen
as indicated by patient
symptoms, oxygen
saturation and ABGs.

 Encourage periods of  Rationale: Reduces

rest and assist with all cardiac workload and minimizes
activities. myocardial oxygen
consumption.

 Assist the patient in  for better chest expansion,,

assuming a high thereby improving pulmonary
Fowler’s position. capacity.

 Teach patient the  To relieve pt's anxiety

pathophysiology of
disease, medications.
2.
Subjective cues :  Excessive  Monitor and record  Rationale: To obtain  Patient will
Pt may complain of Fluid volume  STG-Patient will Vital signs and Assess baseline data And To determine verbalize
swollen legs and related verbalize patient’s general what approach to use in understanding of
hands and difficulty to decreased understanding of condition. treatment causative factors and
in breathing. cardiac output causative factors and demonstrate
and sodium demonstrate behaviors to resolve
and water behaviors to resolve  Monitor I&O every 4  Rationale: I&O balance excess fluid volume.
The patient may retention excess fluid volume. hours reflects fluid status  Patient will
manifest the  LTG-Patient will demonstrate adequate
following: demonstrate adequate fluid balanced AEB
fluid balanced AEB  Weigh patient daily  Rationale: Body weight is output equal to
 Edema of output equal to and compare to previous a sensitive indicator of fluid exceeding intake,
extremities exceeding intake, weights. balance and an increase clearing breath
 Difficulty of clearing breath indicates fluid volume excess. sounds, and
breathing sounds, and decreasing edema.
 Crackles decreasing edema  pt will maintain
 Change in  pt will maintain normal fluid volume
mental status normal fluid volume  Auscultate breath  Rationale: When increased as evidenced by
 Restlessness as evidenced by sounds Q 2hr for the pulmonary capillary hydrostatic weight loss and
and anxiety weight loss and presence of crackles and pressure exceeds oncotic pressure, decrease in edema ,
decrease in edema , monitor for frothy fluid moves within the alveolar juglar vein distension
juglar vein distension sputum production. septum and is evidenced by the and abdominal
and abdominal auscultation of crackles. Frothy, distension..
distension.. pink-tinged sputum is an indicator
that the client is developing
pulmonary edema.
 monitor Cxray for
pulmonary edema.

 Assess for presence of  Rationale: Decreased

peripheral edema. Do not systemic blood pressure to
elevate legs if the client stimulation of aldosterone,
is dyspneic. which causes increased renal
tubular absorption of sodium
Low-sodium diet helps prevent
increased sodium retention,
 which decreases water
retention. Fluid restriction may
be used to decrease fluid intake,
hence decreasing fluid volume
excess.
 Follow low-  Rationale: The client senses thirst
sodium diet and/or fluid because the body senses
restriction and dehydration. Oral care can
potassium supplements alleviate the sensation without an
to replace k lost during increase in fluid intake.
diuresis. i.e K-DUR.
Diuretics with
potassium-sparing
agents: spironolactone
(Aldactone)

 Encourage or provide  Rationale: May include

oral care Q2H increased fluids or sodium
 Obtain patient history intake, or compromised
to ascertain the probable regulatory mechanisms.
cause of the fluid
disturbance.
 Monitor for distended  Rationale: Indicates fluid
neck veins and ascites overload

 Evaluate urine output  Rationale: Focus is on

in response to diuretic monitoring the response to the
therapy. diuretics, rather than the actual
amount voided

 Assess the need for an  Rationale: Treatment focuses on

indwelling urinary diuresis of excess fluid.
catheter.

 Institute/instruct  Rationale: This helps reduce

patient regarding fluid extracellular volume.
restrictions as
appropriate.
3.  Auscultate breath  Rationale: Reveals
Pt. will
Risk for Impaired  STG- sounds, noting crackles, presence of pulmonary
Demonstrate
Subjective cues: Gas Exchange: At Participate in wheezes. congestion and collection of
adequate
risk for excess or treatment secretions, indicating need
Pt complains of ventilation and
deficit in regimen within for further intervention.
repeated dry coughs oxygenation of
oxygenation level of
and weakness' in tissues by
and/or carbon ability/situation
body ABGs/oximetry
dioxide .  Instruct patient in  Rationale: Clears airways and
within patient’s
elimination at the effective coughing, deep facilitates oxygen delivery.
Patient may manifest normal ranges
alveolar-capillary breathing.
the following: and free of
membrane.
symptoms of
 LTG-
 weakness respiratory
Demonstrate  Encourage frequent  Rationale: Helps prevent
 rales on BLF distress.
adequate position changes. atelectasis and pneumonia.
 productive ventilation and
cough oxygenation of
 frothy tissues by
sputum ABGs/oximetry  Maintain chair or bed rest,  Rationale: Reduces
 pursed lip within patient’s with head of bed elevated oxygen demands and
breathing normal ranges 20–30 degrees, semi- promotes maximal lung
 tachypnea and free of Fowler’s position. Support inflation.
symptoms of arms with pillows
respiratory
distress.
 Place patient in Fowler’s  rationale: Hypoxemia can be
position and give severe during pulmonary edema.
supplemental oxygen to Compensatory changes are usually
help patient breath more present in chronic HF. Note: In
easily and promote patients with abnormal cardiac
maximum chest expansion. index, research suggests pulse
oximeter measurements may
exceed actual oxygen saturation
by up to 7%

 Graph graph serial ABGs,  Rationale: Determines

pulse oximetry.,Administer adequacy of breathing
supplemental oxygen as
indicated.
 Inspect thorax for  Rationale: Identifies
symmetry of respiratory increased work of
movement Breathing

 Observe breathing pattern

for SOB, nasal flaring,  Rationale: Indicates
pursed-lip breathing or volume of air moving in and
prolonged expiratory phase out of lungs
and use of accessory
muscles
 Measure tidal volume and
vital capacity

 Assess emotional response  Rationale: Detects use of

hyperventilation as a
causative factor .

 Position patient in optimal  Rationale: Reduces

body alignment in semi- muscle tension, decreases
fowler’s position for work of breathing.
breathing,Assist patient to
use relaxation techniques

 Administer Diuretics:
furosemide (Lasix)-
Reduces alveolar  Rationale:
congestion, enhancing gas Increases oxygen delivery by
exchange. dilating small airways, and exerts
 Administer mild diuretic effect to aid in
Bronchodilators: reducing pulmonary congestion.
aminophylline-
 4  Assess patient pain for  Rationale: To identify intensity,
Subjective  Ineffective intensity using a pain rating precipitating factors and location to
cues.: tissue  Patient will scale, for location and for assist in accurate diagnosis.  Patient will
N/A perfusion demonstrate precipitating factors. demonstrate
related to behaviors to improve behaviors to improve
Patient may manifest decreased circulation.  Administer or assist with  Rationale: The vasodilator circulation.
the following during cardiac  Display vital signs self administration of nitroglycerin enhances blood flow to  Display vital signs
assessment: output. within acceptable vasodilators, as ordered. the myocardium. It reduces the within acceptable
limits, dysrhythmias amount of blood returning to the limits, dysrhythmias
absent/controlled,and heart, decreasing preload which in absent/controlled,and
no symptoms of turn decreases the workload of the no symptoms of
 Pale failure heart. failure
conjunctiva,
nail beds, and  Assess the response to  Rationale: Assessing response
buccal mucosa medications every 5 determines effectiveness of
 Generalized minutes medication and whether further
weakness interventions are required.
 Chest pain  Give beta blockers as  Rationale: Beta blockers decrease
 Difficulty of ordered. oxygen consumption by the
breathing myocardium and are given to prevent
 Abnormal subsequent angina episodes.
pulse rate and
rhythm  Establish a quiet  Rationale: A quiet environment
 Bradycardia environment. reduces the energy demands on the
 Altered BP patient.
readings
 With pitting  Elevate head of bed.  Rationale: Elevation improves chest
edema on both expansion and oxygenation
forearms and
hands  Monitor vital signs,  Rationale: Tachycardia and elevated
 Bipedal especially pulse and blood blood pressure usually occur with
pitting edema pressure, every 5 minutes angina and reflect compensatory
until pain subsides. mechanisms secondary to
sympathetic nervous system
stimulation.

 Provide oxygen and  Rationale: Oxygenation increases the

monitor oxygen saturation amount of oxygen circulating in the
 via pulse oximetry, as blood and, therefore, increases the
ordered. amount of available oxygen to the
myocardium, decreasing myocardial
ischemia and pain.
 Assess results of cardiac  Rationale: These enzymes elevate in
markers—creatinine the presence of myocardial infarction
phosphokinase, CK- MB, at differing times and assist in ruling
total LDH, LDH-1, LDH-2, out a myocardial infarction as the
troponin, and myoglobin cause of chest pain.
ordered by physician.

 Assess cardiac and  Rationale: Assessment establishes a

circulatory status. baseline and detects changes that may
indicate a change in cardiac output or
perfusion

 Monitor cardiac rhythms on  Rationale: Notes abnormal tracings

patient monitor and results that would indicate ischemia.
of 12 lead ECG.

 Teach patient relaxation  Rationale: Anginal pain is often

techniques and how to use precipitated by emotional stress that
them to reduce stress. can be relieved non-pharmacological
measures such as relaxation.

 Teach the patient how to  Rationale: In some case, the chest

distinguish between angina pain may be more serious than stable
pain and signs and angina. The patient needs to
symptoms of myocardial understand the differences in order to
infarction. seek emergency care in a timely
fashion.

 Reposition the patient  Rationale: To prevent bedsores

every 2 hours

 Instruct patient on eating a  Rationale: To prevent heartburn and

small frequent feeding. acid indigestion.