i.

INTRODUCTION Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is a disease state that occurs when the blood supply to a part of the heart is interrupted. The resulting ischemia or oxygen shortage causes damage and potential death of heart tissue. It is a medical emergency, and the leading cause of death for both men and women all over the world. Important risk factors are a previous history of vascular disease such as atherosclerotic coronary heart disease and/or angina, a previous heart attack or stroke, any previous episodes of abnormal heart rhythms or syncope, older ageespecially men over 40 and women over 50, smoking, excessive alcohol consumption, the abuse of certain illicit drugs, high triglyceride levels, high LDL ("Lowdensity lipoprotein") and low HDL ("High density lipoprotein"), diabetes, high blood pressure, obesity, and chronically high levels of stress in certain persons. Heart diseases constitute the second most common cause of death. Coronary heart disease death rates have shown consistent declines over the past 15 years, with men having almost twice the death rates of women. The difference in rates has remained constant over the years. In 2008, the age-standardized death rate for men was 105 per 100 000 resident population, compared with 56 for women. The incidence of acute myocardial infarction events among adults has generally decreased since 1990. The incidence rate for men is about twice that for women; in 2007, the agestandardized incidence rate for men was 179 per 100 000 resident population, compared with 79 for women.
Myocardial infarction is a leading cause of morbidity and mortality in the United States. Approximately 1.3 million cases of nonfatal MI are reported each year, for an annual incidence rate of approximately 600 cases per 100,000 people. The proportion of patients diagnosed with NSTEMI compared with STEMI has progressively increased. MI continues to be a significant problem in industrialized countries and is becoming an increasingly significant problem in developing countries.

This is a case of patient FT, 89 years old, male, Roman Catholic, from Talakag, Bukidnon; admitted at MRH on Feb. 3, 2010 with chief complaints of facial asymmetry associated with slurring of speech and chest pain. His previous diagnosis from last 1

hospitalization includes CAD, AF with RVR (AF with CVR); CHF Class IV (Clan I, Stage C); Stress Hyperglycemia; and BPH. In organizing patient care, the group utilized Primary Nursing, also known as relationship-based nursing. The group viewed themselves as the primary nurses. They were the ones who assessed and established the nursing care plans which were then clearly communicated to the student nurses directly assigned to the patient when the group was not present. Feedback was then sought from them with regards to the evaluation and progress of the clients condition. Physician Charge Nurse Health care Organization Resources

Clinical Instructor

Primary Student Nurse

Staff Nurse

Associate Level 3 Student Nurse

Staff Nurse

A. GENERAL OBJECTIVES: This case presentation seeks to enhance the students knowledge with regards to the patients general health and disease condition, its pathophysiology, possible complications, treatment plan and medical regimen. This also seeks to assimilate the students skills through application of several nursing interventions and medical management. Furthermore, this case presentation intends to improve the students attitude by conveying open-mindedness and utilizing therapeutic communication all throughout the activity.

B. SPECIFIC OBJECTIVES: The student nurses aim to achieve the following objectives in 1 hour of case presentation: 1. Accurately present a thorough general health assessment of the client which includes physical assessment and family history taking. 2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited by the client 3. Thoroughly discuss, explain, and elaborate the nature of the disease process 4. Efficiently provide appropriate and proper nursing diagnosis in line with the clients medical condition 5. Skillfully formulate nursing care plans for the different problems identified 6. Appropriately provide nursing interventions according to the standards of nursing practice 7. Effectively apply the learned concepts and theories of disease 8. Efficiently appraise the effectiveness and efficacy of nursing interventions rendered to the client 9. Impart the outcome of the rendered nursing interventions 10. Convey the significance of clients response to the rendered nursing interventions 11. Correctly provide concise and concrete information to the audience with regards to the patients disease condition. 12. Appropriately provide appropriate environment for learning for the audience C. SCOPE AND LIMITATION The data presented in this case was primarily obtained from student nursepatient interaction as well as with the significant other who partly served as informant. Further information is based on the patients chart. The student nurses were only able to render care to the patient during the assessment on February 4, 7, and 10, 2010 since the formers clinical exposure at MRH already ended during that period. Additionally, subsequent assessments after the 3rd visit were not done because the patient was then discharged. The Nursing Care Plans presented herein were implemented at a very limited time but were endorsed and continued by the student nurse assigned to the patient. Nevertheless, the evaluation bears the nursing outcome observed upon assessing the patient

II. ASSESSMENT COLLEGE OF NURSING Xavier University Ateneo de Cagayan LEVEL IV NURSING HISTORY and ASSESSMENT RECORD Dates of Assessment: February 4, 2010 first assessment day February 7, 2010 second assessment day February 10, 2010 third assessment day I. PATIENTS PROFILE Name of Patient: FT Age: 89 y.o. Admitting Diagnosis: CVD, coronary infarct, HPN2,HCVD, CD, AF with CVR Latest Diagnosis: Myocardial infarction, chronic obstructive pulmonary disease, benign prostatic hyperplasia Religion: Roman Catholic Name of Attending Physician: Dr. Elbis Nacua Married Date and Time of Admission: Feb. 3, 2010; 7:15 AM Language/Dialect Spoken: Cebuano February 4, 2010 Temperature 36.4 oC Blood Pressure 120/70 mmHg February 7, 2010 Temperature 37 oC February 10, 2010 Temperature 36.6 oC Pulse 76 bpm Respiration 23 cpm 4 Pulse 85 bpm Respiration 24 cpm Blood Pressure 110/70 mmHg Pulse 92 bpm Respiration 26 cpm Civil Status:

Blood Pressure 130/70 mmHg Height: 54 Weight 55 kls.

CHIEF COMPLAINT/REASON FOR HOSPITALIZATION: Weakness; facial asymmetry and slurring of speech HISTORY OF PRESENT ILLNESS: Patient FT, 89 years old, male, Roman Catholic, from Talakag, Bukidnon; admitted at MRH on Feb. 3, 2010 with chief complaints of facial asymmetry associated with slurring of speech and chest pain. Last January 16, 2010, the patient experienced pain on the nape, dyspnea and verbalized to his daughter, naglain ako ginhawa which alarmed the SO to seek medical assistance at MRH and was then admitted. He was then discharged on Jan. 23, 2010, with discharge diagnoses of CAD, AF with RVR (AF with CVR); CHF Class IV (Clan I, Stage C); Stress Hyperglycemia; and BPH. Patient discharged with home medications: Digoxin 0.7g/tab OD before lunch, Metoprolol 50mg tab BID, Rovustatin 10 mg/tab OD, Losartan 50mg tab OD AC BF, Spiriva rotacup thru inhaler OD, Allopurinol 100 mg 1tab OD and Avodart 1tab OD. catheter, such apparatus taken with good compliance. The patient recovered well after the hospitalization he was able to continue activities without dyspnea and fatigue. He was able to move freely in the house, perform ADLs and did not manifest any symptoms of his illness, but SO verbalized persisting coughs a week prior to admission. On the evening of Feb. 2, 2010, the patient slept early. 3 hours PTA at around 4:00 am, the patient was found restless and moaning in bed. Upon observation by the daughter, she noticed that the patients face was already asymmetrical, accompanied with shortness of breath and slurring of speech. The patient was also observed clutching his chest and grimacing in pain. The situation above prompted the family to bring the patient to the hospital (MRH). Thus lead to the patients admission. FOOD AND DRUG ALLERGIES: Pls. specify: no known food and drug allergy PAST MAJOR ILLNESS, OPERATIONS, AND HOSPITALIZATIONS ILLNESS/HOSPITALIZATION Admitted for CAD, AF with RVR (AF with DATE Jan. 2010 5 Patient discharged with foley

CVR); CHF Class IV (Clan I, Stage C); Stress Hyperglycemia; and BPH at MRH Hypertension Family Medical History (X) Heart disease: Paternal side (X) Stroke: Maternal side Abuse (-) Lung Disease Others: _______________________________________________________________ II. FUNCTIONAL PATTERN A. NUTRITION/METABOLIC PATTERN Meal Pattern: Patient normally eats three times a day (breakfast, lunch and dinner). Reports of patients fondness of eating fatty food (e.g. humba, chicharon). Appetite: Changes in Eating Habits? Appetite Changes? Weight loss/gain: 55kls-50kls TEETH: Comments/Nursing Problem Identified: February 4, 2010 - Patient is on NGT feeding of 1,600 kcal/feeding. February 7, 2010 Patient is still on NGT feeding. February 10, 2010 Patient is on soft diet. Lugaw ra gyud iya pwede kaonon kay galisod pa siya ug tulon. Mukaon man pod siya pero gamay ra kay murag wala man siya gana. Mao man sab ang ingon sa doctor na lugaw lang sa ang ipakaon sa iya. as verbalized by the SO. B. ELIMINATION PATTERN BLADDER (X) No difficulty ( ) Dysuria ( ) Oliguria 6 ( ) Good ( X ) Fair ( ) No ( ) No ( ) Poor ( X ) Yes ( X ) Yes ( ) Others (-) Renal Disease (-) Cancer (-) Substance (X) Hypertension: Both maternal and paternal side 2005

Special Diet: low salt, low fat, diabetic diet

( ) Incontinence ( ) UTI Comments/Nursing Problem Identified:

( ) Nocturia ( ) Stones

( ) Anuria

February 4, 2010 Patient is with foley bag catheter. Dili man namo mabantayan kung galisod ba siya og ihi o dili kay gi catheter man siya. Daghan biya pod iyang ihi kay dali ra man mapuno ang kanang sudlanan usahay. as verbalized by the SO. Urine output: 2, 700 cc (in 24 hours) February 7, 2010 Mao ra man gihapon, naka catheter ra gihapon siya. as verbalized by the SO. Urine output: 2, 250 cc (in 24 hours) February 10, 2010 Patient is still with Foley bag catheter. Urine output: 480 cc (in 6-2 Shift) BOWEL February 4, 2010 February 7, 2010 ( ) No difficulty ( ) Constipation ( ) Incontinence Comments/Nursing Problem Identified: February 4, 2010 Pila na kaadlaw wala siya kalibang. Pero naa man siya tambal kalibang na man pud siya. As verbalized by SO February 7, 2010 Nakalibang man siya. Humok tungod sa iyang tambal as verbalized by the SO. February 10, 2010 Makalibang na siya adalw. as verbalized by the SO. C. SLEEP/REST PATTERN ( X ) No difficulty ( ) Yes (X) Yes Use of sleeping aids: ( ) No ( ) Ileostomy (X) Constipation

February 10, 2010 ( ) Constipation (X) Laxative aids (specify: Lactulose (ordered Feb. 3, 2010)

Comments/Nursing Problem Identified: 7

Diretso-diretso man iyang tulog. Sa iya sa kapoy sa iyang sakit mao tingali diretsodiretso iyang tulog. As verbalized by SO Activities of Daily Living Dependent) Eating (D) Grooming (D) ACTIVITY LEVEL ( Bathing (D) Toileting (D) ) Active Dressing (D) Ambulating (D) (X) Sedentary (I = Independent, A = With Assistance, D =

Comments/Nursing Problem Identified: February 4, 2010 Kadtong wala pa siya nagsakit, maglihok-lihok man pod siya sa balay. Karon dili man niya kaayo malihok iya kamot kay luya. Karon kay magghigda ug matulog ra gyud siya.. as verbalized by the SO. The patient is very dependent to his SO due to his condition. February 7, 2010 Karon na naa siya sa hospital, maghigda ra gyud na siya kay luya man gud pod siya. as verbalized by the SO. Kami man gyud ga ilis ug gapakaon niya kay maglisod man siya ug lihok-lihok. as verbalized by the SO. February 10, 2010 Makaya-kaya naman niya nga maglihok-lihok nga siya ra. Pero amo ra gihapon siya i-assist kay basin ma-unsa bah. as verbalized by the SO. E. COGNITIVE PERCEPTION PATTERN Glasses ( ) No (X) Yes Contact Lens ( ) Yes ( ) Left Hearing Aids (X) No Right ( ) Right ( ) Left Left Comments/Nursing Problem Identified: ( ) ( ) Yes Prosthesis ( ) Yes ( ) ( ) Right

Makakita pa man pod siya gamay pero kung magbasa siya kay gagamit siya ug antipara. Karon naa siya sa hospital kay dili man niya ginagamit iyang antipara. Makadungog pa man pod na siya. as verbalized by the SO. F. BEHAVIOR PATTERN (COPING/VALUES) BEHAVIOR (X) Relaxed ( ) Moderately anxious ( ( ) Mildly Anxious ) Very anxious

Psychiatric History: none SUBSTANCE ABUSE (If yes, pls. indicate frequency/# of packs/glasses per day) Tobacco Drugs Alcohol Cigarette/Cigar/Pipe (X) No (X) No ( ) No (X) No ( ) Yes _____________________________ ( ) Yes _____________________________ ( ) Yes

( X ) Yes approximately twice a week______

_____________________________ Comments/Nursing Problem Identified: Dili man na siya ga sigarilyo, ga inom siya usahay ra pod dayon ginagmay ra pod. as verbalized by the SO. G. PAIN

February 4, 2010 ( ) No (X) Yes (describe) crushing pain on the chest with a pain scale of 3/5, 5 being the highest Present Pain Management: relaxation technique, deep breathing exercises, Dolcet 1 tab TID; movement stopped, rest provided along with diversional activities

February 7, 2010 ( ) No (X) Yes (describe) crushing pain on the chest with a pain scale of 2/5, 5 being the highest Present Pain Management: relaxation technique, deep breathing exercises, Dolcet 1 tab TID February 10, 2010 (X) No ( ) Yes (describe) Present Pain Management: _________________________________________________________________ Comments/Nursing Problem Identified: February 4, 2010 - sighing with no intent to move unless absolutely necessary; very slow movement with facial grimace; shortness of breath upon pain onset with facial grimace and sighing Murag gi-kumot. 3/5. Replied the client when asked by the SN regarding the description of pain and the pain rate scale. Muingon na siya na sakit iyahang dughan. Sauna ga reklamo naman siya nga musakit iyang dughan labaw na kanang mahago siya. as verbalized by the SO. February 7, 2010 Gasakit man gihapon iya dughan usahay. as verbalized by the SO. February 10, 2010 - Kaluoy sa Ginoo wala na siya ga-reklamo of sakit sa iyang dughan as verbalized by SO. H. SEXUALITY/REPRODUCTION PATTERN Date of last menstrual period (LMP): N/A Date of Last Pap Smear: N/A Is the patient pregnant? ( ) No ( ( ) Unsure ( ) No ( ) Yes, no of weeks _____________ ) Yes 10 Breast (cyst, lump, discharge)

Testicular/prostate problem: Birth Control: (X) NA ( hyperplasia.

( (

) NA ) No

) No

(X) Yes

) Yes (describe) ______________________________

Comments/Nursing Problem Identified: Patient is diagnosed with benign prostatic I. ROLE RELATIONSHIP PATTERN Occupation: none With whom does patient live? Family (one son, one daughter and 2 grandchildren) Anticipating to return home? ________________________ Person(s) available to assist at home: children Comments/Nursing Problem Identified: The patient is taken care of by his children. Wala man gyud lain makatabang ug makabantay ni papa mao na kami ra gyud magbantay. as verbalized by the SO. III. PHYSICAL ASSESSMENT (Indicate subjective and objective cues for abnormalities noted) A. NEUROLOGICAL ASSESSMENT Alert and oriented to person, place and time? Subjective February 4, 2010 Gahapon, dili na siya kabalo kung aha siya. Unya murag ga-tanga ra siya pirminti. Naa pud usahay na dili siya kaila sa amo matulog lang dayun siya balik., as verbalized by the SO. February 7, 2010 Makaila naman siya. Katulgon na siya pero dili na kaayo pareha sa una. Murag wala lang siya kabalo sa oras ug adlaw kay naa siya diri sa hospital, as verbalized by the SO. 11 (X) Yes ( ) No (specify the reason)

February 10, 2010 Naa ko ospital karun. Mga alas kwatro naman tingale sa hapon as verbalized by the client. Objective February 4, 2010 GCS score: eyes 4, verbal 4, motor 4 =12 moderate brain injury, conscious and coherent but drowsy. Not oriented to person, place and time. February 7, 2010 GCS score: eyes 4, verbal 4, motor 5 = 13 minor brain injury, There is difficulty remembering persons, place and time but patient is able to recognize close members of the family. February 10, 2010 GCS score: eyes 4, verbal 4, motor 6 = 14 minor brain injury. The patient can recognize close members of the family, is oriented and is able to respond to questions although slurring of speech is still present. Pupils equally round & reactive to light? No paresthesia (weakness) or paralysis of extremities? Subjective February 4, 2010 Luya na iyang tuo nga side sa lawas., as verbalized by the SO. February 7, 2010 Kami ra gyud magilis ug pakaon niya kay maglisod siya ug lihok-lihok., as verbalized by the SO. February 10, 2010 Medyo okay naman siya. Pero luya ra gihapon daw iyang tuo. As verbalized by SO. Objective February 4, 2010 R: weakness on upper and lower extremities present, Grade 1 : no active range of motion & No muscle resistance; L: normal ROM, Grade 3: full active range of motion & No muscle resistance 12

February 7, 2010 with complaints of generalized body weakness, R: Grade 2: Reduced active range of motion & No muscle resistance; L: Grade 4: full active range of motion & reduced muscle resistance February 10, 2010 still with complaints of generalized weakness, R: Grade 4: full active range of motion & Reduced muscle resistance; L: Grade 4: full active range of motion & Reduced muscle resistance No difficulty in speech or swallowing noted? Subjective February 4, 2010 Maglisod man siya ug istorya dili kaayo mi kasabot., as verbalized by the SO. Sa tubo ra man ginapaagi iyang pagkaon, dili mi maka ingon na maglisod siya ug tulon. as verbalized by the SO. February 7, 2010 Maglisod man gihapon siya ug istorya., as verbalized by the SO. Gaapason niya iyang ginhawa kung magsturya siya. As verbalized by SO. February 10, 2010 Lugaw ra gyud iya pwede kaonon kay galisod pa siya ug tulon. Mukaon man pod siya pero gamay ra kay murag wala man siya gana. Mao man sab ang ingon sa doctor na lugaw lang sa ang ipakaon sa iya. as verbalized by the SO Makasturya siya pero dili kaayo ingon ana ka klaro.. Objective February 4, 2010 Slurred speech noted Difficulty in expressing thoughts verbally and use of facial or body expression due to condition. February 7, 2010 There is difficulty swallowing thus patient is still on NGT feeding. February 10, 2010 There is difficulty uttering words. Difficulty in expressing thoughts verbally and use of facial or body expression due to condition. There is improved swallowing. Patient is on soft diet.

13

B. RESPIRATORY ASSESSMENT Resp. 12 to 22 breath/minute at rest? Subjective February 4, 2010 Gi oxygen man siya kay maglisod siya ug ginhawa. Gi ubo man gud siya., as verbalized by the SO. Naay plema iyang ubo, medyo white na sticky., as verbalized by the daughter. February 7, 2010 Galisod gyud siya ug ginhawa tungod sa iyang ubo., as verbalized by the SO. Nakaluwa siya ug dugo ganina buntag., as verbalized by the SO. February 10, 2010 Medyo arangan na iya pamati kay wala naman pod siya gi oxygen pero naa gihapon siyay ubo., as verbalized by the SO. Objective February 4, 2010 RR=26 cpm, shallow breathing, use of accessory muscles February 7, 2010 RR= 24 cpm, shallow breathing February 10, 2010 RR= 23 cpm, normal breathing Respirations quiet & regular? Breath sounds in both lung fields are clear? Objective Rales and ronchi present at both lung fields upon auscultation. Positive for lung congestion based upon chest x-ray result, productive cough noted. Nail beds and lips pink. Objective Nail beds and lips are pale. C. CARDIOVASCULAR ASSESSMENT Regular apical pulse. Heart rate 60 to 100 beats/minute? Objective February 4, 2010 HR= 92 bpm, regular rhythm February 7, 2010 HR= 85 bpm, regular rhythm Dilated aorta based upon chest x-ray result. February 10, 2010 14

HR = 76 bpm, regular rhythm No complaints of chest pain? Subjective Gareklamo man siya nga sakit iyang dughan usahay., as verbalized by the SO. Musakit iyang dughan usahay. Sauna ga reklamo naman siya nga musakit iyang dughan labaw na kanang mahago siya. as verbalized by the SO. Objective Sighing with no intent to move unless absolutely necessary; very slow movement with facial grimace; shortness of breath upon pain onset associated with facial grimace and sighing No Edema? None noted D. PERIPHERAL-VASCULAR ASSESSMENT Extremities are pink, warm and movable within normal ROM? Subjective Pale extremities and cold. Upper and lower extremities movable within ROM with assistance but there weakness on the right side of the body. Peripheral pulses palpable. No edema. No complaints of numbness or calf tenderness? Objective February 4, 2010: Capillary refill: 4 sec February 5, 2010: Oxygen Saturation =93% February 7, 2010: Capillary refill: 2 sec February 10, 2010: Capillary refill: 2 sec E. GENITOURINARY ASSESSMENT Voiding without discomfort or difficulty? Urine clear, frequency within own pattern? Subjective

15

Dili man namo mabantayan kung galisod ba siya og ihi o dili kay gi catheter man siya. Daghan biya pod iyang ihi kay dali ra man mapuno ang kanang sudlanan usahay. as verbalized by the SO. Objective February 4, 2010 -The patient is with foley bag catheter. Urine output: 2, 700 cc (in 24 hours) February 7, 2010 Mao ra man gihapon, naka catheter ra gihapon siya. as verbalized by the SO. Urine output: 2, 250 cc (in 24 hours) February 10, 2010 Patient is still with foley bag catheter. No unusual penile irritation/discharge noted? No unusual penile discharges.

F. MUSCOLUSKELETAL ASSESSMENT Absence of joint swelling and tenderness, no evidence of inflammation? Normal ROM of all joints? Subjective Kinahanglan gyud namo siya tabangan kung mulihok kay luya man gyud siya., verbalized by the SO. No muscle weakness? Objective Generalized body weakness noted. No complaints of back pain? No complaints of backpain G. INTEGUMENTARY ASSESSMENT Skin color within patients norm, skin warm, dry & intact? 16

Objective Skin is cold, pale and saggy. Pale mucous membranes. Scalp condition: oily. Decubiti/burns present? Medications Topamax Dolcet Keppra Coumadine Piperacillin + Tazobactam Combivent ( ) Yes ( X ) No Indications To prevent migraine headache Moderate to severe pain. adjunctive therapy in the treatment of partial onset seizures in adults Myocardial Infarction Moderate to severe nosocomial pneumonia To prevent bronchospasm in people with chronic obstructive pulmonary disease (COPD) who are also using other medicines to control their condition Short term treatment of duodenal ulcer. For acute & chronic resp tract affections w/ abundant mucus secretions Myocardial Infarcion Used to treat cerebrovascular disease Used to treat high blood pressure Essential hypertension.), and reduction of risk of cardiac events in patients with a history of myocardial infarction Used to prevent heart attacks, strokes, and blood clots in veins and arteries. Used in treating an abnormal heart rhythm Used to treat high cholesterol Used in treatment of bronchial spasms (wheezing) associated with chronic obstructive pulmonary disease. It reduces the production of uric acid in your body Avodart is used to treat benign prostatic hyperplasia (BPH) in men with an enlarged prostate. Used to treat constipation

Sucralfate Fluimocil Metoprolol Citicoline drops Perindopril

Warfarin (coumadin)
Digoxin Rosuvastatin Tiotropium Bromide (Spiriva Rotacap)

Allopurinol Dutasteride (Avodart)

LACTULOSE

17

Body Map: February 4, 2010 first assessment day 1. Nasogastric Tube on left nostril 2. O2 cannula 3. IV on left arm 4. COPD 5. BPH 6. Myocardial infarction 7. Foley catheter

February 7, 2010 second assessment day 1. Nasogastric Tube on left nostril 2. O2 cannula 3. IV on left arm 4. COPD 5. BPH 6. Myocardial infarction 7. Foley catheter

February 10, 2010 second assessment day 18

1. COPD 2. BPH 3. Myocardial infarction 4. Foley catheter

LABORATORY RESULTS COAGULATION PROTHROMBIN TIME Normal Value: 11-15 seconds (2-3-10) (2-7-10) (2-10-10) Prothrombin Time: 14.6 seconds 14.5 seconds 16.3 seconds Control: 13.9 seconds 13.9 seconds 14.4 seconds Percent Activity : 70.6 % 71.2 % 62. 3 % INR: 1.45 1.44 1.66 Ratio: 1.05 1.04 1.13 Interpretation: Slightly increased prothrombin time; Indicates that the patient has some abnormal amounts of clotting factors VII and X. Increased clotting factors is due to damage in the endothelial tissue of the heart. ACTIVATED PARTIAL THROMBOPLASTIN TIME Normal Value: 25 to 35 seconds APTT : 27.7 seconds Control : 29.8 seconds Ratio: 0.60 Interpretation: Normal

BLOOD SUGAR MONITORING RECORD Normal Value: 70-125 mg/dl 19

HGT Results: 2-3-10 (8:40 am) : 93 mg/dl 2-3-10 (12 nn): 92 mg/dl 2-3-10 (6 pm): 91 mg/dl 2.4.10 (12 am): 94 mg/dl 2.4.10 (6 am): 124 mg/dl 2-10-10 (11pm): 107 mg/dl Interpretation: Normal CLINICAL CHEMISTRY (2-5-10) (2-7-10) (2-9-10) Normal Values: Sodium : 129 135 134 135-145 mmol/L Potassium : 4.2 4.7 4.3 3.6-5.1 mmol/L Creatinine : 1.2 1.0 0.8-1.5 mg/dl Urea Nitrogen : 16 9-20 mg/dl ALT : 49 21-72 U/L Interpretation: slight decreased of sodium is of little clinical value URINALYSIS (2-4-10) Color : Yellow Transparency : Turbid Specific Gravity : 1.000 pH : 7.5 Sugar : Negative Protein : Track Microscopic Findings RBC : Loaded/ hpf Pus Cells : 0-1/ hpf Epithelial Cells : Rare Bacteria : Few Interpretation: there is a presence of hematuria; possible bacterial infection BLOOD CHEMISTRY Parameters COMPLETE BLOOD COUNT Total WBC Total RBC Hemoglobin Hematocrit MCV MCH MCHC Result 6.0 3.70 12.6 35.5 95.4 34.1 17.0 4.9 14.2 35.5 94.3 33.3 35.7 5.4 4.09 13.9 39.1 95.6 34.0 35.3 Normal Values 3.0-10.0 x 109/liter 2.60-5.30 x 1012/liter 12.70-16.70mmol/L 40.0-49.70% 70.0-97.0 fl 28.0-34.0 pg 32-36%

35.5

20

Platelet Count 109/liter DIFFERENTIAL COUNT Neutrophils Lymphocytes Monocytes Eosinophils Basophils RDW-CV

124 69.2 20.6 6.5 1.2 0.5 14.3 84.9 10.9 9.7 0.3 0.2 14.4

109 58.9 30.5 8.2 1.7 0.7 14.5

145

150.0-390.0 x 27.00-72.00 % 20.00-50.00 % 8.00-14.00 % 0.00-6.00 % 0.0-1.0 % 11.50-14.50 %

Interpretation: Increased WBC,shows the bodys effort to transport cells and substances nvolved in immune reactions Decreased Hematocrit,indicates ineffective transport of oxygen and carbon dioxide. Decreased Platelet Count suggests ineffective clotting at breaks in blood vessels. Increased Neutrophil is due to the necrotic of tissue present from MI. Neutrophils are the major components in phagocytosis. Decreased Lymphocytes, indicates severity of illness due to the bodys lack of production of principal agents for the bodys immune response. Decreased Monocyte levels can indicate bone marrow injury or failure X-RAY REPORT (2-4-10) Heart is enlarged with CT ratio of .78. The aorta is atheromatous and sclerotic. Minimal haziness in the right base. Rest of the lungfields are clear. Hemi diaphragms and sulci are intact. Impression: Cardiomegaly LV and LA form. Atheromatous thoracic aorta. Consider Pneumonia, right base (2-5-10) No significant change of the densities in right base (edema and/or pneumonia) Cardiomegaly LV form Atherosclerosis thoracic aorta Rest of findings unchanged

CT SCAN REPORT 21

(2-1-10) Plain CT Scan of the brain with serial arial views disclose the following findings. > There are punctuate hypodensities in the peri ventricular white matter. There is a 2.2 cm hypodense focus in the left mid peri ventricular white matter. > Ventricles are not dilated. > Midline structures are intact. > There is prominence of the sulci and cisterns. > The middle cerebral arteries are calcified. > Cerebellum, brain stem, petro mastoids, sinuses, orbits, and sellar areas are unremarkable. Impression: Consider small vessel ischemic changes both peri ventricular white matter.. Consider an infarct, left mid peri ventricular white matter likely old. Mild cerebro cerebellar atrophy. Arteriosclerosis of the middle cerebral arteries. ECG (2-3-10) Interpretation: ST segment depression and T-wave inversion indicates pattern of ischemia Q wave present tissue necrosis Atrial fibrillation present S3 and S4 present

22

ECG RESULTS

III. 23

ANATOMY AND PHYSIOLOGY The Heart The heart is a hollow, muscular organ located in the center of the thorax, where it occupies the space between the lungs (mediastinum) and rests on the diaphragm. It weighs approximately 300 g (10.6 oz), although heart weight and size are influenced by age, gender, body weight, extent of physical exercise and conditioning, and heart disease. The hearts consists of three distict layers of tissue: endocardium (inner most layer), myocardium (middle layer) consists of muscle fibers and is the actual contracting muscle of the heart, and the epicardium (which covers the outer surface of the heart). The heart pumps blood to the tissues, supplying them with oxygen and other nutrients. The heart also consists of four chambers: two upper collecting chambers (atria) and two lower pumpung chambers (ventricles). The right atrium recieves deoxygenated blood from the body. The blood moves to the right ventricle, which pumps it to the lungs against low resistance. The left atrium recieves oxygenated blood from the lungs. The blood flows into the left ventricle (the heart's largest, most muscular chamber), which pumps it against high resistance into the systemic circulation. The pumping action of the heart is accomplished by the rhythmic contraction and relaxation of its muscular wall. During systole (contraction of the muscle), the chambers of the heart become smaller as the blood is ejected. During diastole (relaxation of the muscle), the heart chambers fill with blood in preparation for the subsequent ejection. A normal resting adult heart beats approximately 60 to 80 times per minute. Each ventricle ejects approximately 70 mL of blood per beat and has an output of approximately 5 L per minute.

Respiratory Tract The respiratory system is an organ system which is used for gas exchange. the respiratory system generally includes tubes, such as the bronchi, used to carry air to the lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it out. The respiratory system can be conveniently subdivided into a conducting zone and a respiratory zone. The conducting zone starts with the nares (nostrils) of the nose, which open into the nasopharynx (nasal cavity), which in fact opens into the oropharynx (behind the oral cavity). The oropharynx leads to the larynx (voicebox), which contains 24

the vocal cords, and connects to the trachea (wind pipe) which leads down to the thoracic cavity (chest) where it divides into the right and left "main stem" bronchi, which continue to divide up to 16 more times into even smaller bronchioles. The bronchioles lead to the respiratory zone of the lungs which consists of respiratory bronchioles, alveolar ducts and the alveoli, the multi-lobulated sacs in which most of the gas exchange occurs. Ventilation of the lungs is carried out by the muscles of respiration. Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approis filtered, warmed, and humidified as it flows to the lungs.aching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoidAir moves through the body in the following order: Nostrils, Nasal cavity, Oropharynx Larynx (voice box), Trachea (wind pipe), Thoracic cavity (chest), Bronchi (right and left), Alveoli (site of gas exchange). The major function of the respiratory system is gas exchange. Respiration consists of a mechanical cycle of inhalation and exhalation, with gaseous exchange occurring in between. Inhalation is driven primarily by the diaphragm. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume, which in turn causes a decrease in intrathoracic pressure. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs. Exhalation, on the other hand, is typically a passive process. The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium. During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles further expand the thoracic cavity. During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic pressure, which forces air out of the lungs. Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometres), and are permeable to gases. The alveoli are lined with pulmonary 25

capillaries, the walls of which are also thin enough to permit gas exchange. All gases diffuse from the alveolar air to the blood in the pulmonary capillaries, as carbon dioxide diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide. Exhalation follows, thereby ridding the body of the carbon dioxide and completing the cycle of respiration.

Prostate gland
The prostate sits in front of and below the bladder and is wrapped around the urethra. That's why prostate problems (e.g. enlargement, infection, inflammation, etc.) may interfere with a man's ability to urinate and/or to have sex. The prostate happens to be where it is because it is needed for ejaculation, and the ejaculate passes through the same urethra as the urine does. The prostate gland's primary job is to add special fluid to the sperm before it is ejaculated out from the penis. Sperm is produced in the testicles. From the testicles it moves up into the epididymis, where it matures, then into the two small, muscular tubes called the vas deferens, which coil up and around the bladder to the seminal vesicles. During ejaculation, the seminal vesicles and the prostate gland contract and expel contents into the prostatic portion of the urethra and then down this route it washes out toward the tip of the penis. The two ejaculatory ducts pass through the prostate and open into the prostatic urethra. One of the prostate's main duties is to add to the seminal fluid nutrients and other substances which mix with, nourish, protect, and carry sperm out of the penis upon ejaculation. The prostate also helps to push the semen containing sperm with sufficient power out of a man's body on its way to fertilizing a woman's egg. The prostate functions as a gland and contains muscle fibers which contract and relax.

26

IV. PATHOPHYSIOLOGY A. Narrative Coronary Artery Disease (CAD) is a disease characterized by the accumulation of plaque within the layers of the coronary arteries. The plaques progressively enlarge, thicken and calcify, causing a critical narrowing (75% occlusion) of the coronary artery lumen, resulting in a decrease in coronary blood flow and an inadequate supply of oxygen to the heart muscle. The most widely accepted cause of CAD is atherosclerosis. Angina pectoris caused by inadequate blood flow is the most common manifestation of CAD. Nonmodifiable risk factors includes: age (risk increases with age), male sex (women typically suffer from heart disease 10 years later than men due to postmenopausal decrease in cardiac-protective estrogen), and family history. Modifiable risk factors include: elevated lipid levels, hypertension, obesity, sedentary lifestyle and stress. Myocardial Infarction (MI) refers to a dynamic process by which one or more regions of the heart to experience a severe and prolonged decrease in oxygen supply because of insufficient coronary blood flow; subsequently, necrosis or death to the myocardial tissue occurs. The onset of MI may be sudden or gradual, and the progression of the event to completion takes approximately 3 to 6 hours. MI is one manifestation of Acute Coronary Syndromes. Sever CAD (greater than 70% narrowing of the artery) precipitates thrombus formation. The first step in thrombus formation involves plaque rupture. Platelets adhere to the damaged area. Activation of the exposed platelets causes expression of glycoprotein IIb/IIIa receptors that bind fibrinogen. Further platelet aggregation and adhesion occurs, enlarging the thrombus and occluding the artery. Heart Failure is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape and function of the ventricles ability to pump enough oxygenated blood to meet the metabolic demands of the body. Cardiac compensatory mechanisms (increases in heart rate, vasoconstriction, heart enlargement) occur to assist the struggling heart. These mechanisms are able to compensate for the hearts inability to pump effectively and maintain sufficient blood flow to organs and tissue at rest. Physiologic stressors increase the workload of the heart and may cause these mechanisms to fail and precipitate the clinical syndrome associated with a failing heart (elevated ventricular/atrial pressures, sodium and water retention, decreased cardiac output and circulatory and pulmonary congestion. These compensatory mechanisms may hasten the onset of failure because they increase afterload and cardiac work. In Diastolic failure, a stiff myocardium impairs the ability of the left ventricle to fill up with blood. This causes and increases pressure in the left atrium and pulmonary vasculature causing the pulmonary signs of heart failure. With the pulmonary signs of heart failure, the patients mucus secretion and fluid accumulation in the lungs causes obstruction in the airways. With this, elasticity of lung fibers are lost. There is impaired expiratory flowrate, increased air trapping which can cause airway collapse. The collapse of the alveoli or the airways there is decreased surface for gas exchange. This causes COPD. With the patients old age and imbalance in hormones (e.g. androgens) hypertrophy of the nodules and capsules in the prostate occurs. The hypertrophy obstructs urine flow. Acute retention may occur together with othe lower urinary tract infections 27

B. Schematic

28

V. Medical Management A. General Management IDEAL MEDICAL MANAGEMENT Rationale I. Laboratory Test 1. Complete Blood Count A complete blood count (CBC) will alert the doctor to an infection as well as telling him, among other things, how much hemoglobin is present in your blood. Hemoglobin is the iron-containing pigment in your blood that carries the oxygen from your lungs to the rest of your body. In COPD, the amount of air that you breathe into and out of your lungs is impaired. Arterial blood gases (ABGs) measure the oxygen and carbon dioxide levels in your blood and determine your body's pH and sodium bicarbonate levels. ABGs are important in forming a diagnosis of COPD as well as in adjusting oxygen therapy. Although a CT is not required for making a diagnosis of COPD, the doctor may order it when its indicated (infection is not resolving, change of symptoms, consideration for surgery etc.) While a chest X-ray shows larger areas of density in the lungs, a CT scan is more definitive, showing fine details that a chest Xray does not. Sometimes, prior to a CT scan, material called contrast is injected into the vein. This allows your doctor to see the abnormalities in your lungs more clearly. PFTs are used to evaluate lung function and determine the extent of the damage within your lungs. The most common PFT is spirometry. A noninvasive method, pulse oximetry measures how well your tissues are being supplied with oxygen. A probe or sensor is normally attached to the finger, forehead, earlobe or bridge of the nose. Pulse oximetry can be continuous or intermittent. A measurement of 95% to 100% is considered normal. Sputum or mucus from your lungs can be obtained by coughing it up or suctioning. Your sputum specimen will be evaluated in a laboratory and will provide your doctor with a guide in both the diagnosis and treatment of your lung disease.

2. Arterial Blood Gases

3. Computerized Tomography (CT) Scan

4. Pulmonary Functions Tests (PFTs)

5. Pulse Oximetry 6. Sputum Culture

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7. Lung Diffusion Studies

Measuring the diffusing capacity of the lungs for carbon monoxide (DLCO), tells the doctor how well the air that you breathe travels from your lungs to your blood. Abnormal results mean that your lungs do not have the ability to move gases in and out of the lungs properly. Other pulmonary function tests may also be done as an adjunct to DLCO. To assess heart size and presence or absence of heart failure and pulmonary edema. May also assist in differential diagnosis. The doctor will perform an initial chest X-ray when trying to reach a diagnosis of COPD, and then throughout your treatment to monitor your progress. is helpful if the diagnosis is in question, can define the extent of the infarction and can identify complications, such as acute mitral regurgitation, left ventricular rupture or pericardial effusion Defines the patient's coronary anatomy and the extent of the disease. Whether all patients with acute myocardial infarction should ideally undergo cardiac catheterization is controversial and present consensus is for angiography only if indicated by recurrent chest pain or significant ischemia shown by exercise ECG or perfusion imaging. Patients with cardiogenic shock, intractable angina despite medications or severe pulmonary congestion should undergo cardiac catheterization immediately. Performed before hospital discharge to assess the extent of residual ischemia if the patient has not already undergone cardiac catheterization and angiography.

8. Chest x-ray

9. Echocardiography

10. Coronary angiography

Features that increase the likelihood of infarction are: imaging new ST segment elevation; new Q waves; any ST segment elevation; new conduction defect. Other features of ischemia are ST segment depression and 12. Electrocardiography (ECG) T wave inversion. 11. Myocardial perfusion scintigraphy using SPECT 13. Digital Rectal Examination (DRE) This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland. To rule out cancer as a cause of urinary symptoms, the doctor may recommend a PSA blood test. PSA, a protein produced by prostate cells, is frequently

14. Prostate-Specific Antigen (PSA) Blood Test

30

present at elevated levels in the blood of men who have prostate cancer. 15. Rectal Ultrasound and Prostate Biopsy If there is a suspicion of prostate cancer, the doctor may recommend a test with rectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. To determine whether an abnormallooking area is indeed a tumor, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumor. The needle collects a few pieces of prostate tissue for examination with a microscope. In this examination, the doctor inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system that help the doctor see the inside of the urethra and the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction The doctor may ask the patient to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH. Patients who have COPD are often prescribed medications called bronchodilators. Bronchodilators work by relaxing and expanding the smooth muscle of the airways, making it easier to breath. f you have COPD, your doctor may have prescribed glucocorticoids, or steroids, as part of your COPD treatment plan. This drug is liquefy the mucus in your lungs which reduce the swelling in your breathing tubes. People with COPD are more prone to bacterial lung infections than most. And, if you have a bacterial lung infection, then chances are your doctor will have prescribed you an antibiotic. Supplemental oxygen is a very helpful treatment that enables many patients with severe COPD lead a more normal and productive life. Flu shots not only help prevent the flu, they can help

16. Cystoscopy

17. Urine Flow Study

II. Medications 1. Bronchodilators

2. Glucocorticoids

3. Antibiotics

4. Oxygen Therapy

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5. Flu Vaccine

COPD patients fight off potential exacerbations of symptoms, which are periods of time when your COPD may worsen. People with COPD are at greater risk for developing pneumococcal pneumonia, a serious lung infection that kills 1 out of every 20 people who get it. And, even if you have already had a pneumonia vaccine, the Centers for Disease Control recommend that certain high-risk groups have a second dose. Aspirin reduces mortality, non-fatal reinfarction, nonfatal stroke and vascular death and the survival benefit is maintained for at least four years. When started within hours of infarction, beta blockers reduce mortality, non-fatal cardiac arrest and nonfatal reinfarction. Unless contraindicated, the usual regime is to give intravenously on admission and then continue orally, titrate upwards to the maximum tolerated dose.

6. Pneumonia Vaccine

7. Antiplatelet agent o Clopidogrel o Warfarin (INR 2-3) 8. Beta blockers

Reduce mortality whether or not patients have clinical 9.Angiotensin-converting enzyme heart failure or left ventricular dysfunction. They also reduce the risk of non-fatal heart failure. Titrate dose inhibitors: Heparin infusion upwards to the maximum tolerated or target dose. Measure renal function, U+E and blood pressure before starting an ACE inhibitor (or ARB) and again within 1-2 weeks.1 10.Prophylaxis against thromboembolism 11.Cholesterol lowering agents: 12.Heparin infusion If not already receiving heparin by infusion, then patients should be given regular subcutaneous heparin until fully mobile Ideally initiate therapy with a statin as soon as possible on all patients with evidence of CVD unless contraindicated - after discussing risks and benefits with the patient, taking into account comorbidities and life expectancy. Is used as an adjunctive agent in patients receiving alteplase but not with streptokinase. Heparin is also indicated in patients undergoing primary angioplasty 13. Alpha-adrenergic blockers

32

terazosin (Hytrin) in 1993 doxazosin (Cardura) in 1995 tamsulosin (Flomax) in 1997 alfuzosin (Uroxatral) in 2003 Relaxes the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. Prevent conversion of testosterone to dihydrotestosterone to decrease glandular cell activity and the size of prostate. Inhibit production of the hormone DHT which is involved with prostate enlargement.

14. Anti-androgen agents

Finasteride (Proscar)

Is regarded as superior to fibrinolysis in the III. Surgical Management management of acute myocardial infarction and is Primary percutaneous becoming increasingly available for initial patient care. transluminal coronary angioplasty (PTCA) Following myocardial infarction reduces death, nonfatal MI and stroke compared to thrombolytic reperfusion. However up to 50% of patients Balloon angioplasty experience restenosis and 3% to 5% recurrent myocardial infarction. Are particularly indicated in patients with large infarcts, anterior infarction, cardiogenic shock, those who do not fit the criteria for thrombolytic therapy, and when thrombolysis is contraindicated or has failed and have persistent ischaemia. Surgery is indicated in patients in whom angioplasty fails and in patients who develop mechanical complications such as a ventricular septal defect, left ventricular rupture, or a papillary muscle rupture. All patients should be offered a cardiological assessment to consider whether coronary revascularisation is appropriate. This operation can improve shortness of breath and quality of life. This is also to improving dyspnea by removing areas of major lung damage from emphysema. In this type of surgery, no external incision is needed.

Cardiac angiography angioplasty

Coronary artery bypass

Coronary revascularisation

Lung volume reduction surgery, (LVRS)

33

Transurethral Surgery

After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use. laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. PVP uses a high-energy laser to destroy prostate tissue and seal the treated area. Unlike other laser procedures, interstitial laser coagulation places the tip of the fiberoptic probe directly into the prostate tissue to destroy it.

Open Surgery

Laser Surgery

Photoselective Vaporization of the Prostate (PVP) Interstitial Laser Coagulation

IV. General Management A. Diet 1. Monitor Your Body Weight

Weighing yourself at least once a week will help you keep your weight under control. If you are taking diuretics or steroids, however, your doctor may recommend daily weigh-ins. If you have a weight gain or loss of 2 pounds in one day or 5 pounds in one week, you should contact your doctor. Unless your doctor tells you otherwise, you should drink 6 to 8, eight-ounce glasses of non-caffeinated beverages daily. This helps to keep your mucus thin, making it easier for your body to cough it up. Some people find it easier to fill a container full of their daily fluid requirement in the morning and spread it out during the day. If you try this method, it is best to slow down your intake of fluids towards evening so you are not up all night urinating. Eating too much salt causes your body to retain fluid. Too much fluid can make breathing more difficult. To

2. Drink Plenty of Fluids

34

3. Decrease Sodium Intake

reduce sodium intake, don't add salt when you cook and make sure you read all food labels. If the sodium content in food is greater than 300 milligrams of sodium per serving, don't eat it. If you are thinking of using salt substitutes, make sure you check with your doctor first, as some ingredients in them may be just as harmful as salt. When you overeat, your stomach can feel bloated making breathing more difficult. Carbonated beverages or gas-producing foods such as beans, cauliflower or cabbage can also cause bloating. Eliminating these types of beverages and foods will ultimately allow for easier breathing. If you are underweight, eating smaller, more frequent meals that are higher in calories can help you meet your caloric needs more efficiently. This can also help you feel less full making it easier to breathe. Avoid low-fat or low-calorie food products. Supplement your meals with high-calorie snacks like pudding or crackers with peanut butter. High fiber foods such as vegetables, dried legumes, bran, whole grains, rice, cereals, pasta and fresh fruit aid in digestion by helping your food move more easily through your digestive tract. Your daily fiber requirement should be between 20 to 35 grams of fiber each day. These four types of exercises can help you if you have COPD. How much you focus on each type of exercise may depend upon the COPD exercise program your health care providers suggests for you. lengthen your muscles, increasing your flexibility. Stretching can also help prepare your muscles for other types of exercise, decreasing your chance of injury. Use large muscle groups to move at a steady, rhythmic pace. This type of exercise works your heart and lungs, improving their endurance by working your respiratory muscles. This helps your body use oxygen more efficiently and, with time, can improve your breathing. Walking and using a stationary bike are two good choices of aerobic exercise if you have COPD. Involve tightening muscles repeatedly to the point of fatigue. When you do this for the upper body, it can

4. Avoid Overeating and Foods that Cause Gas

5. Eat Smaller, More Frequent Meals that Are High in Calories

6. Include Enough Fiber in Your Diet

B. Exercise 4 Types of Exercises for COPD

1. Stretching exercises

2. Aerobic exercises

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36

B. Drug Study
Name of Drug Citicoline drops Date Ordered 02-09-10 Classification CNS Stimulant Dose/ Frequency 2cc TID Mechanism of Action Citicoline increases blood flow and O2 consumption in the brain. It is also involved in the biosynthesis of lecithin. Specific Indication Used to treat cerebrova scular disease. Contraindication Contraindicated to any allergies (especially drug allergies), kidney problems, liver problems, heart or blood vessel diseases, history of angioedema, diabetes. Side Effects/ Adverse Effects Headache, dry cough, nausea, Unusual weakness, back pain, diarrhea, cramps, chest pain, one-sided arm or leg weakness, vision changes,tingling of the hands or feet, fever, persistent sore throat, dizziness, fainting, unusual change in amount of urine, yellowing of the eyes or skin, dark urine, stomach/ abdominal pain, persistent fatigue, persistent nausea, Nursing Responsibilities May be taken with or without food. (Take w/ or between meals.) Best taken on an empty stomach at the same time each day. To avoid dizziness and lightheadedness when rising from a seated or lying position, get up slowly. Limit your intake of alcohol Use caution when exercising or during hot weather as these can aggravate dizziness and lightheadedness. Follow all directions exactly and take the medication as directed. Do not stop taking this drug without consulting your doctor. Some conditions may become worse when the drug is abruptly stopped. Check BP before giving the medication and do not give the

Perindopri l

02-09-10

angiotensinconverting enzyme (ACE)

5m tab OD per BF

Block the action of a chemical in the body called

Used to treat high blood

Contraindicated in patients known to be hypersensitive

Cough, fatigue, asthenia, headache,

37

inhibitors

angiotensin converting enzyme (ACE). Normally ACE produces another chemical, angiotensin. Angiotensin has two actions: Firstly it acts on blood vessels to make them narrow Secondl y it acts on the kidney to produce less urine As perindopril stops the production of angiotensin, these actions are reversed. Therefore more urine is produced by the kidneys, which results in less fluid in the blood vessels. The blood vessels also

pressure Essential hypertensi on.), and reduction of risk of cardiac events in patients with a history of myocardia l infarction

to this product or to any other ACE inhibitor. It is also contraindicated in patients with a history of angioedema.

disturbances of mood and/or sleep, taste impairment, epigastric discomfort, nausea, abdominal pain, and rash, dizziness, diarrhea,

medication if pulse is below 60bpm. Comes as a tablet to take by mouth. It is usually taken once or twice a day. Follow the directions on your prescription. Perindopril controls high blood pressure but does not cure it. Continue to take perindopril even if you feel well. Do not stop taking perindopril without talking to your doctor. Talk to your doctor before using salt substitutes containing potassium. If your doctor prescribes a low-salt or low-sodium diet, follow these directions carefully

38

Warfarin (coumadin )

02-09-10

anticoagulant (blood thinner)

2.5mg 1/2tab OD

widen. The overall effect of this is a drop in blood pressure and a decrease in the workload of the heart. It reduces the formation of blood clots. It works by blocking the synthesis of certain clotting factors. Without these clotting factors, blood clots are unable to form.

Used to prevent heart attacks, strokes, and blood clots in veins and arteries.

Contraindicated in any localized or general physical condition or personal circumstance in which the hazard of hemorrhage might be greater than the potential clinical benefits of anticoagulation.

Bleeding and necrosis (gangrene) of the skin. Bleeding can occur in any organ or tissue. Bleeding around the brain can cause severe headache and paralysis. Bleeding in the joints can cause joint pain and swelling. Bleeding in the stomach or intestines can cause weakness, fainting spells, black tarry stools, vomiting of blood, or coffee ground material. Bleeding in the kidneys can cause back pain and blood in urine, purple, painful toes, rash, hair loss, bloating, diarrhea, and jaundice.

May be taken with or without food. Frequent blood tests are performed to measure blood clotting time (protime) during Coumadin treatment. Since it is metabolized by the liver and excreted by the kidneys, caution is needed in giving this drug to patients with liver and kidney dysfunction. Instruct the patient to seek immediate medical care if symptoms of overdose will manifest, these includes: bleeding gums, bruising, nosebleeds, heavy menstrual bleeding, and prolonged bleeding from cuts.

39

02-09-10 Digoxin

Digitalis glycoside

25mg tab

Increases the force of contraction of the muscle of the heart by inhibiting the activity of an enzyme (ATPase) that controls movement of calcium, sodium and potassium into heart muscle. Calcium controls the force of contraction. Inhibiting ATPase increases calcium in heart muscle and therefore increases the force of heart contractions. Digoxin also slows electrical conduction between the atria and the ventricles of the heart and is useful in treating abnormally rapid atrial rhythms such as atrial fibrillation, atrial

Used in treating an abnormal heart rhythm

Contraindicated to Digitalis toxicity, ventricular tachycardia/fibrill ation, obstructive cardiomyopathy. Arrhythmias due to accessory pathways (e.g. Wolff-ParkinsonWhite syndrome). Special Precautions on Cardiac dysrhythmias, hypokalaemia, hypertension, IHD, hypercalcaemia, hypomagnesaemi a, electroconversion , chronic cor pulmonale, aortic valve disease, acute myocarditis, congestive cardiomyopathies , constrictive pericarditis, heart block, renal impairment, abnormalities in thyroid function

Extra beats, anorexia, nausea and vomiting, confusion, dizziness, drowsiness, restlessness, nervousness, agitation and amnesia, visual disturbances, gynaecomastia,

People of Asian descent may absorb rosuvastatin at a higher rate than other people. Make sure your doctor knows if you are Asian. You may need a lower than normal starting dose. Take digoxin exactly as prescribed by your doctor. Do not take it in larger amounts or for longer than recommended. May be taken with or without food. Take it with full glass of water. Take the medication at the same time of the day. Do not stop taking digoxin without first talking to your doctor. Stopping suddenly may make your condition worse. Store digoxin at room temperature away from moisture and heat.

40

Rosuvasta tin

02-09-10

cholesterollowering medication

10mg 1tab OD

Blocks the production of cholesterol (a type of fat) in the body. It works by reducing levels of "bad" cholesterol (low-density lipoprotein, or LDL) and triglycerides in the blood, while increasing levels of "good" cholesterol (high-density lipoprotein, or HDL).

Used to treat high cholestero l.

Do not take this medication if you are allergic to rosuvastatin, if you have liver disease.

Special precaution on patients with kidney disease; underactive thyroid; muscle disorder; epilepsy or other seizure disorder; an electrolyte imbalance (such as high or low potassium levels in your blood); a severe infection or illness.

Muscle pain, tenderness, or weakness with fever or flu symptoms and dark colored urine;urinating more or less than usual, or not at all; nausea, stomach pain, low fever, loss of appetite, dark urine, claycolored stools, jaundice (yellowing of the skin or eyes);chest pain; or swelling in your hands or feet.

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. You may take the medicine with or without food. Take rosuvastatin at the same time each day. It is best to take this drug in the evening. Take this medication with a full glass of water. Avoid drinking alcohol while taking this medication. Alcohol can increase triglyceride levels, and may also damage your liver while you are taking rosuvastatin. Call your doctor at once if you have unexplained muscle pain or tenderness, muscle weakness, fever or flu symptoms, and dark colored urine. Rosuvastatin is only part of a

41

Tranexami c acid

02-07-10

antifibrinolytic agent

500mg, PRN

Tranexamic acid is a man-made form of an amino acid (protein) called lysine. It works by blocking the breakdown of blood clots, which prevents bleeding.

short-term control of bleeding

Do not use Tranexamic Acid if: you are allergic to any ingredient in Tranexamic Acid, you have blood clots, bleeding within the brain, or eye problems (retinal disease), you are colorblind, you are using factor IX complex concentrate

Nausea, vomiting, diarrhea might occur. If these persist or worsen, notify your doctor promptly. Very unlikely but report promptly: vision changes, dizziness. If you notice other effects not listed above, contact your doctor or pharmacist. Diarrhea; giddiness; nausea; vomiting. Severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest; swelling of

complete program of treatment that also includes diet, exercise, and weight control. Follow your diet, medication, and exercise routines very closely. Do not stop using rosuvastatin without first talking to your doctor. Store rosuvastatin at room temperature away from moisture and heat. Take this medication exactly as prescribed by your doctor. Do not take it in larger amounts or for longer than recommended. To be sure this medication is not causing harmful effects, your vision may need to be checked while you are using tranexamic acid. Store this medication at room temperature away from moisture and heat.

42

s or antiinhibitor coagulant concentrate s.

Tiotropiu m Bromide (Spiriva Rotacap)

02-03-10

Muscarinic receptor antagonist

1 cap OD

Opens the respiratory tract and makes breathing easier. Tiotropium acts on the lungs, where it blocks muscarinic receptors on the muscle surrounding the airways. The natural chemical in the body the Acetylcholine normally acts on these receptors, causing the

Used in treatment of bronchial spasms (wheezing) associated with chronic obstructiv e pulmonary disease.

Titropium is contraindicated in Hypersensitivity. Spiriva should not be used for the initial treatment of acute episodes of bronchospasm.

the mouth, face, lips, or tongue); calf pain, swelling, or tenderness; changes in vision (disturbance of color, sharpness, or field of vision); chest pain; decreased urination; onesided weakness; pain, swelling, or redness at the injection site; severe headache; shortness of breath; speech problems. Dry mouth, dry throat, increased heart rate, blurred vision, glaucoma, urinary difficulty, urinary retention, narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction and constipation.

Spiriva capsules are packaged as a blister card containing two strips. Each strip has three capsules. When removing a capsule from the blister card, peel back only the foil that is covering the capsule you are about to use. The capsule's effectiveness may be reduced if it is not used immediately after the foil is opened. If you accidentally remove the foil covering any of the

43

muscle in the airways to constrict and the airways to narrow. Tiotropium blocks the muscarinc receptors in the lungs and therefore stops the action of acetylcholine on them. This allows the muscle around the airways to relax and the airways to open.

other capsules, you must throw them away.

44

02-03-10 Allopurino l

xanthine oxidase inhibitor

100mg tab OD PO

Reduces the production of uric acid in your body. Uric acid buildup can lead to gout or kidney stones.

It reduces the productio n of uric acid in your body.

Contraindicated to allergic to any these drugs, or if you have: kidney disease; liver disease; diabetes; congestive heart failure; high blood pressure

Diarrhea, nausea, rash and itching, and drowsiness, skin rash.

Take each dose with a full glass of water. To reduce your risk of kidney stones forming, drink 8 to 10 full glasses of fluid every day, unless your doctor tells you otherwise. Avoid drinking alcohol. It can make your condition worse. Allopurinol can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Allopurinol can lower the blood cells that help your body fight infections. This can make it easier for you to bleed from an injury or get sick from being around others who are ill, so advised patient to boost immune system by taking vitamin s supplements and eating nutritious food. Allopurinol should be discontinued immediately at the first appearance of rash, painful urination, blood in the urine, eye irritation, or swelling

45

Dutasterid e (Avodart)

02-03-10

1tab OD PO

Avodart prevents the conversion of testosterone to dihydrotestoster one (DHT) in the body. DHT is involved in the development of benign prostatic hyperplasia (BPH). Dutasteride helps improve urinary flow and may also reduce your need for prostate surgery later on.

Avodart is used to treat benign prostatic hyperplasi a (BPH) in men with an enlarged prostate.

Contraindicated to clinically significant hypersensitivity (e.g., serious skin reactions, angioedema) to AVODART or other 5reductase inhibitors.

Decreased libido (sex drive); decreased amount of semen released during sex; impotence (trouble getting or keeping an erection); or breast tenderness or enlargement.

Take 1 capsule once a day. Do not chew, crush, or open an Avodart capsule. The capsule should be swallowed whole. Dutasteride can irritate your lips, mouth, or throat if the capsule has been broken or opened before you swallows it. It may take up to 6 months of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Can be taken with or without meals. Take this medicine with a full glass of water. Do not stop taking Avodart without talking to your doctor.

To be sure this medication is helping your condition, your prostate will need to be checked on a regular basis. Store Avodart at room temperature away from moisture and heat. Avodart

46

LACTULO SE

02-03-10

laxative

20cc OD

Lactulose is a synthetic sugar used to treat constipation. It is broken down in the colon into products that pull water out from the body and into the colon. This water softens stools. Lactulose is also used to reduce the amount of ammonia in the blood of patients with liver disease. It works by drawing ammonia from the blood into the colon where it is removed from the body.

Used to treat constipati on.

This medication contains galactose and lactose. Be sure to tell your doctor if you have diabetes. And if you are having surgery or tests on your colon or rectum, tell the doctor that you are taking lactulose.

Gas, belching or stomach cramps, diarrhea, nausea, vomiting.

capsules may become soft and leaky, or they may stick together if they get too hot. Do not use any capsule that is cracked or leaking. This medication is taken by mouth. To improve the taste, the dose may be mixed in a glass of fruit juice, water or milk. Take this medication as prescribed. Take this medication exactly as prescribed by your doctor. Do not take it in larger amounts or for longer than recommended. The liquid form of lactulose may become slightly darken in color, but this is a harmless effect. However, do not use the medicine if it becomes very dark, or if it gets thicker or thinner in texture. Instruct the patient that it may take up to 48 hours before you have a bowel movement after taking

47

lactulose. Store lactulose at room temperature away from moisture and heat.

Topamax

2/3/10

Anticonvulsan t Sulfamate substituted monosacchari de

25mg tab BID PO

May block a sodium channel, potentiate the activity of GABA and inhibit kainates ability to activate an amino acid receptor.

To prevent migraine headache

Hypersensitivity to drug

Dizziness, Nervousness, Chest pain, Palpitations, Anorexia, Muscle Weakness.

Tell pt. to drink plenty of fluids during therapy to minimize risk of forming kidney stones. Inform patient that drug can be taken without regard to food.

Dolcet

2/3/10

Analgesic

1 tab TID

Inhibits prostaglandin synthesis reducing sensitivity of pain receptors

Moderate to severe pain.

Acute intoxication w/ alcohol, Hypersensitivity

Keppra

2/3/10

Anticonvulsan t Pyrrolidine derivative

500mg/tab 1tab TID

May act by inhibiting simultaneous neuronal firing that leads to seizure activity

adjunctive therapy in the treatment of partial onset seizures in adults

Hypersensitivity to drug Immunocompromi sed patients

CNS & GI disturbances. Nausea, dizziness, somnolence. Asthenia, fatigue, hot flushes, constipation, diarrhea, flatulence, dry mouth, pruritus, increased sweating, tinnitus. Headache, emotional lability, vertigo, leukopenia, neutropenia, anorexia

Assess for level of pain relief and administer dose as needed but not to exceed the recommended total daily dose. Discontinue drug and notify physician if S/Sx of hypersensitivity occur. Take drug with food to avoid GI disturbances. Drug can be taken with or without food Warn patient to use extra care when sitting up or standing up to avoid falling

48

Piperaci llin + Tazoba ctam

2/3/10

Anti infectives

4.5g IVTT q 8h

Inhibits cell wall synthesis during bacterial multiplication

Moderate to severe nosocomi al pneumoni a

Hypersensitivity to drug Caution to pts. with bleeding tendencies

Headache, seizure, fever, hypertension, abdominal pain, dyspnea

Ask patient about allergic reactions pror to med administration Monitor hematologic and coagulation parameters Tell patient to report adverse reactions promptly Auscultate breath sounds before and after nebulization Monitor HR and RR Do chest and back tapping after nebulization

Combiv ent

2/3/10

bronchodilato r combinations

1/2neb +1cc NSS q 6h

Reduces bronchospasm through two distinctly different mechanisms, anticholinergic (parasympathol ytic) and sympathomimet ic. Simultaneous administration of both an anticholinergic and a beta2sympathomimet ic is designed to benefit the patient by producing, a greater bronchodilator effect than when either drug is utilized alone at its recommended dosage.

To prevent bronchosp asm in people with chronic obstructiv e pulmonary disease (COPD) who are also using other medicines to control their condition.

Hypersensitivity to drug

Headache, Chest Pain, Dyspnea, Coughing, Bronchospasm, Palpitations

49

Sucralfate

2/3/10

Anti ulcer

1 tab q6h NGT

An antiulcer that forms an ulceradherent complex with proteinaceous exudates such as albumin, at ulcer site. Also forms a viscous, adhesive barrier on the surface of intact mucosa of the stomach or duodenum. Protects damaged mucosa from further destruction by absorbing gastric acid, pepsin and bile salts. N-acetylcysteine (NAC) is the Nacetyl derivative of the naturally occurring amino acid l-cysteine. NAC has an intense fluidifying action, through its free sulfhydryl group, on the mucoid or mucopurulent

Short term treatment of duodenal ulcer.

Allergy to sucralfate

Constipation, Dry mouth, Backach, Diarrhea, Dizziness, Nausea, Rash, Abdomina, discomfort.

Take medication on an empty stomach

Monitor pattern of bowel activity and stool consistency Increase fluid intake as indicated. Monitor for hypersensitivity reactions.

Fluimocil

2/3/10

Cough and cold preparations , Mucolytic

600mg/ta b 1 tab in 100cc H2O q 12h NGT

For acute & chronic resp tract affections w/ abundant mucus secretions .

Hypersensitivit y to any of the ingredients. Caution in asthma patients.

nausea, headache, tinnitus, stomatitis, chills, fever, bronchospasm Occasional cases of nausea and dyspepsia Rare cases of urticaria

Dilute with normal saline solution or sterile water for injection Inform patient that nebulization may produce an initial disagreeable solution but will soon disappear

50

secretions by cleaving the intra- and intermolecular disulfide bonds in glycoprotein aggregates. Metoprolol 2/3/10 Beta-Blocker 50mg tab BID Competetively blocks betaadrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system of these tissues and the excitability of the heart, decreasing cardiac output and the release of rennin, and lowering BP; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone Increases the force of contraction of the muscle of the heart by Myocardia l Infarcion Hypersens itivity to drug Bronchos pasm or asthma History of obstructiv e airway disease Sinus bradycardi a or partial heartblock & CHF Heartfailure, heartblock & bronchospasm, fatigue & coldness of extremities, bradycrdia, CHF pneumonitits, depression, hallucination,GI retroperitoneal fibrosis, sclerosing pentoritis Monitor HR prior to administration of drug Hold drug if HR<60 bpm Give drug with food to facilitate absorption Instruct patient to swallow tablet whole; do not crush or chew

Digoxin

02-0710disconti nued on 02-09-10

Digitalis Glycoside

25 mg tab

Used in treating an abnormal heart rhythm

Contraindicated to Digitalis toxicity, ventricular tachycardia/fibrill

Extra beats, anorexia, nausea and vomiting, confusion, dizziness,

People of Asian descent may absorb rosuvastatin at a higher rate than other people. Make sure

51

captopril

02-08-10 -

angiotensin converting

25mg tab q12h

inhibiting the activity of an enzyme (ATPase) that controls movement of calcium, sodium and potassium into heart muscle. Calcium controls the force of contraction. Inhibiting ATPase increases calcium in heart muscle and therefore increases the force of heart contractions. Digoxin also slows electrical conduction between the atria and the ventricles of the heart and is useful in treating abnormally rapid atrial rhythms such as atrial fibrillation, atrial flutter, and atrial tachycardia. Angiotensin II is a very potent

ation, obstructive cardiomyopathy. Arrhythmias due to accessory pathways (e.g. Wolff-ParkinsonWhite syndrome). Special Precautions on Cardiac dysrhythmias, hypokalaemia, hypertension, IHD, hypercalcaemia, hypomagnesaemi a, electroconversion , chronic cor pulmonale, aortic valve disease, acute myocarditis, congestive cardiomyopathies , constrictive pericarditis, heart block, renal impairment, abnormalities in thyroid function

drowsiness, restlessness, nervousness, agitation and amnesia, visual disturbances, gynaecomastia,

your doctor knows if you are Asian. You may need a lower than normal starting dose. Take digoxin exactly as prescribed by your doctor. Do not take it in larger amounts or for longer than recommended. May be taken with or without food. Take it with full glass of water. Take the medication at the same time of the day. Do not stop taking digoxin without first talking to your doctor. Stopping suddenly may make your condition worse. Store digoxin at room temperature away from moisture.

used for treating

Contraindicated to allergic to it; or

dry, persistent cough, abdominal

Take this medication by mouth,

52

disconti nued

enzyme (ACE) inhibitors

chemical that causes the muscles surrounding blood vessels to contract, thereby narrowing the vessels. The narrowing of the vessels increases the pressure within the vessels causing high blood pressure (hypertension). Angiotensin II is formed from angiotensin I in the blood by the enzyme angiotensin converting enzyme or ACE. ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE and decrease the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced. The

high blood pressure

to other ACE inhibitors (e.g., benazepril, lisinopril); or if you have any other allergies (including allergies to bee or wasp stings, or exposure to certain membranes used for blood filtering). Special precaution on patients with specially of: kidney disease, liver disease, high blood levels of potassium, heart problems, severe dehydration (and loss of electrolytes such as sodium), diabetes (poorly controlled), strokes, blood vessel disease (e.g., collagen vascular diseases such as lupus, scleroderma).

pain, constipation, diarrhea, rash, dizziness, fatigue, headache, loss of taste, loss of appetite, nausea, vomiting, fainting and numbness or tingling in the hands or feet.

usually two to three times a day; or as directed by your doctor. Take this drug on an empty stomach, one hour before a meal. Use this medication regularly in order to get the most benefit from it. Remember to use it at the same time(s) each day. Do not take potassium supplements or salt substitutes containing potassium without talking to your doctor or pharmacist first.

53

NaCl

02-0710disconti nued on 02-09-10

NaCl supplement

1 tab TID

lower blood pressure makes it easier for the heart to pump blood and can improve the function of a failing heart. Treatment of deficiencies of sodium and chloride ions.

Prevention or treatment of deficiencie s of sodium and chloride ions (e.g., caused by excessive diuresis or excessive salt restriction ).

Cautious to patient with congestive heart failure, severe renal insufficiency, and in clinical states in which there is sodium retention with edema.

Peripheral edemas, pulmonary edema.

Check and limit sodium intake to decrease adverse effect reaction. Checks signs of edema and seek medical advice if it is manifesting.

54

VI. NURSING MANAGEMENT

Nursing Care Plan #1

55

Cues Subjective: Gi oxygen man siya kay maglisod siya ug ginhawa. Gi ubo man gud siya., as verbalized by the SO. Naay plema iyang ubo, medyo white na sticky., as verbalized by the daughter. Objective: -productive cough with copious bronchial secretions - dyspnea

Nursing Dx Ineffective airway clearance related to copious bronchial secretions secondary to chronic obstructive pulmonary disease as evidenced by presence of productive cough

Objectives Short term: At the end of 2 hours of nursing intervention the patient will be able to : a. have the ability to effectively cough up secretions b. demonstrate behaviors to improve or maintain clear airway c. demonstrate improved oxygen exchange, reduction with breath sounds and respirations noiseless d. verbalize understanding of cause & therapeutic management regimen Long term:

Intervention Independent: 1. Remind patient to drink fluids per cardiac tolerance. Provide warm or hot drinks instead of cold fluids 2. Assist the patient in coughing, huffing, and breathing efforts to make them more productive

Rationale -Hydration helps decrease the viscosity of secretions facilitating expectoration.

Evaluation Short term: At the end of 2 hours, the patient: a. effectively expectorated secretions. b. maintained airway patency c. demonstrated improved oxygen exchange as evidenced by reduction of breath sounds and noiseless respirations d. verbalized understanding of cause & therapeutic management regimen Long term objectives were not met.

- Deep breathing and diaphragmatic breathing allow for greater lung expansion and ventilation as well as a more effective cough -Cupping and clapping loosen secretions and assist expectoration. -Teaching the family allows them to participate in care under supervision and promotes continuation of the procedure after discharge.

3. Assist with cupping and clapping activities q4h while awake. Teach the family these procedures. 4. Assist the patient with clearing secretions from mouth or nose by: -Providing tissues -Using gentle suctioning if necessary Collaborative: 1. Administer medications such as antibiotics as ordered. Noting effectiveness and side effect

- respiratory rate: 26 cpm (as of 2/4/10) 24 cpm (as of 2/7/10) 23 cpm (as of 2/10/10) - abnormal breath sounds (Rales and ronchi present at both lung fields upon auscultation) -changes in respiratory depth shallow(as of 2/4 and 2/7) -Positive for lung congestion based upon chest x-ray result

At the end of 16 hours of nursing intervention, the patient will be able to: a. maintain airway free of secretions b. show evidence of clear lung sound and eupnea c. demonstrate absence of congestion with breathing, absence of cyanosis, ABG/ pulse oximetry results within clients norms. d. Demonstrate behaviors to maintain clear airway.

-This aids the patient in recovering from the disease process and eliminate signs and symptoms

Nursing Care Plan #2

56

Cues Subjective: Galisod gyud siya ug ginhawa tungod sa iyang ubo., as verbalized by the SO. Gahapon, dili na siya kabalo kung aha siya. Unya murag ga-tanga ra siya pirminti. Naa pud usahay na dili siya kaila sa amo. Magkabali0bali na among ngalan. Kung musturya pud siya, dili lang kaayo klaro, as verbalized by the SO. Objective: -February 4, 2010 RR=26 cpm, shallow breathing PR: 99 bpm -February 7, 2010 RR= 24 cpm, shallow breathing -February 10, 2010 RR= 23 cpm, normal breathing -productive cough -Oxygen Saturation: 93% (with Oxygen inhalation) -pale skin

Nursing Diagnosis Impaired Gas Exchange related to alveolar-capillary membrane changes secondary to chronic obstructive pulmonary disease

Objectives Short Term: By the end of 4 hours of nursing interventions, the client and his SOs must be able to: a. Verbalize understanding of causative factors and appropriate interventions b. Participate in treatment regimen within level of ability c. Demonstrate an improvement in ventilation and adequate gas exchange. Long term: By the end of 16 hours, patient must maintain optimal gas exchange as evidenced by arterial blood gases and oxygen saturation within the patients usual range, alert and responsive mentation or no further reduction in mental status, and no signs of respiratory distress.

Interventions Independent: 1. Maintain oxygen administration device as ordered, attempting to maintain O2 Saturation at 90% or greater. Avoid high concentration of O2 in patients with COPD unless ordered.

Rationale -This provides for adequate tissue oxygenation. Hypoxia stimulates the drive to breathe in the chronic CO2 container patient. When applying O2, close monitoring is imperative to prevent unsafe increases in the patients PaO2 which could result in apnea. -This prevents the abdominal contents from crowding the lungs and preventing their full expansion. -When the patient is positioned on the side, the good side down.

Evaluation Short and long term goals were fully met as evidenced by: a. A decrease in the RR and PR of the client after interventions. b. An increase in the oxygen saturation of the client. c. Client already has alert and responsive mentation but still with slurring of speech.

2.

Position the patient with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45.) Position patient to facilitate ventilationperfusion matching when a side-lying position is used. Pace activities and schedule rest periods to prevent fatigue. Assist with ADLs. Change position every 2 hours. Encourage deep breathing.

3.

4.

-Even simple activities during bed rest can cause fatigue and increase O2 demand, resulting in dyspnea. -This facilitates secretion movement and drainage. -This reduces alveolar collapse

5. 6.

57

Nursing Care Plan #3 Cues Subjective: Gi oxygen man siya kay maglisod siya ug ginhawa., as verbalized by the SO. Gasakit man gihapon iya dughan usahay., as verbalized by the SO. Objective: -radiating pain on the chest with a pain scale level of: 3/5 (as of 2/4/10) 2/5 (as of 2/7/10) -dyspnea -use of accessory muscles -capillary refill: 4 seconds 5. Provide adequate rest. -Blood-tinged sputum -prescence of atrial fibrillation and S3& S4 based on ECG result -Pulmonary congestion Dependent: 1. Administer supplemental oxygen (1-2LPM)as indicated -to conserve energy and lower oxygen demand. - This increases amount of oxygen available for myocardial uptake, reducing ischemia and dysrhythmias At the end of 16 hours nursing interventions, patient will be able to demonstrate improved cardiopulmonary tissue perfusion as evidenced by absence of dyspnea and respiratory distress Nursing Dx Ineffective cardiopulmonary tissue perfusion related to imbalance between myocardial oxygen demand and supply Objectives Short-term: At the end of 30 minutes nursing interventions, patient will be able to demonstrate techniques to improve circulation such as passive ROM exercises and positioning Long-term: Intervention Independent: 1. Elevate head of bed. Rationale -This is to reduce oxygen consumption & promotes maximal lung function. -This is to enhance venous return, reduce venous stasis and reduce risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and consumption. - This avoids an increase cardiac overload. -This prevents skin breakdown and pulmonary complications associated with bed rest. Evaluation The Short term goal was met for patient was able to perform passive ROM exercises and positioning as ways to improve circulation. The Long term goal was not met.

2. Encourage passive leg exercise, avoidance of isometric exercises.

3. Prevent straining at stools. 4. Reposition frequently.

Nursing Care Plan #4

58

Cues Subjective: Murag gi-kumot. 3/5. Replied the client when asked by the SN regarding the description of pain and the pain rate scale. Muingon na siya na sakit iyahang dughan. Sauna ga reklamo naman siya nga musakit iyang dughan labaw na kanang mahago siya. as verbalized by the SO. Objective: -sighing with no intent to move unless absolutely necessary -very slow movement with facial grimace - shortness of breath upon pain onset with facial grimace and sighing

Nursing Diagnosis Acute chest pain related to reduced coronary blood flow resulting to myocardial ischemia

Objectives Short Term: At the end of 30 minutes the patient will be able to: a. Report that pain/discomfort is alleviated or controlled, as evidenced by a decrease in pain rating the scale. b. Display a relaxed appearance and be able to sleep/rest comfortably and engage in desired activities she can tolerate. c. Demonstrates ability to cope with partially relieved pain. (e.g., deep breathing exercises and position changes) d. Demonstrate use of relaxation skills and diversional activities as indicated for individual situation and verbalize nonpharmacologic methods that provide relief. Long Term: At the end of four days, client will remain free from pain as evidenced by no reports of pain, and normal vital signs.

Interventions Independent: 1. Assist the patient to a comfortable position. Maintain bed rest, at least during periods of pain. 2. Provide comfort measures, quiet environment and calm activities 3. Encourage use of relaxation techniques, such as focused breathing and imagery. 4. Eliminate additional stressors or sources of discomfort when possible. 5. Provide rest periods to facilitate comfort, sleep and relaxation. Dependent: 1.Administers analgesics as ordered

Rationale -A semi-fowlers is usually most comfortable. Restricted activity reduces oxygen demands of the heart. -Techniques are used to bring about a state of physical and mental awareness and tranquillity. The goal of these techniques is to reduce tension, subsequently, reducing pain. -This heightens ones concentration upon nonpainful stimuli to decrease ones awareness and experience of pain. -Patient may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapsychic, intrapersonal factors are further stressing him. -Patients experience of pain may become exaggerated due to fatigue.

Evaluation At the end of 30 minutes of nursing interventions, patient was able to experience relief from pain as evidenced by a decrease in the Pain Scale Rate: 2/5, with 5 as the most painful - Short term goal was fully met 02/10/10 At the end of 8 hours of nursing interventions patient was able to demonstrate use of relaxation skills to help alleviate pain. Long term goal was fully met: 02/10/10

-Analgesics are given to alleviate pain. Nursing Care Plan #5

59

Cues Subjective: February 4, 2010 Gahapon, dili na siya kabalo kung aha siya. Unya murag ga-tanga ra siya pirminti. Naa pud usahay na dili siya kaila sa amo. Magkabali-bali na among ngalan. Pero karun, okay naman. Kung musturya lang, dili pa kaayo klaro, as verbalized by the SO. Medyo luya na iyang tuo nga side sa lawas., as verbalized by the SO.

Nursing Diagnosis Ineffective cerebral tissue perfusion related to interruption of blood flow as evidenced by slurring of speech, right-sided weakness and decreased mentation

Objectives Short Term: By the end of 4 hours of nursing interventions, patient and SOs will be able to: a. Verbalize understanding of causative factors of such problem and appropriate interventions needed to be done. b. Participate in treatment regimen.

Interventions Independent: 1. Maintain optimal cardiac output. 2. Avoid measures that may trigger increase ICP (ex. Straining, strenuous coughing, positioning with neck in flexion, head flat) 3. Reorient to environment as needed. Dependent:

Rationale -This ensures adequate perfusion to the brain. -Increased intracranial pressures will further reduce cerebral blood flow.

Evaluation Goals partially met. Client and his SO were able to participate in the treatment regimen. Client already has responsive mentation but his slurring of speech is still present.

-Decreased blood flow may result in changes in the LOC.

Long Term: 1. By then end of 16 hours, client must be able to obtain optimal perfusion to vital organs, as evidenced by alert level of consciousness, clearer and more understandable speech and gradual recovery of his right-sided weakness. Administer anticoagulants, thrombolytics and anticonvulsants as prescribed. -These facilitate perfusion when obstruction to blood flow exists or when perfusion has dropped to such a dangerous level that ischemic damage would be inevitable without treatment. Anticonvulsants reduce risk of seizures which may result from cerebral edema or ischemia.

Objective: -Slurring of speech -Decreased mentation -Right-sided weakness -GCS Score 2/4/10=12 (moderate brain injury) 2/7/10=13(minor brain injury) 2/10/10=14(mild brain injury) -arteriosclerosis of the middle-cerebral arteries (CT scan result)

Nursing Care Plan #6

60

Cues Subjective: Kapoy kaayo ako panlawas as verbalized by the patient February 7, 2010 Karon na naa siya sa hospital, maghigda ra gyud na siya kay luya man gud pod siya. as verbalized by the SO. Kami man gyud ga ilis ug gapakaon niya kay maglisod man siya ug lihok-lihok. as verbalized by the SO. February 10, 2010 Makaya-kaya naman niya nga maglihok-lihok nga siya ra. Pero amo ra gihapon siya i-assist kay basin ma-unsa bah. as verbalized by the SO. Kinahanglan gyud namo siya tabangan kung mulihok kay luya man gyud siya., verbalized by the SO. Objective: -generalized body weakness noted. - seeks help in ADL -ECG reflecting atrial fibrillation with pattern of ischemia and tissue necrosis

Nursing Dx Activity Intolerance related to generalized weakness

Objectives Intervention Short term: Independent: At the end of 30 minutes of nursing interventions, the patient 1. Assess cardiopulmonary will be able to: response to physical activity, including vital signs before, a. Identify negative factors during and after activity. affecting activity tolerance. 2. Reduce intensity level or b. Verbalize understanding of discontinue activities that techniques to enhance activity cause undesired tolerance. physiological changes. Long term: At the end of 24 hours of nursing intervention the patient will be able to: a. Participate willingly in necessary activities. b. Report measurable increase in activity tolerance. c.Demonstrate a decrease in physiologic signs of intolerance (PR, RR, and BP within patients normal range). 3. Assist with ADLs as indicated; however, avoid doing for patients what they can do for themselves. 4. Encourage active ROM exercises; if further reconditioning is needed, confer with rehabilitation personnel. Dependent: 1. Administer O2 inhalation as prescribed.

Rational -Assessing cardiopulmonary notes progression or accelerating degree of fatigue. -Adjust activities to prevent overexertion.

Evaluation After 30 minutes, the patient: a. identified the factors that affected her activities of daily living. b. used identified techniques to enhance activity tolerance. Long Term: After 16 hours, the patient a. particated willingly in necessary or desired activities. b. reported increase in activity tolerance

-Assisting the patient with ADLs allows for conservation of energy.

-Exercise maintains muscle strength and joint ROM.

-Providing oxygenation reduces fatigue and anxiety for patient.

Nursing Care Plan #7

61

Cues Subjective: February 7, 2010 Kami man gyud ga ilis ug gapakaon niya kay maglisod man siya ug lihok-lihok. as verbalized by the SO. Objective: -Scale for measuring RIGHT hand muscle score: 2/4/10= grade1( no active range of motion and palpable muscle contraction only) 2/7/10=grade2( reduced active range of motion and no muscle resistance) 2/10/10=grade4 (full active range of motion and normal muscle resistance)

Nursing Diagnosis Impaired physical mobility related to decreased muscular control and function as evidence by generalized weakness

Objectives Short Term: At the end of 30 minutes of nursing intervention the patient will be able to : a. verbalize understanding odf situation, individual treatment and regimen and safety measures. b. Demonstrate techniques and behaviors that enable resumption of activities participate in ADLs and desired activities. Long Term: At the end of 32 hours of Nursing intervention the patient will be able to: a. Maintain position of function and skin integrity as evidenced by absence of contractures, foot drop, decubitus and the likes. b. Maintain or increase strength and function of affected and compensatory part.

Intervention Independent: 1. Assist patient reposition self on a regular schedule as dictated by individual situation. 2. Inspect skin regularly particularly over bony prominences. Gently massage any reddened areas as necessary. 3. Perform passive ROM exercises of upper and lower extremities. 4. Encourage participation in self care and other activities. 5. Provide safety measure such as raising the side rails as indicated by individual situation. Dependent: 1. Administer medications prior to activities as needed for pain. 2. Administer laxative as ordered.

Rationale -This is to promote proper circulation and prevent formation of skin/decubitus ulcer. -This prevents skin breakdown and decubitus ulcer development.

Evaluation Goals met as evidenced by: a. Patient able to verbalize improvement of condtion. b. Motor control on all upper and lowe extremities would return to normal as preferred by the patient. c. No signs and symptoms of paralysis.

-This helps maintain/enhance maximum neuromuscular control and function. - This enhances self concept and sense of independence. -This prevents injury from falling.

-This permits maximal effort/involvement in activity. -

62

Cues Subjective: Lugaw ra gyud iya pwede kaonon kay galisod pa siya ug tulon. Mukaon man pod siya pero gamay ra kay murag wala man siya gana. Mao man sab ang ingon sa doctor na lugaw lang sa ang ipakaon sa iya. as verbalized by the SO.

Nursing Diagnosis Imbalanced Nutrition: Less than body requirements related to inability to ingest adequate nutrients secondary to dysphagia as evidenced by weight loss of 5 kg

Objective: -Weight loss- 55kg-50kg -With NGT -Weakness of muscle required for mastication related to right-sided weakness -Dysphagia -Pale and dry mucous membranes -Dry lips

Nursing Care Plan #8 Objectives Intervention Short Term: Independent: At the end of 10 minutes of nursing interventions, the 1.Discuss with the patient will be able to: significant others the need of having right diet for the a. Receive adequate and patient and introduce the desired amount of calories food pyramid. per feeding 2.Place patient in Long Term: moderate high back rest At the end of hours of during feeding. nursing interventions, patient will be able to: 3.Check the tubes patency a. Receive adequate before feeding (auscultate amount of caloric for bubbling sound using requirement per 8 hours in stethoscope just above the relation to patients status stomach area) 4.Flush 30 cc of water before and after feeding.

Rationale - Success rates are higher when the family incorporates a healthy eating plan. - This promotes comfort during feeding and allow flow of food by gravity. - This ensures correct tube placement in the stomach.

Evaluation At the end of 20 minutes of nursing interventions, the patient was able to: a. Receive adequate and desired amount of calories per feeding Long Term: At the end of 8 hours of nursing interventions, patient was able to: a. Receive adequate amount of caloric requirement per 8 hours in relation to patients status

- This is to rinse tubing, provide fluid source to maintain adequate hydration and to ensure that all feeding goes into the stomach. -To meet nutritional demands of the patient per day.

Dependent: 1. Administer OF 1600 kcal in 4 divided feedings via NGT.

63

Cues Subjective: February 4,2010 Maglisod man ni siya ug storya. Dili kayo mi kasabot, as verbalized by SO. February 7,2010 Gaapason niya iyang ginhawa kung magstorya siya., as verbalized by SO. February 10,2010 Makastorya na siya ug tarong pero dili kayo klaro., as verbalized by SO

Nursing Diagnosis Impaired Verbal Communication related to loss of facial or oral muscle control as evidenced by slurring of speech

Nursing Care Plan #9 Objectives Intervention Short term: Independent: After an hour of nursing 1.Provide alternative intervention the patient will methods of communication be able to demonstrate like pictures or visual cues, improved ability to express gestures or demonstration self 2. Anticipate and provide for patients needs Long Term: After 8 hours of nursing intervention the patient will be able to: 3. Talk directly to the a. Have decreased patient, speaking slowly frustration and isolation and clearly. Use yes or no with communication. questions to begin with. b. Establish method of communication in which needs can be expressed 4. Speak in normal tones and avoid talking too fast. Give patient time an ample time to respond. 5. Encourage family members to persist effort to communicate with the patient.

Rationale -Provide communication needs or desires based on individual situation or underlying deficits. -This is helpful in decreasing frustration when dependent on others and unable to communicate desires. -It reduces confusion and anxiety at having to process and respond to large amount of information at one time -Patient is not necessarily hearing impaired and raising voice may irritate or anger the patient. -It is important for family members to continue talking to the patient to reduce patient isolation, promote establishment of effective communication and maintain sense of connectedness or bonding with the family

Evaluation The Short term objectives were partially met because was still having a hard time with his speaking ability although he already managed to use nonverbal cues The Long term objectives were fully met. Patient was able to show decreased frustration and communicates well using non verbal mode of communication.

Objective: -right-sided weakness -Facial asymmetry -Slurred speech -with difficulty in pronouncing words

Nursing Care Plan #10

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Cues Risk Factors: -age: 89 years old -inadequate secondary defenses -chronic disease -malnutrition -presence of indwelling catheter -invasive procedures -insufficient knowledge to avoid exposure to pathogens

Nursing Dx Risk for infection

Objectives Short term: At the end of 30 minutes of Nursing intervention, the patient will be able to: a. Verbalize understanding of individual risk factors b. Identify interventions to prevent risk of infection Long term:

Intervention Independent: 1. Help patient wash hands before and after meals after using bathroom, bedpan or urinal. 2. Help the patient turn to sides every two hours. Provide skin care, particularly over bony prominences. 3. Ensure adequate nutrition intake. Offer high protein supplements such egg white. 4. Arrange protective isolation for compromised immune function. Monitor flow and numbers of visitors. 5. Teach patients about good hand washing technique, factors increase infection risk, infection sign and symptoms. Dependent: 1. Administer prophylactic antibiotics as ordered.

Rational - Hand washing prevents spread of pathogens to other objects and food. - To help prevent venous stasis and skin breakdown

Evaluation Short term goal were met because the patient and his SO were able to verbalize understanding of individual risk factors and identify interventions to prevent risk of infection Long term goal was met since patient was able to promote safe environment and did not show any signs of infection.

Note: A risk diagnosis is not evidenced by signs and symptoms, and the problem has not occurred and nursing interventions are directed at prevention

At the end of one week of Nursing intervention, the patient will be able to: a. Demonstrate techniques and lifestyle changes to promote safe environment b. Show no signs of infection such as fever

- This helps stabilize weight, improves muscle tone and mass, aids in wound healing. Also serves to minimize edema. - These measures prevent patient pathogens in the environment and protect from skin breakdown. - These measures allow patient to participate in care and help patient modify lifestyle to maintain optimum health level. - To prevent infection caused by pathogen.

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VII. DISCHARGE PLANNING

Medications

Encourage strict medication compliance and to take medications as directed to attain therapeutic effects. Instruct patient and significant others to keep a list of medications with their respective dosage and frequency of intake to prevent medication errors and their purpose. Digoxin 0.7g/tab OD before lunch Metoprolol 50mg tab BID Rosuvastatin 10mg/tab OD Losartan 50mg tab OD, AC, BF Spiriva rotacup thru inhaler OD Allopurinol 100mg 1 tab OD Avodart 1 tab OD

Inform patient regarding side effects of medication to allay patient anxiety if said side affects manifest. Encourage patient to discuss with health care provider concerns regarding medications. Exercise Teach patient and his significant others to do passive and active range of motion with slow progressions in frequency. Adequate rest periods must be given in between exercises to prevent straining. Always bear in mind that one has to start on easy-to-do exercises first and must rest frequently, building up strength is essential as one goes on until hard exercises are tolerated. Moderate exercise such as walking should be encouraged. Treatment Instruct patients SO to seek medical advice and immediately treat infections of the upper respiratory system, and oral cavity. Provide patient and relative written and verbal information regarding the following: 1. Explain the indications of the prescribed medications, their actions, dosages, contraindications and side effects.

Health Teachings

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2. Immediate notification of physician for presence of adverse reactions in medicines and home care complications. 3. Contacting the healthcare provider when signs of recurrence or complications of the disease appear, especially shortness of breath and chest tightness. 4. Seek medical advice from healthcare provider for immediate treatment of upper respiratory system, and oral cavity infections. 5. Compliance to follow up examinations. 6. Providing support. The patient and family need assistance, explanation, and support every time patient requires treatment to prevent serious complications and improve condition. 7. Indicate enough bed rest to reduce exertion and to avoid all strenuous activities that has not been approved by the physician. Outpatient Follow-up Assert importance of follow up visits to physician. Advise patient and family to report to the physician if any recurrence or severity of symptoms, any adverse effects of the medication, and any development of complication. Patients should be encouraged to keep a record of their daily weights. An action plan should be developed so that if the patient experiences unexplained weight gain of greater than 3 pounds since their last clinical evaluation the patient can take action (call physician or take additional medication). Promote the use of the communitys available resources such as carrying out regular visits to the nearest health center for continuing monitoring of clients over all status. If there are things that are unclear, advise patient and SO to refer concerns to physician.

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1. Alcohol use should be discouraged. Diet 2. Depending on the health care provider a diet that is low in sodium content, about 2 grams per day is recommended. 3. It is advisable that cholesterol intake be limited 4. Sources of fiber are to be added to the diet to aid in digestion. 5. Protein intake is recommended but must not be from fatty sources. Fish, chicken and beans are good sources of protein so long as it is not contraindicated by the patients physician. 6. Intake of vitamin supplements and other sources of minerals are recommended. 7. Excessive fluid intake should be discouraged, but fluid restriction is rarely indicated. Spiritual Care Encourage significant others to contact the family pastor to provide spiritual guidance. Participating in religious ceremonies together can be a form of family bonding and can strengthen the family internally. Encourage patient to verbalize anxieties to spiritual guide (i.e. pastor, priest) to relieve pent up frustrations. Ask the significant others to constantly remind patient that the disease is not a form of punishment from God and that it is not the patients fault for getting the disease in the first place.

VIII. PROGNOSIS 68

CRITERIA

GOOD PROGNOSIS

POOR PROGNOSIS

ANALYSIS/IMPLICATION

Onset of Illness Duration of Illness / /

The patients severe manifestations occurred very late to be able to be treated. There was a late detection of the disease of the patient, thus contributes to a late prevention. The old age of the patient, his gender, family history of having heart disease, stroke and / hypertension, sedentary lifestyle, and his diet that is rich in cholesterol and fats predisposes him and puts him at risk for acquiring such disease. Such factors manifested by the patient cannot already be altered and prevented. But manifestations showed by the patient may be improved through the medication regimen prescribed and provided by the healthcare team. The patients admission and adherence to medication treatment may somehow show that / patient is very willing to take treatment in order for him to recover from the disease.

Precipitating and Predisposing Factors

Attitude & Willingness to take Treatment

It is very important to note that prognosis for patients having such diseases vary greatly depending on a persons health, the extent of the damage, the treatment given and the patients adherence to it, and most importantly, the early detection of the disease. Most of the prognosis in the chart exhibited poor prognosis especially that the patient manifest important factors that may lead to life-threatening complications. Patient is responsive to the treatment given as evidenced by diminished symptoms of the disease which also suggest a good prognosis for the patient. But still, long term prognosis may suggest that the clients problem may not lead to a full recovery of the patient as such that the patient is already in the late stage of treating the disease.

IX. CONCLUSION 69

At the end of this case study we were able to attain goals that we have set from the start of this study. Through the gathered data we were able to formulate nursing care plans that we were able to apply to our patient. By studying on the patients prescribed medication we were able to understand its effects which could aid in his recovery. A review on the affected anatomy and physiology of the body enabled us to create interventions that could alleviate pain and any discomforts from the patient, if not completely prevent it. With the help of the patients family, we were able to explore part of the patients personality and this information was used on the formulation of the interventions. Today it is but promising to note that the number of heart related diseases affecting aged people are increasing. Myocardial Infarction is the interruption of blood supply to part of the heart, causing some heart cells to die.There are a lot of factors which may lead to the development of such disease one of the most noticeable factor is poor or unhealthy lifestyle which the patient practiced for many years. Chronic Obstructive Pulmonary Disease refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed.This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. This is caused by noxious particles or gas, most commonly from tobacco smoking, which triggers an abnormal inflammatory response in the lung. The patients condition was greatly aggravated because of the many complications of congested heart failure. It is but evident that the patients condition was worsening due to the prevalence of other manifestations thereof. It is therefore important for the patient to strictly follow the doctors orders specially on the medication regimen and the diet for palliative treatment since the patients condition cant be cured mainly because of his old age. Measures show focus on how to prevent the deterioration of the patients condition. Therefore it is most important to include the family in the plans of care for the patient.

XI. RECOMMENDATION 70

The recommendations made by the proponents for this grand case presentation are necessary for a patient who is diagnosed with Benign Prostatic Hyperplasia; Myocardial Infarction; and Chronic Obstructive Pulmonary Disorder. Although the data presented are factual and relevant, the papers aspect is limited to the patients case and the data gathered. The recommendations will serve as a guided care for the well being of the patient. These involve the patient, her significant others and the health care providers. Recommendations made for the patient are as follows: First, cooperation in his treatment therapy is needed. He should continue to report any abnormalities she will experience or manifest that could be a sign of a more serious problem. Second, the patient should be able to adhere well with the medication regimen as prescribed. Third, the patient must be set to follow dietary guidelines for metabolic needs and his daily nutritional requirement. Fourth, he should be able to establish in his mind a positive outlook regarding her condition. Fifth, spiritual health should also be strengthened with his condition since it is important for his holistic care and in maintaining a healthy status. For the significant others, it is encouraged that they continue to provide comfort and care measures to the patient throughout the disease process. Their presence is also an important factor for the emotional and mental stability of the patient. They can convince and supervise the patient in the adherence to the treatment regimen and providing the daily needs of the patient either with personal necessities or adequate rest. For the health care providers, they should be able to provide quality health care to the patient by being equipped with knowledge and skills necessary for the appropriate interventions needed by the patient and also by being sensitive to the needs and being observant to possible manifestations of the patient. Constant monitoring is also very important as to the critical status of the patient. For us, since availability of time and length of duty is limited, further care and interventions was not done to the patient. The sources of data used were also based only on the patients chart, assessment tools and textbooks. Thus, ample time to do further research and interaction of the patient is recommended.

XI. BIBLIOGRAPHY 71

Book sources: Black, Joyce M. Hawks, Jane Hokanson. Medical-Surgical Nursing Clinical Management for Positive Outcomes. 8th Ed. Philippines. Saunder-Elsevier, Inc.,2008 Brunner , Suddarth . Textbook of Medical-Surgical Nursing volume 1 & 2. 11th edition, Lippincott Williams and Wilkins, 2007 Doenges, Marilynn E et al. Nurses Pocket Guide Diagnosis, Prioritized Interventions & Rationales. 10th edition, F.A. Davis Company, 2006 Karch, Amy M. Focus on Nursing Pharmacology. 3rd edition, Lippincott Williams and Wilkins, 2006 Kindersley, Dorling. British Medical Associations New Guide to Medicines and Drugs. Great Britain: Dorling Kindersley.6th Ed. 2004 Kozier, B., Erb, G., and Berman, A. Fundamentals of Nursing: Concepts, Process and Practice. 6th edition, Upper Saddle River, NJ: Prentice-Hall Inc., 2000 Turgeon, M. (2005). Instrumentation in hematology. Clinical Hematology: Theory and Procedures 4th ed. Copyright 2005 Lippincott Williams & Wilkins 351 West Camden Street Baltimore, MD 21201 pp. 507-508 Wilson, Billie Ann, et. al. Prentice Halls Drug guide. New Jersey: Pearson Education, Inc., 2004.

Internet sources: Management of Chronic Obstructive <http://www.nlhep.org.ugcopd.about.com> Pulmonary Disease. NHLEP.

http://www.mayfieldclinic.com/IM-AnatCardio.htm http:www.drugs.com/mmx/tranexamic-acid.htm http:www.umm.edu.search.index.htm http://medterms.com/script/main.art.asp?articlekey=9349s

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