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A.) OVERVIEW OF THE STUDY Acute myocardial infarction (MI) is defined as death or necrosis of myocardial cells. It is a diagnosis at the end of the spectrum of myocardial ischemia or acute coronary syndromes. Myocardial infarction occurs when myocardial ischemia exceeds a critical threshold and overwhelms myocardial cellular repair mechanisms that are designed to maintain normal operating function and hemostasis. Ischemia at this critical threshold level for an extended time period results in irreversible myocardial cell damage or death. Critical myocardial ischemia may occur as a result of increased myocardial metabolic demand and/or decreased delivery of oxygen and nutrients to the myocardium via the coronary circulation. An interruption in the supply of myocardial oxygen and nutrients occurs when a thrombus is superimposed on an ulcerated or unstable atherosclerotic plaque and results in coronary occlusion. A high-grade (> 75%) fixed coronary artery stenosis due to atherosclerosis or a dynamic stenosis associated with coronary vasospasm can also limit the supply of oxygen and nutrients and precipitate an MI. Conditions associated with increased myocardial metabolic demand include extremes of physical exertion, severe hypertension (including forms of hypertrophic obstructive cardiomyopathy), and severe aortic valve stenosis. Other cardiac valvular pathologies and low cardiac output states associated with a decreased aortic diastolic pressure, which is the prime component of coronary perfusion pressure, can also precipitate MI Myocardial infarction can be subcategorized on the basis of anatomic, morphologic, and diagnostic clinical information. From an anatomic or morphologic standpoint, the two types of MI are transmural and nontransmural. A transmural MI is characterized by ischemic necrosis of the full thickness of the
2 affected muscle segment(s), extending from the endocardium through the myocardium to the epicardium. A nontransmural MI is defined as an area of ischemic necrosis that does not extend through the full thickness of myocardial wall segment(s). In a nontransmural MI, the area of ischemic necrosis is limited to either the endocardium or the endocardium and myocardium. It is the endocardial and subendocardial zones of the myocardial wall segment that are the least perfused regions of the heart and are most vulnerable to conditions of ischemia. An older subclassification of MI, based on clinical diagnostic criteria, is determined by the presence or absence of Q waves on an electrocardiogram (ECG). However, the presence or absence of Q waves does not distinguish a transmural from a non-transmural MI as determined by pathology A more common clinical diagnostic classification scheme is also based on ECG findings as a means of distinguishing between two types of MI—one that is marked by ST elevation and one that is not. The distinction between an STelevation MI and a non-ST-elevation MI also does not distinguish a transmural from a non-transmural MI. The presence of Q waves or ST segment elevation is associated with higher early mortality and morbidity; however, the absence of these two findings does not confer better long-term mortality and morbidity. The most common etiology of MI is a thrombus superimposed on a ruptured or unstable atherosclerotic plaque. . Myocardial infarction is the leading cause of death in the United States (US) as well as in most industrialized nations throughout the world. Approximately 800,000 people in the US are affected and in spite of a better awareness of presenting symptoms, 250,000 die prior to presentation to a hospital.4 The survival rate for US patients hospitalized with MI is approximately 90% to 95%. This represents a significant improvement in survival and is related to improvements in emergency medical response and treatment strategies.
In general, MI can occur at any age, but its incidence rises with age. The actual incidence is dependent upon predisposing risk factors for atherosclerosis, which are discussed below. Approximately 50% of all MI's in the US occur in people younger than 65 years of age. However, in the future, as demographics shift and the mean age of the population increases, a larger percentage of patients presenting with MI will be older than 65 years
OBJECTIVES OF THE STUDY
The main reason and purpose student nurses conduct care study and exposure in the clinical area is for them to identify problems encountered by the clients; this is one of their tools of learning knowledgeably and skillfully. We, as health care providers, it is indeed our vocation to adjoined hands w/ the health team for the promotion of wellness of our clients. Our main objectives for this study are the following: • • • • To identify the chief complaints and admitting diagnosis of our patient so that we can give specific nursing interventions. To determine the family and personal health history of our patient that may affect present health condition To identify the cause and effect of the main problem through a correct analysis of the pathophysiology of the case. To determine the medical management given through identifying the significant implication of the laboratory and diagnostic examinations ordered as well as the medical orders and its rationale. • • To make a nursing care plan for the different health problems encountered by the client. To establish an ideal plan of care for a specific diagnosis or problem of the client.
4 • • • To evaluate the effectiveness of the actual nursing care plan that was established. To impart health teachings to the client giving emphasis on his medications, exercises, treatment, out- patient follow- up and diet To give referrals and follow-up for the health promotion of the client.
In general, this study aims to enhance the skills and knowledge of the students in providing holistic care to the patient. Students logically search further knowledge in order to attain the desired goal and intervention for the wellness of the patient. C.) SCOPE AND LIMITATION
Prior to the day of duty, the group has already chosen a patient for care study. They performed a physical assessment to the patient to properly identify the nursing problems, which require necessary and direct interventions and medical regimen. The study on medications and doctor’s order were limited to our chosen patient The preventive care and anticipatory guidance are integral to nursing practice. Thus, this care study focuses on the particular case of the patient. Since the patient’s diagnosis is more on cardiovascular disease, the group has focused on acute myocardial infarction as one of his admitting diagnosis. However, the group did not just limit the interventions on monitoring cardiac activity of the patient. Any symptoms and unusualties were kept watch and monitored. Any Referrals and follow-up, so as with the nursing management were fully granted and analyzed for the said case. Supposedly, this case study should be focused on Gynecology concept but due to the unavailability and presence of gyne patient in Cagayan de Oro Polymeric General Hospital, the concept is focused on medical from Station 7.
5 The care for our chosen patient is only limited for 2 days of duty excluding the physical assessment done prior to the day of duty.
A.) PATIENT’S PROFILE Name of Patient: Sex: Age: Religion: Civil Status: Occupation: Income: Nationality: Date Admission: Time: BASELINE VITAL SIGNS Temperature: Pulse Rate: Respiratory rate: Blood Pressure: Height: Weight: Chief complaints: Admitting Diagnosis: 36.6 C 54 bpm 18 cpm 130/100 mmHg 5’3’’ 55.5 kgs epigastric pain Acute myocardial infarction; Hypertensive cardiovascular disease; ruled out PUD; diabetic neprhopathy Attending Physician: Dr. Alenton ? Male 64 years old Roman Catholic Married ? P 6,000/ month Filipino June 29, 2007 09:40 pm
B.) FAMILY AND PERSONAL HEALTH HISTORY
?, 64-year-old, male, a resident of ? has a critical health problem. He said that he was an alcohol drinker during his adolescence and late adulthood and confessed that he only drinks 2-6 glasses even more on occasional basis; however, he has no history of cigarette smoking. At fist, he experienced hypertension in the year 1998 when he was still 55 years old. On the year 2006, because of over workload and emotional stress, Mr. Agustin has experienced severe chest pain and that same year he was diagnosed of having Diabetes Nephropathy and Chronic Renal Insufficiency and was admitted at Northern Mindanao Medical Center. During his admission last 2006, Mr. Sarmiento has been transfused with 5 bags of Packed Red Blood Cell and there were no reports of allergic reaction. At that time, he was advised by the doctor to have his monthly check-up for his health problems.
According to the patient’s wife, there is no history of health problems from their family. Nobody aside from Mr. Agustin Sarmiento has been admitted for chronic illness. His children were neither non-smoker nor alcoholic but they do drink alcohol occasionally Although there were presence of minor illnesses before like cough, colds, LBM but they were able to catch on the treatment regimen as a home care management.
7 C.) CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS
On the 29th of June, Mr. ? has experienced chest pain with complaints of acute epigastric pain, growing in character and on and off. The patient was anorexic and hypertensive (180/ 60 mm Hg). With the help of his family he went to the hospital for check-up, they thought that it was just an ulcer, but the doctor came out to have a diagnosis of Acute myocardial infarction; Hypertensive
cardiovascular disease; ruled out PUD; diabetic neprhopathy, and due to the severity of pain he was prompted for admission in the Polymedic General Hospital.
ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY Later Maturity (60 y.o- ) The fact that man learns his way through life is made radically clear by consideration of the learning tasks of older people. They still have new experiences ahead of them, and new situations to meet. At age sixty-five when a man often retires from his occupation, his changes are better than even of living another ten years. During this time the man or his wife very likely will experience several of the following things: decreased income, moving to a smaller house, loss of spouse by death, a crippling illness or accident, a turn in the business cycle with a consequent change of the cost of living. After any of these events the situation may be so changed that the old person must learn new ways of living. The developmental tasks of later maturity differ in only one fundamental respect from those of other ages. They involve more of a defensive strategy--of holding on the life rather than of seizing more of it. In the physical, mental and economic
8 spheres the limitations become especially evident; the older person must work hard to hold onto what he already has. In the social sphere there is a fair chance of offsetting the narrowing of certain social contacts and interests by the broadening of others. In the spiritual sphere there is perhaps no necessary shrinking of the boundaries, and perhaps there is even a widening of them. Our patient Agustin Sarmiento is already at the later maturity stage. At his age he will be adjusting in decreasing physical strength and health, adjusting to retirement and reduced income, adjusting to death of spouse, establishing an explicit affiliation with one's age group, meeting social and civic obligations, establishing satisfactory physical living arrangements: The principal values that older people look for in housing, according to studies of this matter, are: quiet, privacy, independence of action, nearness to relatives and friends, residence among own cultural group, closeness to transportation lines and communal institutions like libraries, shops, movies, churches, etc.
ERIK ERICKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT Ego Integrity vs Despair (65-) Erik Erikson adapted and expanded Freud’s theory of development to include the entire life span, believing that people continue to develop throughout life. He describes eight stages of development. Erikson envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieve. The resolution of the task can be complete, partial or unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve the task influences the person’s ability to achieve the new task. This developmental task can be viewed as a series of crisis and successful resolution of this crisis and successful resolution of these crisis is supportive to the person’s ego failure to resole the crisis is damaging to the ego.
Our patient Agustin Sarmiento belongs to the older adult stage. His central task is Ego Integrity versus Despair. Ego integrity is the ego's accumulated assurance of its capacity for order and meaning. Despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends. He must learn to accept the life that he has led (good and bad) to have a life in facing death. As he learns to live with his choices and the certainty of death, he fined a inner-strength to go on with integrity. Some despair is inevitable, a he mourn his own deaths. When he recognizes all that he have been, are and will be, then we show his wisdom.
KOHLBERG’S STAGES OF MORAL DEVELOPMENT Post conventional (Universal Ethical and Principle Orientation Lawrence Kohlberg’s theory specifically addresses moral development in children and adults. The morality of an individual’s decision was not Kohlberg’s concern; rather he focused on the reasons of an individual makes a decision. According to Kohlberg, moral development progress to three levels and six stages. At Kohlberg first level, called the premolar or preconventional level, children are responsive to cultural rules and labels of good and bad, right and wrong. However, children interpret these terms of the physical consequence of their action, that is, punishments or reward. At the second level, the conventional level, the individual is concerned about maintaining the expectation of the family, group or nation and sees this is right. The emphasis at third level is conformity and loyalty to one’s own expectation as well as society’s. level three is called the post conventional, autonomous or principal level. At this level people make an effort to define valid values and principles without regard to outside authority or to the expectation of others. Our patient Agustin Sarmiento belongs to the Post Conventional level and on the Universal Ethical principle orientation stage. His decisions and
10 behaviors re based on internalized rules, on conscience rather than social laws, and on self- chosen ethical and abstract principles that are universal, comprehensive and consistent.
IV. MEDICAL MANAGEMENT
A.) DATE June 29, 2007 9:50pm Hgt:188mgs/dL BP: 180/60mmHg HR:92bpm DOCTOR’S ORDER RATIONALE
Please admit under the serviceof Dr. Alenton Secure consent to care TPR qh
For proper monitoring of the patient’s condition To have consent in rendering medical treatment to patient To have baseline data and monitor patient’s condition Diet prescribed in treatment of type 2 Diabetes mellitus To have baseline data in planning of giving treatment and care to the patient To keep vein open; to have patent line in cases of administering IVT drugs Antianginals; to prevent situations that may cause anginal attacks of the patient
Lab. CBC, crea,K,Hgt stat. FBS, lipid profile, ECG IVF PNSS1L @ 10gtts/min Meds. ISMO 60g Isordil 5g SL PRN
11 Zantac IVT now then q8h Please refer accordingly Troponine T now 11:07pm Blood typing now Cross-matching now To determine blood type of the patient & the presence of ABO and Rh factor For blood replacement For continued surveillance of the heart’s electrical activity Relieve of moderate to severe pain Inhibits proton pump activity thus suppresses gastric acid secretion To lower down BP of the patient To determine the effectivity of the medication (captopril) Relieve of moderate to severe pain Anticoagulant drug; to maintain arterial patency To measure levels of cardiac troponins Antiulcer drug; to reduce gastric acid secretions
Transfuse 2’U’ PRBC Repeat ECG in AM
June 30,2007 11:00am Tramadol 50mg IVT now Pantoprazole (Ulcepraz) 40g IVT OD,start now Please give captopril 25mg tab SL now Get BP & HR after 15 minutes 8:00pm Tramadol 50mg IV now then PRN Arixtra 25mg SC now then OD
12 To reduce the thrombotic events in patient with atherosclerosis Increases myocardial oxygen supply & relieves pain
Plavix 75mg 4 tabs now then 1tab OD
O2 inhalation 2L/min
Repeat ECG in AM
VS qh & record
For continued surveillance of the heart’s electrical activity To monitor the health status of the patient & have baseline data in giving medications Adjunct to diet to reduce LDL cholesterol, total cholesterol, and to increase HDL cholesterol of the patient To determine the level of the blood components of the patient after transfusion Antihypertensive drug; to lower the BP of the patient Antihypertensive drug; to lower the BP of the patient To keep vein open; to have patent line in cases of administering
Lipitor 1 tab OD start tonight
July 1. 2007 CBC after 2’U’ PRBC July 2, 2007 12:20am BP: 190/90mmHg 10:25am BP: 160/80mmHg HR: 88bpm Give captopril 25mg tab SL now, T.O. Dr. Taboclaon Give captopril 25mg SL now, T.O. Dr. Espina IVF PNSS1L @ 10gtts/min
13 IVT drugs BP: 200/80mmHg HR: 94bpm Give captopril 25mg tab SL now Bepridil (Vascor) 10 mg. 1 tab now then OD P.O. O2 inhalation 2l/min July 3, 2007 BP: 200/110mmHg Give Isordil 5mg tab SL for 3 doses q 5 minutes if chest pain is not relieved Increase O2 inhalation to 4L/min Give captopril 25mg tab SL now Give Isordil 5mg SL now Antihypertensive drug; to lower the BP of the patient For hypertension; For chronic stable angina, used alone or in combination ĉ Bblockers nitrates Increases myocardial oxygen supply & relieves pain Antianginal; to reduce cardiac oxygen demand by decreasing preload and afterload. Increases myocardial oxygen supply & relieves pain Antihypertensive drug; to lower the BP of the patient Antianginal; to reduce cardiac oxygen demand by decreasing preload and afterload For continued surveillance of the heart’s electrical activity Antihypertensive drug; to lower the BP of the patient To keep vein open; to have patent line in cases of administering
Repeat ECG in AM 5:30pm Therabloc 50mg 1tab now then OD IVF PNSS1L @ 10gtts/min
14 IVT drugs B.) LABORATORY AND DIAGNOSTIC EXAMINATIONS RESULTS 1.) HEMATOLOGY Date: June 30, 2007 Time: 3: 46 pm Cross- matiching Patient’s blood type Donor’s blood type Bag serial # (s) 35147 segment 36353022 35260 segment 36352489 Re-screening Blood component Remarks Method Blood Rh (D) positive Blood Rh (D) positive RBCs have antigen- can initiate antibodies reaction IMPLICATIONS
Not done Packed red blood cell Compatible Dia- med microsystem
RESULTS 1.) BLOOD CHEMISTRY Date: June 30, 2007 Time: 5:00 am Lipid Profile Triglycerides 221.64 mgs/dl
28.39 mgs/dl HDL
30.00 – 85.00
166.01 mgs/dl LDL
Increased- Risk of atherosclerotic occlusive coronary diseases and peripheral vascular disease Decreased- HDL cholesterol is lower in patients with increased risk for coronary heart disease Increased-
15 higher in patients with increased risk for coronary heart disease Increased- Risk of nephrotic syndrome Increased- risk for diabetes mellitus and chronic renal insufficiency
44.33 mgs/dl VLDL 106.18 mgs/dl Fasting blood sugar .
0.00- 40.00 70.00- 99.00
3.) HEMATOLOGY Date: June 30, 2007 Time: 1:02 am Troponin- T
Troponin levels rise rapidly and are detectable within 1 hour of myocardial cell injury and renal diseases
ABO + Rh Blood Rh (D) positive Blood group 4.) CHEMISTRY Date: June 29, 2007 Time: 11:43 pm 6.17 mgs/ dl Creatinine 0.90 – 1.50 Increased- risk of nephritis; chronic renal insufficiency; diabetic nephropathy; reduced renal blood flow
5.) HEMATOLOGY Date: June 29, 2007 Time: 11:43 pm
Complete blood count Total RBC Hgb
2.57x 10^9/L • g/dl
5.0- 10.0 13.70- 16.70
28.0 Hct 108.9 MCV 28.2 MCHC Differential count Neutrophils 70.9
40.00- 49.70 70.00- 97.00
Decreased- risk of renal failure and dietary deficiency Decreased- risk of kidney disease and dietary deficiency Decreased- risk of nutritional deficiency Increased- RBC is macrocytic; risk of foilc acid deficiency Decreased- risk of iron deficiency anemia Increased- acute bacterial infection, physical or emotional stress
6.) HEMATOLOGY Date: July 1, 2007 Time: 6: 36 pm Complete Blood Count Total RBC Hgb 32.5 Hct Differential count Neutrophils 66.0 54.0- 62.0 40.0- 49.70 3.49 x10^ 9/L 11.1 g/dl 3.69- 5.90 13.70- 16.70 Decreased- risk of renal failure; dietary deficiency Decreased- risk of dietary deficiency and kidney disease Decreased- risk of nutritional deficiency Increased- acute bacterial infection;
17 physical or emotional stress Increased- viral infection Increased- viral infection; other chronic disease
15.4 Lymphocytes Monocytes 13.1
20.0- 40.0 4.0- 10.0
C.) DRUG STUDY
Name of Patient:
Name of Drug Generic (Brand) Isosorbide dinitrale (Isordil) SARMIENTO, AGUSTIN M. Date Classification Ordered 7-2-07 Antianginals Dose/ Frequency Route 5 mg tab SL for 3 doses every 5 minutes if chest pain is not relieved Mechanism of Action
Thought to reduce cardiac oxygen demand by decreasing preload & afterload: also, may increase blood flow through the collateral coronary vessels Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces, relaxation of coronary vascular muscle diseases coronary vascular arteries, myocardial 02 delivery in pts ĉ vasospastic angina SA/AV node conduction inhibits fast sodium current.
Specific Indication (why drug is ordered) Acute anginal attacks
Contraindicatio n Contraindicated potentials ĉ hypersensitivity or idiosyncrasy to nitrates & in those ĉ severe hypolension
Side Effects/ Toxic Effects Flushing, vascular headache, cerebral ischemia associated ĉ postural hypotension, N/V weakness, restless, pallor, persipiration & collapse Rarely: fatigue, dizziness, hotflush, diarrhea, nausea, vomiting Discomfort in the throat, nonproductive cough, palpitation headache & rash
Nursing Precaution To prevent tolerance a nitrate-free interval of 8 to 12 hours per day is recommended.
Calcium Channel Blocker Antianginal Antihypertensive
10 mg. 1 tab now then OD P.O.
Hypertension For chronic stable angina, used alone or in combination ĉ B-blockers nitrates
Pts. ĉ history of angineurotic edema & other allergic reactions due to ACE inhibitors: pregnancy lactation
CHF, hypotension, hepatic injury, pregnancy C, lactation, renal disease, concomitant Bblocker therapy
19 DRUG STUDY Name of Patient:
Name of Drug Generic (Brand) Ranitidine Hydrochloride (Zantac) SARMIENTO, AGUSTIN M. Classification Dose/ Frequency Route 50 mg IV q 8H 6-2-10 Mechanism of Action Completely inhibits action of histamine on the H2 at receptors sites of parietal cells, decreasing gastric acid secretion Selectively blocks the binding of angiotensin to specific issue receptors found in the vascular smooth muscle & adrenal gland this action blocks the vasoconstrictio n effect of the rennin. Angiotensin system as well as the release of aldosterone to decrease BP. Specific Indication (why drug is ordered) NSAIDassociated peptic ulceration Contraindicatio n Contraindicated in patients hypersensitive to drug and those ĉ acute porphyria acute dosage in pt. ĉ impaired renal function Contraindicated ĉ hypersensitivity to any component of the drug, pregnancies lactation Use caution ĉ renal dysfunction Side Effects/ Toxic Effects Occasionally, reversible hepatitis. Rarely agranulocytosis, acute pancreatic, hypersensitivity, reversible mental confusion, skin rash; headache CNS: headache CU: hypertension SKIN: rash, dry GI: diarrhea, abdominal pain nausea, constipation Respiratory URL, symptoms, bronchitis, cough, angioedema, flue like symptoms Nursing Precaution Assess pt. for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate
Date Ordered 6-29-07 9:45 pm
Olmesartain Medoxomil (Olmetec)
ACE inhibitors antihypertensive
20 g/mL 1 tab OD
For hypertension, alone or in combination ĉ other antihypertensive
Administers regard to meals Monitor pt. closely in any situation that may lead to a decrease BP 20 to seduction in fluid volume
20 Name of Patient:
Name of Drug Generic (Brand) tramadol HCI (Dolmal) SARMIENTO, AGUSTIN M. Date Classification Ordered 6-30-07 Opioid Analgesics Dose/ Frequency Route 50 mg IV now then PRN for moderate to severe pain Mechanism of Action A centrally acting synthetic analgesic compound not chemically related to opioid. Thought to bind to opioid receptors & of norepinephrine & serotonin Specific Indication (why drug is ordered) For moderate to severe pain Contraindicatio n Contraindicated in patients hypersensitive to drug or other opioids, in breast feeding women and in those ĉ acute intoxication from alcohol use cautiously in pts. at risk for renal or hepatic impairment Side Effects/ Toxic Effects Respiratory depression, palpitations, chills, chest pain, decrease in BP, arrhythmia, vomiting, nausea, GI distention, borborygymi, urticaria, excessive bronchial secretions Nursing Precaution Releases pt’s level of pain at least 30 min. after administration. Monitor CV and respiratory status w/hold dose & notify prescribe if RR is below 12 cm. Monitor bowel & bladder function anticipate need for laxative for better analgesic effect give drug before onset of pain. Stop treatment ĉ IV pantoprazole when P.O. form is warranted drug can’t be given regard to meals symptomatic response to therapy doesn’t preclude the presence of gastric malignancy.
pantoprazole sodium (ulcepraz)
40 mg IV OD (-6)
Inhibits proton pump activity by finding to hydrogen potassium oderosine triphosphatase, located at secretory surface of gastric parietal cells, to suppress gastric acid secretion
Doudenal & gastric ulcer in combination ĉ 2 appropriate antibiotics for the reduction of H Pylon in pts. ĉ peptic ulcer of the objective of reducing the recurrence of duodemal are unknown
Contraindicated in pts. hypersensitive to any component of the formulation safety & efficacy of using the IV for mutation to start, therapy for GERD are unknown.
Headache, diarrhea, rarely, nausea, upper abdominal pain, flatulence, skin rash, pruritus or dizziness, edema, fever, onset of depression & disturbance in vision
21 DRUG STUDY Name of Patient:
Name of Drug Generic (Brand) captopril (Capoten) SARMIENTO, AGUSTIN M.
Date Ordered 7-2-07
Dose/ Frequency Route 1. 25 mg Tab SL now 12:10 pm 2. 25 mg ½ tab SL now
Mechanism of Action Inhibits ACE, preventing conversion of Angiotensin II, a potent vasoconstrictor less angiotensin II decreasing aldosterone secretion, which reduces sodium & water retention & lowers blood pressure.
Specific Indication (why drug is ordered) Hypertension diabetic nephropathy
Contraindicatio n Contraindicated in pts. hypersensitive to drug or ACE inhibitors use cautiously in pts. ĉ impaired renal function
Side Effects/ Toxic Effects CNS: dizziness fatigue; rash, pruritus, flushing, angioedema, loss of taste perception; stomatitis, GI irritation & abdominal pain; leucopenia; cough
Nursing Precaution Monitor patient’s blood pressure & pulse rate frequently elderly pts may be moiré sensitive to drug’s hypotensive effects in patients ĉ impaired renal function or collagen vascular disease, monitor WBC and differential counts before starting treatment, every 2 wks for the first 3 months of therapy and periodically thereafter.
Name of Patient:
Name of Drug Generic (Brand) atenol (Therabloc)
SARMIENTO, AGUSTIN M.
Date Ordered 7-3-07)
Dose/ Frequency Route 50 mg 1 tab now then OD (-6-)
Mechanism of Action A beta-blocker that selectively blocks betaadrenergic receptors, decreases cardiac output and cardiac oxygen consumption and depresses rennin secretion
Specific Indication (why drug is ordered) Hypertension Angina Pectoris, Acute MI
Contraindicatio n Contraindicated in patients ĉ sinus bradycardia, heart blocker greater than first degree overt cardiac failure, or cardiogenic shock use cautiously in pts at risk for heart failure diabetes & impaired renal function
Side Effects/ Toxic Effects CNS: fatigue dizziness CV: hypotension heart failure GI: nausea, diarrhea Musculoskeletal: leg pain Respiratory bronchospasm Skin: rash
Nursing Precaution Check apical pulse before giving drug if slower than 60 beats /min. withhold drug & call prescriber. Monitor pts blood pressure drug may mask signs & symptoms of hypoxemia in diabetic pts drug may cause changes in exercise tolerance & ECG
23 DRUG STUDY
Name of Patient:
Generic name of Ordered Drug Senna
SARMIENTO, AGUSTIN M.
Brand Name Date Ordered Classification Dose/ Frequency/ Route 2 tabs tonight -9 pm Mechanism Of Action Stimulant laxative that increases peristalsis, probably by relaxing the effect on smooth muscle of the intestine. Drug also promotes fluids accumulation in colon and small intestine. Binds to antithrombin III (at-III) and potentates the neutralization of factor Xa by III which interrupts coagulation and inhibits formation of thrombin and blood clots. Inhibits the binding of adenosine diphosphale to its platelet, receptors infecting ADPmediated activation and subsequent platelet aggregation clopedogiel irreversibly modifies the platelet ADP receptor Specific Indication Acute constipation preparation, for bowel elimination ContraIndication Contraindicated in pts. ĉ ulceration bowel lesions, fecal infaction, S/sx of appendicitis, acute surgical abdomen, N/V abdominal pain Side Effects/ Toxic Effects GI: nausea, abdominal cramps GU: red-pink discoloration in alkaline urine, yellow brown discoloration in acid urine Nursing Precaution Before giving drug for constipation determine whether pt. has adequate fluid intake exercise & diet Limit diet to clear liquids after X-prep liquid is taken. Give by S.C. injection only never I.M. Don’t mix ĉ other injections or infusions to avoid loss of drug don’t expel air bubble from the syringe Platelet aggregation wont return normal for at least 5 days after drug has been stopped Don’t confuse plavix with Paxil
2.5 mgs SC now then OD 9 pm-8 am
To prevent deep-vein thrombosis (VDT) w/c may lead to acute pulmonary embolism
Contraindicated in pts with creatirine clearance less than 30 mL/min. and in those who are hypertensive to the drug or weigh less than 50 kgs. Contraindicated in patients hypersensitive to drug or its components and in those with pathologic bleeding (such as peptic ulcer) use cautiously in patients at risk for increased bleeding from trauma or other pathologic conditions
45 mgs, 4 tabs now, then 1 tab OD P.O. 106
To reduce thrombotic events with acute coronary syndrome, ĉ atherosderosis documented by recent MI, or established peripheral artenal disease.
CNS: fever, dizziness, confusion CU: hypotension, edema GI: nausea GU: UTI, urine retention Hematologic: hemorrhage, thrombocylopeni a GI Bleeding purpora, bruising, hematoma, epistaxis, hematutia, ocular hemorrhage intracranial bleeding, abdominal pain, dyspepsia gastritis & constipation, rash, pruritus
24 DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M. Generic Brand Date Classification name of Name Ordered Ordered Drug isosorbide Imdur 6-30-07 Anti-anginal mononitate
Dose/ Frequency/ Route 60 mgs 1 Tab OD P.O. -660 mgs ½ tab OD P.O. -6Mechanism Of Action Thought to reduce cardiac oxygen demand by decreasing preload and afterload.. drug also may blood through collateral coronary vessels Specific Indication Acute anginal attacks, post-MI angina; to prevent situations that may cause anginal attacks ContraIndication Contraindicat ed in pts. hypersensitiv e or idiosyncratic to nitrates & in those ĉ severe hypotension or acute MI ĉ low left ventricular filling pressure. Side Effects/ Toxic Effects CNS: headache CV: orthostatic hypotensio n, tachycardia , palitations, edema nausea Nursing Precaution To prevent tolerance a nitrate free interval of 8 to 12 hours per day is recommended. The regimen for isosobide mononitrate (1 tab.) on awakening with the second dose in 4 hrs. or 1 extended release tab. Daily is intended to minimize nitrate to tolerance by providing a substantial nitrate free interval Monitor BP and intensely and duration of drug response
Use only after diet & other condition therapy prove infective Pt should follow a standard low cholesterol diet before & during therapy. Before starting treatment assess pt for underlying causes for hypercholesterolemi a.
80 mgs 1 tab OD tonight
Inhibits HMGCOA reductase, an early (and rale-limiting) step in cholesterol biosynsthesis
Reduction of elevated total L LDL cholesterol, apolipoprotein B & triglycerides & increase HDL cholesterol in pts. ĉ primary hypercholesterole mia
Withhold or stop drug in pts. at risk for renal failure caused by rhabdomyoly sis resulting from trauma, in serious acute conditions like myopathy
GI disturbances , headache, myalgia asthenia, insomnia muscle cramps, bronchitis, rash infection, flu like syndrome allergic reactions
ANATOMY AND PHYSIOLOGY
Human system is also called our cardiovascular system, and is composed of our heart plus our arteries and veins. In a person’s heart, the atria (plural of atrium) receive blood from the veins and the ventricles send blood to the arteries. As the arteries become more finely divided, they are called arterioles. The finest divisions of our vascular system are called capillaries. As the vessels get larger again, the smallest are called venules which join and enlarge to form veins. Note that the distinction between arteries and veins is by direction of blood flow, not oxygen content. Veins carry blood toward the heart and arteries carry it away from the heart. Because of this, not all arteries carry oxygenated blood. The two major exceptions, in which arteries are carrying deoxygenated blood are the pulmonary artery which carries deoxygenated blood from the heart to the lungs (to pick up oxygen there) and the umbilical arteries which carry deoxygenated blood away from the baby’s body to the placenta (to pick up oxygen there). We have double circulation: we have a separate pulmonary circuit to the lungs and a systemic circuit to the body.
26 The path of blood flow in a human, then, is as follows:
1. The superior (a) and inferior (b) vena cava are the main veins that receive blood from the body. The superior vena cava drains the head and arms, and the inferior vena cava drains the lower body. 2. The right atrium receives blood from the body via the vena cavae. The atria are on the top in the heart.
3. The blood then passes through the right atrioventricular valve, which is forced shut when the ventricles contract, preventing blood from reentering the atrium.
4. The blood goes into the right ventricle (note that it has a thinner wall; it only pumps to lungs). The ventricles are on the bottom of the heart.
5. The right semilunar valve marks the beginning of the artery. Again, it is supposed to close to prevent blood from flowing back into the ventricle.
27 6. The pulmonary artery or pulmonary trunk is the main artery taking deoxygenated blood to the lungs.
7. Blood goes to the right and left lungs, where capillaries are in close contact with the thin-walled alveoli so the blood can release CO2 and pick up O2.
8. From the lungs, the pulmonary vein carries oxygenated blood back into the heart.
9. The left atrium receives oxygenated blood from the lungs.
10. The blood passes through the left atrioventricular valve.
11. The blood enters the left ventricle. Note the thickened wall; the left ventricle must pump blood throughout the whole body.
12. The blood passes through the left semilunar valve at the beginning of the aorta.
13. The aorta is the main artery to the body. One of the first arteries to branch off is the coronary artery, which supplies blood to the heart muscle itself so it can pump. The coronary artery goes around the heart like a crown. A blockage of the coronary artery or one of its branches is very serious because this can cause portions of the heart to die if they don’t get nutrients and oxygen. This is a coronary heart attack. From the capillaries in the heart muscle, the blood flows back through the coronary vein, which lies on top of the artery.
14. The aorta divides into arteries to distribute blood to the body.
28 15. Small arteries are called arterioles.
16. The smallest vessels are the capillaries.
17. These join again to form venules, the smallest of the veins.
These, in turn, join to form the larger veins, which carry the blood back to the superior and inferior vena cava. PHYSIOLOGY OF THE HEART The work of the heart is to pump blood to the lungs through pulmonary circulation and to the rest of the body through systemic circulation. This is accomplished by systematic contraction and relaxation of the cardiac muscle in the myocardium. Conduction System An effective cycle for productive pumping of blood requires that the heart be synchronized accurately. Both atria need to contract simultaneously, followed by contraction of both ventricles. Specialized cardiac muscle cells that make up the conduction system of the heart coordinate contraction of the chambers. Cardiac Cycle The cardiac cycle refers to the alternating contraction and relaxation of the myocardium in the walls of the heart chambers, coordinated by the conduction system, during one heartbeat. Systole is the contraction phase of the cardiac cycle, and diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8 second.
29 Heart Sounds The sounds associated with the heartbeat are due to vibrations in the tissues and blood caused by closure of the valves. Abnormal heart sounds are called murmurs. Heart Rate The sinoatrial node, acting alone, produces a constant rhythmic heart rate. Regulating factors are reliant on the atrioventricular node to increase or decrease the heart rate to adjust cardiac output to meet the changing needs of the body. Most changes in the heart rate are mediated through the cardiac center in the medulla oblongata of the brain. The center has both sympathetic and parasympathetic components that adjust the heart rate to meet the changing needs of the body. Peripheral factors such as emotions, ion concentrations, and body temperature may affect heart rate. These are usually mediated through the cardiac center.
30 PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTION Predisposing factors • Age- 64 y.o • Hypertension • High HDL; Low LDL • Diabetes Mellitus Precipitating Factors: • Coronary atherosclerotic heart disease • Coronary thrombosis/ embolism • Decreased blood flow
Myocardial Oxygen supply
Altered Cell Membrane Int.
Stimulation of Baroreceptors
Stimulation of Sympathetic Receptors
Afterload Decreased Myocardial Tissue Per.
Increased myocardial oxygen demand
S/Sx:- chest pain, oliguria, ECG changes, Elevated CK-M, Troponin T, LDH, AST Myocardial Oxygen Demand
Mechanisms of Occlusion Most MIs are caused by a disruption in the vascular endothelium associated with an unstable atherosclerotic plaque that stimulates the formation of an intracoronary thrombus, which results in coronary artery blood flow occlusion. If such an occlusion persists long enough (20 to 40 min), irreversible myocardial cell damage and cell death will occur.5 The development of atherosclerotic plaque occurs over a period of years to decades. The initial vascular lesion leading to the development of atherosclerotic plaque is not known with certainty. The two primary characteristics of the clinically symptomatic atherosclerotic plaque are a fibromuscular cap and an underlying lipid-rich core. Plaque erosion may occur due to the actions of metalloproteases and the release of other collagenases and proteases in the plaque, which result in thinning of the overlying fibromuscular cap. The action of proteases, in addition to hemodynamic forces applied to the arterial segment, can lead to a disruption of the endothelium and fissuring or rupture of the fibromuscular cap. The degree of disruption of the overlying endothelium can range from minor erosion to extensive fissuring that results in an ulceration of the plaque. The loss of structural stability of a plaque often occurs at the juncture of the fibromuscular cap and the vessel wall—a site otherwise known as the plaque's "shoulder region." Any amount of disruption of the endothelial surface can cause the formation of thrombus via plateletmediated activation of the coagulation cascade. If a thrombus is large enough to completely occlude coronary blood flow for a sufficient time period, MI can result. • Mechanisms of Myocardial Damage
The severity of an MI is dependent on three factors: the level of the occlusion in the coronary artery, the length of time of the occlusion, and the presence or absence of collateral circulation. Generally speaking, the more proximal the coronary occlusion, the more extensive is the amount of
32 myocardium at risk of necrosis. The larger the MI, the greater is the chance of death due to a mechanical complication or pump failure. The longer the time period of vessel occlusion, the greater the chances of irreversible myocardial damage distal to the occlusion. The death of myocardial cells first occurs in the area of myocardium that most distal to the arterial blood supply—that is, the endocardium. As the duration of the occlusion increases, the area of myocardial cell death enlarges, extending from the endocardium to the myocardium and ultimately to the epicardium. The area of myocardial cell death then spreads laterally to areas of watershed or collateral perfusion. Generally, after a 6- to 8-hour period of coronary occlusion, most of the distal myocardium has died. The extent of myocardial cell death defines the magnitude of the MI. If blood flow can be restored to at-risk myocardium, more heart muscle can be saved from irreversible damage or death.
A.) IDEAL NURSING CARE PLAN • Nursing Diagnosis: Acute pain may be related to tissue ischemia secondary to coronary artery occlusion • Possibly evidenced by Reports of pain with our without radiation Facial grimacing Restlessness, changes in level of consciousness Changes in pulse, BP • Desired outcomes Patient will verbalize relief control of pain Demonstrate use of relaxation techniques Display reduced tension, relaxed manner, ease of movement INTERVENTIONS Independent 1. Obtain full description of pain from patient including location, intensity (010), duration; quality (dull/crushing); and radiation 2. Instruct patient immediately to report RATIONALE Pain is a subjective experience and must be described by the patient. Assist patient to quantify pain by comparing it to other experiences.
pain Delay in reporting pain hinders pain relief/ may require increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnosis and relief of pain. Decreases external stimuli, which may aggravate anxiety and cardiac strain and limit coping abilities and adjustment to current situation.
3. Provide quiet environment, calm activities, and comfort measures (e.g., dry/ wrinkle—free linens, backrub). Approach the patient calmly and confidently 4. Assist/ instruct in
relaxation Helpful in decreasing perception of/
34 techniques, e.g, deep/ slow breathing, response to pain. Provides a sense of distraction behaviors, visualization, having some control over the situation, guided imagery increase in positive attitude. Collaborative 5. Administer supplemental oxygen by Increases amount of oxygen available means of nasal cannula for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia Administer medications as indicated, e.g.: • Antianginals, e.g nitroglycerin Nitrates are useful for pain control by coronary vasodilating effects, which (Nitro-Bid, Nitro-stat, Nitro-Dur) may increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial work and oxygen demand. Beta-blockers, e.g., pindolol, propanolol atenolol, Important second-lineagents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. morphine Although IV morphine is the usual drug of choice, other injectable narcotics may be used in acute phase/ recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload.
Analgesics, e.g., sulfate (Demerol)
Nursing diagnosis Risk for decreased cardiac output may include changes in rate, rhythm, electrical conduction, reduced preload/ increased SVR, infracted/dyskinetic muscle
Possibly evidenced by Presence of signs and symptoms establishes actual diagnosis Desired outcomes
Patient will demonstrate hemodynamic instability, e.g., BP, cardiac output within normal range, adequate urinary output, decreased/ absent dysrhythmias, Report decreased episodes of dyspnea,angina Demonstrate an increase in activity tolerance INTERVENTIONS Independent 1. Evaluate quality and equality of pulses, as indicated RATIONALE Decreased cardiac output results in diminished weak/ thready pulses. Irregularities suggest dysrhythmias, which may require further evaluation. Monitoring. S3 is usually associated with HF, but it may also be noted with mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening and pulmonary or systemic hypertension Heart rate and rhythm respond to medication and activity, as well as developing complications/ dysrhythmias, which could compromise cardiac function or increase ischemic damage. Large meals may increase myocardial workload and cause vagal stimulation resulting in bradycardia/ ectopic beats. Caffeine is direct cardiac stimulant that can increase heart rate. 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.
2. Auscultate heart sound Note development of S3,S4
3. Monitor heart rate and rhythm. Document dysrhythmias via telemetry
4. Provide small/ easily digested meals. Restrict caffeine intake, e.g., coffee, chocolate, cola Collaborative 5. Administer antidysrhythmics drugs and ACE inhibitors as indicated
Tissue perfusion, altered, risk factors may include reduction/ interruption of blood flow, e.g., vasoconstriction, hypovolemia/ shunting and thromboembolic formation • Possibly evidence by Presence of signs and symptoms establishes an actual diagnosis • Desired outcome Patient will demonstrate adequate tissue perfusion as individually appropriate, e.g. skin warm and dry, peripheral pulses present/strong, vital signs within patient’s normal range, patient alert/ oriented, balanced intake/ output,absence of edema, free of pain/ discomfort. INTERVENTIONS RATIONALE Independent 1. Inspect for pallor, cyanosis, Systemic vasoconstriction resulting mottling, cool/ clammy skin. Note from diminished cardiac output may be strength of peripheral pulses evidenced by decreased skin perfusion and diminished pulses. 2. Encourage active/ passive leg Enhances venous return, reduces exercises, avoidance of isometric venous stasis, and decreases risk of exercises thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption. 3. Monitor respirations, note work of Cardiac pump failure may precipitate breathing respiratory distress, sudden/ continued dyspnea may indicate thromboembolic pulmonary complications 4. Monitor intake, note changes in Decreased intake/ persistent nausea urine output. Record urine specific may result in reduced circulating gravity volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function. Collaborative 5. Administer medications, e.g.:
37 • Ranitidine antacids (Zantac), Reduces or neutralizes gastric acid, preventing comfort or gastric irritation, especially in presence of reduced mucosal circulation
Nursing diagnosis Activity intolerance may be related to imbalance between myocardial oxygen supply and demand; presence of ischemia/necrotic myocardial tissues; cardiac depressant effects of certain drugs (Beta- blockers, antidysrythmics)
Possibly evidenced by Alterations in heart rate and BP with activity Development of dysrythmias Changes in skin color/ moisture Exertional angina Generalized weakness
Desired outcomes Patient will demonstrate measurable/ progressive increase in tolerance for activity with heart rate/ rhythm and BP within patient’s normal limits and skin warm, pink, dry. Report pain absent/ controlled within time frame for administered medications
INTERVENTIONS RATIONALE Independent 1. Promote rest (bed/ chair) initially. Reduces myocardial workload. Oxygen Limit activity on basis of pain/ consumption, reducing risk of hemodynamic response. Provide complications (e.g., extension of MI) nonstress diversional activities. 2. Instruct patient to avoid increasing Activities that require holding the breath abdominal pressure, e.g., straining and bearing down (Valsalva maneuver) during defecation can result in bradycardia, temporarily reduced cardiac output, and rebound tachycardia with elevated BP. Progressive activity provides a 3. Explain pattern of graded increase controlled demand on the heart,
38 of activity level, e.g., getting up in increasing strength and preventing chair when there is no pain, overexertion progressive ambulation, and resting for 1 hour after meals Lengthy/ involved conversations can be 4. Limit visitors and or/ visit by patient, very taxing for the patient; however, initially periods of quiet visitation can be therapeutic Collaborative 5. Refer to program • cardiac Provides continued support/ additional rehabilitation supervision and participation in recovery and wellness process
Nursing diagnosis Anxiety may be related to threat to or change in health and socioeconomic status; threat of loss/ death; unconscious conflict about essential values, beliefs, and goals of life
Possibly evidenced by Fearful attitude Apprehension, increased tension, restlessness, facial tension Uncertainty, feelings of inadequacy Somatic complaints/ sympathetic stimulation Focus on self, expressions of concern about current and future events Fight or flight behavior
Desired outcomes Patient will recognize feelings; identify causes, contributing factors; verbalize reduction of anxiety/ fear; demonstrate positive problemsolving skills; identify/ use resources appropriately
INTERVENTIONS RATIONALE Independent 1. Maintain confident manner (without Patient and SO can be affected by the false reassurance) anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety. 2. Accept but do not reinforce use of Denial can be beneficial in decreasing denial. Avoid confrontations. anxiety but can postpone dealing with
39 the reality of the current situation. Confrontation can promote anger and increase use of denial, reducing cooperation and possibly impeding recovery. 3. Encourage patient/ SO to Sharing information elicits support. communicate with one another, Comfort and can relieve tension of sharing questions and concerns unexpressed worries 4. Provide rest periods/ uninterrupted Conserves energy sleep time, quiet surroundings, with coping abilities patient controlling type, amount of external stimuli and enhances
Collaborative 5. administer antianxiety/ hypnotics as Promotes relaxation/ rest and reduces indicated, e.g., diazepam (Valium), feelings of anxiety lorazepam (Ativan), flurazepam (Dalmane) B.) ACTUAL NURSING MANAGEMENT
“Ah! Dili jud makatarong ug tulog. Maka mata-mata man jud labi
na dini sa hospital. Ug tigulang naman “ as verbalized by the patient verbalizations of interrupted sleep complaints of not feeling rested yawning pain/ discomfort
Sleep pattern disturbance related to internal factors such as illness, psychologic stress and external factors such as facility routines At the end of 2 days, the patient will be able to report improvement of sleep/ rest pattern and verbalize increased sense of well- being and feeling rested.
At the end of 4 hours, the patient will be able to get enough uninterrupted sleep/ rest. 1. provided comfortable bedding and some of own possession, e.g., pillows Rationale: Increases comfort for sleep as well as physiologic and psychologic support 2. Maintained environment conducive to sleep/ rest (e.g. quiet comfortable temperature, ventilation and closed door) Rationale: This Provides atmosphere conducive to sleep 3. Encouraged position of comfort, assist in turning Rationale: Repositioning alters areas of pressure and promotes rest 4. Provided nursing aids (e.g. back rub, bedtime care, pain relief, comfortable position [semi- fowler’s], relaxation techniques) Rationale: To promote rest, relaxation; to induce sleep 5. Attempted to allow for sleep cycles for at least 90 minutes Rationale: Experimental studies have indicated that 60- 90 minutes are needed to complete one sleep cycle and the completion of an entire cycle is necessary to benefit from sleep. At the end of 4 hours, the patient was able to have sleep and verbalized of feeling rested.
At the end of 2 days, the patient was able to verbalize a fair improvement of his sleep/ rest pattern in between his medication/ treatment regimen.
“Dili ko palakwon sa doctor kay dili pwede sa ako mangusog kay sakit akong heart” as verbalized by the patient
patient report chest pain with radiation to epigastrium pain scale of 6 facial grimaces changes in vital signs, baseline: HR=54 bpm, BP=140/90 mmHg
-Acute pain related to tissue ischemia of myocardial tissue secondary to myocardial infarction.
At the end of 30 minutes, patient will be able to verbalize relief of pain, display reduced tension, relaxed manner and ease of movement 1.) Obtained full description of pain from patient including location, intensity (0-10), duration, quality and radiation. Rationale: Pain is a subjective experience and must be described by the pt. Assist pt. to quantify pain by comparing it to other experiences. 2.) Maintained bed rest at least during periods of pain. Rationale: To reduce workload of the heart 3.) Positioned patient comfortably, in moderate high back rest Rationale: This allows for lung expansion by lowering the diaphragm
42 4.) Instructed patient in relaxation techniques, i.e., deep/slow breathing Rationale: Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation, increase in positive attitude. COLLABORATIVE 5.) Administered supplemental oxygen by means of nasal cannula @ 3L/min. Rationale: Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia Administered medications as indicated such as: • • Isosorbide dinitrate (Isordil) 5 mg tab SL for 3 doses every 5 minutes if chest pain is not relieved Isosorbide OD P.O Rationale: to reduce cardiac oxygen demand by decreasing preload and afterload. Increases blood flow through the collateral coronary vessels. mononitrate (Imdur) 60 mg ½ tab
At the end of 30 minutes, patient was able to verbalize a slight relief of chest pain and demonstrated the use of relaxation techniques.
“Dili ko pwede mangusog kay magsakit akong heart.” as verbalized by the patient.
weakness Patient’s report of pain
43 Changes in v/s
Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow.
At the end of 2 hours, patient will verbalize a relief from pain and discomfort.
1.) Initially assess document and report to the following physician. Patients description of chest discomfort, including location, intensity, radiation, duration and factors that affect it. Other symptoms such as nausea, diaphoresis complains of universal fatigue.
2.) Monitored respiration and note work of breathing. 3.) Assess GI functions and monitor fluid intake and urine output. 4.) Obtained a 12- lead ECG recording during the symptomatic event as prescribed to determine extension of infarction COLLABORATIVE: 5.) Administered oxygen @ 3L/min via nasal cannula. Rationale: Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia
At the end 2 hours, patient verbalizes the relief from discomfort around the chest.
“Hypertensive nako dugay ra kadto pa ning 55 anyos pa ako edad.” as verbalized by the patient. Elevated BP=140/90 mmHg
Increased creatinine= 6.17 mgs/dl Urine output of less than 30 ml/hr
Decreased cardiac output related to diminished blood flow caused by increased vascular resistance.
At the end of 1 hour, patient will be able to achieve and maintain BP within acceptable range.
1.) Monitored BP using proper equipment with cuff bladder that is twothirds diameter. Rationale: To detect changes from baseline that indicate changes in cardiovascular status
2.) Maintained fluid and dietary sodium restrictions. Rationale: To reduce fluid restriction which contributes to hypertension 3.) Discouraged intake of coffee, tea, cola and chocolate which are high in caffeine. Rationale: Caffeine stimulates sympathetic nervous system
45 4.) Maintained physical and emotional rest. Rationale: Sedatives can be used to reduce stress and associated vasoconstriction; to reduce cardiac workload 5.) Administered antihypertensive as prescribed: • atenol (Therabloc) 50 mg 1 tab now then OD Rationale: A beta-blocker that selectively blocks beta-adrenergic receptors, decreases cardiac output and cardiac oxygen consumption and depresses rennin secretion
At the end of 1 hour, patient was able to maintain BP within individually acceptable range.
REFERRALS AND FOLLOW – UP
(Health teaching) Advised patient to take prescribed medication at regular basis; Atenolol( therabloc) 50 mg.tab once a day P.O Clopidogiel ( plavix) 75 mg. tab once a day P.O ISMN ( Imdur) 60 mg tab once a day P.O Atorvastatin calcium ( lipitor) once a day P.O At the hospital, patient is advised to initiate gradual exercise such as; a) Lying or sitting exercises ( arms, legs, trunk) b.) Exercise progress to standing and slow walking in the hall. c.) Exercise must be done twice a day for about 20 minutes d.) Exercises (Deep, pursed lip or deep breathing exercises) In the hospital, patient is provided with the following treatment ;
46 a.)Supplemental oxygen by nasal cannula @ 2-4 L/min. b.)Cardiac monitoring for continued surveillance of hearts activity. c.)Frequent monitoring of vital signs including temperature , pulse rate ( apical/ radial) and blood pressure and intake and output d.)Pharmacologic management to stabilize client condition. When the patient will be discharge, out patient program consist of supervised , oven ECG monitored , exercised training based on the results of exercised stress test .support and guidance related to the treatment of the disease and education and counseling related to lifestyle modification . Client is advised to follow the prescribed recommended diet ; a) Diabetic diet: eat complex CHO foods with high fiber content avoid added sugar and concentrated sweets and all other CHO foods and eat regularly. b) Eat foods low in calorie, saturated fats and cholesterol; restriction of sodium; avoidance of spicy foods soft fiber food and take small frequent feedings
Recommendations Advised the patient for followed up check up from his assigned physician. Advised patient peer for frequent monitoring of his vital sign to avoid any risk and possible complication Explain the purpose and preparation for diagnostic test to have clear understanding of procedures and what is happening increase feeling of control and lessens anxiety. Provide positive reinforcement for gains/ improvement and participation in self care/treatment program. This encourages continuation of healthy behavior.
47 Advice patient to take his medication at home as prescribed by the physician for continues medication treatment. Suggest engaging in relaxing, non strenuous activity to avoid any risk due to over stress Teach client on coping mechanisms with recurring pain and other clinical manifestations Encourage patient to eat nutritious food like vegetable fruits, foods the high fiber contain like cereal and foods rich in protein.
EVALUATION & IMPLICATION (PROGNOSIS)
This case study was done successfully although we experienced some difficulties analyzing the health status of the client and understanding the medical orders given. Using our critical thinking, we were able to carefully identify the problem of our patient who needs direct interventions for the wellness of his health. Moreover, the group was able to discuss some health teachings as stated above for the improvement of the client’s health and fast recovery. The patient was able to understand the imparted health teachings and verbalized to consistently follow his treatment regimen in home care management. Although patient’s blood pressure did not lower down to his normal range of blood pressure, other clinical manifestations such as severe chest pain was not subjectively verbalized by the patient and labored breathing was not evident. Still, patient has unproductive, dry cough. Mr. Sarmiento is progressing well in his health condition and is for discharge any soon. Patient may have an uncomplicated episode of myocardial infarction and may return to normal activities and lifestyle with moderation and modification to some of those.
Upon assessment last July 3, 2007, patient X was received with a diagnosis of Acute myocardial infarction; Hypertensive cardiovascular disease; ruled out
48 PUD; diabetic nephropathy. Pt. was sitting on bed and complaint on pain on chest area upon coughing was noted. Instructed to do deep, breathing exercises everytime chest pain is recurring. Pertinent data about the patient’s family and personal health history were gathered. The next day on the group’s duty, pt. has oxygen inhalation regulated at 3l/min via nasal cannula and vital signs were monitored every 4 hours with special consideration to the client’s blood pressure. Due medication were properly given and kept patient in moderate, high back rest and kept comfortably on bed, keeping back dry. Pt. was observed for any unsualties during the shift. No further complaints were noted from the patient.
On the 2nd day of duty the doctor ordered that client may go home the next day if stable. So, the group imparted health teachings important for the client to follow as his home care management. We helped the client in discharged planning and reminded them the health teachings that we had discussed.
This study also tests our abilities and skills on how to find answers to the patient’s problem, what action to be done in order to solve it and how to properly and correctly use our initiative for the success and for the good outcome of our care study. This is one of our tasks as a student or future nurses and it serves as our training ground backed up with strict training in order for us to become equipped, productive, efficient, and world-class nurses in the future.
B I B L I O G R A P H Y
• Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10th edition) Lippincott-Raven Publisher.Copyright 1996
49 • Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education Inc.,Copyright 2000 Mosby’s Pocket Dictionary of Medicine, Nursing and Allied Health (4th edition) Elsevier(Singapore) PTE LTD> Copyright 2002 Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing Patient Care(6th edition) F.A Davis Company. Copyright 2000 Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition). Addison esley Longman Inc. 1998. MacMahon, S. Blood pressure and the risk of cardiovascular disease. N Engl J Med 2000; 342:50
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HTML1Rollins Gina. "With smoking cessation drugs, dosing is key", ACPASIM Observer, 22(4); 1,16-17.
W E B L I O G R A P H Y
• • http://biology.clc.uc.edu/courses/bio105/circulat.htm wwwmedlib.med.utah.edu\webpath\TUTORIAL\MYOCARD\MYOCARD