Case Presentation

Case Presentation
on
Coronary Artery Disease, Acute Myocardial Infarction
In Partial Fulfillment of the Course Requirements in

Nursing Care Management
Presented to the Clinical Instructors of

Ateneo de Davao University
Nursing Division
Submitted to:
Anselmo Lafuente, R.N.

Clinical Instructor
Submitted by:
Yap, Novelynne Joy A.

4H
Submitted on:
February 22, 2007
Table of Contents
I.
Introduction....................................................................................................................3
II.
Objectives......................................................................................................................5
III.
Patients Data.................................................................................................................6
IV.
Genogram.......................................................................................................................7
V.
Health Status..................................................................................................................9
VI.
Complete Diagnosis.....................................................................................................12
VII.
Developmental Data.....................................................................................................16
VIII.
Physical Assessment....................................................................................................20
IX.
Anatomy and Physiology.............................................................................................23
X.
Pathophysiology...........................................................................................................34
XI.
Doctors Order.........................................................................................................40
XII.
Diagnostic Examination...............................................................................................50
XIII.
Drug Study...................................................................................................................64
XIV.
Nursing Care Plan........................................................................................................93
XV.
Prognosis....................................................................................................................108
XVI. Bibliography...............................................................................................................110
INTRODUCTION
Coronary Artery Disease (CAD) is characterized by the presence of atherosclerosis in the
epicardial coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis,
progressively narrow the coronary artery lumen and impair myocardial blood flow. The reduction
in coronary artery flow may be symptomatic or asymptomatic, may occur with exertion or at
rest, and may culminate in a myocardial infarction, depending on obstruction severity and the
rapidity of development.
The term myocardial infarction is derived from myocardium (the heart muscle) and
infarction (tissue death due to oxygen starvation). Myocardial infarction (MI) is the rapid
development of myocardial necrosis caused by a critical imbalance between the oxygen supply
and demand of the myocardium. This usually results from plaque rupture with thrombus
formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the
myocardium.
Cardiovascular disease is the leading cause of mortality in the United States among both
men and women in every major ethnic group. It accounts for nearly 1 million deaths per year and
was responsible for one in five deaths in the United States in 2001. Approximately 6 million men
have a history of a myocardial infarction, angina pectoris, or both. Coronary artery disease is the
most common form of cardiovascular disease. In 2001, the death rate from coronary artery
disease was 228 per 100,000 white men, 262 per 100,000 black men, 137 per 100,000 white
women, and 177 per 100,000 black women. The estimated prevalence of coronary artery disease
in men is 6.9%; among women the prevalence is 6.0%.
Internationally, diseases of the heart are the leading cause of death, causing a higher
mortality than cancer (malignant neoplasms). Some 7,200,000 men and 6,000,000 women are
living with some form of coronary heart disease. 1,200,000 people suffer a (new or recurrent)
coronary attack every year, and about 40% of them die as a result of the attack. This roughly
means that every 65 seconds, an individual dies of a coronary event.
In the Philippines, 92 percent of Filipinos 20 years and above have at least one of the risk
factors that may soon lead to coronary artery disease and cardiovascular disease if not addressed
immediately. These risk factors include diabetes, hypercholesterolemia (high cholesterol levels in
3
the bloodstream), obesity, high blood pressure and smoking. In addition the National Nutrition
and Health Survey (NNHeS) report also showed that 22 out of 100 Filipino adults are
hypertensive (with blood pressure of 140/90 or higher), and 40 percent of those between 20 and
29 already have prehypertensive findings.
During my clinical exposure in the Coronary Care Unit at the Davao Medical Center last
November 27-29, 2006, I had a patient with a diagnosis of CAD, AMIK II, (+) LVH, (+) LVD,
FC III. This patient is Mr. Perfecto Pandacan Balili, a 60 years old male and will be the focus of
my case study.
OBJECTIVES
General Objective:
Through this paper, I will be able to present details about Coronary Artery Disease,
Myocardial Infarction. The proponent gathered data through interviewing the patient and his
watchers, making use of the patients records from the hospital, and other researches to provide
the readers information about the said condition.
This case study would preserve and improve the quality of nursing responsibilities by
rendering care, holistically, spiritually, and whole heartedly in a manner that the client, the
student nurses and others would benefit.
This case study would be able to:
COGNITIVE: Discuss in details of the chosen illness for the case study so as to gain
insight and knowledge about CAD, AMI
AFFECTIVE: Have a purposeful interaction with the clients significant others
PSYCHOMOTOR: Enhance the ability to identify and apply nursing interventions to

provide a better care for the clients suffering from the mentioned illness.
Specifically, this paper would be able to:
Present the patients personal data with accuracy
Present the genogram that includes the disease of the family members
Discuss the health status of the patient that includes the past and present condition
Present and discuss the complete diagnosis of the patient
Interpret and discuss the developmental data of the patient
Obtain the physical assessment of the patient
Discuss the anatomy and physiology of the affected system
Trace the pathophysiology of the disease and its underlying causes in relation to the
patients predisposing and precipitating factors
Interpret and present the Physicians orders
Discuss the different laboratory and diagnostic examinations done top the patient
Make a drug study on the drugs prescribed to the patient
Formulate nursing care plans for the patient

5
State the prognosis and relate it with the patients condition
PATIENTS DATA
Patients Name: Perfecto Pandacan Balili
Hospital Number: 919684
Age: 60 years old

Sex: Male
Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City
Civil Status: married
Religion: Roman Catholic
Citizenship: Filipino
Birthday: July 9, 1946
Birthplace: Tagum City
Name of Spouse: Lydia Balili
Age: 57 years old
Name of Father: Julio Balili (Deceased)
Name of Mother: Vicenta Pandacan (Deceased)
Area: Coronary Care Unit
Bed: 1
Attending Physician: Dr. Voltaire Egnora
Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killips II, Left
Ventricular Hypertrophy, Left Ventricular Dilatation, FC III
Chief Complaint: Dyspnea
Date and Time Admitted: November 12, 2006, 12:01 P.M.
LEGEND:
Couple
Hypertension
Rheumatic Heart Disease
Deceased
Heart Problem
Renal Failure
Asthma
Pulmonary Tuberculosis
Arthritis
Cancer
CAD, AMI
Pneumonia
Twin
HEALTH STATUS
A.
Personal Data
Patients Name: Perfecto Pandacan Balili
Age: 60 years old
Sex: Male
Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City
Chief Complaint: Dyspnea
Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killips II,
Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III
B.
Family Background
The family has been living in Ecoland ever since Perfecto and Lydia got married, except
for some years in between when the family went to Manila but apparently they also came back
here in Davao. The couple has eleven children with 6 girls and 5 boys. Aside from that within the
6 girls there is a twin and the same applies with the 5 boys, apparently their third set of twins
died due to miscarriage.
Among the eleven children only two of them were able to finish college and the rest were
only able to study until their high school years for varied reasons. In addition, currently the
couples children are in Manila, one is in Japan and three stayed here in Davao. All of their
children are currently married except for the youngest three.
Mr. Perfecto Balili has an educational attainment of until second year high school and his
wife Lydia got until second year College with a course of Accountancy. According to Mrs. Balili
they got married when she was in third year high school because she already got pregnant with
their first child. But even though this is the case she still continued her schooling until second
year college with the financial support of her husband. In addition, she got pregnant with only a
years difference on all of her children.
Perfecto has always been a taxi driver. He supported his familys daily needs, educational
needs and others with only this kind of job. He worked as a taxi driver both here in Davao and
even when they came to Manila he also worked as an FX driver. Back then when their children
was young Mr. Perfecto is the only one that works because Lydia is the one that takes care of the
children and until today she is still a plain house wife. But when Mr. Balili experienced his first
10
heart attack in Manila, he temporarily stopped driving and took a rest. After a few months he
then continued his work and did not totally stop driving until after his third attack and so their
children are the ones that supported the family. Currently, they get their financial support in their
daughter who is in Japan.
Some of his vices include drinking and smoking. He is a hard drinker and started drinking
when he was only a teenager. He can consume half a box of cigarette in a day and this started
during his twenties. He is also fond of eating meat compared to fish and vegetables.
Furthermore, Perfectos father died due to cancer and his mother died due to asthma.
Among his siblings, 3 of his siblings had pulmonary tuberculosis namely Emilio, Carlos and
Lucia. One of his sisters had a renal failure and hypertension. Other than that they have no trace
of any hereditary diseases. Perfectos son, Adrian, had PTB and 3 of his children had pneumonia.
His daughter, Jackilyn, had Rheumatic Heart Disease and his son, Jeffrey, had asthma.
C.
History of Past Illness

Back in 1986, Perfecto was diagnosed of pulmonary tuberculosis and he sought medical
help from the Barangay Health Center. He was then given the 6 months treatment for PTB, after
the completion of the medication the patient failed to have a follow-up check-up after the
treatment.
Perfecto had his first attack 7 years ago; he had his first and second heart attack in
Manila. During his first attack he was admitted in Manila Hospital then was transferred to San
Juan Hospital for five days and was then brought back to Manila Hospital. His third and fourth
heart attack happened in Davao. He was admitted in Med-Main in DMC on his third attack and
his fourth attack was in Med CP for he had COPD and was then transferred to CCU for he was
diagnosed with Coronary Artery Disease basing on his result of Echocardiogram. His fourth
attack happened only last July 2006.
D.
History of Present Illness

One month PTA, the patient had his available oxygen via oxygen tank in his house as aid
for his breathing, which they bought for P4,500. He also had an air conditioned room at his home
just to aid his condition. Two weeks PTA, patient had bipedal edema, loss weight; decrease
appetite and experienced paroxysmal nocturnal dyspnea. He had difficulty sleeping during the
night. Three days PTA, patient has been having episodes of chest pain at the left anterior chest
11
radiating to the arm, lasting for a minute. Five hours PTA, he had recurrence of chest pain of the
same character. He then took isosorbide mononitrate SL but without relief. Persistence of
symptoms prompted this admission, with a previously diagnosed coronary artery disease by 2D
Echo result.
E.
Effects and Expectation of Illness to Family

Mr. Perfecto already had five heart attacks and his condition got worse every time this
happens. Although the family is very well aware of his degenerating condition they are still
hoping that he will get better and that will live much longer. As observed the family is not really
affluent and that they are having financial problems due to the recurrent attacks of the patient.
Luckily, they are being assisted by his daughter, Jackilyn, who had a Japanese husband and
currently resides in Japan. In addition, he also had a senior citizens identification card that
becomes a big aid in their financial needs. Aside from the financial help the family is greatly
affected by the patients condition and thus still tries their best to live a normal life.
12
COMPLETE DIAGNOSIS
Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killips II, Left Ventricular
Hypertrophy, Left Ventricular Dilatation, FC III
Coronary
Term applied to vessels

(Stedmans Medical Dictionary, 25th Edition)
Used to describe the arteries that supply blood to the muscle tissue of the heart, or the
veins that take blood away from it
(Microsoft Encarta Premium Suite 2005)
Relating to or being the coronary arteries or coronary veins, or relating to the heart
(http://education.yahoo.com/reference/dictionary/entry/coronary)
Artery
A vessel through which the blood passes away from the heart to the various parts of the
body
Blood vessel that carries blood away from the heart

(Medical Dictionary by Gupta and Gupta)
Are muscular blood vessels that carry away blood from the heart
(http://en.wikipedia.org/wiki/Artery)
Disease
A definite morbid process having a characteristic train of symptoms

Any departure from health of a structure, organ, or system

Disorder with a specific cause and recognizable signs and symptoms, any bodily
abnormality or failure to function properly
(Webster Dictionary)
13
Coronary Artery Disease
A disease in which there is a narrowing or blockage of the coronary arteries (blood

vessels that carry blood and oxygen to the heart
(Medical-Surgical Nursing, 9th Edition)
Characterized by the presence of atherosclerosis in the epicardial coronary arteries.

(The Bantam Medical Dictionary)
Occurs when the arteries that supply blood to the heart muscle (the coronary arteries)
become hardened and narrowed
(http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html)
Acute
Having rapid onset, short or relatively severe course

Myocardial
Pertaining to the muscular tissue of the heart

Relating to or affecting the thick muscular wall of the heart.

The middle of 3 layers forming the wall of the heart. It is composed of cardiac muscles
and forms the greater part of the heart wall, being thicker in the ventricles than in atria.
(http://education.yahoo.com/reference/dictionary/entry/myocardial)
Infarction
Formation of an infarct (coronary thrombosis)

Cessation of blood flow by thrombus formation and causing issue death

The death of part of the whole of an organ that occurs when the artery carrying its blood
supply is obstructed by a blood clot
(www.ask.com/infarction)
14
Killips II
A classification of Acute Myocardial Infarction that is defined as having moderate heart

failure with basiliar rales -50% of lung field or S3 gallops, tachycardia or signs and
symptoms or right heart failure like venous or hepatic congestion
(Harrisons Internal Medicine)
Myocardial Infarction
A disease that occurs when the blood supply to a part of the heart is interrupted. The
resulting oxygen shortage causes damage and potential death of heart tissue
(http://en.wikipedia.org/wiki/Myocardial_infarction)
Is the rapid development of myocardial necrosis caused by a critical imbalance between

the oxygen supply and demand of the myocardium
(http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/complications/compl
ications.htm)
It is a disease that occurs when the blood supply to a part of the heart is interrupted
(http://www.yahoo.com/reference/dictionary/acutemyocardial infarction)
Ventricular
Pertaining to ventricles
Involving, affecting or relating to a ventricle

One of the chambers of the heart, the largest and the most important chamber
(www.ask.com/dictionary/left ventricle)
Hypertrophy
Morbid enlargement or overgrowth of an organ or part due to an increase in size of its

constituent cells
An increase in cell size

15
Increase the size of a tissue or organ brought about by the enlargement of its cells rather
than by cell multiplication, muscles undergo these changes in response to increased work
(http://education.yahoo.com/reference/dictionary/hypertrophy)
Dilatation
The act or process of widening or being widened, stretching or being stretched, or

enlarging or being enlarged
something, especially a part of something else, that has become enlarged, expanded, or
stretched
The enlargement or expansion of a hollow organ or cavity

(The Bantam Medical Dictionary)
Left Ventricle Hypertrophy & Dilatation
There were increase in the size of the left ventricle or enlargement of the left ventricle
due to increase blood volume and pressure
(http://education.yahoo.com/reference/dictionary/hypertrophy/dilatation)
FC III
A classification of chronic heart failure that is defined as having dyspnea that occurs with
less than ordinary physical activity, can climb one or less than one flight of stairs
16
DEVELOPMENTAL DATA
The middle years from 40-65, have been called the years of stability and consolidation.
For most people it is the time when children have grown and moved away or are moving away
from home. Thus, partners generally have more time for and with each other and time to pursue
interests they may have deferred for years.
Physical Development
A number of changes take place during the middle years. Both men and women
experience decreasing hormonal production during the years. The climacteric (andropause) refers
to the changes of life in men, when sexual activity decreases. In men, there is no change
comparable to menopause in women. Androgen levels decreases very slowly; however men can
still have children even in late life. The psychological problems that men experience is generally
relate to fear of getting old and to retirement, boredom and finances.
Physical changes that occurred to Perfecto were his decreasing ability to perform
activities. He easily gets tired and constantly needs assistance upon doing things or moving
about. Due to his condition he only has limited capabilities and can no longer do what he usually
does unlike the previous years before his first attack occurred.
Robert Havighursts Developmental task theory
Since Perfecto belonged to the middle-aged group, he had seven tasks to accomplish
according to Havighursts theory. These tasks are:
1.
Achieving adult, civic and social responsibility. The family agreed that Perfecto has
achieved this because he was able to perform his role well. He is able to support his
eleven children and send them to school although unfortunate personal circumstances
hindered eight of them from finishing school. Although this is the case Perfecto is a
responsible citizen and is concerned for the betterment of his family and community.
2.
Establishing and maintaining an economic standard of living. Perfecto works really

hard for his family. Ever since he got married he did his best to support his family. He did
a very good job since he was also able to support the schooling of his wife. He worked as
a taxi driver both here in Manila and Davao.
17
3.
Assisting teenage children to become responsible and happy adults. He is the

authority of the house and he makes sure that he is able to guide his children to the right
path. Many of his children did not finish their schooling because many are just not
interested to do so and there may be lack of guidance since they were a big family and
their behavior was affected by the changing environment. Although this is the case his
children as adults are responsible enough to work hard to support each other and help the
family especially when the family is on financial crisis.
4.
Developing adult leisure time activities. They spend they leisure time talking at each
other, watching television or talking to neighbors and establish good relationships. Back
then he would smoke and drink with his male friends but ever since he ha his first attack
he stopped his vices.
5.
Relating oneself to ones spouse as a person. Usual petty fights happen between the
couple but they are able to patch things up and still work as a couple. They value each
others opinion and respect each others decisions.
6.
Accepting and adjusting to the physiologic changes of middle age. Perfecto had
accepted the fact that he is not getting any younger anymore and it is evident on his
condition. That is why he already anticipated any changes that would happen to him
especially with his current illness. He is very well aware that his body is no longer like
before and that each attacks that occurs is worse than the previous.
7.
Adjusting to aging parents. Perfectos parents died many years ago and so he is very
well adjusted now and accepted the fact that everyone dies eventually.
Psychosocial Development
According to Erik Erikson, a person develops throughout his lifetime. He noted that there
are levels of achievement that a person must achieve or experience. These can be achieved and
be ranked as partial, complete or unsuccessful. The greater the achievement of a person, the more
he is better and healthier in development of hid personality. Failure to achieve the task may affect
the persons ability to achieve the next task.
According to Erik Erikson the middle adulthood belongs to the generativity versus
stagnation. In this stage work is most crucial. He observed that middle age is when they tend to
be occupied with creative and memorable work and with issues surrounding their family. It is
when they expect to be in charge, and the significant task is to perpetuate culture and transmit
18
values of the cultures through the family and working to establish a stable environment. Strength
comes through the care of others and production of something that contributes to the betterment
of society, which Erikson calls generativity, and when they are in this stage they often fear
inactivity and meaninglessness.
As their children leave home, their goals change and they may be faced with major life
changes-midlife crisis- and the struggle with finding new meanings and purposes. If they do not
get through this stage successfully, they can become self-absorbed and stagnate.
In the case of my patient, he is on the middle adulthood stage. As of now, he has on the
stage wherein he is still guiding some of his children. He is now concerned more on his
childrens future. He is aware of social responsibility and develops leisure activities and hobbies
appropriate for his age. He previously does his best to become productive and contribute to the
society but due to his current condition he is no longer able to do that. But being the head of the
family continues to be his role only with restrictions on some actions.
Cognitive Development
Cognitive and intellectual abilities of the middle adult change very little from the young
adults. There is motivation to learn, especially if the knowledge gained can be immediately
applied and had personal relevance. Problem solving abilities remain throughout adulthood,
although the time response may be slightly longer. This is not due to a decrease in ability, but
rather due to longer memory research of increased amounts of material.
According to my patient, every problem has a solution. This shows that he is very
positive when it comes to problem solving. My patient is able to find solutions to his problems
and he does not lose hope that he could not overcome any problem he is experiencing. One
example was his admission due to his debilitating illness. He was able to surpass this problem
because of his positive attitude towards problem solving. He had undergone 4 attacks before and
he was still very positive & opens to any modification regarding his health just to live longer.
Moral Development
The middle adulthood remain at the conventional level or may move to post conventional
level, especially if the person had sustained responsibility for the welfare of others and has
consistently applied ethical principles developed in adolescence. At this level, the adult believes
that the rights of others take precedence and takes steps to support those rights.
19
My patient belongs to post conventional level or self accepted moral principles. He is

able to distinguish right from wrong. He respected and takes priority the rights of others and also
maintains self respect. He believes that relationships are based on mutual trust. He has his
personal values as to the standards of our society. He views each of then as right and proper
because that is what the society wants. But the decision is still coming from him. He decides on
his own if he should follow the things that the society dictates him or simply follow what is right
for him.
20
PHYSICAL ASSESSMENT
I. General appearance & mental status
Mr. Perfecto Balili, a 60 year old male client, was admitted on November 12, 2006 in
Davao Medical Center. Upon assessment the patient was lying on bed in moderate high back rest
and is awake, conscious, coherent & responsive. He has an IVF of D5W 500cc @ 300cc level
running at KVO infusing well @ right cephalic vein, with O2 inhalation @ 5Liters per minute
via nasal cannula, is wearing a hospital gown and has diaper.
The client has a generalize weakness and needs assistance upon moving or position
changes. He has difficulty of breathing and is constantly expectorating whitish phlegm into his
bedside receptacle. He is 56 in height and weighs 59 kg.
II. Vital Signs:
BP- 110/80mmHg
CR- 43 bpm; irregular rate and rhythm
RR- 25 cpm; regular rhythm
Temp- 36.5 C
III. Skin
The color of the skin is brown with rough and dry texture. The patient has poor skin
turgor and clammy to touch. Scars in lower extremities are observed; no wounds or lesions are
noted.
IV. Head
He has a normocephalic configuration with head circumference of 22 cm. His facial
movements are symmetric and he has a thin, evenly distributed, white in color hair. Scalp is dry
but there is no presence of dandruff or lice upon inspection
V. Eyes
Eyes have symmetrical lids and normal periorbital area. Conjunctiva is pale and sclera is
observed to be anicteric. Both left and right pupils are black in color with pupillary size of 3mm,
21
briskly reactive to light. He has a slightly sunken periorbital region, eye bugs present with
eyebrows and eyelashes evenly distributed. Client wears eyeglasses only upon reading.
VI. Ears
Clients ears are symmetrical and are in line with the outer canthus of the eyes. His
pinnae are normal, normoset and symmetric. No tenderness and lesions noted. Absence of
discharges on the external canal is noted. No hearing problem noted.
VII. Nose
The clients nasolabial fold is normal, septum is medially located and no discharges are
noted. There are no deformities or inflammation on the nose noted. No nasal flaring is noted and
both nostrils are patent. He has an O2 inhalation via nasal cannula.
VIII. Mouth
The mucosa and gums of the client are pinkish and lips are dry. His tongue is medially
located. Teeth were yellowish in color with loose teeth, he do not use dentures. He has no
difficulty of swallowing and no halitosis and bleeding noted upon observation.
IX. Neck
There are no signs of abnormal growth or enlargement of the nodes of the neck of the
client. There are no lesions noted.
X. Chest and Lungs
The client has rapid, regular breathing at the rate of 25 cpm. Wheezing is noted upon
auscultation with symmetrical chest expansion. He has productive cough with whitish phlegm..
XI. Heart and Breast
The client has symmetrical, rounded shape breast with smooth surface. The areolas are
bilaterally the same and are dark brown in color. There are no masses, lesions or tenderness
noted on these areas. He has a capillary refill time of 4 seconds. His pericardial area is flat and
heart sound is weak and irregular in rate and rhythm with a rate of 43 bpm. He is hooked to a
22
cardiac monitor with Atrial Fibrillation in slow to moderate response with ST elevation pattern.
An IVF of D5W 500cc @ KVO rate infusing well @ right cephalic vein @ 300cc level
XII. Abdomen
The skin in this area has uniform color and no lesions; with flat abdominal contour thus
there is no evidence of an enlarged spleen or lived noted. He has normal bowel sound of one
every 15 seconds.
XIII. Genito-Urinary
The client wears diaper but voids freely. There are no lesions or discharges noted. He can
defecate without difficulty at least once a day.
XIV. Back and Extremities
Client needs assistance upon moving around and in doing activities of daily living. He
can extend and flex both his upper and lower extremities with (-) bipedal edema or anasarca.
Weakness upon movement is noted. He has dirty and untrimmed nails on all extremities.
23
ANATOMY and PHYSIOLOGY

The cardiovascular system is sometimes called the
blood-vascular or simply the circulatory system. It consists of
the heart, which is a muscular pumping device, and a closed
system of vessels called arteries, veins, and capillaries. As the
name implies, blood contained in the circulatory system is
pumped by the heart around a closed circle or circuit of vessels
as it passes again and again through the various "circulations"
of the body. It transports food, hormones, metabolic wastes,
and gases (oxygen, carbon dioxide) to and from cells.
Components of the circulatory system include:
blood: consisting of liquid plasma and cells
Blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry
blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to
the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange
occurs.)
heart: a muscular pump to move the blood
The Cardiovascular System

In order to pump blood through the body, the heart is connected to the vascular system of
the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of
the body and remove carbon dioxide and metabolic waste products from the body. The
cardiovascular system is actually made up of two major circulatory systems, acting together. The
right side of the heart pumps blood to the lungs through the pulmonary artery (PA), pulmonary
capillaries, and then returns blood to the left atrium through the pulmonary veins (PV). The left
side of the heart pumps blood to the rest of the body through the aorta, arteries, arterioles,
systemic capillaries, and then returns blood to the right atrium through the venules and great
veins.
There are two circulatory "circuits": Pulmonary circulation, involving the "right heart,"
delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the
24
"right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary
veins carry oxygen-rich blood from the lungs back to the "left heart." Systemic circulation,
driven by the "left heart," carries blood to the rest of the body. Food products enter the system
from the digestive organs into the portal vein. Waste products are removed by the liver and
kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cava.
A specialized component of the circulatory system is the lymphatic system, consisting of
a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone
marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the
veins, and through the lymph nodes and into the lymph, the body is able to eliminate the
products of cellular breakdown and bacterial invasion.
Blood Components
Forty-five percent (45%) consists of cells - platelets, red blood cells, and white blood
cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood
cells, neutrophils and lymphocytes are the most important.
Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Major Blood Components
Component Type
Source
Function
Platelets, cell fragments
Bone marrow Blood clotting

life-span:
10
days
Lymphocytes (leukocytes)
Bone marrow, Immunity

spleen, lymph T-cells attack cells containing
nodes
viruses.
B-cells
produce
antibodies.
Red blood cells (erythrocytes), Filled with Bone marrow Oxygen transport
hemoglobin, a compound of iron and protein
Neutrophil (leukocyte)
Plasma, consisting of 90% water and 10%
dissolved materials -- nutrients (proteins, salts,
glucose), wastes (urea, creatinine), hormones,
enzymes
Bone marrow
Phagocytosis
1.
Maintenance of pH level
near 7.4
2.
Transport
of
large
molecules
(e.g. cholesterol)
3.
Immunity (globulin)
4.
Blood
clotting
25
(fibrinogen)
Vascular System - the Blood Vessels
Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run
parallel throughout the body with a web-like network of capillaries connecting them. Arteries use
vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use
one-way valves controlled by muscle contractions.
Arteries
Arteries are strong, elastic vessels adapted for carrying blood away from the heart at
relatively high pumping pressure. Arteries divide into progressively thinner tubes and eventually
become fine branches called arterioles. Blood in arteries is oxygen-rich, with the exception of the
pulmonary artery, which carries blood to the lungs to be oxygenated.
The aorta is the largest artery in the body, the main artery for systemic circulation. The
major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood to the
head, abdomen, and extremities. Of special importance are the right and left coronary arteries
that supply blood to the heart itself.
Capillaries
The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed
in interstitial fluid, or lymph, produced by the lymphatic system. Capillaries are the points of
exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries
by passing through or between the cells that line the capillary. The extensive network of
capillaries is estimated at between 50,000 and 60,000 miles long.
Veins
Blood leaving the capillary beds flows into a series of progressively larger vessels, called
venules, which in turn unite to form veins. Veins are responsible for returning blood to the heart
after the blood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low,
so veins depend on nearby muscular contractions to move blood along. Veins have valves that
prevent back-flow of blood.
Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry
oxygenated blood from the lungs back to the heart. The major veins, like their companion
26
arteries, often take the name of the organ served. The exceptions are the superior vena cava and
the inferior vena cava, which collect body from all parts of the body (except from the lungs) and
channel it back to the heart.
Artery/Vein Tissues
Arteries and veins have the same three tissue layers, but the proportions of these layers
differ. The innermost is the intima; next comes the media; and the outermost is the adventitia.
Arteries have thick media to absorb the pressure waves created by the heart's pumping. The
smooth-muscle media walls expand when pressure surges, then snap back to push the blood
forward when the heart rests. Valves in the arteries prevent back-flow. As blood enters the
capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure.
Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along
veins. As with arteries, valves are again used to ensure flow in the right direction.
Anatomy of the Heart
The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies
left of the chest midline. The heart, along with the pulmonary (to and from the lungs) and
systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated
blood.
Internally,
the
heart is designed
as a pump with
four chambers -
right
(RA),
ventricle
right
atrium
(RV),
left atrium (LA),
and left ventricle
(LV).
atria
The two
smaller,
heart
upper
and
the
are
the
chambers of the
two
ventricles
are the larger,
lower chambers
of the heart. The
heart is oriented
in
rotated about 30
the
chest
degrees to the left lateral side such the right ventricle is the most anterior structure of the heart.
The left ventricle is generally about twice as thick as the right ventricle because it needs to
27
generate enough force to push blood through the entire body while the right ventricle only needs
to generate enough force to push blood through the lungs. Ventricular contraction forces blood
into the arteries.
The heart also has four valves. The tricuspid valve is between the right atrium and right
ventricles. The pulmonary valve is between the right ventricle and the pulmonary artery. The
mitral valve is between the left atrium and the left ventricle and the aortic valve is between the
left ventricle and the aorta. The valves, under normal conditions, insure that blood only flows in
one direction in the heart.
Cardiac Muscle
Cardiac muscle is a type of involuntary mononucleated, or uninucleated, striated muscle
found exclusively within the heart. Its function is to "pump" blood through the circulatory
system
by
contracting.
Inside each cardiomyocyte are hundreds of myofibrils which are thin, elongated
structures. Each myofibril, in turn, consists of thin filaments and thick filaments. Each of the thin
filaments is composed of a protein called actin. Each of the thick filaments is composed of a
protein called myosin. Each myosin filament is composed of about 200 myosin molecules. Each
myosin molecule contains what is called a myosin head. Inside each cardiomyocyte there are
compartments filled with calcium. The action potential causes these compartments to release the
calcium into the cell. This calcium allows myosin heads to bind to actin filaments and pull them
by a process called a power stroke. That is how action potential causes the individual muscle
cells to contract.
Basic Cardiac Physiology
28
A basic understanding of cardiac physiology is also essential to interpreting the physical

finding during a cardiac exam. Each pump or beat of the heart consists of two parts or phases diastole and systole. During diastole the ventricles are filling and the atria contract. Then during
systole, the ventricles contract while the atria are relaxed and filling.
For the purposes for this discussion of cardiac physiology, we will focus on the
physiology associated with the heart sounds S1, S2, S3, and S4. S1 occurs near the beginning of
(ventricular) systole with the closing of the tricuspid and mitral valves. The closing of these two
valves with increasing pressure in the ventricles as they begin to contract should be
simultaneous. Any splitting in which the closing of the two valves are heard separately should be
considered pathological. S2 occurs near the end of (ventricular) systole with the closing of the
pulmonary and aortic valves. The closing of these two valves occurs with beginning of backward
flow in the pulmonary artery and aorta respectively as the ventricles relax. The two valves can
occur simultaneously or with slight gap between them under normal physiologic circumstances.
S3 occurs at the end of the rapid filling period of the ventricle during the beginning of
(ventricular) diastole. An S3, if heard should occur 120-170 msec after S2. S4 occurs, if heard
coincides with atrial contraction at the end of (ventricular) diastole.
The Circulation
Poorly oxygenated blood collects in two major veins: the superior vena cava and the
inferior vena cava. The superior and inferior vena cava empty into the right atrium. The coronary
sinus which brings blood back from the heart itself also empties into the right atrium. The right
atrium is the larger of the two atria although it receives the same amount of blood. The blood is
then pumped through the tricuspid valve, or
right atrioventricular valve, into the right
ventricle. From the right ventricle, blood is
pumped through the pulmonary semi-lunar
valve into the pulmonary artery. This blood
leaves the heart by the pulmonary arteries
and travels through the lungs (where it is
oxygenated) and into the pulmonary veins.
The oxygenated blood then enters the left
atrium. From the left atrium, the blood then
29
travels through the bicuspid valve, also called mitral or left atrioventricular valve, into the left
ventricle. The left ventricle is thicker and more muscular than the right ventricle because it
pumps blood at a higher pressure. Also, the right ventricle cannot be too powerful or it would
cause pulmonary hypertension in the lungs. From the left ventricle, blood is pumped through the
aortic semi-lunar valve into the aorta. Once the blood goes through systemic circulation,
peripheral tissues will extract oxygen from the blood, which will again be collected inside the
vena cava and the process will continue. Peripheral tissues do not fully deoxygenate the blood,
thus venous blood does have oxygen, only in a lower concentration in comparison to arterial
blood.
The Heart's Conduction System
There are four basic components to the heart's conduction system
1. sinoatrial node (SA node)
2. inter-nodal fibre bundles
3. atrioventricular node (AV node)
4. atrioventricular bundle
The sinoatrial (SA) node is a
small mass of specialised cardiac muscle
situated in the superior aspect of the
right
atrium.
It
lies
along
the
anterolateral margin of this chamber

between the orifice of the superior vena
cava and the auricle. The specialized
cardiac muscle of the SA node is
characterized
by
the
property
of
automatic self-excitation and it initiates

each beat of the heart. Therefore, the SA
node is often referred to as the
pacemaker of the heart.
Since the fibers of the SA node fuse with the surrounding atrial muscle fibers, the action
potential generated in the nodal tissue spreads throughout both atria at a rate of approximately
0.3 meter per second and produces atrial contraction. Interspersed among the atrial muscle fibers
30
are several inter nodal fiber bundles which conduct the action potential to the atrioventricular
(AV) node with a greater velocity (approximately 1.0 meter per second) than ordinary atrial
muscle. The AV node is located in the right atrium near the lower part of the interatrial septurn.
Here there is a short delay (approximately 0.1 second) in transmission of the impulse to the
ventricles.
This is important because it permits the atria to complete their contraction and empty
their blood into the ventricles before the ventricles contract. The delay occurs within the fibers of
the AV node itself as well as in special junctional fibers that connect the node with ordinary atrial
fibers.
Once the action potential leaves the AV node, it enters specialized muscle fibers called
Purkinje fibers. These are grouped into a mass termed the atrioventricular (AV) bundle, or the
bundle of His. The Purkinje fibers are very large and conduct the action potential at about six
times the velocity of ordinary cardiac muscle (i.e., 1.5 to 4.0 meters per second). Thus the
Purkinje fibers permit a very rapid and simultaneous distribution of the impulse throughout the
muscular walls of both ventricles.
As the AV bundle leaves the AV node, it descends in the interventricular septurn for a
short distance and then divides into two large branches, the right and left bundle branches. Each
of these descends along its respective side of the interventricular septum immediately beneath
the endocardium and divides into smaller and smaller branches. Terminal Purkinje fibers extend
beneath the endocardium and penetrate approximately one-third of the distance into the
myocardium. Their endings terminate upon ordinary cardiac muscle within the ventricles, and
the impulse proceeds through the ventricular muscle at about 0.3 to 0.5 meters per second. This
results in a contraction of the ventricles that proceeds upward from the apex of the heart toward
its base.
The spontaneous generation of an action potential within the SA node initiates a sequence
of events known as the cardiac cycle. Each cardiac cycle lasts approximately 0.8 second and
spans the interval from the end of one heart contraction to the end of the subsequent heart
contraction. Ordinarily this occurs about 72 times each minute.
Blood Pressure and Heart Rate
The heart beats or contracts around 72 times per minute. The human heart will undergo
over 3 billion contraction/cardiac cycles during a normal lifetime.
31
One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular
contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice
versa. Heart valves open and close to limit flow to a single direction. The sound of the heart
contracting and the valves opening and closing produces a characteristic "lub-dub" sound.
The
cardiac
cycle
has
two
basic
components:
(1) contraction phase (systole) during which
blood is ejected from the heart
(2) relaxation phase (diastole) during which
the chambers of the heart are filled with
blood.
The spontaneous generation of an action
potential within the SA nodal tissue represents the start of the cardiac cycle. This electrical
impulse spreads throughout the atrial muscle and leads to contraction of the two atria.
As the atria contract, the AV valves remain open and additional blood is forced into the
ventricles from the veins. A large amount of blood has already passed from the atria to the
ventricles prior to atrial contraction.
The aortic and pulmonary (pulmonic) semilunar valves remain closed.
After the ventricles have filled (mostly by blood returning from the large veins) and the
atria have contracted, the AV valves close as the ventricles begin their contraction.
Ventricular contraction forces blood through the semilunar valves into the aorta and
pulmonary trunk.
Next, as the ventricles begin to relax, the aortic and pulmonic semilunar valves close, the
AV valves open, and blood flows into the ventricles to begin another cycle.
While the atria are in systole, the ventricles are relaxed (in diastole). The atria relax
during ventricular systole and remain in this phase even during a portion of ventricular diastole.
Blood (like any other fluid) tends to flow from a region of high pressure to one of lower
pressure.
As each chamber of the heart fills with blood, the pressure increases within it. The blood
moves out of the chamber, when the various one-way valves guarding those chambers permit it
to do so.
32
As the ventricles contract, the blood is forced in a retrograde fashion against the AV
valves, which causes them to bulge inward slightly toward the atria and which also elevates atrial
pressure.
In doing so, the AV valves are effectively closed and blood is prevented from
regurgitating back into the atria. Near the end of ventricular systole the AV valves are still closed
and since the atria are in the process of filling, this too contributes to a rise in intra-atrial
pressure.
Even before the atria enter systole, the ventricles are filled with blood to approximately
70% of their capacity. When the atria do finally contract, additional blood enters the ventricles
and elevates the intraventricular pressure. As the ventricles contract, blood is forced backward,
closing the AV valves, and a sharp rise in ventricular pressure occurs.
Although the ventricles exist as closed chambers for a brief moment, the pressure within
them soon exceeds that in the aorta and pulmonary trunk. When this happens the aortic and
pulmonic semilunar valves are forced open under pressure and blood rushes out of the ventricles
and is driven into these large vessels. Accompanying the opening of the semilunar valves is a
rapid decline in intraventricular pressure that continues until the pressure within the ventricles
becomes less than that of the atria. When this pressure differential is reached, blood within the
atria pushes the AV valves open and begins to fill the ventricles once again.
Receptors in the arteries and atria sense systemic pressure. Nerve messages from these
sensors communicate conditions to the medulla in the brain. Signals from the medulla regulate
blood pressure.
Electrocardiography (ECG, EKG)
An electrocardiogram measures
electrical
potential
across
the
heart
changes in
and
detects
contraction pulses that pass over the surface of the heart.

There are three slow, negative changes, known as P, R,
and T. Positive deflections are the Q and S waves. The P
wave represents atrial contraction ("the lub"), the T wave
the ventricular contraction ("the dub").
33
The Lymphatic System

The lymphatic system functions 1) to absorb
excess fluid, thus preventing tissues from swelling; 2)
to defend the body against microorganisms and
harmful foreign particles; and 3) to facilitate the
absorption of fat (in the villi of the small intestine).
Capillaries release excess water and plasma
into intracellular spaces, where they mix with lymph,
or interstitial fluid. "Lymph" is a milky body fluid that
also contains proteins, fats, and a type of white blood
cells, called "lymphocytes," which are the body's firstline defense in the immune system.
Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in
having valves that prevent backflow. Contraction of skeletal muscle causes movement of the
lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone
marrow, liver, spleen, thymus), or to the cardiovascular system.
Lymph nodes are small irregularly shaped masses through which lymph vessels flow.
Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the primary
function (along with bone marrow) of producing lymphocytes.
The spleen filters, or purifies, the blood and lymph flowing through it.
The thymus secretes a hormone, thymosin, which produces T-cells, a form of

lymphocyte.
34
PATHOPHYSIOLOGY
Predisposing Factors
Present () / Absent (x)
Family History
Age
Gender
Race
Precipitating Factors

Past
Present
Cigarette smoking
Hyperlipidemia
Rationale
Individuals with history of heart diseases
within their family or first degree relatives are
more prone in developing one himself. The
presence of coronary atherosclerosis in a parent
or sibling under 50 years old is associated with
the same finding in another family member.
More common in male aged (45 -70 y.o.)
Men are at a greater risk for the development
of CAD. Women are usually not affected by
this
disease
until
after
menopause.
Postmenopausal increase has been attributed to
decrease levels of estrogens and rising blood
lipids.
Black Americans have a higher risk than
whites. This is because they have increased
incidence of hypertension (33%)
Rationale
Inhalation of smoke increases the blood carbon
monoxide level causing hemoglobin, the
oxygen carrying component of blood to
combine more readily with carbon monoxide
than with oxygen resulting to decrease amount
of available oxygen which may decrease the
hearts ability to pump.
Nicotinic acid in tobacco triggers the release
of catecholamines which raises both heart rate
and blood pressure. It can also cause the
coronary arteries to constrict and increase
catecholamines may be a factor in the
increased incidence of sudden heart death.
It could also cause detrimental vascular
response and increase platelet adhesion
leading to high probability of thrombus
formation.
This refers to the elevation of cholesterol and
triglyceride levels within the blood.
Cholesterol can be obtained directly from
animal dietary source or manufactured by the
liver and intestine. Triglycerides are derived
from fatty acids found in adipose tissue or the
diet. Cholesterol and triglycerides are involved
35
Hypertension
Sedentary lifestyle
Diabetes Mellitus
Obesity
in the transportation, digestion and absorption

of fats.
High levels of low-density lipoproteins are
attributed to the development atherosclerosis
that would latter on cause obstruction in the
artery. LDL unlike HDL could not be
metabolized by the body. The HDL cannot
carry the bad cholesterol to the liver for
metabolism. The macrophages will then need
to modify it before HDL could interact with it.
During modification the macrophages cause
injury to the endothelial wall resulting to
fibrous formation and later on to formation of
emboli that would lead to obstruction of blood
flow to the myocardial artery.
Increase stiffness of the vessel walls leading to
vessel injury and a resulting inflammatory
response within the intima. It can also increase
the work of the left ventricle which must pump
harder to eject blood into the arteries. Increase
workload causes the heart to enlarge and
thicken (hypertrophy) a condition that may
eventually lead to cardiac failure.
In addition, increased peripheral vascular
resistance associated with hypertension
increases afterload and the demand on the left
ventricle. The result is an increased demand
for myocardial oxygen in the face of a
diminished supply.
It is noted that increase in activity can improve
the efficacy of the heart by the reduction of
heart rate and blood pressure. It also decreases
the level of low-density lipoproteins, lowered
blood glucose levels, and improved cardiac
output has been associated with lesser chance
of CAD.
Hyperglycemia fosters increase platelet
aggregation and altered RBC function, which
can lead to thrombus formation. Also, insulin
injures the vessel wall leading to inflammatory
response.
Obesity or excess body weight in relation to
height increases the workload and hence the
oxygen demands of the heart. Obesity highly
correlates with hypertension, hyperlipidemia,
and diabetes. It is also associated with
increased caloric intake and elevated levels of
36
low-density lipoproteins.
Stress
History of CAD
Symptomatology
Dyspnea
Bradycardia
Pulmonary Edema
Stress stimulates the cardiovascular system by

the release of cathecolamines, which in turn
increase the heart rate and produce
vasoconstriction.
Individuals with history of CAD are more
predisposed to reoccurrence or development of
heart diseases. Since there is already previous
formation of atherosclerosis and obstruction
within the myocardial artery the person may
then easily develop the same problem. It is
also noted that these individuals may have had
a portion of their heart than no longer
functions properly due to ischemia or necrosis.
Rationale
Collection of fats, cells and debris result to
development of fatty streaks. Narrowing of
epicardial blood vessel due to atheromatous
plaque would then result to coronary artery
disease. Progressive narrowing of the arterial
lumen, body will compensate through
vasodialation. But increase in occlusion will
result to gradual weakening of the
myocardium. Damage to the heart limits the
output of the left ventricle. Poor ventricular
compliance would result to dyspnea.
Development of fatty streaks between the
endothelium and internal elastic lamina.
Narrowing of epicardial blood vessel due to
atheromatous plaque would then result to
coronary artery disease. Progressive narrowing
of the arterial lumen would result to gradual
weakening of the myocardium. This would
then result to decrease in the cardiac output.
Formation of fatty streaks within the
endothelium and lamina. Narrowing of
epicardial blood vessel due to atheromatous
plaque would then result to coronary artery
disease. Progressive narrowing of the arterial
lumen, body will compensate through
vasodialation. But increase in occlusion will
result to gradual weakening of the
myocardium. Damage to the heart limits the
37
Chest pain
S3 heart sound
output of the left ventricle. Poor ventricular

compliance would result to Pulmonary edema.
When mural thrombus forms at site of rupture,
initial platelet monolayer forms at the site.
Various agonists (collagen, ADP, epinephrine,
serotonin)
promote
platelet
activation.
Production and release of thromboxane A2
result to further platelet activation, and
potential resistance to thrombolysis. Von
Willebrand factor (vWF) and fibrinogen are
multivalent molecules which bind to two
different platelets simultaneously, resulting in
platelet
cross-linking
and
aggregation.
Coagulation cascade is activated on exposure
of tissue factor in damaged endothelial cells at
the site of the ruptured plaque.
Conversion of prothrombin to thrombin, which
then converts fibrinogen to fibrin would result
to fluid-phase and clot-bound thrombin
participate in an autoamplification reaction that
leads to further activation of the coagulation
cascade. Coronary artery eventually becomes
occluded by a thrombus containing platelet
aggregates and fibrin strands. Imbalance
between oxygen supply and demand of the
myocardium would then lead to compromised
myocardial blood flow which does not meet the
metabolic demands of myocardial tissue.
Disruption of mid-sized atheromatous plaque
due to injury or rupture would result to an
injured but still living heart muscle which
could still conduct electrical impulses slowly.
Speed can become so slow that the spreading
impulse is preserved long enough for the
uninjured muscle to complete its contraction.
Slowed electrical signal still traveling within
the injured area can re-enter and trigger the
healthy muscle to beat again too soon. Rapid
rhythm abnormalities can occur and negatively
influence the function of the heart. This result
to increase rate or volume of ventricular filling
enabling us to hear a third heart sound.
Disruption of mid-sized atheromatous plaque
due to injury or rupture would result to an
injured but still living heart muscle which
could still conduct electrical impulses slowly.
Speed can become so slow that the spreading
38
S4 heart sound
Arrhythmia
Fever
impulse is preserved long enough for the

uninjured muscle to complete its contraction.
Slowed electrical signal still traveling within
the injured area can re-enter and trigger the
healthy muscle to beat again too soon. Rapid
rhythm abnormalities can occur and diminished
ventricular compliance. This may reduce the
filling of the heart thus the fourth heart sound
becomes audible.
Upon the presence of abnormal heart sounds
the myocardial cells are noted to be active but
produce quivering instead of forceful rhythmic
contractions. This prevents the heart from
pumping blood effectively thus resulting to an
abnormal intraventricular conduction leading
to abnormal heart rate and rhythm.
Obstruction of blood flow to certain parts of
the heart allows the pyruvic acid to produce
lactic acid that injures the myocardial tissue. It
then releases cardiac enzymes that trigger the
pyrogens which increases the temperature of
the body.
39
40
DOCTORS ORDERS
Date/Time
November
12,2006
12:10 pm
Doctors Order
Admit under white
service
Low salt low fat diet
Temperature, pulse,
respiratory every
hour and record
Rationale
Patient is admitted
under the white
service for close
monitoring
Remark
Done
LSLF is ordered
for patients with
cardiac conditions to
decrease the salt and
fats that further
aggravates the pts
current condition
Done
Done
Monitoring of TPR
is done to detect any
variation or changes
from the normal range
that would determine
an abnormality in the
patients condition
Done
Done
Venoclysis
D5W 500cc x KVO rate
It is an isotonic
solution that is needed
by our body to help
regulate the bodys
nutrients; it doesnt
swell or shrink the
cell. Regulated only at
the rate to maintain
vein open for
emergency and IVTT
meds
Diagnostics:
Complete Blood Count
Complete Blood
Count offers
necessary information
about the kinds and
numbers of cells in
the blood. This
analyzes the 3 major
types of cells in the
body which are the
41
Red Blood Cell,

White Blood Cell and
Platelet
Platelet
Random Blood Sugar
Creatinine
Sodium, Potassium
Chest x-ray
Electrocardiogram
Troponin T qualitative
Therapeutics
Isosorbide Mononitrate
(ISMN) 60mg/tab
tab OD
Done
Done
Detects alterations
in glucose metabolism
Done
For evaluation of
renal function
Done
Blood test
evaluates platelet
production
Evaluates fluid
and electrolyte
balance as well as
renal or adrenal
disorders
This
identifies
various abnormalities
of the lungs and
structures
in
the
thorax Also used to
identify localize fluid
and air in the pleural
cavity
Used to screen for
and diagnose a variety
of cardiac conditions
as well as abnormal
heart
rhythms,
conduction
disturbance,
hypertrophy and other
disorders
Primarily ordered
to determine if heart
attack
or
other
changes in the heart
occurred
Not
Done
Done
Done
Done
ISMN is the
42
Isosorbide Dinirate (ISDN)

5mg/tab
1 tab now
Metoprolol 50mg/tab tab
BID
treatment for anginal

attacks
Done
Done
Captopril 25mg/tab tab

OD
Done
Atorvastatin 80mg/tab 1 tab

OD
Treat
hypertension,
management of
angina pectoris and
prevention of MI
Treat hypertension
and reduce risk of
developing congestive
heart failure following
MI
Reduction of
elevated total and
LDL cholesterol and
triglycerides
Done
Lactulose 30cc at HS
ISDN is the
treatment for anginal
attacks
Moderate High Back

Rest
Monitor intake and

output
O2 at 4Lpm via nasal

cannula
Hook to cardiac monitor
Refer accordingly
For chronic
constipation
Lowers
diaphragm, promoting
chest expansion
Determine fluid
and electrolyte
balance and
effectiveness of
replacement
Help restore or
improve breathing
function and prevent
damage to vital
organs resulting from
inadequate oxygen
Done
Done
Done
Done
Done
Done
43
12:30 pm
supply
Retrieve previous
2Decho result c/o
watcher and attach to chart
Repeat ECG after 6

hours
Enoxaparin 6000 IV every

12 hours
Done
It is necessary to
refer any unusualities
to the physician
prevent further
complications
Done
Done
Done
Done
Done
Done
Have a basis of the

patients current
situation base on the
result of the previous
laboratory exam
For monitoring of
any changes in the
result
Treatment of mild
to moderate pain and
prophylaxis of MI
Furosemide 40mg 1 tab OD
Digoxin 0.25 mg/tab OD
Additional meds
ASA 80mg/tab OD
Clopidogrel 25mg/tab OD
Monitor the
patients BP, CR and
ECG reading
Reduction of
atherosclerotic events
in patients with
atherosclerosis
resulted from recent
MI
Prevention of deep
vein thrombosis and
pulmonary embolism
Management of
edema secondary to
CHF and treatment of
hypertension
Used to slow the

ventricular rate in
tachyarrhythmias such
as AF and atrial flutter
44
November
12, 2006
8:30 pm
November
13, 2006
To CCU
Start O2 5Lpm per
nasal cannula
Furosemide 40 mg
IVTT now
Spironolactone 100 mg
1 tab now
then OD
Refer
Continue meds
10:35 am
(+) Chest
tightness
O2 = 96
BP = 140/120
Complete bed rest

without bathroom privilege
Refer
Give Isordil 5mg SL
If not relieved by Isordil
may give Tramadol 1 amp
IVTT
Give Isordil 5g SL now

Start Isoket drip D5W
500cc + 1 amp Isoket to run
out at 10cc/hr
Avoid valsalva
maneuver
For Pro-time
Counteracts
potassium loss
induced by other
diuretics, for edema
and hypertension
Done
Done
Done
Done
Done
Medication needs
to be continued for
continuity of
treatment
Done
Minimize the
workload of the heart
and promote rest
Done
Done
Done
Done
Done
Done
Done
Done
(+) chest pain
Place in a special
area for close
monitoring
Treatment of
moderate to
moderately severe
pain
Treatment and
prevention of angina
pectoris attacks
Activities that
require holding of
breath and bearing
down can result in
bradycardia,
temporarily reduced
cardiac output and
rebound tachycardia
with elevated BP.
Screens for lack of

coagulation factors
necessary for blood
45
clotting. Measures
time required for a
fibrin clot to form
6:30 pm
7:30 pm
8:45 pm
(+) chest pain
November
14, 2006
100/64
1.
2.
3.
4.
5.
6.
7.
8.
November
15, 2006
10:20 am
Activated Partial
Thromboplastin Time
Refer
Isordil 5mg SL now

Increase Isoket drip to
15cc/hr
Morphine 2mg IVTT
now
Repeat ECG 12 leads

with long lead II
Review of medicines
Spironolactone 25mg 1
tab OD
Digoxin 0.25 mg/tab OD
Carvedilol 6.25mg tab
OD
Captopril 25mg/tab OD
Atorvastatin 80 mg tab
OD
ASA 80 mg 1 tab OD
Clopidogrel 75mg/tab
OD
Enoxaparin 0.6ml SQ
every 12
Discontinue meds not in
review of
medicines
Refer
Continue meds
Refer
Assess bleeding
disorders or the
effectiveness of
heparin therapy by
evaluating intrinsic
coagulation factors
necessary for blood
clotting
Management of
severe pain,
pulmonary edema and
pain associated with
MI
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Treatment for
essential hypertension
and CHF
98/61
I = 1085
46
O = 800
(-) chest pain
(+) bowel
movement
November
16, 2006
2:50 am
Give Isordil 5mg 1 tab

SL now then PRN for chest
pain
Done
Continue meds
ISDN 5mg/tab SL PRN
for chest pain
Senna concentrate 2 tabs
at HS
Refer
Diagnostics: repeat ECG
12 leads now
Repeat Creatinine,
Sodium, Potassium
Continue all meds
Refer accordingly
Diagnostics: repeat
serum electrolyte
ISMN 60 mg tab
OD
Continue all other meds
Done
Done
Done
Done
Done
Done
Done
Done
Not
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
(+) chest pain

7:15 am
still with
occasional
chest pain
November
17, 2006
9:30 am
November
18, 2006
(+) chest pain
125/98
November
19, 2006
8:30 am
November
20, 2006
7:20 am
Treatment for
constipation
Resume Isoket drip

(D5W 90cc + 1 amp Isoket)
to run at 10cc/hr
Continue other meds
Refer
Continue all meds
Refer accordingly
Continue Isoket drip
102/68
9:00 am
(+) chills
(+) dyspnea
130/100
O2 sat 97
Start Warfarin 5mg

tab OD
For stat Complete blood
count, Platelet count and
Creatinine
Prophylaxis and
treatment of venous
thrombosis,
pulmonary embolism,
AF with embolization
and management MI
47
Hgt 72
130/90
Referred due to dyspnea

Diagnostics:
Hemogluco test now
Determine blood
glucose level
Electrocardigram now
Arterial Blood Gas now
Determine the
acid-base balance
and/or the respiratory
or metabolic status
Creatinine, Sodium,
Potassium
November
21, 2006
7:22 am
(-) chest pain
November 22,
2006
November 23,
2006
7:05am
Give D5W 50cc 1 vial

slow IVTT now
Refer once with result
Ceftazidime 1gram
IVTT q8 ANST (-)
Clindamycin 300mg
1cap q6 PO
For repeat chest x-ray
today
Continue antibiotics
A hypertonic
solution used for the
treatment of
hypoglycemic shock
Review of medicines
Spironolactone 20 mg 1 tab
OD
Digoxin 0.25 mg tab OD
Captopril 25 mg 1 tab OD
Atorvastatin 40 mg 1 tab
OD
ASA 80 mg 1 tab OD
Clopidogrel 75 mg/tab OD
Senna concentrate 2 tabs
OD
ISMN 60mg tab OD
Warfarin 5mg tab OD
Enoxaparin 0.6 ml SQ every
12 hours
Refer
Diagnostics:
Repeat Protime
Continue all meds
Refer
Third generation
cephalosporins used
as treatment for
infection
Anti-infective for
infection
For mild to
moderate pain and
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
48
November 24,
2006
8:00am
(+) epigastric
pain
(+) increase
salivation
(-) chest pain
8:15 am
10:30am
1:00pm
q4
Refer
CXR was read
Bibasal pneumonia
Left sided cardiomegaly
Underlying minimal
pleural effusion
Pericardial effusion not

entirely ruled out
Not congested
Dr. Daguman
Omeprazole 40mg IVTT

every 12 hours
please retrieve chest xray place on bedside
hold aspirin, warfarin,

enoxaparine temporarily
Refer
fever
Paracetamol 500mg 1tab
for STAT 12 lead ECG

Omeprazole 80mg IVTT
now then 40mg IVTT q12
Rebamipide 100mg 1
tab 3x a day
Continue Omeprazole
and Rebamipide
retrieve chest x-ray
ASAP
Refer
Ranitidine 1 ampule
IVTT OD
Vitamin K 1 ampule
IVTT OD
Refer
Management for
GERD and duodenal
ulcer
Treatment of
gastric mucosal
lesions, acute gastritis
and gastric ulcer
Short-term
treatment for
duodenal and gastric
ulcer and GERD
Prevention and
treatment of
hypothrombinemia
associated with
excessive doses of
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
Done
49
anticoagulants
4:15 pm
November 25,
2006
November 26,
2006
5:45 am
November 27,
2006
10:15am
November 28,
2006
9:35 am
November 29,
2006
10:30am
Metoclopramide 1
ampule IVTT now
Hold clindamycin
House Omeprazole IV to
Pantoprazole 40mg 1 tab
OD
Rebamipide 100mg 1
tab TID
Repeat CBC, platelet
count
Continue meds
Refer
Diagnostics:
Follow up repeat CBC,
platelet
Repeat protime, Sodium,
Potassium
Continue meds
Continue all meds
Consume and
discontinue ceftazidime,
start levofloxacin
500mg/cap OD
Still for repeat protime
Refer
Resume Coumadin
(Warfarin) 2.5mg tab OD
Resume Aspirin 80mg 1
tab OD
Continue Pantoprazole
PO
Repeat chest x-ray today
Please retrieve chest xray due 11/28/06
Continue meds
refer
Treatment and
prevention of nausea
and vomiting
Treatment of mild
reflux
Treatment of mild,
moderate or severe
infection
Done
Done
Done
Done
Done
Done
Done
Done
Done,
protime
Not Done
Done
Done
Done
Not
Done
Done
Done
Done
Done
Done
Not
Done
Done
Done
50
51
DIAGNOSTIC EXAMINATIONS
Date
November
12,
2006
Diagnostic Procedure
Arterial Blood
Gas(ABG)- Arterial
blood gas analysis is
a test in which blood
is taken from an
artery in your wrist
to evaluate how
effective your lungs
in bringing oxygen to
the blood and
removing carbon
dioxide from it
Rationale
Blood gases are
used to determine
the acid-base
balance and/or the
respiratory or
metabolic status of
the client.
The pH is the
measurement of
the free hydrogen
ion concentration
in the blood.
pCO2 represents
the partial pressure
carbon dioxide
exerts in the
arterial blood.
pO2 represents the
partial pressure of
oxygen in the
blood, identifies
how well the lungs
are oxygenating
the blood.
Normal values
pH
7.35-7.45 mmHg
Result
pH
7.568mmHg
Impression
pCO2
35-45 mmmHg
pCO2
16mmHg
pO2
80-100mmHg
pO2
137.3mmHg
Increased pO2
HCO3
22.0-27.0 mmol/L
HCO3
14.2mmol/L
Decreased HCO3
BE(ecf)
(-2)-(+2) mmol/L
BE(ecf)
-7.8
O2sat
80-100%
O2sat
99.1%
Increased pH
Decreased pCO2;
Decreased base excess;

indicates non respi/meta
disturbance or true base
deficit
Normal
Partially Compensated
Respiratory Alkalosis
HCO3 is an
alkaline substance
52
November
21,
2006
that functions as an
important buffer in
the blood stream.
O2 sat is the
amount of oxygen
actually bound to
the hemoglobin
and available for
transport
throughout the
body.
pH
7.35-7.45 mmHg
pH
7.439 mmHg
Normal
pCO2
35-45 mmmHg
pCO2
22.9 mmmHg
Decreased pCO2
pO2
80-100mmHg
pO2
124.2 mmHg
Increased pO2
HCO3
22.0-27.0 mmol/L
HCO3
15.2 mmol/L
Decreased HCO3
BE(ecf)
(-2)-(+2) mmol/L
BE(ecf)
-9.0 mmol/L
Decreased base excess
O2sat
80-100%
O2sat
98.6%
Normal
Fully Compensated
Respiratory Alkalosis
53
Date
November
12, 2006
Rationale
Blood Chemistry
Analysis of the
physical, chemical,
and
microbiological
properties of
blood, carried out
to diagnose
disease, monitor
treatment, or detect
the presence of
specific substance.
RBS is used as a
random screen for
glucose level.
Creatinine is
essential in the
evaluation of renal
function.
November
17, 2006
Sodium and
Potassium
evaluates fluid and
electrolyte balance
as well as renal or
adrenal disorders
Chloride helps
diagnose disorders
of acid-base and
water balance.
Normal values
Glucose RBS
3.90-6.10
Result
Impression
6.52
Increased; may indicate

DM or stress
Creatinine
53.0-115.0 mmol/L
146.53

impaired renal function,
essential hypertension,
acute MI, severe CHF or
urinary obstruction
Sodium
136.0-145.0 mmol/L
140
Normal
Potassium
3.5-5.5 mmol/L
5.1
Normal
Chloride
098.0-106.0 mmol/L
107.0

dehydration, cardiac
decompensation, or
metabolic acidosis
Creatinine
53.0-115.0 mmol/L
123.61
Increased
Sodium
136.0-145.0 mmol/L
144
Normal
Potassium
3.5-5.5 mmol/L
4.0
Normal
54
November
21, 2006
November
26, 2006
Responsible for
maintaining water
balance and
cellular integrity
through its
influence on
osmotic pressure.
Creatinine
53.0-115.0 mmol/L
127.80
Sodium
136.0-145.0 mmol/L
140
Normal
Potassium
3.5-5.5 mmol/L
4.4
Normal
Sodium
136.0-145.0 mmol/L
141
Normal
Potassium
3.5-5.5 mmol/L
4.0
Normal
Increased
55
Date
November
12,
2006
Blood Hematology
Hemoglobin
Hematocrit
Erythrocyte
Rationale
Evaluates blood
loss, erythropoietic
ability, anemia and
response to
therapy. It is an
important
component of red
blood cell that
carries oxygen and
carbon dioxide to
and from the
tissues.
Evaluates blood
loss, anemia, blood
replacement
therapy and fluid
balance and
screens red blood
cell status. It is the
measure of red
blood cells within
the volume and
also evaluates
dehydration and
hypervolemia.
Evaluates anemia,
polycythemia and
Normal values
Hgb
135-175g/L
Result
Impression
157
Normal
Hct
0.40-0.52
0.47
Normal
RBC
4.20-6.10x106/uL
5.08
Normal
WBC
5.0-10.0x103/uL
5.40
Normal
Neutrophil
55-75%
67
Normal
Lympocytes
20-35
21
Normal
Monocytes
2-10
10
Normal
Eosinophil
1-5
Normal
Basophil
0-1
Normal
Platelet
150-400x103/uL
132
Decreased; may be due to

medication, blood clotting
factor is decreased and so
at high risk for
56
calculates red
blood cell indices.
Oxygen transport
to the cells
throughout the
body depends upon
sufficient numbers
of red blood cells
with adequate
amount of
hemoglobin.
November
21,
2006
Leukocytes
Neutrophils
Evaluates a
number of
conditions and
differentiates
causes of
alterations in the
total WBC count
including
inflammation,
infection, tissue
necrosis and/or
leukemic
neoplasm.
Increase neutrophil
count may indicate
parasitic or
bacterial infection,
metabolic disorder
including diabetic
acidosis. Decrease
spontaneous bleeding
Hgb
135-175g/L
161
Normal
Hct
0.40-0.52
0.49
Normal
RBC
4.20-6.10x106/uL
5.14
Normal
WBC
5.0-10.0x103/uL
11.26

infection, inflammation,
tissue necrosis or stress
Neutrophil
55-75%
91

bacterial infection, tissue
necrosis or MI
Lympocytes
20-35
Decreased; may indicate

defective lymphatic
circulation, renal failure
or advanced tuberculosis
Monocytes
2-10
Normal
Eosinophil
1-5
Normal
57
in level may
indicate infection
and anemia.
Lymphocyte
November
25,
2006
Monocyte
Evaluate bacterial
and viral infection,
immune disease,
leukemia and
ulcerative colitis.
Elevated levels
may indicate active
viral infection and
depressed level
may indicate
exhausted immune
system.
Evaluates function
of phagocytic
scavenger to
remove foreigh
materials.
Eosinophils
Primary influenced
by antigen-body
responses.
Basophils
Basophil function
not understood as
well as other white
cell types; it is
believed to be
related to allergic
Basophil
0-1
Platelet
150-400x103/uL
133

at high risk for
Hgb
135-175g/L
165
Normal
Hct
0.40-0.52
0.46
Normal
RBC
4.20-6.10x106/uL
5.31
Normal
WBC
5.0-10.0x103/uL
4.83

bone marrow failure,
overwhelming infection,
dietary deficiency or drug
toxicity
Neutrophil
55-75%
74
Normal
Lympocytes
20-35
14

defective lymphatic
Normal
58
and anaphylactic
responses.
Platelet
Evaluates platelet
production. It notes
the platelet size
and shape. Low
levels predispose
bleeding while
high levels may
increase the risk of
thrombocytosis.
circulation, renal failure

or advanced tuberculosis
Monocytes
2-10
12

infection such as
tuberculosis and subacute
bacterial endocarditis
Eosinophil
1-5

stress response associated
with trauma, shock or
CHF
Basophil
0-1
Normal
Platelet
150-400x103/uL
141

at high risk for
59
Date
November
12, 2006
Diagnostic
Procedure
Urinalysis- is the
testing of the
physical
characteristics and
compositions of
freshly voided urine
Rationale
Screens for
abnormalities
within the urinary
system as well as
for systemic
problems that may
manifest symptoms
through the urinary
tract.
Normal Values
Result
Impression
Color- Pale-star colored Color- yellow

to amber color
Normal
Appearance- clear to
slightly hazy
Appearanceslightly cloudy
Hazy or cloudy urine may

indicate the presence of
RBC, WBC, bacteria, pus,
phosphate, uric acid or
spermatozoa
Reaction- 4.8-7.8
Reaction- 6.0
Normal
Specific gravity- 1.003- Specific gravity1.035

1.025
Normal
Albumin- Negative
Albumin- (+++)
Positive albumin may

indicate nephritic
syndrome, UTI, fever,
trauma, CHF, acute
infection, or kidney
disease
Sugar- Negative
Sugar-(-)
Normal
Normal RBC- 0- 2 hpf
Result RBC - 2530hpf

renal problem
Normal Pus cells- 0-2

hpf
Result pus cells 34hpf

presence of infection or
tuberculosis
60
Date: May 15, 2006

Diagnostic procedure:
Echocardiogram (2D Echo report) test evaluates the size, shape & motion of various
structures within the heart, it is a noninvasive test.
Rationale:
This ultrasonic test diagnoses abnormalities in anatomy and valvular function within the
heart. Sound waves are bounced off the heart using a transducer to image the heart in motion as
well as its valves and vessels.
Normal findings:
Normal anatomical structure and position, normal and patent arteries and/or veins of the
heart, normal valve structure, normal valve structure, normal blood flow within the heart, normal
ventricular function, absence of thrombi or bacterial vegetations, absence of pericardial effusions
Result: Echo-Doppler findings
Eccentric left ventricular hypertrophy with multisegmental wall
motion abnormal with depressed systolic function
Left ventricular ejection fraction of 23%
Dilated left atrium
Normal right atrium, main pulmonary artery & aortic root
dimension
Aortic sclerosis with aortic regurgitation of 2+
Mitral sclerosis with mild mitral regurgitation
Mild tricuspid regurgitation
Structurally normal tricuspid valve & pulmonic valve
No intra-cardiac thrombus or pericardial effusion noted
Normal pulmonary artery pressure by tricuspid regurgitation jet
61
Date: November 23, 2006

Chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray
makes images of the lungs, airway, blood vessels and the bones of the spine and chest
Rationale:
Identify various abnormalities of the lungs and structures in the thorax, including the
heart, great vessels, ribs or diaphragm. It may also be used as a general screening tool or for a
specific diagnostic purpose, including identification of pulmonary diseases or orthopedic
abnormalities. It is also used to evaluate the status of respiratory abnormalities or cardiac
conditions.
Normal Findings:
Normal chest and surrounding structures, including bony thorax, soft tissues,
mediastinum, lungs, pleura, heart, and great vessels
Result:
Study done in AP supine view. Haziness is noted in both lower lung fields. A thin band of
opacity is noted in the right apex. The rest of the lungs are clear. Tracheal air column is at
midline. The heart is enlarged with inferolateral displacement of the cardiac apex, fullness of the
retro cardiac space and splaying of the carina. Both costophrenic sulci are blunted. The
hemidiaphragms are obscured. The rest of the included structures are unremarkable.
Impression:
Left sided cardiomegaly. Please correlate with ECG findings
Bibasal pneumonia with underlying minimal pleural effusion
Apico-pleural thickening, right
62
Electrocardiogram (ECG) most common test of hearts condition and is used to
graphically record the electrical current generated by the beating heart
Rationale:
This electrophysiologic test is used primarily to screen for and diagnose a variety of
cardiac conditions as well as to monitor the hearts response to therapy. It is used to diagnose
abnormal heart rhythms, conduction disturbances, hypertrophy of cardiac chambers, myocardial
infarction and ischemia and pericarditis.
Normal findings:
Normal sinus rhythm, normal conduction patterns, absence of areas of infarct or ischemia
First result:
AF in MVR
Old inferior wall infarct
Incomplete RBBB,
Anterolateral wall infarct
Second result:
Course AF in slow VR
Infarction anterolateral wall
LAD, PVW R wave program
Incomplete RBBB
63
Date: November 12, 2006

Immunology:
Troponin T qualitative is reliable markers of myocardial injury and is found in human
serum within 4-6 hours following MI
Rationale:
Primarily ordered for people who have chest pain to see if they have had a heart attack or
other damage to the heart. It is done 2-3 times in 12-16 hours period.
Result: POSITIVE
Implication:
It indicates pulmonary embolism because of right ventricular dilatation and myocardial

injury
64
Hematology:
PROTIME and APTT
Rationale (ProTime):
Screens for lack of coagulation factors necessary for blood clotting. Prothrombin time
measures the time required for a fibrin clot to form in a citrated plasma sample after addition of
calcium ions and tissue thromboplastin and compares this with fibrin clotting time in a control
sample plasma.
Rationale (APTT):
Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic
coagulation factors necessary for blood clotting. The basis of the test is fibrin clot formation and
it evaluates all the clotting factors of the intrinsic pathway except factors VII and VIII.
Normal Findings (ProTime): 11-14 seconds
Normal Findings (APTT): 27-34 seconds
November 16, 2006
Result: 19.5 seconds
November 16, 2006

Result: 40 seconds
November 22, 2006

Result: 16.3 seconds
Increased
protime
may
indicate
deficiency of
clotting factors or circulating
anticoagulant products
Increased Activated Partial

Thromboplastin
Time
(APTT),
may
indicate
vitamin k deficiency or
presence
of
circulating
anticoagulants
Increased protime may indicate

deficiency of clotting factors or
circulating
anticoagulant
products
65
DRUG STUDY
Generic Name: Isosorbide Mononitrate
Brand Name: Monoket
Classification: Anti-angina
Frequency/Route/Dose: 60 mg/tab tab OD
Action: Produces vasodilation; decreases left ventricular end-diastolic pressure and left
ventricular end-diastolic volume. Net effect is reduced myocardial oxygen consumption;
increase coronary blood flow by dilating coronary arteries and improving collateral flow
of ischemic regions.
Indication: Acute treatment of anginal attacks; long term prophylactic management of angina
pectoris
Contraindication: Hypersensitivity to nitrates, severe anemia, head trauma, cerebral hemorrhage
Adverse Effects:
CNS: headache, apprehension, weakness, dizziness
CV: tachycardia, hypotension, syncope, paradoxical bradycardia
GI: nausea, vomiting, abdominal pain
Misc: Flushing, tolerance, pruritus, rash
Drug Interaction: Additive hypotension with anti-hypertesiv, acute ingestion of alcohol, betaadrenergic blocking agents, calcium channel blockers and phenothiazines.
Nursing Responsibilities:
Assess location, duration, intensity, and precipitating factors of anginal pain
Monitor BP and pulse routinely
Taken on an empty stomach with a full glass of water
Instruct to take medication as directed
Caution to make position changes slowly to minimize orthostatic hypotension
Advise to avoid activities that requires alertness
66
Advise to notify physician or other health care provider if dry mouth or blurred vision
occurs
Generic Name: Isosorbide Dinitrate

Brand Name: Isordil
Classification: Anti-angina
Frequency/Route/Dose: 5 mg/tab 1 tab now
Action: Produces vasodilation; decreases left ventricular end-diastolic pressure and left
ventricular end-diastolic volume. Net effect is reduced myocardial oxygen consumption;
increase coronary blood flow by dilating coronary arteries and improving collateral flow
of ischemic regions.
Indication: Acute treatment of anginal attacks; long term prophylactic management of angina
Pectoris; treatment of chronic congestive heart failure
Contraindication: Hypersensitivity to nitrates, severe anemia, head trauma, cerebral hemorrhage
Adverse Effects:
CNS: headache, apprehension, weakness, dizziness
CV: tachycardia, hypotension, syncope, paradoxical bradycardia
GI: nausea, vomiting, abdominal pain
Misc: Flushing, tolerance, pruritus, rash
Drug Interaction: Additive hypotension with anti-hypertesiv, acute ingestion of alcohol, betaadrenergic blocking agents, calcium channel blockers and phenothiazines.
Assess location, duration, intensity, and precipitating factors of anginal pain
Monitor BP and pulse routinely
Taken 1 hour before or 2 hours after with full glass of water for better absorption
Caution to make position changes slowly to minimize orthostatic hypotension
Advise to avoid activities that requires alertness
67
Advise to notify physician or other health care provider if dry mouth or blurred vision
occurs
Generic Name: Metoprolol

Brand Name: Lopressor
Classification: Beta-Adrenergic blocking agents (Anti-hypertensive)
Frequency/Route/Dose: 50 mg/tab tab BID
Action: Block stimulation of beta1 adrenergic receptors, do not usually affect beta2 receptor sites
Indication: Management of hypertension, angina pectoris; prevention of myocardial infarction
Contraindication: Uncompensated congestive heart failure, pulmonary edema, cardiogenic
shock, bradycardia or heart block, known alcohol intolerance
Adverse Effects:
CNS: fatigue, weakness, dizziness, depression, insomia, memory loss, mental status
changes, anxiety, nervousness, drowsiness
CV: bradycardia, hypotension, congestive heart failure, pulmonary edema, peripheral
vasoconstriction
Resp: bronchospasm, wheezing
EENT: blurred vision, stuffy nose
GI: constipation, nausea, diarrhea, vomiting, liver function abnormalities
GU: impotence, decreased libidourinary frequency, urinary retention
Derma: rashes
Endo: hyperglycemia, hypoglycemia
MS: joint pain, back pain
Drug Interaction: Barbiturates, rifampicin: increase metabolism of metorpolol effect Cardiac
glycosides, diltiazem, verapamil: cause excessive bradycardia and increase depressant
effect on myocardium. Catecholamine-depleting drugs such as H2 antagonist, MAO
inhibitors,
reserpine:
have
additive
effect
when
given
with
beta-blockers.
68
Chlorpromazine, cimetidine, verapamil: decrease hepatic clearance. Indomethacin:

decrease anti-hypertensive effect
Always check apical pulse rate before giving drug
Monitor BP, ECG and pulse frequently
Monitor Intake and Output ratios and daily weight
Assess frequency and characteristics of anginal attacks periodically throughout therapy
Instruct patient to take drug exactly as prescribed and to take it with meals.
Advise to avoid activities that require alertness
Advise to make position changes slowly to prevent orthostatic hypotension
69
Generic Name: Captopril

Brand Name: Capoten
Classification: ACE Inhibitors (Anti-hypertensive)
Frequency/Route/Dose: 25 mg/tab tab OD
Action: Prevents production of angiotensin II, a potent vasoconstrictor that stimulates the
production of aldosterone by blocking its conversion to the active form-result is systemic
vasodilation
Indication: Management of hypertension, management of congestive heart failure, reduction of
risk of death or development of congestive heart failure following myocardial infarction
Contraindication: Hypersensitivity to ACE inhibitors, hypotension, oliguria, renal impairment,
hepatic impairment, elderly patients
Adverse Effects:
CNS: dizziness, headache, fatigue, insomia, weakness
CV: hypotension, tachycardia, angina pectoris
Resp: cough
GI: anorexia, loss of taste perception, nausea, diarrhea
GU: proteinuria, renal failure, impotence
Derma: rashes
Hemat: neutropenia, agranulocytosis
Misc: angioedema, fever
Drug Interaction: Excessive hypotension may occur with concurrent use of diuretics. Additive
hypotension with other anti-hypertensive, nitrates, phenothiazines, and acute ingestion of
alcohol. Anti-hypertensive response may be blunted by NSAIDs. Absorption may
70
decrease with antacids, increases levels and may increase risk of lithium or digoxin
toxicity.
Monitor BP and pulse frequently
Administer 1 hour before or 2 hours after meals for better absorption
Instruct patient to take drug exactly as prescribed
Instruct to notify physician or other health care provider is mouth sores, sore throat, fever,
swelling of hands and feet, irregular heart beat, chest pain, difficulty swallowing or skin
rash occurs
Advise to avoid foods containing high levels of potassium or sodium unless directed
71
Generic Name: Lactulose

Brand Name: Lactulose PSE
Classification: Laxative (hyperosmotic)
Frequency/Route/Dose: 30 cc at HS
Action: Increases water content and softens stool; lowers the pH of the colon, which inhibits the
diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia
levels
Indication: Treatment of chronic constipation
Contraindication: Patients with low-galactose diets, diabetes mellitus, excessive or prolonged use
Adverse Effects:
GI: cramps, distention, flatulence, belching, diarrhea
Endo: hyperglycemia
Drug Interaction: Should not be used with other laxatives. Anti-infectives may diminish
effectiveness and antacids may decrease the effect of lactulose on colonic pH
Assess for abdominal distention, presence of bowel sounds, and normal pattern of bowel
function
Assess color, consistency, and amount of stool produced
Instruct patient to take drug exactly as prescribed
Mix with fruit juice, water, milk or carbonated citrus beverages to improve flavor; may
be administered on an empty stomach for more rapid results
Encourage to use other forms of bowel regulation, such as increasing bulk in the diet,
increasing fluid intake, increasing mobility
Caution patient that medication may cause belching, flatulence, or abdominal cramping
72
Generic Name: Aspirin

Brand Name: ASA
Classification: Salicylates, NSAID, Antiplatelet, Antipyretic
Frequency/Route/Dose: 80 mg/tab 1 tab OD
Action: Produce analgesia and reduce inflammation and fever by inhibiting the production of
prostaglandins, decreases platelet aggregation
Indication: Management of inflammatory disorders including: rheumatoid arthritis; treatment of
mild to moderate pain; treatment of fever; prophylaxis of transient ischemic attacks and
myocardial infarction
Contraindication: Hypersensitivity to aspirin, salicylates, NSAIDs; bleeding disorders; history of
GI bleeding; severe renal disease; severe hepatic disease
Adverse Effects:
EENT: tinnitus, hearing loss
GI: dyspepsia, heartburn, epigastric distress, nausea, vomiting, anorexia, abdominal pain,
GI bleeding, hepatotoxicity
Hemat: anemia, hemolysis, increased bleeding time
Misc: noncardiogenic pulmonary edema, allergic reactions
Drug Interaction: May potentiate warfarin, heparin or thrombolytic agents. May increase the
bleeding with valproic acid, cefoperazone, cefamandole. May enhance the activity of
penicillins, phenytoin, valproic acid, oral hypoglycemic agents and sulfonamides. May
antagonize the beneficial effects of probenecid
Assess pain and limitation of movement
Assess fever and note associated signs
73
Advise patient to take drug with food, milk, antacid, or large glass of water to reduce
adverse GI reactions.
Tell patient that sustained-release or enteric-coated forms shouldnt be crushed or chewed

but swallowed.
Advise to report signs of tinnitus, bleeding of gums, bruising, fever, black tarry stools
Teach patient on sodium restricted diet to avoid buffered-aspirin preparations
Advise patient to take only prescribed dosage
Generic Name: Clopidogrel

Brand Name: Plavix
Classification: Anticoagulant, Antithrombotics
Frequency/Route/Dose: 25 mg/tab OD
Action: Obtained by depolymerization of unfractioned porcine heparin. An antithombolytic drug.
They enhance the inhibition of factor Xa and thrombin by binding to and accelerating
anti-thrombin II activity
Indication: Reduction of atherosclerotic events in patients wit hatherosclerosis documented by
recent ischemic stroke or Myocardial infarction
Contraindication: Severe liver impairment, peptic ulcer and intracranial hemorrhage
Adverse Effects:
GI: bleeding, abdominal pain, dyspepsia, gastritis, constipation
EENT: ocular hemorrhage
Derm: purpura, bruising, rash pruritus
Drug Interaction: Warfarin, aspirin, heparin, thrombolytic or NSAIDS, increase risk of bleeding
Tell patient to refrain from activities in which trauma and bleeding may occur
Advise patient that drug may be taken without regards to meals
Instruct patient to inform physician or other health care provider if unusual bleeding or
bruising occur
74
Generic Name: Enoxaparin

Brand Name: Lovenox
Classification: Heparin, anticoagulant (antithrombotic)
Frequency/Route/Dose: 6000 IU q 12
Action: Potentiate the inhibitory effect of antithrombin on factor Xa and thrombin. In low doses
it prevents conversion of prothrombin to thrombin by its effects on factor Xa. In high
doses it neutralize thrombin, preventing the conversion of fibrinogen to fibrin.
Indication: Prevention of deep vein thrombosis and pulmonary embolism, atrial fibrillation with
embolization
Contraindication: Hypersensitivity to the drug, open wounds, severe liver or kidney disease,
untreated hypertension, spinal cord or brain injury, history of bleeding disorders
Adverse Effects:
CV: edema
GI: hepatitis
Derm: rashes
Hemat: bleeding, anemia
Local: irritation, pain, hematoma
Misc: fever
Drug Interaction: Risk of bleeding may be increased by concurrent use of drugs that affect
platelet function, including aspirin, NSAIDs, some penicillins, valproic acid,
cefmetazole, quinidine, dextran and thrombolytic agents
Assess for signs of bleeding and hemorrhage
75
Assess for evidence of additional or increased thrombosis.
Monitor patient for hypersensitivity reactions
Advise to report any symptoms of unusual bleeding or bruising
Instruct not to take medications containing aspirin, ibuprofen, naproxen or ketoprofen
Generic Name: Furosemide

Brand Name: Lasix
Classification: Loop diuretics
Frequency/Route/Dose: 40 mg 1 tab OD
Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal
tubule. Increases renal excretion of water, sodium, chloride, magnesium, hydrogen and
calcium.
Indication: Management of edema secondary to congestive heart failure, hepatic or renal disease,
treatment of hypertension
Contraindication: Hypersensitivity to the drug, hepatic coma, severe liver disease, electrolyte
depletion, geriatric patients, diabetes mellitus
Adverse Effects:
CNS: dizziness, headache, nervousness, insomia
CV: hypotension
GI: nausea, vomiting, diarrhea, constipation, dry mouth, dyspepsia
EENT: hearing loss, tinnitus
Derm: rashes, photosensitivity
F and E: hyperglycemia
Hemat: blood dyscrasias
MS: muscle cramps
Misc: increased BUN
Drug Interaction: Additive hypotension with antihypertensives or nitrates. Decreases lithium
76
excretion, may cause toxicity. May increase the effectiveness of warfarin, thrombolytics
and anticoagulants
Assess fluid status throughout therapy
Monitor BP and pulse before and during administration
Assess patient for tinnitus and hearing loss
Administer medication in the morning to prevent disruption of sleep cycle
Administer orally with food or milk to minimize gastric irritation
Caution to make position changes slowly to prevent orthostatic hypotension
Generic Name: Digoxin

Brand Name: Lanoxin
Classification: Antiarrhythmics, digitalis glycosides
Frequency/Route/Dose: 0.25 mg/tab OD
Action: Inhibits sodium potassium-activated adenosine triphosphate, thereby promoting
movement of calcium from extracellular to intracellular cytoplasm and strengthening
myocardial contraction.
Indication: Heart failure, paroxysmal supra-ventricular tachycardia, atrial fibrillation and flutter
Contraindication: Hypersensitive to drug and in those with digitalis-induced toxicity, ventricular
fibrillation, or ventricular tachycardia unless caused by heart failure.
Adverse Effects:
CNS: fatigue, weakness, headache, blured vision, yellow vision
CV: arrhythmias, bradycardia, ECG changes
GI: nausea, vomiting, diarrhea, anorexia
Endo: gynecomastia
Hemat: thrombocytopenia
Drug Interaction: Antacids, decreased absorption of oral digoxin. Antibiotics: increased risk for
toxicity because of altered intestinal flora. Anticho-linergics: may increase digoxin
absorption of oral digoxin tablets
Monitor apical pulse and BP periodically
77
Monitor ECG throughout therapy
Monitor intake and output and daily weights
Monitor potassium levels. Take corrective measures before hypokalemia occurs
Can be administered without regard to meals
Tell patient to report pulse below 60 bpm or above 110 bpm, or skipped beats or other
rhythm changes
Generic Name: Spironolactone

Brand Name: Aldactone
Classification: Potassium-sparing diuretics
Frequency/Route/Dose: 100 mg 1 tab now then OD
Action: Causes excretion of sodium bicarbonate and calcium while conserving potassium and
hydrogen ions
Indication: Counteracts potassium loss induced by other diuretics, treat edema or hypertension
Contraindication: Hypersensitivity to drug, hyperkalemia, hepatic dysfunction, renal
insufficiency, history of gout or kidney stone
Adverse Effects:
CNS: headache, clumsiness, dizziness
CV: arrhythmias
GI: gastrointestinal irritation
GU: impotence
Endo: gynecomastia
F and E: hyperkalemia, hyponatremia
Hemat: dyscrasias
MS: muscle cramps
Misc: allergic reactions
Drug Interaction: ACE inhibitors: increased risk of hyperkalemia; Aspirin: possible blocked
diuretic effect
78
Monitor intake and output
Monitor signs and symptoms of hypokalemia
Give the drug with meals, to enhance absorption
Administer in the morning to avoid interrupting sleep pattern
Warn patient to avoid excessive ingestion of potassium-rich foods
Caution patient not to perform hazardous activities if adverse CNS reactions occur
Advise patient to notify physician or other health care provider if muscle cramps or
weakness occurs
Generic Name: Tramadol

Brand Name: Ultram
Classification: Analgesic
Frequency/Route/Dose: 1 amp IVTT
Action: A centrally acting synthetic analgesic compound not chemically related to opiates. Drug
is thought to bind to opioid receptors and inhibit reuptake of nor-epinephrine and
serotonin
Indication: Treatment of moderate to moderately severe pain
Contraindication: Hypersensitivity to drug and those with acute intoxication from alcohol,
hypnotics, centrally acting analgesics, opioids
Adverse Effects:
CNS: headache, drowsiness, sleep disorder, nervousness, seizures
CV: vasodilation
GI: nausea, constipation, vomiting, dyspepsia, dry mouth, diarrhea, abdominal pain
GU: urinary retention, urinary frequency
EENT: visual disturbances
Derm: pruritus, sweating
Drug Interaction: Carbamazepine: increased tramadol metabolism
Assess type, location, and intensity of pain
79
Assess BP and respiratory rate before and periodically during administration
Assess bowel function routinely
May be administered without regards to meal
Instruct patient to avoid activities that require alertness
Generic Name: Morphine

Brand Name: Astramorph
Classification: Opioid Analgesic
Frequency/Route/Dose: 2 mg IVTT now
Action: Binds with opiate receptors in the CNS, altering both perception and emotional response
to pain.
Indication: Management of severe pain, pulmonary edema, pain associated with MI
Contraindication: Hypersensitivity to drug and in those with conditions that would prelude
administration of opioids by IV route (acute bronchial asthma or upper airway
obstruction)
Adverse Effects:
CNS: sedation, somnolence, clouded sensorium, euphoria, seizures, dizziness,
nightmares, hallucinations
CV: hypotension, bradycardia, shock, cardiac arrest
Resp: respiratory depression
EENT: diplopia, blurred vision
GI: nausea, vomiting, constipation, ileus
GU: urinary retention
Derm: sweating, flushing, itching
80
Misc: tolerance, physical dependence

Drug Interaction: CNS depressants, general anesthetics, hypnotics, sedatives: may cause
respiratory depression, hypotension, profound sedation, or coma
Assess type, location, and intensity of pain
Assess BP, pulse and respiration before and periodically during administration
Assess bowel function routinely
May be administered with food or milk to minimize GI irritation
Dont crush, break or chew extended-release tablets
Watch for pruritus and skin flushing with epidural administration
Caution ambulatory patients about going out of bed or walking
Advise patient to change position slowly to prevent orthostatic hypotension
Generic Name: Senna Concentrate

Brand Name: Senokot
Classification: Laxative (stimulant)
Frequency/Route/Dose: 2 tabs HS
Action: Active components of senna alter water and electrolyte transport in the large intestine,
resulting in accumulation of water and increased peristalsis
Indication: Treatment of constipation, particularly when associated with slow transit time,
constipating drugs, irritable or spastic bowel syndrome
Contraindication: Hypersensitivity to any ingredient, nausea or vomiting or other symptoms of
appendicitis, acute surgical abdomen, fecal impaction, abdominal pain
Adverse Effects:
GI: nausea, diarrhea, cramping
GU: pink-red or brown-black discoloration of urine
F and E: electrolyte abnormalities
Misc: laxative dependence
Drug Interaction: Laxatives containing aluminum, calcium or magnesium impair absorption of
tetracycline due to release of free calcium
81
Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of
bowel function
Assess color, consistency and amount of stool produced
Take with a full glass of water. Administer at bedtime for evacuation 6-12 hours later
Advise patient that laxative should be used only for short-term therapy
Encourage to use other forms of bowel regulation such as increasing bulk in diet,
increasing fluid intake, increasing mobility
Inform patient that this medication may cause changes in urine color
Advise not to use laxatives when abdominal pain, nausea, vomiting or fever are present
Generic Name: Warfarin

Brand Name: Coumadin
Classification: Anticoagulant
Frequency/Route/Dose: 5 mg tab OD
Action: Inhibits vitamin K-dependent activation of clotting factors II, VII, IX, and X, formed in
the liver
Indication: Prophylaxis and treatment of venous thrombosis, atrial fibrillation with embolization,
pulmonary embolism, adjunct in prohylaxis of systemic embolism after MI
Contraindication: Hemorrhage tendency, blood dyscrasias, recent or contemplated surgery of
CNS bleeding tendencies associated with active ulceration or overt bleeding
Adverse Effects:
GI: nausea, cramping
Derm: dermal necrosis
Hemat: bleeding
Misc: fever
Drug Interaction: Effects diminished by barbiturates, cholestyramine, gluthetimide, rifampicin,
vitamin K
82
Assess patient for signs of bleeding and hemorrhage
Administer medication same time each day
Medication requires 3-5 days to reach effective levels
Review foods high in vitamin K
Advise to report signs of unusual bleeding or bruising
Instruct not to drink alcohol or OTC medications such as those containing aspirin,
ibuprofen, or naproxen
Generic Name: Ceftazidime

Brand Name: Ceptaz
Classification: Anti-infective (third generation cephalosporins)
Frequency/Route/Dose: 1 gm IVTT q 8 hours
Action: Binds to bacterial cell wall membrane, causing cell death. Bactericidal action against
susceptible bacteria
Indication: Treatment of skin an skin structure infections, bone and joint infections, urinary
infections, respiratory infections, intra-abdominal infections, septicemia
Contraindication: Hypersensitivity to cephalosporins, serious hypersensitivity to penicillins,
renal impairment, hepatic or renal impairment
Adverse Effects:
CNS: seizures
GI: nausea, vomiting, diarrhea, cramping, colitis
Derm: rashes, urticaria
Hemat: blood dyscrasias, hemolytic anemia, bleeding
Misc: superinfection, allergic reactions
83
Drug Interaction: Probenecid decreases excretion and increases serum levels. Ingestion of
alcohol within 48-72 hours of cefoperazone may result in a disulfiram-like reaction.
Assess patient for infection
Obtain history to determine previous use of and reactions to penicillins or cephalosporins
Observe for signs and symptoms of anaphylaxis
May be administered on full or empty stomach. Administer with food may minimize GI
irritation
Tell patient to take exact amount as prescribed
Inform patient not to crush, break or chew extended-release tablets
Advise to report signs of superinfection
Instruct patient to finish the medication completely
Instruct patient to notify physician and other health care provider if fever and diarrhea
develops
Generic Name: Clindamycin

Brand Name: Dalacin
Classification: Anti-infective
Frequency/Route/Dose: 300 mg 1 tab q 6 hours
Action: Inhibits protein synthesis in susceptible bacteria. Bactericidal or bacteriostatic
Indication: Treatment of skin an skin structure infections, bone and joint infections, urinary
infections, respiratory infections, intra-abdominal infections, septicemia
Contraindication: Hypersensitivity to drug, severe liver impairment, diarrhea, alcohol intolerance
Adverse Effects:
CNS: dizziness, vertigo, headache
CV: hypotension, arrhythmias
GI: nausea, vomiting, diarrhea, colitis
Derm: rashes
Drug Interaction: Erythromycin: may block access of clindamycin to its site of action.
Neuromuscular blockers: increase neuromuscular blockade possible
84
Assess patient for infection
Observe for signs and symptoms of anaphylaxis
Administered with a full glass of water. May be given with meals
Instruct patient to finish the medication completely
Instruct patient to notify physician and other health care provider if fever and diarrhea
develops
Observe patient for signs and symptoms of superinfection
Generic Name: Acetaminophen

Brand Name: Paracetamol
Classification: Nonopioid analgesic, antipyretic
Frequency/Route/Dose: 500 mg 1 tab q 4 hours
Action: Thought to produce analgesia by blocking generation of pain impulses, probably by
inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substance
that synthesize pain receptors to mechanical or chemical stimulation
Indication: Mild to moderate pain, fever
Contraindication: Hypersensitivity to drug, products containing alcohol, severe hepatic disease,
renal disease, malnutrition
Adverse Effects:
GI: hepatic necrosis
Derm: rash, urticaria
Drug Interaction: Chronic concurrent use with NSAIDs including aspirin may increase the risk
85
of adverse reactions. Barbiturates, carbamazepine, rifampicins: may reduce therapeutic

effects and cause hepatotoxicity
Assess type, location, and intensity prior to and 30-60 minutes following administration
Assess fever and associated signs
Administer with full glass of water
May be taken with food or on an empty stomach
Advise patient to take medication exactly as directed
Advise patient to notify physician or other health care provider if discomfort or fever is
not relieved
Generic Name: Omeprazole

Brand Name: Losec
Classification: Anti-ulcer, Gastric acid pump inhibitor
Frequency/Route/Dose: 80 mg IVTT now then 40 mg IVTT q 12 hours
Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH,
preventing the final transport of hydrogen ions into the gastric lumen
Indication: Management of GERD, management of gastric ulcer, treatment of gastric
hypersecretory conditions
Contraindication: Hypersensitivity to drug
Adverse Effects:
CNS: weakness, dizziness, headache, fatigue
CV: chest pain
GI: abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea,
86
vomiting
Derm: rash, itching
Drug Interaction: Decreases metabolism and may increase effects of phenytoin,
diazepam, and warfarin. May interfere with absorption of drugs requiring acid gastric pH
including ketoconazole, ampicillin and iron salts
Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool
Administer doses before meals, preferably in the morning
May be administered concurrently with antacids
May cause occasional drowsiness, or dizziness. Caution patient to avoid activities that
require alertness
Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent
headache to the physician promptly
Generic Name: Metoclopramide

Brand Name: Clopra
Classification: Antiemetic, GI stimulant
Frequency/Route/Dose: 10 mg 1 tab 3 times a day
Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates the
motility of the upper GI tract and accelerates gastric emptying
Indication: Nausea and vomiting with GI disorder, disorders in reduced GI motility
Contraindication: Hypersensitivity, GI hemorrhage or obstruction, perforation, epilepsy
Adverse Effects:
CNS: restlessness, drowsiness, fatigue, extrapyramidal effect, depression, irritability,
anxiety
CV: arrhythmias
87
GI: constipation, diarrhea, nausea, dry mouth

Endo: gynecomastia
Drug Interaction: Phenothiazines, lithium, centrally-active agents including anti-depressants,
anti-epileptics and sympathemimetics
Assess patient for nausea, vomiting, abdominal distention and bowel sounds prior to or
following administration
Assess patient for extrapyramidal effects
Assess for signs of depression
Administer 30 minutes before meals and at bedtime
Caution to avoid activities that requires alertness
Advise to notify physician or other health care provider if involuntary movements occurs
Generic Name: Levofloxacin

Brand Name: Levox
Classification: Quinolones
Frequency/Route/Dose: 500 mg 1 cap OD
Action: Synthetic, broad spectrum antibacterial agents, the fluorine molecule confers increased
activity against gram positive organism as well as broadens the spectrum against gram
positive organism
Indication: Acute bacterial exacerbation of chronic bronchitis, community acquired pneumonia
Contraindication: Hypersensitivity to quinolones, epilepsy, history of tendon disorders related to
fluoroquinolones therapy
Adverse Effects:
88
CNS: headache, insomnia, dizziness

GI: Nausea and vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence,
Derm: rash, pruritus
Drug Interaction: Absorption impaired by antacids, sucralfate, mental cautions, and Zinccontaining multi-vitamin preparation, probeneclol and cimetidine may affect the rate and
extent of levofloxacin absorption
Obtain specimen for culture and sensitivity test
Tell patient that drug may be taken with meals
Generic Name: Ranitidine

Brand Name: Zantac
Classification: Antiemetic, antacids
Frequency/Route/Dose: 1 amp IVTT OD
Action: Potent anti-ulcer drug that competetively and reversibly inhibits histamine action at H2
receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces
pepsin secretion.
Indication: Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal
ulcer patient after healing of acute ulcer
Contraindication: Acute poyphyria; hyper-sensitivity to ranitidine
Adverse Effects:
89
CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo, mental confusion,

agitation
Resp: bradycardia
GI: constipation, nausea, abdominal pain
Drug Interaction: Antacids: interfere with ranitidine absorption. Diazepam: decrease absorption
of diazepam
Assess patient for nausea, vomiting, abdominal distention and bowel sounds prior to or
following administration
Administer 30 minutes before meals
Caution to avoid activities that requires alertness
Advise to notify physician or other health care provider if involuntary movements occurs
Be alert for signs of hepatotoxicity
Long-term therapy may lead to vitamin B12 deficiency
Monitor creatinine clearance
Generic Name: Phytonadione

Brand Name: Vitamin K
Classification: Vitamin
Frequency/Route/Dose: 1 amp IVTT
Action: Required for hepatic synthesis of blood coagulation factors II, VII, IX and X.
Indication: Prevention and treatment of hypoprothrombinemia, which may be associated with
excessive doses of oral anticoagulants, salicylates. Nutritional deficiencies, prevention of
hemorrhagic disease
Contraindication: Hypersensitivity and intolerance, impaired liver function
Adverse Effects:
90
GI: gastric upset, unusual taste

Derm: rash, urticaria, flushing
Local: swelling, pain at IV site
Misc: hemolytic anemia, hyperbilirubinemia, allergic reactions
Drug Interaction: Large doses will counteract the effect of warfarin. Large doses of salicylates or
broad-spectrum anti-infectives may increase vitamin K requirements.
Monitor for frank and occult bleeding
Monitor BP and pulse frequently
Instruct to take medication as ordered
Advise patient to report any symptoms of unusual bleeding or bruising
Generic Name: Pantoprazole

Brand Name: Pantoloc
Classification: Antacids, antiulcerants
Frequency/Route/Dose: 40mg/tab OD
Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH,
preventing the final transport of hydrogen ions into the gastric lumen
Indication: Treatment of mild reflux, duodenal or gastric ulcer, reflux esophagitis
Contraindication: Hypersensitivity, impaired liver function
Adverse Effects:
CNS: headache, dizziness
91
GI: diarrhea, nausea, upper abdominal pain, flatulence

Derm: rash, pruritus
Drug Interaction: Ketoconazole may affect absorption of drugs whose absorption is pHdependent
stool
Administer doses before meals, preferably in the morning
May be administered concurrently with antacids
May cause occasional drowsiness, or dizziness. Caution patient to avoid activities that
require alertness
Generic Name: Rebamipide

Brand Name: Mucosta
Classification: Gastrointestinal/ hepatobiliary drugs
Frequency/Route/Dose: 100 mg/tab TID
Action: Reacts with gastric acid to form thick paste which selectively adheres to ulcer surface
Indication: Treatment of gastric mucosal lesions, acute gastritis, gastric ulcer
Contraindication: Hypersensitivity to the drug
Adverse Effects:
GI: diarrhea, nausea, vomiting, constipation
92
Derm: pruritus
Drug Interaction: Antacids interfere with absorption. Diazepam decrease absorption
stool
Assess for abdominal pain
Administer on empty stomach, 1 hour before meals
Increase fluid intake
Generic Name: Atorvastatin

Brand Name: Lipitor
Classification: Antihyperlipidemic agent
Frequency/Route/Dose: 80 mg/tab 1 tab OD HS
Action: Inhibits an enzyme, 3 hydroxy-3-methylglutaryl-coenzyme A reductase, which is
responsible for catalyzing an early step in the synthesis of cholesterol. Slowing the
progression of CAD with resultant decrease in MI and need for myocardial
revascularization
93
Indication: Reduction of elevated total and LDL cholesterol and triglycerides in patients with
primary hypercholesterolemia, mixed hyperlipidemia
Contraindication: Hypersensitivity to the drug, active liver disease
Adverse Effects:
CNS: dizziness, headache, insomia
GI: GI disturbance
MS: muscle cramps
Derm: pruritus
Drug Interaction: Risk of myopathy increased with concurrent administration of cyclosporine,
fibric acid derivatives, erythromycin, niacin.
Obtain diet history, especially on fatty foods
Administer with food
Instruct patient to have diet restrictions on fats, cholesterol, carbohydrates and alcohol
Advise to take medication as directed
Caution patient to avoid activities that require alertness
Advise patient to notify physician or other health care provider if any unusualities occurs
Generic Name: Carvedilol

Brand Name: Dilatrend
Classification: Beta Adrenergic Blocking agent
Frequency/Route/Dose: 6.25 mg tab OD
Action: Block stimulation of beta1 adrenergic receptors, do not usually affect beta2 receptor sites
Indication: CHF, hypertension
Contraindication: Hypersensitivity to the drug, disease of the respiratory tract, , asthma, chronic
94
bronchitis, SA block, 2nd and 3rd degree AV block, MI with complications, severe liver
dysfunction, metabolic acidosis
Adverse Effects:
CNS: dizziness, headache, tiredness, nausea
GI: andominal pain, diarrhea, constipation, vomiting
Resp: bronchospastic reactions
Drug Interaction: BP lowering drugs, reserpine, methyldopa, clonidine, rifampicin
Always check apical pulse rate before giving drug
Monitor BP, ECG and pulse frequently
Monitor Intake and Output ratios and daily weight
Assess frequency and characteristics of anginal attacks periodically throughout therapy
Instruct patient to take drug exactly as prescribed and to take it with meals
95
NURSING CARE PLAN

Name: Perfecto Pandacan Balili
Age: 60 y.o.
Sex: Male
Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III
Date and
Time
Cues
November S:
28, 2006 Sakit
akong
dughan
as
3-11 shift verbalized by the
patient.
5:00
p.m.
O:
Pupillary
size
3mm
isocoric, brisk
and reactive to
light
Pale
conjunctiva
noted
Pink
mucous
membrane and
lips noted
Grimaced
face noted
Crackles
noted
upon
Room and Bed #: CCU bed 1

Institution: Davao Medical Center
Need
Nursing Diagnosis
Objective
C
O
G
N
I
T
I
V
E
Acute pain related to

decreased myocardial
blood flow as
evidenced by reports
of chest pain
secondary to CAD,
AMI
Pain is an unpleasant
sensory
and
emotional experience
arising from actual or
potential
tissue
damage.
Within my 1
hour span of
care
my
patient will
be able to
report relief
or control of
chest pain as
evidenced by
patients
verbalization,
absence
of
restlessness,
diaphoresis,
facial
grimace and
vital
signs
within
normal range
P
E
R
C
E
P
T
U
A
L
Rationale:
Acute
Myocardial
Infarction
(AMI)
occurs when coronary
blood flow decreases
abruptly
after
a
thrombotic occlusion
Nursing Intervention
Evaluation
Administer medication
as indicated (antianginal,
beta-blocker, analgesics)
R: Immediate response in relief
of pain.
Goal Met
1.
November 28,
2006
6:00 p.m.
2.
Administer
supplemental oxygen as
indicated
R: Increases amount of oxygen
available
for
myocardial
uptake and thereby may relieve
discomfort associated with
tissue ischemia.
Within my 1
hour span of care
my patient was
be able to
report relief or
control of chest
pain
as
3.
Monitor characteristics evidenced by:
of pain, noting verbal
reports, nonverbal cues, Dili na sakit
and
hemodynamic akong dughan.
response.
as verbalized by
R: Variation of appearance and the patient
behavior
may
occur.
Respirations may be increased absence
auscultation
Productive
cough noted
Whitish
phlegm noted
Irregular
cardiac
rate
and
rhythm
noted
Clutching
chest noted
diaphoresi
s noted
cold,
clammy skin
noted
Pale nail
beds noted
Capillary
refill of 1
second
Weakness
noted
restlessnes
s noted
irritability
noted
narrowed
focus (reduced
interaction
with people)
noted
Pain scale
P
A
T
T
E
R
N
of a coronary artery
previously narrowed
by
atherosclerosis.
Infarction
occurs
when
an
atherosclerotic plaque
fissures, ruptures, or
ulcerates and when
conditions (local or
systemic)
favor
thrombogenesis,
so
that a mural thrombus
forms at the site of
rupture and leads to
coronary
artery
occlusion. After an
initial
platelet
monolayer forms at
the site of the
ruptured
plaque,
various
agonists
(collagen,
ADP,
epinephrine,
serotonin)
promote
platelet
activation.
There is production
and
release
of
thromboxane A2 (a
potent
local
vasoconstrictor),
further
platelet
activation,
and
potential resistance to
as a result of pain and

associated
anxiety,
while
release of stress induced
catecholamines will increase heart rate and BP.
4.
Review
history
of
previous angina or MI pain R: May differentiate current
pain from preexisting patterns,
as
well
as
identify
complications
such
as extension
of
infarction,
pulmonary
embolus,
or
pericarditis.
5.
Instruct patient to report

pain immediately
R: Delay in reporting pain
hinders pain relief or may
require increased dosage of
medication to achieve relief.
Severe pain may induce shock
by stimulating the sympathetic
nervous
system,
thereby
creating further damage and
interfering with diagnostics
and relief of pain.
6.
Provide
environment,
activities and
measures.
of
restlessness
noted
absence
of
diaphoresis
noted
Absence
of
facial
grimace
noted
vital
signs within
normal range
(Temp=36,
RR=22 cpm,
CR= 60 bpm,
BP=
90/60
mmHg)
Evaluated by:
quiet
calm
comfort Yap, Novelynne
Joy
97
of 6 out of 10
(0 being no
pain and 10 as
very
severe
pain)
Temp=35,
RR=25 cpm,
CR= 47 bpm,
BP=
80/60
mmHg
thrombolysis.
The
coagulation
cascade is activated
on exposure of tissue
factor in damaged
endothelial cells at the
site of the ruptured
plaque. Factors VII
and X are activated,
ultimately leading to
the conversion of
prothrombin
to
thrombin, which then
converts fibrinogen to
fibrin. The culprit
coronary
artery
eventually becomes
occluded
by
a
thrombus containing
platelet
aggregates
and fibrin strands.
This occlusion will
impede the flow of
blood to the cardiac
muscles.
Decrease
cardiac
functioning
will lead to imbalance
between myocardial
oxygen supply and
demand wherein the
heart is unable to meet
R: Decreases external stimuli,

which may aggravate anxiety
and cardiac strain and limit
coping abilities and adjustment
to current situation.
7.
Assist in relaxation
techniques such as deep
breathing, visualization and
guided imagery
R: Helpful in decreasing
perception of pain. Provides a
sense of having some control
over the situation, increase in
positive attitude.
8.
Check vital signs before

and
after
narcotic
medication
R: Hypotension or respiratory
depression can occur as a result
of narcotic administration.
These may increase myocardial
damage in presence of
ventricular insufficiency.
9.
Place
patient
at
complete
rest
during
anginal episodes
R: Reduces myocardial oxygen
demand to minimize risk of
tissue injury or necrosis.
98
the
metabolic
demands of the body.
Lack of blood and
oxygen supply in the
cardiac muscle will
lead to ischemia and
thus to experience of
pain.
10.
Elevate head of bed if

patient is short of breath
R: Facilitates gas exchange to
decrease hypoxia and resultant
shortness of breath.
11.
Monitor heart rate and

rhythm
R: Patient may have acute lifethreatening
dysrhythmias,
which occur in response to
ischemic changes or stress.
12.
Source:
Pathophysiology:
Concepts
and
Applications
for
Health
Care
Professionals,
3rd
Edition by Nowak
Stay with the patient

who is experiencing pain or
appears anxious
R:
Anxiety
releases
catecholamines, which increase
myocardial workload and can
prolong
ischemic
pain.
Presence of nurse can reduce
feelings
of
fear
and
helplessness.
13.
Harrisons
Internal
Medicine, 5th Edition
Provide light meals.

Have patient rest for 1 hour
after meals
R:
Decreases
myocardial
workload associated with work
of digestion, reducing risk of
anginal attack.
14.
Monitor
serial
ECG
99
changes
R: Ischemia during anginal
attack may cause transient ST
segment
depression
or
elevation
and
T
wave
inversion. Serial tracing verify
ischemic changes, which may
disappear when patient is painfree. They also provide a
baseline with which to
compare later pattern changes.
Source:
Nursing Care Plan, 4th
Edition by Doenges
Nurses Pocket Guide,
8th Edition by Doenges
100

Age: 60 y.o.
Sex: Male
Date and
Time
Cues

Need
Nursing Diagnosis
Objective
A
C
T
I
V
I
T
Y
Decrease
Cardiac
Output related to
altered heart rate and
rhythm as evidenced
by atrial fibrillation in
slow to moderate
ventricular response
with ST elevation
pattern secondary to
CAD, AMIK II
Within my 8
hours span of
care
my
patient will
be able to
maintain
hemodynamic
stability
as
evidenced by:
Evaluation
Determine
baseline
vital signs
R: Provide opportunities to
track changes.
Goal Partially
Met
1.
S/O:
November Pupillary
27, 2006
size
3mm
isocoric, brisk
3-11 shift
and reactive to
light
4:30
Pale
p.m.
conjunctiva
noted
O2
inhalation at 5
lpm via nasal
cannula noted
Pink
mucous
membrane and
lips noted
Symmetri
cal
chest
expansion
noted
Crackles
noted
upon
auscultation
Productive
E
X
E
R
C
I
S
E
Rationale:
Acute
Myocardial
Infarction
(AMI)
generally
occurs
when coronary blood
flow
decreases
abruptly
after
a
previously narrowed
by
atherosclerosis.
When a coronary
2.
Auscultate BP, compare

both arms and obtain lying,
sitting
and
standing
pressures when able
R: Hypotension may occur
related
to
ventricular
dysfunction, hypoperfusion of
the myocardium, and vagal
stimulation.
However,
hypertension is also a common
phenomenon, possibly related
to pain, anxiety, catecholamine
release, and/or preexisting
vascular problems. Orthostatic
hypotension may be associated
with complications of infarct.
November 27,
2006
10:00 p.m.
Within my 8
hours span of
care my patient
was able to
maintain
hemodynamic
stability
as
evidenced by:
BP
within
normal
range
(90/60120/90
mmHg)
CR
BP
within
within normal
normal
range
range (60(110/80mmHg)
100 bpm)
3.
Evaluate quality and Adequate
Adequ
equality of pulse as urinary output
ate urinary
indicated
(I-370 cc, Ooutput
R: Decreased cardiac output 300 cc)
101
cough noted
Whitish
phlegm noted
Irregular
cardiac
rate
and
rhythm
noted
Showing
atrial
fibrillation in
slow
to
moderate
ventricular
response with
ST elevation
pattern
Nondistended
abdomen
noted
Grossly
normal
extremities
noted
Cool skin
noted
Pale nail
beds noted
Capillary
refill of 1
second
Weakness
noted
P
A
T
T
E
R
N
artery
thrombus
develops rapidly at a
site of vascular injury,
this
injury
is
produced
or
facilitated by factors
such as cigarette
smoking,
hypertension,
and
lipid accumulation.
Infarction
occurs
when
an
ulcerates and when
systemic)
favor
thrombogenesis, so
coronary
artery
occlusion. After an
initial
platelet
monolayer forms at
the site of the
ruptured
plaque,
various
agonists
(collagen,
ADP,
epinephrine,
serotonin)
promote
platelet
activation.
After
agonist
Decre
results
in
diminished Absence
ase
weak/thready
pulses. of
dyspnea
dysrhythmia Irregularities
suggest (RR-20 cpm)
Absen dysrhythmias, which may
ce
of require further evaluation or But was not able
dyspnea
monitoring.
to
maintain
hemodynamic
4.
Auscultate heart sound; stability on:
note development of S3
and S4
CR (52
R: S3 is usually associated
bpm)
with HF, but it may also be Cardiac
noted with mitral insufficiency rhythm remains
and left ventricular overload the same
that can accompany severe
infarction.
S4
may
be
associated with myocardial
ischemia,
ventricular
stiffening, and pulmonary or
systemic hypertension.
5.
Presence
or
murmurs/rubs
R: Indicates disturbance of
normal blood flow within the Evaluated by:
heart. Presence of rub with an
infarction is all associated with
inflammation.
Yap, Novelynne
Joy
6.
Auscultate
breath
sounds
R:
Crackles
reflecting
pulmonary congestion may
102
Temp=35.
6,
RR=23
cpm, CR= 43
bpm,
BP=
80/60 mmHg
stimulation
of
platelets, there is
production
and
release
of
thromboxane A2 (a
potent
local
vasoconstrictor),
further
platelet
activation,
and
thrombolysis.
The
coagulation
factor in damaged
endothelial cells at
the site of the
ruptured
plaque.
Factors VII and X are
activated, ultimately
leading
to
the
conversion
of
prothrombin
to
fibrin.
Fluid-phase
and
clot-bound
thrombin participate
in
an
autoamplification
reaction that leads to
further activation of
develop because of depressed

myocardial function.
7.
Monitor heart rate and

rhythm
R: Heart rate and rhythm
respond to medication and
activity, as well as developing
complications/dysrhythmias,
which
could
compromise
cardiac function or increase
ischemic damage. Acute or
chronic atrial flutter/fibrillation
may be seen with coronary
artery or valvular involvement
and may or may not be
pathogenic.
8.
Place on moderate high

back rest
R:
Lowers
diaphragm,
promoting chest expansion.
9.
Note
response
to
activity and promote rest
appropriately
R: Overexertion increases
oxygen consumption/demand
and
can
compromise
10.
Provide
bedside
commode if unable to use
103
the
coagulation
cascade. The culprit
coronary
artery
eventually becomes
occluded
by
a
thrombus containing
platelet
aggregates
and fibrin strands.
This occlusion will
impede the flow of
muscle and other parts
of the body. Therefore
there is inadequate
blood pumped by the
heart to meet the
metabolic demands of
the body. This cardiac
problem also alters
the cardiac rate and
rhythm as the body
reacts to the lack of
blood carrying oxygen
in which the occlusion
results
to
tissue
ischemia
and
eventually to necrosis.
The infracted area in
AMI will eventually
heal and the necrotic
myocardial cells will
bathroom
R: Attempts at using bedpan
can
be
exhausting
and
psychologically
stressful,
thereby increasing oxygen
demand and cardiac workload.
11.
Provide small or easily

digested meals. Restrict
caffeine intake
R: Large meals may increase
myocardial workload and
cause
vagal
stimulation
resulting in bradycardia or
ectopic beats. Caffeine is a
direct cardiac stimulant that
can increase heart rate.
12.
Avoid activities such as

isometric exercises, rectal
stimulation,
vomiting,
spasmodic
coughing.
Administer stool softeners
as ordered.
R: These may stimulate
valsalva response.
13.
Administer
supplemental oxygen, as
indicated
R: Increases amount of
.oxygen
available
for
myocardial uptake, reducing
104
be replaced by dense
fibrous
connective
tissue (scarring). This
area cannot contribute
to pumping except to
maintain the integrity
of the ventricular
wall.
ischemia
and
dysrhythmias.
resultant
14.
Maintain IV access as
indicated
R: Patent line is important for
administration of emergency
drugs in presence of persistent
dysrhythmias or chest pain.
15.
Source:
Pathophysiology:
Concepts
and
Applications
for
Health
Care
Professionals,
3rd
Edition by Nowak
Administer
antidysrhythmic drugs and
ACE inhibitors as ordered.
R: Dysrhythmias are usually
treated symptomatically, except
for PVCs, which are often
treated prophylactically. Early
inclusion of ACE inhibitor
therapy enhances ventricular
output, increases survival and
may slow progression of heart
failure.
Harrisons
Internal
Medicine, 5th Edition
Source:
Edition by Doenges
th
8 Edition by Doenges
105
106

Age: 60 y.o.
Sex: Male
Date and
Time
Cues
Need

Nursing Diagnosis
Objective
Activity Intolerance
related to decrease
cardiac functioning as
evidenced by irregular
cardiac
rate
and
rhythm secondary to
CAD, AMIK II
Within my 8
hours span of
care
my
patient will
be able to
demonstrate
progressive
increase
in
tolerance for
activity with
heart
rate/rhythm
and
BP
within
patients
normal limits
and
skin
warm, pink
and dry.
Evaluation
Determine
baseline
vital signs
R: Provide opportunities to
track changes.
Goal Partially
Met
1.
S:
November Dali ko makapoy
29, 2006 ug lisod mulihok
as verbalized by
3-11 shift the patient
4:30
p.m.
O:
-
Pupillary
size
3mm
isocoric, brisk
and reactive to
light
Pale
conjunctiva
noted
O2
inhalation at 5
lpm via nasal
cannula noted
Pink
mucous
membrane and
lips noted
Symmetri
cal
chest
A
C
T
I
V
I
T
Y
Rationale:
E
X
E
R
C
I
S
E
There is insufficient
physiological
or
psychological energy
to endure or complete
required or desired
daily activities.
Acute
Myocardial
Infarction
(AMI)
occurs when coronary
blood flow decreases
abruptly
after
a
2.
Record or document
heart rate, rhythm, and BP
changes before, during, and
after activity as indicated.
Correlate with reports of
chest pain or shortness of
breath.
R: Trends determine patients
response to activity and may
indicate myocardial oxygen
deprivation that may require
decrease in activity level or
return to bed rest, changes in
medication regimen or use of
supplemental oxygen.
3.
November 29,
2006
10:00 p.m.
Within my 8
hours span of
care my patient
was able
to
demonstrate
progressive
increase
in
tolerance
for
activity
as
evidenced by:
BP
Promote rest initially. within normal
Limit activities on basis of range
pain or hemodynamic
(100/80mmHg)
response. Provide nonstress Skin
diversional activities
warm to touch
107
expansion
noted
Crackles
noted
upon
auscultation
Productive
cough noted
Whitish
phlegm noted
Irregular
cardiac
rate
and
rhythm
noted
Showing
atrial
fibrillation in
slow
to
moderate
ventricular
response with
ST elevation
pattern
Nondistended
abdomen
noted
Grossly
normal
extremities
noted
Cool skin
noted
Dry, rough
P
A
T
T
E
R
N
previously narrowed
by
atherosclerosis.
Infarction
occurs
when
an
ulcerates and when
systemic)
favor
thrombogenesis,
so
coronary
artery
occlusion. After an
initial
platelet
monolayer forms at
the site of the
ruptured
plaque,
various
agonists
(collagen,
ADP,
epinephrine,
serotonin)
promote
platelet
activation.
After
agonist
stimulation
of
platelets, there is
production
and
release
of
thromboxane A2 (a
potent
local
vasoconstrictor),
further
platelet
R:
Reduce
myocardial Dry skin
workload
or
oxygen noted
consumption, reducing risk of Pinkish
complications
conjunctiva,
mucous
4.
Limit visitors and/or membrane and
visiting by patient, initially
nail beds noted
R: Lengthy or involved
conversations can be very But was not able
taxing for the patient; however, to demonstrate
periods of quiet visitation can progressive
be therapeutic.
increase
in
tolerance
for
5.
Instruct patient to avoid activity
as
increasing
abdominal evidenced by:
pressure like straining
during defecation
CR (57
R: Activities that require bpm)
holding of breath and bearing Cardiac
down can result in bradycardia,
rhythm remains
temporarily reduced cardiac the same
output and rebound tachycardia
with elevated BP.
6.
Explain pattern of
graded increase of activity
level like getting up in
chair when there is no pain,
progressive
ambulation,
and resting for 1 hour after
meals.
Evaluated by:
R:
Progressive
activity
provides a controlled demand
108
skin noted
Pale nail
beds noted
Capillary
refill of 1
second
Weakness
noted
Needing
assistance
upon changing
positions
noted
Temp=35.
5,
RR=23
cpm, CR= 57
bpm,
BP=
90/70 mmHg
activation,
and
thrombolysis.
on the heart,
strength
and
overexertion
The
coagulation
factor in damaged
endothelial cells at the
site of the ruptured
plaque. Factors VII
and X are activated,
ultimately leading to
the conversion of
prothrombin
to
fibrin. The culprit
coronary
artery
eventually becomes
occluded
by
a
thrombus containing
platelet
aggregates
and fibrin strands.
7.
This occlusion will

impede the flow of
muscles.
Decrease
cardiac
functioning
will lead to imbalance
between myocardial
oxygen supply and
increasing Yap, Novelynne

preventing Joy
Review
signs
and
symptoms
reflecting
intolerance
of present
activity level or requiring
notification of nurse or
physician
R:
Palpitations,
pulse
irregularities, development of
chest pain, or dyspnea may
indicate need for changes in
exercise regimen or medication
8.
Place on moderate high

back rest
R:
Lowers
diaphragm,
promoting chest expansion.
9.
Note
response
to
activity
R: Overexertion increases
oxygen consumption/demand
and
can
compromise
10.
Provide
bedside
commode if unable to use
bathroom
R: Attempts at using bedpan
can
be
exhausting
and
109
demand wherein the

heart is unable to meet
the
metabolic
demands of the body.
Performing activities
increases
oxygen
consumption from the
body in which an
individual with such
imbalance will have
difficulty performing
the task.
psychologically
stressful,
thereby increasing oxygen
demand and cardiac workload.
11.
Provide small or easily

digested meals. Restrict
caffeine intake
R: Large meals may increase
myocardial workload and
cause
vagal
stimulation
resulting in bradycardia or
ectopic beats. Caffeine is a
direct cardiac stimulant that
can increase heart rate.
12.
Plan care with

periods in between
R: reduce fatigue
rest
13.
Source:
Pathophysiology:
Concepts
and
Applications
for
Health
Care
Professionals,
3rd
Edition by Nowak
Encourage patient to
maintain positive attitude;
suggest use of relaxation
techniques
such
as
visualization or guided
imagery as appropriate
R: Enhance sense of wellbeing
14.
Harrisons
Internal
th
Medicine, 5 Edition
Administer
supplemental oxygen, as
indicated
R: Increases amount of
.oxygen
available
for
110
myocardial uptake, reducing

ischemia
and
resultant
dysrhythmias.
15.
Maintain IV access as
indicated
R: Patent line is important for
administration of emergency
drugs in presence of persistent
dysrhythmias or chest pain.
Source:
Edition by Doenges
8th Edition by Doenges
111
PROGNOSIS
MI may be associated with a mortality rate as high as 30%, with more than half of deaths
occurring in the prehospital setting. Prognosis is highly variable and depends on a number of
factors related largely on infarct size, left ventricular function and the presence or absence of
ventricular arrhythmias. Prognosis is significantly worsened if a mechanical complication
(papillary muscle rupture, myocardial free wall rupture, and so on) were to occur.
Overall, the prognosis is poor. This is for the reason that the patients condition has been
transpiring for years. He had attacks in the past and his condition has complications already.
Regardless of the patients willingness to comply with all the medical regimens that would
possibly help his condition there is only small hope that normal cardiac rate and rhythm would
be achieved basing on the amount of myocardial tissue that has already been damaged. The
family also lacks the financial support that they would need for medical intervention and this is
also with respect to the patients age.
CRITERIA
Poor
Duration of illness
ACTUAL
Fair
Good
Willingness
to
take medication
Age
Expectations
illness
to
JUSTIFICATION
The patient already had four attacks prior to the
present hospitalization. This implies that the
condition of the patient continuously deteriorates
every after the attack. In addition, it only
indicates that the patient is unable to meet the
necessary interventions to prevent having another
attack.
The patient is very willing to take all the available
prescribed medications. In fact, he always asks
questions regarding it. He would ask for the
purpose of his medicines before taking it.
The patient is not getting any younger and at his
current age (60 y.o.) there is a higher risk for
acquiring such illness. Since the patients immune
system and other bodily functions deteriorates as
he continuously age he will no longer be able to
fight against infection or inflammation that could
also trigger the aforementioned illness.
The patient wanted to go home with ordered
medications however, he is also aware of the
reality that his condition is worsening. He and his
family still hopes that Mr. Perfecto would fully
Environment
Family support
recover from his illness.

The patient lives in an air conditioned room and
is provided with his oxygen tank. There is no air
pollutant present that could worsen his respiratory
problems and the patient already stopped all his
vices ever since he had his attack.
The family is always there to provide assistance
and support the patient. Although this is the case
the family still lacks assistance on other matter
such as financial aid. The help the patient gets
from his daughter is not enough to sustain all that
should necessarily be done to achieve optimal
health.
113
BIBLIOGRAPHY
Harrisons Internal Medicine
Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Geissler-Murr, Nurses Pocket
Guide, Diagnoses, Interventions and Rationales. 9th Edition
Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Geissler-Murr, Nursing Care Plan
Guidelines for Individualizing Nursing Care 6th Edition
Nowak, Thomas. Pathophysiology: Concepts and Application for Health Care Professionals, 3rd
Edition
Rod Seeleys, Trent D. Stephens, Philip Tate, Essentials of Anatomy and Physiology 4th Edition
Suzanne C. Smeltzer, Brenda G. Bare, Brunner and Suddharts Textbook on Medical-Surgical
10th Edition
Sylvia A. Price, Lorraine M. Wilson, Pathophysiology Clinical Concepts of Disease Process 4th
Edition
Wilson, et al. Harrisons Principles of Internal Medicine, 12th Edition
http://www.geocities.com/baddarni/Myocardial-Infarction.html
http://members.tripod.com/~dgholgate/four.html
http://biology.about.com/library/organs/heart/blheartintro.htm
http://texasheart.org/HIC/Anatomy/Anatomy.cfm
http://www.cvphysiology.com/Heart%20Disease/HD002.htm
http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/complications/complicati
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http://www.emedicine.com/EMERG/topic327.htm
http://en.wikipedia.org/wiki/Myocardial_infarction
http://circ.ahajournals.org/cgi/content/abstract/111/25/3481
http://training.seer.cancer.gov/module_anatomy/unit7_1_cardvasc_intro.html
http://filer.case.edu/~dck3/heart/intro.html
http://webschoolsolutions.com/patts/systems/heart.htm
http://en.wikipedia.org/wiki/Cardiovascular_system
http://www.kidshealth.org/teen/your_body/body_basics/heart.html
http://www.americanheart.org/scientific/statements/1994/079402.html
http://circ.ahajournals.org/cgi/content/full/102/18/2284
http://supplements.inq7.net/mindandbody/main.php?content=health003
http://library.thinkquest.org/C003758/Function/How%20Cardiac%20Muscle%20Contracts.htm
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114

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Case Presentation

Coronary Artery Disease, Acute Myocardial Infarction

In Partial Fulfillment of the Course Requirements in

Presented to the Clinical Instructors of

Anselmo Lafuente, R.N.

Yap, Novelynne Joy A.

February 22, 2007

Anatomy and Physiology.............................................................................................23

Nursing Care Plan........................................................................................................93

AFFECTIVE: Have a purposeful interaction with the clients significant others

PSYCHOMOTOR: Enhance the ability to identify and apply nursing interventions to

Specifically, this paper would be able to:

Present the patients personal data with accuracy

Present and discuss the complete diagnosis of the patient

Interpret and discuss the developmental data of the patient

Obtain the physical assessment of the patient

Discuss the anatomy and physiology of the affected system

Interpret and present the Physicians orders

Make a drug study on the drugs prescribed to the patient

Formulate nursing care plans for the patient

State the prognosis and relate it with the patients condition

Hospital Number: 919684

Age: 60 years old

Rheumatic Heart Disease

History of Past Illness

History of Present Illness

Effects and Expectation of Illness to Family

Term applied to vessels

Blood vessel that carries blood away from the heart

A definite morbid process having a characteristic train of symptoms

Any departure from health of a structure, organ, or system

Coronary Artery Disease

A disease in which there is a narrowing or blockage of the coronary arteries (blood

Characterized by the presence of atherosclerosis in the epicardial coronary arteries.

Having rapid onset, short or relatively severe course

Pertaining to the muscular tissue of the heart

Relating to or affecting the thick muscular wall of the heart.

Formation of an infarct (coronary thrombosis)

Cessation of blood flow by thrombus formation and causing issue death

A classification of Acute Myocardial Infarction that is defined as having moderate heart

Is the rapid development of myocardial necrosis caused by a critical imbalance between

Involving, affecting or relating to a ventricle

Morbid enlargement or overgrowth of an organ or part due to an increase in size of its

An increase in cell size

The act or process of widening or being widened, stretching or being stretched, or

The enlargement or expansion of a hollow organ or cavity

Left Ventricle Hypertrophy & Dilatation

Establishing and maintaining an economic standard of living. Perfecto works really

Assisting teenage children to become responsible and happy adults. He is the

My patient belongs to post conventional level or self accepted moral principles. He is

ANATOMY and PHYSIOLOGY

blood: consisting of liquid plasma and cells

heart: a muscular pump to move the blood

The Cardiovascular System

Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Platelets, cell fragments

Bone marrow Blood clotting

Bone marrow, Immunity

left atrium (LA),

and left ventricle

are the larger,

of the heart. The

Basic Cardiac Physiology

A basic understanding of cardiac physiology is also essential to interpreting the physical