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. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV.

Introduction....................................................................................................................3 Objectives......................................................................................................................5 Patient’s Data.................................................................................................................6 Genogram.......................................................................................................................7 Health Status..................................................................................................................9 Complete Diagnosis.....................................................................................................12 Developmental Data.....................................................................................................16 Physical Assessment....................................................................................................20 Anatomy and Physiology.............................................................................................23 Pathophysiology...........................................................................................................34 Doctor’s Order….........................................................................................................40 Diagnostic Examination..............................................................................................50 Drug Study..................................................................................................................64 Nursing Care Plan.......................................................................................................93 Prognosis....................................................................................................................108

XVI. Bibliography..............................................................................................................110

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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.

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Perfecto Pandacan Balili. (+) LVH. hypercholesterolemia (high cholesterol levels in the bloodstream). 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). This patient is Mr. (+) LVD. 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. I had a patient with a diagnosis of CAD. During my clinical exposure in the Coronary Care Unit at the Davao Medical Center last November 27-29. high blood pressure and smoking. obesity.In the Philippines. a 60 years old male and will be the focus of my case study. 2006. and 40 percent of those between 20 and 29 already have prehypertensive findings. These risk factors include diabetes. FC III. AMIK II. 4 .

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.OBJECTIVES General Objective: Through this paper. This case study would preserve and improve the quality of nursing responsibilities by rendering care. Myocardial Infarction. this paper would be able to: • • • • • • • • • Present the patient’s 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 patient’s predisposing and precipitating factors Interpret and present the Physician’s orders 5 . I will be able to present details about Coronary Artery Disease. Specifically. and whole heartedly in a manner that the client. making use of the patient’s records from the hospital. holistically. The proponent gathered data through interviewing the patient and his watchers. spiritually. the student nurses and others would benefit. AMI AFFECTIVE: Have a purposeful interaction with the client’s significant others PSYCHOMOTOR: Enhance the ability to identify and apply nursing interventions to provide a better care for the client’s suffering from the mentioned illness. and other researches to provide the readers information about the said condition.

Davao City Civil Status: married Religion: Roman Catholic Citizenship: Filipino Birthday: July 9. Hospital Number: 919684 6 . Ecoland. Voltaire Egnora Medical Diagnosis: Coronary Artery Disease. Sabrosa Village. 2006.M. Acute Myocardial Infarction Killip’s II. Left Ventricular Dilatation. 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. 12:01 P. FC III Chief Complaint: Dyspnea Date and Time Admitted: November 12.• • • • 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 State the prognosis and relate it with the patient’s condition PATIENT’S DATA Patient’s Name: Perfecto Pandacan Balili Age: 60 years old Sex: Male Address: Barangay 76-A. Left Ventricular Hypertrophy.

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AMI Rheumatic Heart Disease Renal Failure Arthritis Pneumonia 9 .LEGEND: Couple Deceased Asthma Cancer Twin Hypertension Heart Problem Pulmonary Tuberculosis CAD.

But when Mr. Davao City Chief Complaint: Dyspnea Medical Diagnosis: Coronary Artery Disease. Perfecto has always been a taxi driver. Ecoland. except for some years in between when the family went to Manila but apparently they also came back here in Davao. Aside from that within the 6 girls there is a twin and the same applies with the 5 boys. He worked as a taxi driver both here in Davao and even when they came to Manila he also worked as an FX driver. Sabrosa Village. In addition. Personal Data Patient’s Name: Perfecto Pandacan Balili Age: 60 years old Sex: Male Address: Barangay 76-A. 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. educational needs and others with only this kind of job. 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. Left Ventricular Hypertrophy.HEALTH STATUS A. apparently their third set of twins died due to miscarriage. she got pregnant with only a years difference on all of her children. According to Mrs. Acute Myocardial Infarction Killip’s II. Balili they got married when she was in third year high school because she already got pregnant with their first child. 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. FC III B. Family Background The family has been living in Ecoland ever since Perfecto and Lydia got married. Back then when their children was young Mr. Balili experienced his first 10 . All of their children are currently married except for the youngest three. Mr. The couple has eleven children with 6 girls and 5 boys. 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. currently the couples children are in Manila. one is in Japan and three stayed here in Davao. Left Ventricular Dilatation. He supported his family’s daily needs.

Carlos and Lucia. Perfecto was diagnosed of pulmonary tuberculosis and he sought medical help from the Barangay Health Center. He is also fond of eating meat compared to fish and vegetables. Two weeks PTA. had PTB and 3 of his children had pneumonia. He had difficulty sleeping during the night. loss weight. 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. 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. they get their financial support in their daughter who is in Japan. which they bought for P4. Three days PTA. patient has been having episodes of chest pain at the left anterior chest 11 . Other than that they have no trace of any hereditary diseases. His fourth attack happened only last July 2006.heart attack in Manila. decrease appetite and experienced paroxysmal nocturnal dyspnea. had asthma. History of Past Illness Back in 1986. He was then given the 6 months treatment for PTB. he temporarily stopped driving and took a rest. Jeffrey. Jackilyn. Perfecto’s son. Furthermore. patient had bipedal edema. the patient had his available oxygen via oxygen tank in his house as aid for his breathing. He also had an air conditioned room at his home just to aid his condition. D. History of Present Illness One month PTA. Among his siblings. 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. He can consume half a box of cigarette in a day and this started during his twenties. One of his sisters had a renal failure and hypertension. Perfecto’s father died due to cancer and his mother died due to asthma. His daughter. He is a hard drinker and started drinking when he was only a teenager. 3 of his siblings had pulmonary tuberculosis namely Emilio. Adrian.500. Some of his vices include drinking and smoking. C. Perfecto had his first attack 7 years ago. he had his first and second heart attack in Manila. His third and fourth heart attack happened in Davao. after the completion of the medication the patient failed to have a follow-up check-up after the treatment. had Rheumatic Heart Disease and his son.

Perfecto already had five heart attacks and his condition got worse every time this happens. He then took isosorbide mononitrate SL but without relief. lasting for a minute.radiating to the arm. As observed the family is not really affluent and that they are having financial problems due to the recurrent attacks of the patient. Persistence of symptoms prompted this admission. they are being assisted by his daughter. In addition. Jackilyn. 12 . Luckily. E. Aside from the financial help the family is greatly affected by the patient’s condition and thus still tries their best to live a normal life. 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. he had recurrence of chest pain of the same character. Five hours PTA. Effects and Expectation of Illness to Family Mr. who had a Japanese husband and currently resides in Japan. with a previously diagnosed coronary artery disease by 2D Echo result. he also had a senior citizen’s identification card that becomes a big aid in their financial needs.

organ. any bodily abnormality or failure to function properly (Webster Dictionary) 13 . FC III Coronary • • Term applied to vessels (Stedman’s Medical Dictionary. or relating to the heart (http://education.wikipedia. or system (Medical Dictionary by Gupta and Gupta) Disorder with a specific cause and recognizable signs and symptoms.com/reference/dictionary/entry/coronary) Artery • A vessel through which the blood passes away from the heart to the various parts of the body (Stedman’s Medical Dictionary. 25th Edition) Any departure from health of a structure.yahoo.org/wiki/Artery) Disease • • • A definite morbid process having a characteristic train of symptoms (Stedman’s Medical Dictionary. 25th Edition) • • 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. Acute Myocardial Infarction Killip’s II. 25th Edition) Used to describe the arteries that supply blood to the muscle tissue of the heart. Left Ventricular Dilatation. Left Ventricular Hypertrophy. or the veins that take blood away from it (Microsoft® Encarta® Premium Suite 2005) • Relating to or being the coronary arteries or coronary veins.COMPLETE DIAGNOSIS Diagnosis: Coronary Artery Disease.

gov/health/dci/Diseases/Cad/CAD_WhatIs. It is composed of cardiac muscles and forms the greater part of the heart wall. 25th Edition) Cessation of blood flow by thrombus formation and causing issue death (Medical Dictionary by Gupta and Gupta) 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. (The Bantam Medical Dictionary) Occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed (http://www. being thicker in the ventricles than in atria. 9th Edition) • • Characterized by the presence of atherosclerosis in the epicardial coronary arteries. (http://education.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.html) Acute • Having rapid onset.yahoo. (Microsoft® Encarta® Premium Suite 2005) The middle of 3 layers forming the wall of the heart. 25th Edition) Myocardial • • • Pertaining to the muscular tissue of the heart (Stedman’s Medical Dictionary.nhlbi. 25th Edition) Relating to or affecting the thick muscular wall of the heart.nih.ask.com/reference/dictionary/entry/myocardial) Infarction • • • Formation of an infarct (coronary thrombosis) (Stedman’s Medical Dictionary. short or relatively severe course (Stedman’s Medical Dictionary.com/infarction) 14 .

affecting or relating to a ventricle (Microsoft® Encarta® Premium Suite 2005) One of the chambers of the heart.com/reference/dictionary/acutemyocardial infarction) Ventricular • • • Pertaining to ventricles (Stedman’s Medical Dictionary.com/dictionary/left ventricle) Hypertrophy • Morbid enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells (Stedman’s Medical Dictionary. 25th Edition) Involving.com/diseasemanagement/cardiology/complications/compl ications.Killip’s 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.yahoo.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. The resulting oxygen shortage causes damage and potential death of heart tissue (http://en. 25th Edition) • An increase in cell size (Medical Dictionary by Gupta and Gupta) 15 . the largest and the most important chamber (www.htm) • It is a disease that occurs when the blood supply to a part of the heart is interrupted (http://www. tachycardia or signs and symptoms or right heart failure like venous or hepatic congestion (Harrison’s Internal Medicine) Myocardial Infarction • A disease that occurs when the blood supply to a part of the heart is interrupted.ask.clevelandclinicmeded.

expanded. especially a part of something else.• Increase the size of a tissue or organ brought about by the enlargement of its cells rather than by cell multiplication.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. muscles undergo these changes in response to increased work (http://education. that has become enlarged.yahoo. or enlarging or being enlarged something.yahoo. or stretched (Microsoft® Encarta® Premium Suite 2005) • 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.com/reference/dictionary/hypertrophy) Dilatation • • The act or process of widening or being widened. stretching or being stretched. can climb one or less than one flight of stairs 16 .

He easily gets tired and constantly needs assistance upon doing things or moving about. For most people it is the time when children have grown and moved away or are moving away from home. Thus. 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. The family agreed that Perfecto has achieved this because he was able to perform his role well. Physical changes that occurred to Perfecto were his decreasing ability to perform activities. In men. Establishing and maintaining an economic standard of living. Achieving adult. He is able to support his eleven children and send them to school although unfortunate personal circumstances hindered eight of them from finishing school. He did a very good job since he was also able to support the schooling of his wife. The climacteric (andropause) refers to the changes of life in men. Ever since he got married he did his best to support his family. These tasks are: 1.DEVELOPMENTAL DATA The middle years from 40-65. The psychological problems that men experience is generally relate to fear of getting old and to retirement. 2. Androgen levels decreases very slowly. Both men and women experience decreasing hormonal production during the years. 17 . partners generally have more time for and with each other and time to pursue interests they may have deferred for years. when sexual activity decreases. Although this is the case Perfecto is a responsible citizen and is concerned for the betterment of his family and community. He worked as a taxi driver both here in Manila and Davao. boredom and finances. civic and social responsibility. have been called the years of stability and consolidation. there is no change comparable to menopause in women. he had seven tasks to accomplish according to Havighurst’s theory. however men can still have children even in late life. Robert Havighurst’s Developmental task theory Since Perfecto belonged to the middle-aged group. Physical Development A number of changes take place during the middle years. Perfecto works really hard for his family.

watching television or talking to neighbors and establish good relationships. Relating oneself to one’s spouse as a person. 7. Accepting and adjusting to the physiologic changes of middle age. He noted that there are levels of achievement that a person must achieve or experience. and the significant task is to perpetuate culture and transmit 18 . Adjusting to aging parents. Back then he would smoke and drink with his male friends but ever since he ha his first attack he stopped his vices. He observed that middle age is when they tend to be occupied with creative and memorable work and with issues surrounding their family. a person develops throughout his lifetime. 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. The greater the achievement of a person. Assisting teenage children to become responsible and happy adults. 4. In this stage work is most crucial. According to Erik Erikson the middle adulthood belongs to the generativity versus stagnation. 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. 5. 6. Failure to achieve the task may affect the person’s ability to achieve the next task. They value each others opinion and respect each others decisions. He is the authority of the house and he makes sure that he is able to guide his children to the right path. Usual petty fights happen between the couple but they are able to patch things up and still work as a couple. It is when they expect to “be in charge”. Perfecto’s parents died many years ago and so he is very well adjusted now and accepted the fact that everyone dies eventually.3. Developing adult leisure time activities. These can be achieved and be ranked as partial. They spend they leisure time talking at each other. 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. Psychosocial Development According to Erik Erikson. complete or unsuccessful. He is very well aware that his body is no longer like before and that each attacks that occurs is worse than the previous. the more he is better and healthier in development of hid personality.

As their children leave home. he has on the stage wherein he is still guiding some of his children. 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. This is not due to a decrease in ability.and the struggle with finding new meanings and purposes. He is aware of social responsibility and develops leisure activities and hobbies appropriate for his age. Problem solving abilities remain throughout adulthood. Moral Development The middle adulthood remain at the conventional level or may move to post conventional level. although the time response may be slightly longer. Cognitive Development Cognitive and intellectual abilities of the middle adult change very little from the young adults. This shows that he is very positive when it comes to problem solving. he is on the middle adulthood stage. they can become self-absorbed and stagnate. If they do not get through this stage successfully. As of now. especially if the person had sustained responsibility for the welfare of others and has consistently applied ethical principles developed in adolescence. the adult believes that the rights of others take precedence and takes steps to support those rights. According to my patient. which Erikson calls generativity. and when they are in this stage they often fear inactivity and meaninglessness. In the case of my patient. 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. There is motivation to learn. At this level. He had undergone 4 attacks before and he was still very positive & opens to any modification regarding his health just to live longer. especially if the knowledge gained can be immediately applied and had personal relevance. 19 . every problem has a solution. their goals change and they may be faced with major life changes-midlife crisis.values of the cultures through the family and working to establish a stable environment. He was able to surpass this problem because of his positive attitude towards problem solving. but rather due to longer memory research of increased amounts of material. But being the head of the family continues to be his role only with restrictions on some actions. Strength comes through the care of others and production of something that contributes to the betterment of society. He is now concerned more on his children’s future. One example was his admission due to his debilitating illness.

He is able to distinguish right from wrong. He has his personal values as to the standards of our society.My patient belongs to post conventional level or self accepted moral principles. He respected and takes priority the rights of others and also maintains self respect. 20 . But the decision is still coming from him. He views each of then as right and proper because that is what the society wants. He decides on his own if he should follow the things that the society dictates him or simply follow what is right for him. He believes that relationships are based on mutual trust.

regular rhythm Temp. 21 . conscious. coherent & responsive. II.43 bpm. His facial movements are symmetric and he has a thin. Both left and right pupils are black in color with pupillary size of 3mm.PHYSICAL ASSESSMENT I. no wounds or lesions are noted. Scalp is dry but there is no presence of dandruff or lice upon inspection V. Eyes Eyes have symmetrical lids and normal periorbital area. Scars in lower extremities are observed. Conjunctiva is pale and sclera is observed to be anicteric. The patient has poor skin turgor and clammy to touch.5’ C III. white in color hair.25 cpm. The client has a generalize weakness and needs assistance upon moving or position changes. Perfecto Balili. 2006 in Davao Medical Center. Upon assessment the patient was lying on bed in moderate high back rest and is awake. Vital Signs: BP. was admitted on November 12. evenly distributed. with O2 inhalation @ 5Liters per minute via nasal cannula.36. a 60 year old male client. Skin The color of the skin is brown with rough and dry texture. General appearance & mental status Mr. He has an IVF of D5W 500cc @ 300cc level running at KVO infusing well @ right cephalic vein. He has difficulty of breathing and is constantly expectorating whitish phlegm into his bedside receptacle. He is 5’6” in height and weighs 59 kg. irregular rate and rhythm RR. is wearing a hospital gown and has diaper. IV.110/80mmHg CR. Head He has a normocephalic configuration with head circumference of 22 cm.

Teeth were yellowish in color with loose teeth. He has productive cough with whitish phlegm. VIII. He has no difficulty of swallowing and no halitosis and bleeding noted upon observation. His pericardial area is flat and heart sound is weak and irregular in rate and rhythm with a rate of 43 bpm. Nose The client’s nasolabial fold is normal. No nasal flaring is noted and both nostrils are patent. Mouth The mucosa and gums of the client are pinkish and lips are dry. XI. No hearing problem noted. VII. Ears Client’s ears are symmetrical and are in line with the outer canthus of the eyes. He has an O2 inhalation via nasal cannula. septum is medially located and no discharges are noted. eye bugs present with eyebrows and eyelashes evenly distributed. There are no lesions noted. His pinnae are normal. he do not use dentures. There are no deformities or inflammation on the nose noted. No tenderness and lesions noted. X. His tongue is medially located. Wheezing is noted upon auscultation with symmetrical chest expansion. lesions or tenderness noted on these areas. Chest and Lungs The client has rapid. The areolas are bilaterally the same and are dark brown in color.briskly reactive to light. normoset and symmetric. Heart and Breast The client has symmetrical. regular breathing at the rate of 25 cpm. Absence of discharges on the external canal is noted. VI. Neck There are no signs of abnormal growth or enlargement of the nodes of the neck of the client.. IX. There are no masses. He is hooked to a 22 . He has a capillary refill time of 4 seconds. Client wears eyeglasses only upon reading. rounded shape breast with smooth surface. He has a slightly sunken periorbital region.

Abdomen The skin in this area has uniform color and no lesions. There are no lesions or discharges noted. He can defecate without difficulty at least once a day. Weakness upon movement is noted. XIII. Genito-Urinary The client wears diaper but voids freely. He can extend and flex both his upper and lower extremities with (-) bipedal edema or anasarca.cardiac monitor with Atrial Fibrillation in slow to moderate response with ST elevation pattern. 23 . He has normal bowel sound of one every 15 seconds. XIV. He has dirty and untrimmed nails on all extremities. An IVF of D5W 500cc @ KVO rate infusing well @ right cephalic vein @ 300cc level XII. with flat abdominal contour thus there is no evidence of an enlarged spleen or lived noted. Back and Extremities Client needs assistance upon moving around and in doing activities of daily living.

There are two circulatory "circuits": Pulmonary circulation. and then returns blood to the left atrium through the pulmonary veins (PV). and gases (oxygen. which is a muscular pumping device. Veins return blood to the heart. (Arteries carry blood away from the heart. and a closed system of vessels called arteries. veins.) • heart: a muscular pump to move the blood The Cardiovascular System In order to pump blood through the body. and capillaries.ANATOMY and PHYSIOLOGY The cardiovascular system is sometimes called the blood-vascular or simply the circulatory system. veins. capillaries) which carry blood to/from all tissues. The left side of the heart pumps blood to the rest of the body through the aorta. the heart is connected to the vascular system of the body. carbon dioxide) to and from cells. and then returns blood to the right atrium through the venules and great veins. arterioles. As the name implies. The right side of the heart pumps blood to the lungs through the pulmonary artery (PA). The pulmonary artery carries oxygen-poor blood from the 24 . It transports food. hormones. Components of the circulatory system include: • • blood: consisting of liquid plasma and cells Blood vessels (vascular system): the "channels" (arteries. pulmonary capillaries. The cardiovascular system is actually made up of two major circulatory systems. arteries. systemic capillaries. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs. It consists of the heart. 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. 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." delivers blood to and from the lungs. metabolic wastes. acting together. involving the "right heart.

All systems ultimately return to the "right heart" via the inferior and superior vena cava. hormones. liver.nutrients (proteins. Pulmonary veins carry oxygen-rich blood from the lungs back to the "left heart. neutrophils and lymphocytes are the most important. driven by the "left heart. Maintenance of pH level near 7. Major Blood Components Component Type Platelets. cholesterol) 3. Transport of large molecules (e. wastes (urea. and organs (bone marrow. Blood Components • Forty-five percent (45%) consists of cells . consisting of 90% water and 10% dissolved materials -. thymus). and white blood cells (neutrophils. the liquid component of blood. B-cells produce antibodies. • Fifty-five percent (55%) consists of plasma. basophils. red blood cells. Of the white blood cells. Blood clotting 25 . Lymphocytes (leukocytes) Red blood cells (erythrocytes). spleen. salts."right heart" to the lungs. the body is able to eliminate the products of cellular breakdown and bacterial invasion." carries blood to the rest of the body. lymph T-cells attack cells containing nodes viruses. enzymes Bone marrow Phagocytosis 1. monocytes). vessels (lymphatics). Waste products are removed by the liver and kidneys.g.platelets. Immunity (globulin) 4. cell fragments Source Function Bone marrow Blood clotting life-span: 10 days Bone marrow. and through the lymph nodes and into the lymph. A specialized component of the circulatory system is the lymphatic system. Immunity spleen. Filled with Bone marrow Oxygen transport hemoglobin.4 2. eosinophils. creatinine)." Systemic circulation. Through the flow of blood in and out of arteries. a compound of iron and protein Neutrophil (leukocyte) Plasma. where oxygenation and carbon-dioxide removal occur. lymph nodes. and into the veins. lymphocytes. glucose). consisting of a moving fluid (lymph/interstitial fluid). Food products enter the system from the digestive organs into the portal vein.

Veins Blood leaving the capillary beds flows into a series of progressively larger vessels. called venules. The aorta is the largest artery in the body. elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. veins use one-way valves controlled by muscle contractions. Arteries use vessel size. The major branches of the aorta (aortic arch.(fibrinogen) Vascular System . The extensive network of capillaries is estimated at between 50. nutrients. Arteries Arteries are strong. ascending aorta. Capillaries are the points of exchange between the blood and surrounding tissues. Arteries divide into progressively thinner tubes and eventually become fine branches called arterioles. descending aorta) supply blood to the head. Veins have valves that prevent back-flow of blood. and extremities.000 miles long.the Blood Vessels Arteries. which in turn unite to form veins. which carries blood to the lungs to be oxygenated. Pressure in veins is low. the main artery for systemic circulation. with the exception of the pulmonary artery. which lie bathed in interstitial fluid. Materials cross in and out of the capillaries by passing through or between the cells that line the capillary. and wastes. to move blood by pressure. abdomen. produced by the lymphatic system. Capillaries The arterioles branch into the microscopic capillaries. so veins depend on nearby muscular contractions to move blood along. veins.000 and 60. Veins are responsible for returning blood to the heart after the blood and the body cells exchange gases. Blood in arteries is oxygen-rich. and capillaries comprise the vascular system. 26 . Of special importance are the right and left coronary arteries that supply blood to the heart itself. or lymph. Arteries and veins run parallel throughout the body with a web-like network of capillaries connecting them. controlled by the sympathetic nervous system. or capillary beds.

right left atrium (LA). of the heart. with the exception of the pulmonary veins. a thick media is no longer needed. Anatomy of the Heart The heart is about the size of a man's fist.Blood in veins is oxygen-poor. but the proportions of these layers differ. then snap back to push the blood forward when the heart rests. along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits. By the time blood reaches the veins. the as a pump with and left ventricle chambers of the ventricles lower chambers heart is oriented rotated about 30 27 are the larger. Located between the lungs. As blood enters the capillaries. The two smaller. Valves in the arteries prevent back-flow. The innermost is the intima. The smooth-muscle media walls expand when pressure surges. Artery/Vein Tissues Arteries and veins have the same three tissue layers. Surrounding muscles act to squeeze the blood along veins. often take the name of the organ served. (LV). which carry oxygenated blood from the lungs back to the heart. As with arteries. valves are again used to ensure flow in the right direction. the pressure falls off. next comes the media. Arteries have thick media to absorb the pressure waves created by the heart's pumping. there is little pressure. two-thirds of it lies left of the chest midline. completely separates oxygenated from deoxygenated blood. Thus. The exceptions are the superior vena cava and the inferior vena cava. and the outermost is the adventitia. The major veins. The heart. The in the chest . like their companion arteries. Internally. heart upper the and right ventricle atria two are the atrium (RV). heart is designed four chambers (RA). which collect body from all parts of the body (except from the lungs) and channel it back to the heart.

Each myofibril. Each myosin molecule contains what is called a myosin head. elongated structures. Ventricular contraction forces blood into the arteries. in turn. Cardiac Muscle Cardiac muscle is a type of involuntary mononucleated. The action potential causes these compartments to release the calcium into the cell. The left ventricle is generally about twice as thick as the right ventricle because it needs to 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. This calcium allows myosin heads to bind to actin filaments and pull them by a process called a power stroke. Inside each cardiomyocyte are hundreds of myofibrils which are thin. The tricuspid valve is between the right atrium and right ventricles.degrees to the left lateral side such the right ventricle is the most anterior structure of the heart. The valves. Its function is to "pump" blood through the circulatory system by contracting. Each of the thin filaments is composed of a protein called actin. The pulmonary valve is between the right ventricle and the pulmonary artery. Inside each cardiomyocyte there are compartments filled with calcium. insure that blood only flows in one direction in the heart. 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 heart also has four valves. consists of thin filaments and thick filaments. Each of the thick filaments is composed of a protein called myosin. That is how action potential causes the individual muscle cells to contract. 28 . striated muscle found exclusively within the heart. or uninucleated. under normal conditions. Each myosin filament is composed of about 200 myosin molecules.

The Circulation Poorly oxygenated blood collects in two major veins: the superior vena cava and the inferior vena cava. S2. Any splitting in which the closing of the two valves are heard separately should be considered pathological. 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 closing of these two valves occurs with beginning of backward flow in the pulmonary artery and aorta respectively as the ventricles relax. into the right ventricle. if heard should occur 120-170 msec after S2. Each pump or beat of the heart consists of two parts or phases diastole and systole. The blood is then pumped through the tricuspid valve. For the purposes for this discussion of cardiac physiology. S3 occurs at the end of the rapid filling period of the ventricle during the beginning of (ventricular) diastole. S3. During diastole the ventricles are filling and the atria contract. The two valves can occur simultaneously or with slight gap between them under normal physiologic circumstances. and S4.Basic Cardiac Physiology A basic understanding of cardiac physiology is also essential to interpreting the physical finding during a cardiac exam. S2 occurs near the end of (ventricular) systole with the closing of the pulmonary and aortic valves. The superior and inferior vena cava empty into the right atrium. Then during systole. S1 occurs near the beginning of (ventricular) systole with the closing of the tricuspid and mitral valves. blood is pumped through the pulmonary semi-lunar valve into the pulmonary artery. or right atrioventricular valve. From the right ventricle. S4 occurs. we will focus on the physiology associated with the heart sounds S1. The closing of these two valves with increasing pressure in the ventricles as they begin to contract should be simultaneous. This blood leaves the heart by the pulmonary arteries and travels through the lungs (where it is oxygenated) and into the pulmonary veins. An S3. if heard coincides with atrial contraction at the end of (ventricular) diastole. The oxygenated blood then enters the left 29 . the ventricles contract while the atria are relaxed and filling.

The left ventricle is thicker and more muscular than the right ventricle because it pumps blood at a higher pressure. blood is pumped through the aortic semi-lunar valve into the aorta. Peripheral tissues do not fully deoxygenate the blood. Interspersed among the atrial muscle fibers 30 . inter-nodal fibre bundles 3. only in a lower concentration in comparison to arterial blood. atrioventricular node (AV node) 4. the SA node is often referred to as the pacemaker of the heart. Once the blood goes through systemic circulation. From the left ventricle. the action potential generated in the nodal tissue spreads throughout both atria at a rate of approximately 0. which will again be collected inside the vena cava and the process will continue. the blood then travels through the bicuspid valve. Therefore. 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. It lies along the anterolateral margin of this chamber between the orifice of the superior vena cava and the auricle.atrium. Also. atrioventricular bundle The sinoatrial (SA) node is a small mass of specialised cardiac muscle situated in the superior aspect of the right atrium. thus venous blood does have oxygen. The Heart's Conduction System There are four basic components to the heart's conduction system 1. into the left ventricle.3 meter per second and produces atrial contraction. also called mitral or left atrioventricular valve. sinoatrial node (SA node) 2. Since the fibers of the SA node fuse with the surrounding atrial muscle fibers. From the left atrium. the right ventricle cannot be too powerful or it would cause pulmonary hypertension in the lungs. peripheral tissues will extract oxygen from the blood.

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. Each cardiac cycle lasts approximately 0. Blood Pressure and Heart Rate The heart beats or contracts around 72 times per minute. the right and left bundle branches. 1. This results in a contraction of the ventricles that proceeds upward from the apex of the heart toward its base. it enters specialized muscle fibers called Purkinje fibers. Once the action potential leaves the AV node. or the bundle of His. Ordinarily this occurs about 72 times each minute. Their endings terminate upon ordinary cardiac muscle within the ventricles.e. This is important because it permits the atria to complete their contraction and empty their blood into the ventricles before the ventricles contract. The Purkinje fibers are very large and conduct the action potential at about six times the velocity of ordinary cardiac muscle (i. As the AV bundle leaves the AV node. These are grouped into a mass termed the atrioventricular (AV) bundle.are several inter nodal fiber bundles which conduct the action potential to the atrioventricular (AV) node with a greater velocity (approximately 1.0 meters per second).3 to 0. Here there is a short delay (approximately 0. Terminal Purkinje fibers extend beneath the endocardium and penetrate approximately one-third of the distance into the myocardium. 31 .0 meter per second) than ordinary atrial muscle.. and the impulse proceeds through the ventricular muscle at about 0.1 second) in transmission of the impulse to the ventricles. The human heart will undergo over 3 billion contraction/cardiac cycles during a normal lifetime. Each of these descends along its respective side of the interventricular septum immediately beneath the endocardium and divides into smaller and smaller branches. Thus the Purkinje fibers permit a very rapid and simultaneous distribution of the impulse throughout the muscular walls of both ventricles.5 to 4. The spontaneous generation of an action potential within the SA node initiates a sequence of events known as the cardiac cycle. it descends in the interventricular septurn for a short distance and then divides into two large branches.8 second and spans the interval from the end of one heart contraction to the end of the subsequent heart contraction.5 meters per second. The AV node is located in the right atrium near the lower part of the interatrial septurn.

Heart valves open and close to limit flow to a single direction. Atria contract while ventricles relax. The blood moves out of the chamber. and vice versa. This electrical impulse spreads throughout the atrial muscle and leads to contraction of the two atria. Blood (like any other fluid) tends to flow from a region of high pressure to one of lower pressure. the AV valves remain open and additional blood is forced into the ventricles from the veins. when the various one-way valves guarding those chambers permit it to do so. includes atrial contraction and relaxation. ventricular contraction and relaxation. the ventricles are relaxed (in diastole). 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. A large amount of blood has already passed from the atria to the ventricles prior to atrial contraction. The spontaneous generation of an action potential within the SA nodal tissue represents the start of the cardiac cycle. or cardiac cycle. the aortic and pulmonic semilunar valves close. Ventricular contraction forces blood through the semilunar valves into the aorta and pulmonary trunk. the AV valves close as the ventricles begin their contraction. The aortic and pulmonary (pulmonic) semilunar valves remain closed. As each chamber of the heart fills with blood. and a short pause. the AV valves open. As the atria contract. and blood flows into the ventricles to begin another cycle. the pressure increases within it. While the atria are in systole. The sound of the heart contracting and the valves opening and closing produces a characteristic "lub-dub" sound. Next.One heartbeat. 32 . After the ventricles have filled (mostly by blood returning from the large veins) and the atria have contracted. as the ventricles begin to relax. The atria relax during ventricular systole and remain in this phase even during a portion of ventricular diastole.

There are three slow. Signals from the medulla regulate blood pressure. and T. blood is forced backward. 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 the atria do finally contract. Receptors in the arteries and atria sense systemic pressure. 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. the pressure within them soon exceeds that in the aorta and pulmonary trunk. the T wave the ventricular contraction ("the dub"). Although the ventricles exist as closed chambers for a brief moment. negative changes. the AV valves are effectively closed and blood is prevented from regurgitating back into the atria. and a sharp rise in ventricular pressure occurs. The P wave represents atrial contraction ("the lub"). Nerve messages from these sensors communicate conditions to the medulla in the brain. When this pressure differential is reached. EKG) An electrocardiogram measures changes in electrical potential across the heart and detects contraction pulses that pass over the surface of the heart. Even before the atria enter systole. Positive deflections are the Q and S waves. As the ventricles contract.As the ventricles contract. the blood is forced in a retrograde fashion against the AV valves. known as P. R. closing the AV valves. Electrocardiography (ECG. which causes them to bulge inward slightly toward the atria and which also elevates atrial pressure. 33 . In doing so. Near the end of ventricular systole the AV valves are still closed and since the atria are in the process of filling. the ventricles are filled with blood to approximately 70% of their capacity. blood within the atria pushes the AV valves open and begins to fill the ventricles once again. additional blood enters the ventricles and elevates the intraventricular pressure. this too contributes to a rise in intra-atrial pressure.

and 3) to facilitate the absorption of fat (in the villi of the small intestine). thymus). lymph organs (bone marrow. "Lymph" is a milky body fluid that also contains proteins. All lymph nodes have the primary function (along with bone marrow) of producing lymphocytes.The Lymphatic System The lymphatic system functions 1) to absorb excess fluid. Contraction of skeletal muscle causes movement of the lymph fluid through valves. The thymus secretes a hormone. 34 . groin. or interstitial fluid. fats. or to the cardiovascular system. and a type of white blood cells. Lymph vessels connect to lymph nodes. thymosin. where they mix with lymph. which produces T-cells. 2) to defend the body against microorganisms and harmful foreign particles. • • The spleen filters. • Lymph nodes are small irregularly shaped masses through which lymph vessels flow. liver. Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in having valves that prevent backflow. or purifies. thus preventing tissues from swelling. spleen. the blood and lymph flowing through it. a form of lymphocyte. Capillaries release excess water and plasma into intracellular spaces. and neck. called "lymphocytes." which are the body's firstline defense in the immune system. Clusters of nodes occur in the armpits.

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

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

Individuals with history of CAD are more predisposed to reoccurrence or development of heart diseases. Formation of fatty streaks within the endothelium and lamina. Progressive narrowing of the arterial lumen would result to gradual weakening of the myocardium.low-density lipoproteins. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. body will compensate through vasodialation. Rationale Collection of fats. Since there is already previous formation of atherosclerosis and obstruction within the myocardial artery the person may then easily develop the same problem. Development of fatty streaks between the endothelium and internal elastic lamina. cells and debris result to development of fatty streaks. 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. But increase in occlusion will result to gradual weakening of the myocardium. Stress √ X History of CAD √ √ Stress stimulates the cardiovascular system by the release of cathecolamines. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. body will compensate through vasodialation. which in turn increase the heart rate and produce vasoconstriction. Damage to the heart limits the output of the left ventricle. Damage to the heart limits the 37 Symptomatology Present (√) / Absent (x) Dyspnea √ Bradycardia √ Pulmonary Edema X . Poor ventricular compliance would result to dyspnea. Progressive narrowing of the arterial lumen. This would then result to decrease in the cardiac output. Progressive narrowing of the arterial lumen. But increase in occlusion will result to gradual weakening of the myocardium. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease.

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. Von Willebrand factor (vWF) and fibrinogen are multivalent molecules which bind to two different platelets simultaneously. 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. Production and release of thromboxane A2 result to further platelet activation. Coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. initial platelet monolayer forms at the site. serotonin) promote platelet activation. Speed can become so slow that the spreading impulse is preserved long enough for the uninjured muscle to complete its contraction. When mural thrombus forms at site of rupture. Slowed electrical signal still traveling within the injured area can re-enter and trigger the healthy muscle to beat again too soon. Poor ventricular compliance would result to Pulmonary edema. epinephrine.Chest pain √ S3 heart sound X output of the left ventricle. 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. resulting in platelet cross-linking and aggregation. This result to increase rate or volume of ventricular filling enabling us to hear a third heart sound. Various agonists (collagen. 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. Rapid rhythm abnormalities can occur and negatively influence the function of the heart. Speed can become so slow that the spreading 38 . and potential resistance to thrombolysis. ADP. Coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. Conversion of prothrombin to thrombin.

It then releases cardiac enzymes that trigger the pyrogens which increases the temperature of the body. 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. Rapid rhythm abnormalities can occur and diminished ventricular compliance. Obstruction of blood flow to certain parts of the heart allows the pyruvic acid to produce lactic acid that injures the myocardial tissue. This prevents the heart from pumping blood effectively thus resulting to an abnormal intraventricular conduction leading to abnormal heart rate and rhythm.S4 heart sound √ Arrhythmia √ Fever X impulse is preserved long enough for the uninjured muscle to complete its contraction. 39 . Slowed electrical signal still traveling within the injured area can re-enter and trigger the healthy muscle to beat again too soon.

40 .

DOCTOR’S ORDERS Date/Time November 12. respiratory every hour and record • Done • Venoclysis D5W 500cc x KVO rate • Done 12:10 pm • Diagnostics: Complete Blood Count • Done .2006 Doctor’s Order • Admit under white service Rationale • Patient is admitted under the white service for close monitoring • LSLF is ordered for patients with cardiac conditions to decrease the salt and fats that further aggravates the pt’s current condition • Monitoring of TPR is done to detect any variation or changes from the normal range that would determine an abnormality in the patient’s condition • It is an isotonic solution that is needed by our body to help regulate the body’s nutrients. pulse. it doesn’t swell or shrink the cell. This analyzes the 3 major types of cells in the body which are the 41 Remark • Done • Low salt low fat diet • Done • Temperature. Regulated only at the rate to maintain vein open for emergency and IVTT meds • Complete Blood Count offers necessary information about the kinds and numbers of cells in the blood.

Red Blood Cell. hypertrophy and other disorders • Primarily ordered to determine if heart attack or other changes in the heart occurred • ISMN is the treatment for anginal • • • • Done Done Done Done Chest x-ray • Not Done Electrocardiogram • Done Troponin T qualitative • Done • Therapeutics Isosorbide Mononitrate (ISMN) 60mg/tab ½ tab OD Isosorbide Dinirate (ISDN) • Done • Done 42 . White Blood Cell and Platelet Platelet Random Blood Sugar Creatinine Sodium. conduction disturbance. Potassium • Blood test evaluates platelet production • Detects alterations in glucose metabolism • For evaluation of renal function • 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.

promoting chest expansion • Done • Done Lactulose 30cc at HS • Moderate High Back Rest • • Done Done • Monitor intake and output • Done • Done • O2 at 4Lpm via nasal cannula • 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 supply • Done • Hook to cardiac monitor • Done • Refer accordingly 43 . 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 • For chronic constipation • Lowers diaphragm.5mg/tab 1 tab now Metoprolol 50mg/tab ½ tab BID attacks • ISDN is the treatment for anginal attacks • Done Captopril 25mg/tab ½ tab OD Atorvastatin 80mg/tab 1 tab OD • Treat hypertension.

12:30 pm • Retrieve previous 2Decho result c/o watcher and attach to chart • Monitor the patients BP. 2006 • To CCU • Done 44 .25 mg/tab OD November 12. CR and ECG reading • It is necessary to refer any unusualities to the physician prevent further complications • Have a basis of the patient’s 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 • Done • • Done Done • Repeat ECG after 6 hours • Additional meds ASA 80mg/tab OD Clopidogrel 25mg/tab OD • Done • Done Enoxaparin 6000 IV every 12 hours Furosemide 40mg 1 tab OD • 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 • Place in a special area for close • Done • Done Digoxin 0.

2006 (+) chest pain • Complete bed rest without bathroom privilege • Refer • Give Isordil 5mg SL • If not relieved by Isordil may give Tramadol 1 amp IVTT 10:35 am (+) Chest tightness O2 = 96 BP = 140/120 • Give Isordil 5g SL now • Start Isoket drip D5W 500cc + 1 amp Isoket to run out at 10cc/hr • Avoid valsalva maneuver • Continue meds • • • Counteracts potassium loss induced by other diuretics. Measures time required for a fibrin clot to form • Done Done Done • • Done Done • • • • Done Done Done Done • • Done Done • Done • For Pro-time • Done 45 . for edema and hypertension • Medication needs to be continued for continuity of treatment • Minimize the workload of the heart and promote rest • 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. • Screens for lack of coagulation factors necessary for blood clotting. temporarily reduced cardiac output and rebound tachycardia with elevated BP.monitoring 8:30 pm • Start O2 5Lpm per nasal cannula • Furosemide 40 mg IVTT now • Spironolactone 100 mg 1 tab now then OD • Refer November 13.

Carvedilol 6. ASA 80 mg 1 tab OD 7.• Activated Partial Thromboplastin Time • Refer • Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting • • Done Done 6:30 pm 7:30 pm 8:45 pm (+) chest pain • Isordil 5mg SL now • Increase Isoket drip to 15cc/hr • Morphine 2mg IVTT now • • • Management of severe pain. Spironolactone 25mg 1 tab OD 2. 2006 100/64 November 15. pulmonary edema and pain associated with MI • Done Done Done November 14.25 mg/tab OD 3.6ml SQ every 12 • Discontinue meds not in review of medicines • Refer • Continue meds • Refer • • Done Done • Treatment for essential hypertension and CHF • • • • Done Done Done Done 46 .25mg ½ tab OD 4. Captopril 25mg/tab OD 5. Atorvastatin 80 mg tab OD 6. 2006 10:20 am 98/61 I = 1085 O = 800 (-) chest pain (+) bowel • Repeat ECG 12 leads with long lead II • Review of medicines 1. Clopidogrel 75mg/tab OD 8. Enoxaparin 0. Digoxin 0.

movement November 16, 2006 2:50 am (+) chest pain 7:15 am still with occasional chest pain

• Give Isordil 5mg 1 tab SL now then PRN for chest pain

• Done

November 17, 2006 9:30 am

November 18, 2006 (+) chest pain 125/98 November 19, 2006 8:30 am

• 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 ½ tab OD • Continue all other meds • 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

• Done • Done • Treatment for constipation • Done • Done • Done • Done • Done • Done • Not Done • Done • Done • Done • • • • • Done Done Done Done Done

November 20, 2006 7:20 am 102/68 9:00 am (+) chills (+) dyspnea 130/100 O2 sat 97 Hgt 72 130/90

• Start Warfarin 5mg ½ tab OD • For stat Complete blood count, Platelet count and Creatinine • Referred due to dyspnea • Diagnostics:

• Prophylaxis and treatment of venous thrombosis, pulmonary embolism, AF with embolization and management MI

• Done • Done

• Done • Determine blood 47

Hemogluco test now Electrocardigram now Arterial Blood Gas now Creatinine, Sodium, Potassium • Give D5W 50cc 1 vial slow IVTT now • Refer once with result November 21, 2006 7:22 am (-) chest pain • Review of medicines Spironolactone 20 mg 1 tab OD Digoxin 0.25 mg ½ 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 ½ tab OD Warfarin 5mg ½ tab OD Enoxaparin 0.6 ml SQ every 12 hours • Refer • Diagnostics: Repeat Protime • Continue all meds • Refer • Ceftazidime 1gram IVTT q8 ANST (-) • Clindamycin 300mg 1cap q6 PO • For repeat chest x-ray today • Continue antibiotics • Paracetamol 500mg 1tab q4 • Refer

glucose level • Determine the acid-base balance and/or the respiratory or metabolic status • A hypertonic solution used for the treatment of hypoglycemic shock

• Done • Done • Done • Done • Done • Done • Done

November 22, 2006

• Done • Done • Done • Done • Third generation cephalosporins used as treatment for infection • Anti-infective for infection • Done

• Done • Done • Done • Done

November 23, 2006 7:05am

• For mild to moderate pain and fever

48

November 24, 2006 8:00am (+) epigastric pain (+) increase salivation (-) chest pain 8:15 am

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

• Management for GERD and duodenal ulcer

• Done • Done • Done • Done

• 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

• Done • Done • Treatment of gastric mucosal lesions, acute gastritis and gastric ulcer • Done

10:30am

• Done • Done • Done • Short-term treatment for duodenal and gastric ulcer and GERD • Prevention and treatment of hypothrombinemia associated with excessive doses of anticoagulants • Treatment and prevention of nausea and vomiting • Done

1:00pm

• Vitamin K 1 ampule IVTT OD • Refer 4:15 pm • Metoclopramide 1

• Done • Done

• Done

49

start levofloxacin 500mg/cap OD • Still for repeat protime • Refer • Resume Coumadin (Warfarin) 2. 2006 November 26.5mg ½ 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 of mild reflux • Done • Done • Done • Done • Done • Done • Done • Done. Potassium • Continue meds • Continue all meds • Consume and discontinue ceftazidime. 2006 10:15am • Treatment of mild. moderate or severe infection November 28.November 25. 2006 9:35 am November 29. platelet count • Continue meds • Refer • Diagnostics: Follow up repeat CBC. 2006 10:30am 50 . Sodium. protime Not Done • Done • Done • Done • Not Done • Done • Done • Done • Done • Done • Not Done • Done • Done November 27. platelet Repeat protime. 2006 5:45 am ampule IVTT now • Hold clindamycin • House Omeprazole IV to Pantoprazole 40mg 1 tab OD • Rebamipide 100mg 1 tab TID • Repeat CBC.

35-7. 2006 Diagnostic Procedure Arterial Blood Gas(ABG).45 mmHg pCO2 35-45 mmmHg pO2 80-100mmHg HCO3 22. pCO2 represents the partial pressure carbon dioxide exerts in the arterial blood.0-27.3mmHg HCO3 14.0 mmol/L BE(ecf) (-2)-(+2) mmol/L Result pH 7.DIAGNOSTIC EXAMINATIONS Date November 12. HCO3 is an alkaline substance Normal values pH 7.1% Partially Compensated Respiratory Alkalosis 51 .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.2mmol/L BE(ecf) -7. identifies how well the lungs are oxygenating the blood.568mmHg pCO2 16mmHg pO2 137.8 Impression Increased pH Decreased pCO2. pO2 represents the partial pressure of oxygen in the blood. The pH is the measurement of the free hydrogen ion concentration in the blood. indicates non respi/meta disturbance or true base deficit Normal O2sat 80-100% O2sat 99. Increased pO2 Decreased HCO3 Decreased base excess.

2006 that functions as an important buffer in the blood stream.November 21. pH 7.6% Normal Decreased pCO2 Increased pO2 Decreased HCO3 Decreased base excess Normal Fully Compensated Respiratory Alkalosis 52 .45 mmHg pCO2 35-45 mmmHg pO2 80-100mmHg HCO3 22.2 mmHg HCO3 15. O2 sat is the amount of oxygen actually bound to the hemoglobin and available for transport throughout the body.0-27.35-7.439 mmHg pCO2 22.0 mmol/L O2sat 98.2 mmol/L BE(ecf) -9.9 mmmHg pO2 124.0 mmol/L BE(ecf) (-2)-(+2) mmol/L O2sat 80-100% pH 7.

chemical. or detect the presence of specific substance.0-145. 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. may indicate dehydration. severe CHF or urinary obstruction Normal Normal Increased.0 November 17. acute MI.5 mmol/L 123. 2006 Diagnostic Procedure Rationale Blood Chemistry Analysis of the physical.0 mmol/L 140 5.0-115. may indicate DM or stress Increased.5 mmol/L Chloride 098.5-5.0-106.0-145. Normal values Glucose RBS 3.0 mmol/L Result 6. Creatinine is essential in the evaluation of renal function. essential hypertension.Date November 12.53 Impression Increased. or metabolic acidosis Sodium 136.61 144 4. carried out to diagnose disease.1 107.52 146.5-5.0 Increased Normal Normal 53 . RBS is used as a random screen for glucose level.0 mmol/L Potassium 3. cardiac decompensation. and microbiological properties of blood.0 mmol/L Sodium 136. may indicate impaired renal function.0 mmol/L Potassium 3.0-115. Creatinine 53.90-6.10 Creatinine 53. monitor treatment.

2006 Sodium 136.4 Increased Normal Normal November 26.0 Normal Normal 54 .5-5.0 mmol/L Potassium 3.0-145.November 21.0 mmol/L Potassium 3.0-115.80 140 4. Creatinine 53.5 mmol/L 141 4.5 mmol/L 127. 2006 Responsible for maintaining water balance and cellular integrity through its influence on osmotic pressure.5-5.0-145.0 mmol/L Sodium 136.

2006 Diagnostic Procedure Blood Hematology Hemoglobin Rationale Evaluates blood loss.20-6.0-10.47 5. Evaluates anemia.0x10’3/uL Neutrophil 55-75% Lympocytes 20-35 Monocytes 2-10 Eosinophil 1-5 Basophil 0-1 Platelet 150-400x10’3/uL Result 157 0. It is an important component of red blood cell that carries oxygen and carbon dioxide to and from the tissues. blood replacement therapy and fluid balance and screens red blood cell status. polycythemia and Normal values Hgb 135-175g/L Hct 0. It is the measure of red blood cells within the volume and also evaluates dehydration and hypervolemia. Evaluates blood loss.Date November 12.40 67 21 10 2 0 132 Normal Normal Normal Normal Normal Normal Normal Normal Normal Impression Hematocrit Erythrocyte Decreased. anemia. may be due to medication. erythropoietic ability.10x10’6/uL WBC 5.52 RBC 4.40-0.08 5. blood clotting factor is decreased and so at high risk for 55 . anemia and response to therapy.

52 RBC 4. 2006 calculates red blood cell indices.10x10’6/uL WBC 5.26 Normal Normal Normal Increased. Increase neutrophil count may indicate parasitic or bacterial infection. Oxygen transport to the cells throughout the body depends upon sufficient numbers of red blood cells with adequate amount of hemoglobin.40-0. tissue necrosis and/or leukemic neoplasm. Leukocytes Evaluates a number of conditions and differentiates causes of alterations in the total WBC count including inflammation.20-6. may indicate infection.November 21.14 11. may indicate bacterial infection. inflammation. tissue necrosis or stress Increased.0x10’3/uL Neutrophil 55-75% Lympocytes 20-35 161 0. renal failure or advanced tuberculosis Normal Normal 91 6 Neutrophils Monocytes 2-10 Eosinophil 1-5 2 1 56 . infection. tissue necrosis or MI Decreased. Decrease spontaneous bleeding Hgb 135-175g/L Hct 0.0-10. metabolic disorder including diabetic acidosis. may indicate defective lymphatic circulation.49 5.

immune disease.40-0. may indicate defective lymphatic Monocyte Eosinophils Basophils Neutrophil 55-75% Lympocytes 20-35 74 14 57 . Lymphocyte Evaluate bacterial and viral infection.46 5.0x10’3/uL 165 0.10x10’6/uL WBC 5. leukemia and ulcerative colitis.83 Normal Normal Normal Decreased. may be due to medication. dietary deficiency or drug toxicity Normal Decreased. overwhelming infection. Evaluates function of phagocytic scavenger to remove foreigh materials.31 4. 2006 Hgb 135-175g/L Hct 0.0-10. it is believed to be related to allergic Basophil 0-1 Platelet 150-400x10’3/uL 0 133 Normal Decreased. Basophil function not understood as well as other white cell types.20-6. Elevated levels may indicate active viral infection and depressed level may indicate exhausted immune system.52 RBC 4. blood clotting factor is decreased and so at high risk for spontaneous bleeding November 25.in level may indicate infection and anemia. Primary influenced by antigen-body responses. may indicate bone marrow failure.

shock or CHF Normal Decreased. blood clotting factor is decreased and so at high risk for spontaneous bleeding Eosinophil 1-5 0 Basophil 0-1 Platelet 150-400x10’3/uL 0 141 58 . renal failure or advanced tuberculosis Increased. may be due to medication. Monocytes 2-10 12 circulation. It notes the platelet size and shape.and anaphylactic responses. Platelet Evaluates platelet production. may indicate infection such as tuberculosis and subacute bacterial endocarditis Decreased. Low levels predispose bleeding while high levels may increase the risk of thrombocytosis. may indicate stress response associated with trauma.

CHF.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.Negative Normal RBC.4. fever. 2006 Diagnostic Procedure Urinalysis.Specific gravity1.0 Specific gravity. trauma.8-7.6.025 Albumin. bacteria.yellow Appearanceslightly cloudy Normal Impression Hazy or cloudy urine may indicate the presence of RBC. may indicate renal problem Increased. acute infection.Negative Albumin.clear to slightly hazy Result Color.2 hpf Normal Pus cells.1.Pale-star colored to amber color Appearance.Date November 12. WBC.003. phosphate.0-2 hpf Sugar-(-) Result RBC . uric acid or spermatozoa Normal Normal Positive albumin may indicate nephritic syndrome.0.(+++) Sugar.8 Reaction.035 1.2530hpf Result pus cells 34hpf 59 . UTI. Normal Values Color. pus. may indicate presence of infection or tuberculosis Reaction. or kidney disease Normal Increased.

absence of thrombi or bacterial vegetations. normal blood flow within the heart. normal ventricular function. normal valve structure. normal valve structure. Rationale: This ultrasonic test diagnoses abnormalities in anatomy and valvular function within the heart. normal and patent arteries and/or veins of the heart. Normal findings: Normal anatomical structure and position.Date: May 15. shape & motion of various structures within the heart. absence of pericardial effusions Result: Echo-Doppler findings • • • • 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 Eccentric left ventricular hypertrophy with multisegmental wall Left ventricular ejection fraction of 23% Dilated left atrium Normal right atrium. it is a noninvasive test. main pulmonary artery & aortic root motion abnormal with depressed systolic function 60 . 2006 Diagnostic procedure: Echocardiogram (2D Echo report) test evaluates the size. Sound waves are bounced off the heart using a transducer to image the heart in motion as well as its valves and vessels.

including bony thorax. The rest of the included structures are unremarkable.Date: November 23. 2006 Diagnostic procedure: Chest x-ray is the most commonly performed diagnostic x-ray examination. Both costophrenic sulci are blunted. including the heart. It may also be used as a general screening tool or for a specific diagnostic purpose. fullness of the retro cardiac space and splaying of the carina. blood vessels and the bones of the spine and chest Rationale: Identify various abnormalities of the lungs and structures in the thorax. A chest x-ray makes images of the lungs. mediastinum. Normal Findings: Normal chest and surrounding structures. pleura. soft tissues. The heart is enlarged with inferolateral displacement of the cardiac apex. and great vessels Result: Study done in AP supine view. lungs. The rest of the lungs are clear. Please correlate with ECG findings Bibasal pneumonia with underlying minimal pleural effusion Apico-pleural thickening. Tracheal air column is at midline. It is also used to evaluate the status of respiratory abnormalities or cardiac conditions. airway. A thin band of opacity is noted in the right apex. Haziness is noted in both lower lung fields. Impression: • • • Left sided cardiomegaly. great vessels. The hemidiaphragms are obscured. right 61 . including identification of pulmonary diseases or orthopedic abnormalities. heart. ribs or diaphragm.

myocardial infarction and ischemia and pericarditis. absence of areas of infarct or ischemia First result: AF in MVR Old inferior wall infarct Incomplete RBBB. It is used to diagnose abnormal heart rhythms. conduction disturbances. Normal findings: Normal sinus rhythm. PVW R wave program Incomplete RBBB 62 . hypertrophy of cardiac chambers. normal conduction patterns. Anterolateral wall infarct Second result: Course AF in slow VR Infarction anterolateral wall LAD.Diagnostic procedure: Electrocardiogram (ECG) most common test of heart’s 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 heart’s response to therapy.

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.Date: November 12. 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 63 .

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. Rationale (APTT): Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting.Hematology: PROTIME and APTT Rationale (ProTime): Screens for lack of coagulation factors necessary for blood clotting.3 seconds Increased protime may indicate deficiency of clotting factors or circulating anticoagulant products 64 . 2006 Result: 40 seconds Increased Activated Partial Thromboplastin Time (APTT). 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. 2006 Result: 16.5 seconds Increased protime may indicate deficiency of clotting factors or circulating anticoagulant products November 16. 2006 Result: 19. may indicate vitamin k deficiency or presence of circulating anticoagulants November 22.

Indication: Acute treatment of anginal attacks. rash Drug Interaction: Additive hypotension with anti-hypertesiv. syncope. severe anemia. intensity. Net effect is reduced myocardial oxygen consumption. acute ingestion of alcohol. apprehension. paradoxical bradycardia GI: nausea. increase coronary blood flow by dilating coronary arteries and improving collateral flow of ischemic regions. pruritus. tolerance. long term prophylactic management of angina pectoris Contraindication: Hypersensitivity to nitrates. hypotension. cerebral hemorrhage Adverse Effects: CNS: headache. head trauma. decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume.DRUG STUDY Generic Name: Isosorbide Mononitrate Brand Name: Monoket Classification: Anti-angina Frequency/Route/Dose: 60 mg/tab ½ tab OD Action: Produces vasodilation. betaadrenergic blocking agents. duration. Nursing Responsibilities: • • • • • • • Assess location. abdominal pain Misc: Flushing. dizziness CV: tachycardia. 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 Advise to notify physician or other health care provider if dry mouth or blurred vision occurs 65 . weakness. vomiting. calcium channel blockers and phenothiazines.

head trauma. severe anemia.Generic Name: Isosorbide Dinitrate Brand Name: Isordil Classification: Anti-angina Frequency/Route/Dose: 5 mg/tab 1 tab now Action: Produces vasodilation. Net effect is reduced myocardial oxygen consumption. hypotension. pruritus. long term prophylactic management of angina Pectoris. Indication: Acute treatment of anginal attacks. increase coronary blood flow by dilating coronary arteries and improving collateral flow of ischemic regions. abdominal pain Misc: Flushing. dizziness CV: tachycardia. vomiting. Nursing Responsibilities: • • • • • • • Assess location. intensity. syncope. apprehension. paradoxical bradycardia GI: nausea. weakness. duration. rash Drug Interaction: Additive hypotension with anti-hypertesiv. decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume. 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 Instruct to take medication as directed Caution to make position changes slowly to minimize orthostatic hypotension Advise to avoid activities that requires alertness Advise to notify physician or other health care provider if dry mouth or blurred vision occurs 66 . treatment of chronic congestive heart failure Contraindication: Hypersensitivity to nitrates. tolerance. acute ingestion of alcohol. calcium channel blockers and phenothiazines. cerebral hemorrhage Adverse Effects: CNS: headache. betaadrenergic blocking agents.

cardiogenic shock. urinary retention Derma: rashes Endo: hyperglycemia. stuffy nose GI: constipation. peripheral vasoconstriction Resp: bronchospasm. depression. back pain Drug Interaction: Barbiturates. decreased libidourinary frequency. mental status changes. rifampicin: increase metabolism of metorpolol effect Cardiac glycosides. do not usually affect beta2 receptor sites Indication: Management of hypertension. reserpine: have additive effect when given with beta-blockers. vomiting. known alcohol intolerance Adverse Effects: CNS: fatigue. anxiety. dizziness.Generic Name: Metoprolol Brand Name: Lopressor Classification: Beta-Adrenergic blocking agents (Anti-hypertensive) Frequency/Route/Dose: 50 mg/tab ½ tab BID Action: Block stimulation of beta1 adrenergic receptors. prevention of myocardial infarction Contraindication: Uncompensated congestive heart failure. liver function abnormalities GU: impotence. hypoglycemia MS: joint pain. Indomethacin: decrease anti-hypertensive effect Nursing Responsibilities: • Always check apical pulse rate before giving drug 67 . pulmonary edema. cimetidine. diltiazem. insomia. diarrhea. nausea. drowsiness CV: bradycardia. verapamil: decrease hepatic clearance. congestive heart failure. pulmonary edema. hypotension. nervousness. verapamil: cause excessive bradycardia and increase depressant effect on myocardium. Chlorpromazine. memory loss. wheezing EENT: blurred vision. bradycardia or heart block. MAO inhibitors. Catecholamine-depleting drugs such as H2 antagonist. angina pectoris. weakness.

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 68 .• • • • • • Monitor BP.

oliguria. loss of taste perception. fever Drug Interaction: Excessive hypotension may occur with concurrent use of diuretics.Generic Name: Captopril Brand Name: Capoten Classification: ACE Inhibitors (Anti-hypertensive) Frequency/Route/Dose: 25 mg/tab ½ tab OD Action: Prevents production of angiotensin II. reduction of risk of death or development of congestive heart failure following myocardial infarction Contraindication: Hypersensitivity to ACE inhibitors. diarrhea GU: proteinuria. phenothiazines. elderly patients Adverse Effects: CNS: dizziness. hypotension. renal impairment. Additive hypotension with other anti-hypertensive. impotence Derma: rashes Hemat: neutropenia. nitrates. and acute ingestion of alcohol. hepatic impairment. agranulocytosis Misc: angioedema. weakness CV: hypotension. headache. insomia. Nursing Responsibilities: • • Monitor BP and pulse frequently Administer 1 hour before or 2 hours after meals for better absorption 69 . management of congestive heart failure. renal failure. Anti-hypertensive response may be blunted by NSAIDs. nausea. 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. increases levels and may increase risk of lithium or digoxin toxicity. fatigue. tachycardia. Absorption may decrease with antacids. angina pectoris Resp: cough GI: anorexia.

• • Instruct patient to take drug exactly as prescribed Instruct to notify physician or other health care provider is mouth sores. chest pain. sore throat. difficulty swallowing or skin rash occurs • • • Advise to avoid foods containing high levels of potassium or sodium unless directed Advise to avoid activities that require alertness Advise to make position changes slowly to prevent orthostatic hypotension 70 . fever. swelling of hands and feet. irregular heart beat.

presence of bowel sounds. 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. water. increasing fluid intake. belching. may be administered on an empty stomach for more rapid results Encourage to use other forms of bowel regulation. diabetes mellitus. flatulence. milk or carbonated citrus beverages to improve flavor. flatulence. and normal pattern of bowel function Assess color. consistency. distention. Anti-infectives may diminish effectiveness and antacids may decrease the effect of lactulose on colonic pH Nursing Responsibilities: • • • • • • Assess for abdominal distention. increasing mobility Caution patient that medication may cause belching. and amount of stool produced Instruct patient to take drug exactly as prescribed Mix with fruit juice.Generic Name: Lactulose Brand Name: Lactulose PSE Classification: Laxative (hyperosmotic) Frequency/Route/Dose: 30 cc at HS Action: Increases water content and softens stool. or abdominal cramping 71 . such as increasing bulk in the diet. lowers the pH of the colon. diarrhea Endo: hyperglycemia Drug Interaction: Should not be used with other laxatives. excessive or prolonged use Adverse Effects: GI: cramps.

cefoperazone. abdominal pain. allergic reactions Drug Interaction: May potentiate warfarin. vomiting. heartburn. Antiplatelet. May antagonize the beneficial effects of probenecid Nursing Responsibilities: • • • • • Assess pain and limitation of movement Assess fever and note associated signs Advise patient to take drug with food. hemolysis. prophylaxis of transient ischemic attacks and myocardial infarction Contraindication: Hypersensitivity to aspirin. Tell patient that sustained-release or enteric-coated forms shouldn’t be crushed or chewed but swallowed. milk. or large glass of water to reduce adverse GI reactions. valproic acid. bleeding disorders. nausea. May increase the bleeding with valproic acid. cefamandole. heparin or thrombolytic agents. hepatotoxicity Hemat: anemia. Antipyretic Frequency/Route/Dose: 80 mg/tab 1 tab OD Action: Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. fever. oral hypoglycemic agents and sulfonamides. Advise to report signs of tinnitus. epigastric distress. bruising. history of GI bleeding. hearing loss GI: dyspepsia. severe hepatic disease Adverse Effects: EENT: tinnitus. antacid.Generic Name: Aspirin Brand Name: ASA Classification: Salicylates. NSAIDs. May enhance the activity of penicillins. bleeding of gums. treatment of fever. increased bleeding time Misc: noncardiogenic pulmonary edema. salicylates. severe renal disease. anorexia. decreases platelet aggregation Indication: Management of inflammatory disorders including: rheumatoid arthritis. phenytoin. GI bleeding. black tarry stools 72 . treatment of mild to moderate pain. NSAID.

An antithombolytic drug. Antithrombotics Frequency/Route/Dose: 25 mg/tab OD Action: Obtained by depolymerization of unfractioned porcine heparin. aspirin. increase risk of bleeding Nursing Responsibilities: • • • 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 73 . peptic ulcer and intracranial hemorrhage Adverse Effects: GI: bleeding. thrombolytic or NSAIDS. constipation EENT: ocular hemorrhage Derm: purpura. bruising. dyspepsia. heparin. 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. gastritis.• • 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. rash pruritus Drug Interaction: Warfarin. abdominal pain.

spinal cord or brain injury. hematoma Misc: fever Drug Interaction: Risk of bleeding may be increased by concurrent use of drugs that affect platelet function. preventing the conversion of fibrinogen to fibrin. anticoagulant (antithrombotic) Frequency/Route/Dose: 6000 IU q 12 Action: Potentiate the inhibitory effect of antithrombin on factor Xa and thrombin. ibuprofen. dextran and thrombolytic agents Nursing Responsibilities: • • • • • Assess for signs of bleeding and hemorrhage Assess for evidence of additional or increased thrombosis. In low doses it prevents conversion of prothrombin to thrombin by its effects on factor Xa. quinidine. anemia Local: irritation. severe liver or kidney disease. history of bleeding disorders Adverse Effects: CV: edema GI: hepatitis Derm: rashes Hemat: bleeding. In high doses it neutralize thrombin. naproxen or ketoprofen 74 . cefmetazole. Indication: Prevention of deep vein thrombosis and pulmonary embolism. pain. Monitor patient for hypersensitivity reactions Advise to report any symptoms of unusual bleeding or bruising Instruct not to take medications containing aspirin. some penicillins. valproic acid.Generic Name: Enoxaparin Brand Name: Lovenox Classification: Heparin. untreated hypertension. NSAIDs. atrial fibrillation with embolization Contraindication: Hypersensitivity to the drug. open wounds. including aspirin.

hepatic coma. hydrogen and calcium. insomia CV: hypotension GI: nausea. tinnitus Derm: rashes. may cause toxicity.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. Decreases lithium excretion. chloride. dyspepsia EENT: hearing loss. headache. May increase the effectiveness of warfarin. photosensitivity F and E: hyperglycemia Hemat: blood dyscrasias MS: muscle cramps Misc: increased BUN Drug Interaction: Additive hypotension with antihypertensives or nitrates. diabetes mellitus Adverse Effects: CNS: dizziness. thrombolytics and anticoagulants Nursing Responsibilities: • • • • 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 75 . nervousness. diarrhea. dry mouth. magnesium. treatment of hypertension Contraindication: Hypersensitivity to the drug. sodium. Increases renal excretion of water. Indication: Management of edema secondary to congestive heart failure. electrolyte depletion. severe liver disease. vomiting. geriatric patients. hepatic or renal disease. constipation.

weakness. digitalis glycosides Frequency/Route/Dose: 0. ventricular fibrillation. vomiting.• • 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. Adverse Effects: CNS: fatigue. yellow vision CV: arrhythmias. Antibiotics: increased risk for toxicity because of altered intestinal flora. atrial fibrillation and flutter Contraindication: Hypersensitive to drug and in those with digitalis-induced toxicity. bradycardia. or skipped beats or other rhythm changes Instruct to take medication as directed 76 . anorexia Endo: gynecomastia Hemat: thrombocytopenia Drug Interaction: Antacids.25 mg/tab OD Action: Inhibits sodium potassium-activated adenosine triphosphate. decreased absorption of oral digoxin. Indication: Heart failure. or ventricular tachycardia unless caused by heart failure. headache. ECG changes GI: nausea. thereby promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. blured vision. diarrhea. 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. Anticho-linergics: may increase digoxin absorption of oral digoxin tablets Nursing Responsibilities: • • • • • • • Monitor apical pulse and BP periodically Monitor ECG throughout therapy Monitor intake and output and daily weights Monitor potassium levels. paroxysmal supra-ventricular tachycardia.

hepatic dysfunction. history of gout or kidney stone Adverse Effects: CNS: headache.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. hyponatremia Hemat: dyscrasias MS: muscle cramps Misc: allergic reactions Drug Interaction: ACE inhibitors: increased risk of hyperkalemia. dizziness CV: arrhythmias GI: gastrointestinal irritation GU: impotence Endo: gynecomastia F and E: hyperkalemia. clumsiness. renal insufficiency. treat edema or hypertension Contraindication: Hypersensitivity to drug. 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 77 . Aspirin: possible blocked diuretic effect Nursing Responsibilities: • • • • • • Monitor intake and output Monitor signs and symptoms of hypokalemia Give the drug with meals. hyperkalemia.

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. centrally acting analgesics. hypnotics. nervousness. seizures CV: vasodilation GI: nausea. sweating Drug Interaction: Carbamazepine: increased tramadol metabolism Nursing Responsibilities: • • • • • • Assess type. dyspepsia. and intensity of pain 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 Advise to make position changes slowly to prevent orthostatic hypotension 78 . dry mouth. abdominal pain GU: urinary retention. drowsiness. constipation.• 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. opioids Adverse Effects: CNS: headache. vomiting. location. urinary frequency EENT: visual disturbances Derm: pruritus. sleep disorder. diarrhea.

location. pulmonary edema. hypotension. and intensity of pain Assess BP. profound sedation. flushing. blurred vision GI: nausea. break or chew extended-release tablets 79 . nightmares. clouded sensorium. cardiac arrest Resp: respiratory depression EENT: diplopia. euphoria. 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.Generic Name: Morphine Brand Name: Astramorph Classification: Opioid Analgesic Frequency/Route/Dose: 2 mg IVTT now Action: Binds with opiate receptors in the CNS. physical dependence Drug Interaction: CNS depressants. hypnotics. vomiting. shock. hallucinations CV: hypotension. somnolence. constipation. itching Misc: tolerance. Indication: Management of severe pain. sedatives: may cause respiratory depression. ileus GU: urinary retention Derm: sweating. dizziness. pulse and respiration before and periodically during administration Assess bowel function routinely May be administered with food or milk to minimize GI irritation Don’t crush. or coma Nursing Responsibilities: • • • • • Assess type. bradycardia. seizures. altering both perception and emotional response to pain. general anesthetics.

acute surgical abdomen. increasing fluid intake. 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. abdominal pain Adverse Effects: GI: nausea. resulting in accumulation of water and increased peristalsis Indication: Treatment of constipation. diarrhea. nausea or vomiting or other symptoms of appendicitis. increasing mobility Inform patient that this medication may cause changes in urine color Advise not to use laxatives when abdominal pain. consistency and amount of stool produced Take with a full glass of water. and usual pattern of bowel function Assess color.• • • 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. particularly when associated with slow transit time. vomiting or fever are present 80 . calcium or magnesium impair absorption of tetracycline due to release of free calcium Nursing Responsibilities: • • • • • • • Assess patient for abdominal distention. fecal impaction. presence of bowel sounds. constipating drugs. cramping GU: pink-red or brown-black discoloration of urine F and E: electrolyte abnormalities Misc: laxative dependence Drug Interaction: Laxatives containing aluminum. nausea. irritable or spastic bowel syndrome Contraindication: Hypersensitivity to any ingredient.

blood dyscrasias. pulmonary embolism. cholestyramine.Generic Name: Warfarin Brand Name: Coumadin Classification: Anticoagulant Frequency/Route/Dose: 5 mg ½ tab OD Action: Inhibits vitamin K-dependent activation of clotting factors II. 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. atrial fibrillation with embolization. vitamin K Nursing Responsibilities: • • • • • • • Assess patient for signs of bleeding and hemorrhage Administer medication same time each day Medication requires 3-5 days to reach effective levels Instruct to take medication as directed 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. VII. and X. or naproxen 81 . adjunct in prohylaxis of systemic embolism after MI Contraindication: Hemorrhage tendency. formed in the liver Indication: Prophylaxis and treatment of venous thrombosis. gluthetimide. rifampicin. IX.

renal impairment. intra-abdominal infections. hepatic or renal impairment Adverse Effects: CNS: seizures GI: nausea.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. diarrhea. 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 82 . colitis Derm: rashes. urinary infections. causing cell death. urticaria Hemat: blood dyscrasias. Ingestion of alcohol within 48-72 hours of cefoperazone may result in a disulfiram-like reaction. cramping. bone and joint infections. Bactericidal action against susceptible bacteria Indication: Treatment of skin an skin structure infections. bleeding Misc: superinfection. septicemia Contraindication: Hypersensitivity to cephalosporins. vomiting. hemolytic anemia. respiratory infections. Nursing Responsibilities: • • • • • • • 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. serious hypersensitivity to penicillins. allergic reactions Drug Interaction: Probenecid decreases excretion and increases serum levels.

vertigo. bone and joint infections. Neuromuscular blockers: increase neuromuscular blockade possible Nursing Responsibilities: • • • • • • • • Assess patient for infection Observe for signs and symptoms of anaphylaxis Administered with a full glass of water. arrhythmias GI: nausea. respiratory infections. May be given with meals Tell patient to take exact amount as prescribed Inform patient not to crush. intra-abdominal infections. severe liver impairment. vomiting. alcohol intolerance Adverse Effects: CNS: dizziness. Bactericidal or bacteriostatic Indication: Treatment of skin an skin structure infections. diarrhea. break or chew extended-release tablets 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 83 . headache CV: hypotension. colitis Derm: rashes Drug Interaction: Erythromycin: may block access of clindamycin to its site of action. diarrhea. urinary infections. septicemia Contraindication: Hypersensitivity to drug.• • 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.

antipyretic Frequency/Route/Dose: 500 mg 1 tab q 4 hours Action: Thought to produce analgesia by blocking generation of pain impulses. fever Contraindication: Hypersensitivity to drug. location. Barbiturates. malnutrition Adverse Effects: GI: hepatic necrosis Derm: rash. products containing alcohol. renal disease.Generic Name: Acetaminophen Brand Name: Paracetamol Classification: Nonopioid analgesic. severe hepatic disease. rifampicins: may reduce therapeutic effects and cause hepatotoxicity Nursing Responsibilities: • • • • • • Assess type. urticaria Drug Interaction: Chronic concurrent use with NSAIDs including aspirin may increase the risk of adverse reactions. carbamazepine. 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. 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 84 .

May interfere with absorption of drugs requiring acid gastric pH including ketoconazole. preventing the final transport of hydrogen ions into the gastric lumen Indication: Management of GERD. ampicillin and iron salts Nursing Responsibilities: • • • • • Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool Administer doses before meals. 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. headache. management of gastric ulcer. and warfarin.Generic Name: Omeprazole Brand Name: Losec Classification: Anti-ulcer. vomiting Derm: rash. itching Drug Interaction: Decreases metabolism and may increase effects of phenytoin. treatment of gastric hypersecretory conditions Contraindication: Hypersensitivity to drug Adverse Effects: CNS: weakness. diarrhea. diazepam. dizziness. preferably in the morning May be administered concurrently with antacids Instruct to take medication as directed May cause occasional drowsiness. Caution patient to avoid activities that require alertness 85 . constipation. acid regurgitation. or dizziness. nausea. flatulence. fatigue CV: chest pain GI: abdominal pain.

fatigue. dry mouth Endo: gynecomastia Drug Interaction: Phenothiazines. GI stimulant Frequency/Route/Dose: 10 mg 1 tab 3 times a day Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. diarrhea. Stimulates the motility of the upper GI tract and accelerates gastric emptying Indication: Nausea and vomiting with GI disorder. nausea. epilepsy Adverse Effects: CNS: restlessness. 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 Instruct to take medication as directed Caution to avoid activities that requires alertness Advise to notify physician or other health care provider if involuntary movements occurs 86 .• Advise patient to report onset of black tarry stools. perforation. GI hemorrhage or obstruction. irritability. diarrhea. disorders in reduced GI motility Contraindication: Hypersensitivity. anti-epileptics and sympathemimetics Nursing Responsibilities: • • • • • • • Assess patient for nausea. centrally-active agents including anti-depressants. extrapyramidal effect. drowsiness. anxiety CV: arrhythmias GI: constipation. depression. lithium. abdominal pain or persistent headache to the physician promptly Generic Name: Metoclopramide Brand Name: Clopra Classification: Antiemetic. vomiting.

dyspepsia. Derm: rash. sucralfate. mental cautions. insomnia. community acquired pneumonia Contraindication: Hypersensitivity to quinolones. break or chew extended-release tablets 87 . probeneclol and cimetidine may affect the rate and extent of levofloxacin absorption Nursing Responsibilities: • • • • Obtain specimen for culture and sensitivity test Tell patient to take exact amount as prescribed Tell patient that drug may be taken with meals Inform patient not to crush. diarrhea. abdominal pain. 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. history of tendon disorders related to fluoroquinolones therapy Adverse Effects: CNS: headache. pruritus Drug Interaction: Absorption impaired by antacids.Generic Name: Levofloxacin Brand Name: Levox Classification: Quinolones Frequency/Route/Dose: 500 mg 1 cap OD Action: Synthetic. dizziness GI: Nausea and vomiting. and Zinccontaining multi-vitamin preparation. flatulence. constipation. epilepsy.

Diazepam: decrease absorption of diazepam Nursing Responsibilities: • • • • • • • Assess patient for nausea. abdominal distention and bowel sounds prior to or following administration Administer 30 minutes before meals Instruct to take medication as directed 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 88 . malaise. mental confusion.Generic Name: Ranitidine Brand Name: Zantac Classification: Antiemetic. insomnia. nausea. dizziness. somnolence. Indication: Short-term treatment of active duodenal ulcer. vertigo. agitation Resp: bradycardia GI: constipation. hyper-sensitivity to ranitidine Adverse Effects: CNS: headache. vomiting. thus blocking gastric acid secretion. abdominal pain Drug Interaction: Antacids: interfere with ranitidine absorption. maintenance therapy for duodenal ulcer patient after healing of acute ulcer Contraindication: Acute poyphyria. Indirectly reduces pepsin secretion. 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.

Nutritional deficiencies. IX and X. Nursing Responsibilities: • • • • 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 89 . unusual taste Derm: rash. which may be associated with excessive doses of oral anticoagulants.• 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. flushing Local: swelling. allergic reactions Drug Interaction: Large doses will counteract the effect of warfarin. Indication: Prevention and treatment of hypoprothrombinemia. VII. urticaria. Large doses of salicylates or broad-spectrum anti-infectives may increase vitamin K requirements. hyperbilirubinemia. pain at IV site Misc: hemolytic anemia. impaired liver function Adverse Effects: GI: gastric upset. prevention of hemorrhagic disease Contraindication: Hypersensitivity and intolerance. salicylates.

pruritus Drug Interaction: Ketoconazole may affect absorption of drugs whose absorption is pHdependent Nursing Responsibilities: • • • • • • Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool Administer doses before meals. diarrhea.Generic Name: Pantoprazole Brand Name: Pantoloc Classification: Antacids. duodenal or gastric ulcer. preventing the final transport of hydrogen ions into the gastric lumen Indication: Treatment of mild reflux. preferably in the morning May be administered concurrently with antacids Instruct to take medication as directed May cause occasional drowsiness. nausea. impaired liver function Adverse Effects: CNS: headache. dizziness GI: diarrhea. reflux esophagitis Contraindication: Hypersensitivity. upper abdominal pain. abdominal pain or persistent headache to the physician promptly 90 . antiulcerants Frequency/Route/Dose: 40mg/tab OD Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH. or dizziness. Caution patient to avoid activities that require alertness Advise patient to report onset of black tarry stools. flatulence Derm: rash.

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. diarrhea. abdominal pain or persistent headache to the physician promptly 91 . gastric ulcer Contraindication: Hypersensitivity to the drug Adverse Effects: GI: diarrhea. vomiting. constipation Derm: pruritus Drug Interaction: Antacids interfere with absorption. Diazepam decrease absorption Nursing Responsibilities: • • • • • • Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool Assess for abdominal pain Administer on empty stomach. nausea. 1 hour before meals Increase fluid intake Instruct to take medication as directed Advise patient to report onset of black tarry stools. acute gastritis.

niacin. headache. which is responsible for catalyzing an early step in the synthesis of cholesterol. active liver disease Adverse Effects: CNS: dizziness. 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 92 .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. fibric acid derivatives. erythromycin. Nursing Responsibilities: • • • • • • Obtain diet history. mixed hyperlipidemia Contraindication: Hypersensitivity to the drug. insomia GI: GI disturbance MS: muscle cramps Derm: pruritus Drug Interaction: Risk of myopathy increased with concurrent administration of cyclosporine. especially on fatty foods Administer with food Instruct patient to have diet restrictions on fats. cholesterol. Slowing the progression of CAD with resultant decrease in MI and need for myocardial revascularization Indication: Reduction of elevated total and LDL cholesterol and triglycerides in patients with primary hypercholesterolemia.

Generic Name: Carvedilol Brand Name: Dilatrend Classification: Beta Adrenergic Blocking agent Frequency/Route/Dose: 6. 2nd and 3rd degree AV block.25 mg ½ tab OD Action: Block stimulation of beta1 adrenergic receptors. SA block. asthma. severe liver dysfunction. 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 93 . diarrhea. nausea GI: andominal pain. rifampicin Nursing Responsibilities: • • • • • • • Always check apical pulse rate before giving drug Monitor BP. MI with complications. constipation. hypertension Contraindication: Hypersensitivity to the drug. metabolic acidosis Adverse Effects: CNS: dizziness. disease of the respiratory tract. headache. methyldopa. vomiting Resp: bronchospastic reactions Drug Interaction: BP lowering drugs. chronic bronchitis. tiredness. reserpine. clonidine. . do not usually affect beta2 receptor sites Indication: CHF.

Within my 1 hour span of care my patient was be able to report relief or control of chest pain as 3. AMI Rationale: Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage. as verbalized by R: Variation of appearance and the patient Novembe S: r 28. brisk and reactive to light . (+) LVH.NURSING CARE PLAN Name: Perfecto Pandacan Balili Age: 60 y. Administer medication as indicated (antianginal.Pale conjunctiva noted .Grimaced face noted . Evaluation Goal Met November 28. O: . 2. Sex: Male Diagnosis: CAD. Monitor characteristics evidenced by: of pain. (+) LVD. Voltaire Egnora Institution: Davao Medical Center Objective 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. Administer supplemental oxygen as indicated R: Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia. “ Dili na sakit and hemodynamic akong dughan. FC III Date and Time Cues Need C O G N I T I V E P E R C E P T U A Nursing Diagnosis Acute pain related to decreased myocardial blood flow as evidenced by reports of chest pain secondary to CAD. Acute Myocardial Infarction (AMI) occurs when coronary blood flow decreases Room and Bed #: CCU bed 1 Attending Physician: Dr. diaphoresis. 5:00 p.m. beta-blocker.Pink mucous membrane and lips noted .o.Pupillary size 3mm isocoric. nonverbal cues. 2006 6:00 p. absence of restlessness.” response.m. 2006 “Sakit akong dughan” as 3-11 shift verbalized by the patient. facial grimace and vital signs within normal range Nursing Intervention 1. AMIK II. noting verbal reports. analgesics) R: Immediate response in relief of pain.

further platelet behavior may occur.vital signs within normal range (Temp=36. so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion. RR=22 cpm. as well as identify complications such as extension of infarction. Infarction occurs when an atherosclerotic plaque fissures. After an initial platelet monolayer forms at the site of the ruptured plaque. 4.absence of restlessness noted absence of diaphoresis noted . quiet calm .. while release of stress induced catecholamines will increase heart rate and BP.Capillary refill of 1 second . There is production and release of thromboxane A2 (a potent local vasoconstrictor).irritability noted . thereby creating further damage and interfering with diagnostics and relief of pain. CR= 60 bpm.narrowed focus (reduced interaction with people) L P A T T E R N abruptly after a thrombotic occlusion of a coronary artery previously narrowed by atherosclerosis. Review history of previous angina or MI pain R: May differentiate current pain from preexisting patterns.Irregular cardiac rate and rhythm noted . Provide environment. or pericarditis. clammy skin noted .cold. ADP. BP= 90/60 mmHg) Evaluated by: 95 .Clutching chest noted . serotonin) promote platelet activation. epinephrine. pulmonary embolus. 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. ruptures. Respirations may be increased as a result of pain and associated anxiety.Pale nail beds noted .Productive cough noted .Weakness noted .diaphoresi s noted .restlessnes s noted . or ulcerates and when conditions (local or systemic) favor thrombogenesis.Whitish phlegm noted .Absence of facial grimace noted . 6. various agonists (collagen.Crackles noted upon auscultation . 5.

Pain scale of 6 out of 10 (0 being no pain and 10 as very severe pain) . which then converts fibrinogen to fibrin. This occlusion will impede the flow of blood to the cardiac muscles. 7. Check vital signs before and after narcotic medication R: Hypotension or respiratory depression can occur as a result of narcotic administration. RR=25 cpm. visualization and guided imagery R: Helpful in decreasing perception of pain. Assist in relaxation techniques such as deep breathing. 9. The coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque.Temp=35.noted . 8. Place patient at complete rest during anginal episodes R: Reduces myocardial oxygen demand to minimize risk of 96 . BP= 80/60 mmHg activation. CR= 47 bpm. Joy R: Decreases external stimuli. ultimately leading to the conversion of prothrombin to thrombin. The culprit coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. and potential resistance to thrombolysis. These may increase myocardial damage in presence of ventricular insufficiency. Provides a sense of having some control over the situation. which may aggravate anxiety and cardiac strain and limit coping abilities and adjustment to current situation. Factors VII and X are activated. Novelynne measures. Decrease cardiac functioning will lead to imbalance between myocardial oxygen supply and activities and comfort Yap. increase in positive attitude.

Have patient rest for 1 hour after meals R: Decreases myocardial workload associated with work of digestion. Presence of nurse can reduce feelings of fear and helplessness. Elevate head of bed if patient is short of breath R: Facilitates gas exchange to decrease hypoxia and resultant shortness of breath. 13. which occur in response to ischemic changes or stress. tissue injury or necrosis. 10. Stay with the patient who is experiencing pain or appears anxious R: Anxiety releases catecholamines. 11. which increase myocardial workload and can prolong ischemic pain. 12. reducing risk of anginal attack. 3rd Edition by Nowak Harrison’s Internal Medicine. Monitor heart rate and rhythm R: Patient may have acute lifethreatening dysrhythmias. Source: Pathophysiology: Concepts and Applications for Health Care Professionals. 5th Edition 97 .demand wherein the heart is unable to meet the metabolic demands of the body. Provide light meals. Lack of blood and oxygen supply in the cardiac muscle will lead to ischemia and thus to experience of pain.

which may disappear when patient is painfree. 8th Edition by Doenges 98 . 4th Edition by Doenges .Nursing Care Plan. They also provide a baseline with which to compare later pattern changes.Nurse’s Pocket Guide.14. Serial tracing verify ischemic changes. Source: . Monitor serial ECG changes R: Ischemia during anginal attack may cause transient ST segment depression or elevation and T wave inversion.

When a coronary Room and Bed #: CCU bed 1 Attending Physician: Dr. Evaluate quality and ate urinary equality of pulse as output indicated 99 .Pale p. (90/60hypertension is also a common 120/90 phenomenon. Voltaire Egnora Institution: Davao Medical Center Objective Nursing Intervention Evaluation Goal Partially Met November 27. possibly related mmHg) to pain.O2 inhalation at 5 lpm via nasal cannula noted .m. and vagal range stimulation.Pink mucous membrane and lips noted .with complications of infarct. Determine baseline Within my 8 vital signs hours span of R: Provide opportunities to care my track changes. 2006 size 3mm isocoric.Pupillary 27. Auscultate BP. (+) LVH.Symmetri cal chest expansion noted . conjunctiva noted . 2006 10:00 p. anxiety. O300 cc) S/O: November . Within my 8 hours span of care my patient was able to maintain hemodynamic stability as evidenced by: BP within normal range (110/80mmHg) Adequate urinary output (I-370 cc.Productive A C T I V I T Y E X E R C I S E 1. catecholamine CR release. Orthostatic normal hypotension may be associated range (60. AMIK II. patient will be able to 2.m. brisk 3-11 shift and reactive to light 4:30 .o. hypoperfusion of normal the myocardium. AMIK II Rationale: Acute Myocardial Infarction (AMI) generally occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously narrowed by atherosclerosis. FC III Date and Time Cues Need Nursing Diagnosis 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. and/or preexisting within vascular problems. maintain compare both arms and hemodynamic obtain lying. (+) LVD.Crackles noted upon auscultation . 100 bpm) Adequ 3. Sex: Male Diagnosis: CAD. However.Name: Perfecto Pandacan Balili Age: 60 y. sitting and stability as standing pressures when evidenced by: able R: Hypotension may occur BP related to ventricular within dysfunction.

ventricular stiffening. serotonin) promote platelet activation. ADP.Capillary refill of 1 second .Cool skin noted . Presence of rub with an infarction is all associated with Yap. various agonists (collagen. After agonist - R: Decreased cardiac output ase results in diminished dysrhythmia weak/thready pulses. Decre - Absence of dyspnea (RR-20 cpm) But was not able to maintain hemodynamic stability on: 4. ruptures. hypertension. Presence or murmurs/rubs R: Indicates disturbance of Evaluated by: normal blood flow within the heart.Pale nail beds noted . note development of S3 CR (52 and S4 bpm) R: S3 is usually associated Cardiac with HF.Whitish phlegm noted . Novelynne inflammation. S4 may be associated with myocardial ischemia. 5. Infarction occurs when an atherosclerotic plaque fissures.Grossly normal extremities noted . so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion.Showing atrial fibrillation in slow to moderate ventricular response with ST elevation pattern . which may dyspnea require further evaluation or monitoring. epinephrine.Weakness noted P A T T E R N artery thrombus develops rapidly at a site of vascular injury. Absen Irregularities suggest ce of dysrhythmias.Irregular cardiac rate and rhythm noted . Joy 6. After an initial platelet monolayer forms at the site of the ruptured plaque. but it may also be rhythm remains noted with mitral insufficiency the same and left ventricular overload that can accompany severe infarction. this injury is produced or facilitated by factors such as cigarette smoking. and lipid accumulation.cough noted . or ulcerates and when conditions (local or systemic) favor thrombogenesis. Auscultate heart sound. and pulmonary or systemic hypertension. Auscultate sounds R: Crackles breath reflecting 100 .Nondistended abdomen noted .

Factors VII and X are activated. further platelet activation. which then converts fibrinogen to fibrin. RR=23 cpm. 10. ultimately leading to the conversion of prothrombin to thrombin. BP= 80/60 mmHg stimulation of platelets. which could compromise cardiac function or increase ischemic damage. Fluid-phase and clot-bound thrombin participate in an autoamplification reaction that leads to further activation of pulmonary congestion may develop because of depressed myocardial function. The coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. 9. and potential resistance to thrombolysis. Place on moderate high back rest R: Lowers diaphragm. Monitor heart rate and rhythm R: Heart rate and rhythm respond to medication and activity. as well as developing complications/dysrhythmias. 8.. Acute or chronic atrial flutter/fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathogenic.Temp=35. there is production and release of thromboxane A2 (a potent local vasoconstrictor). Note response to activity and promote rest appropriately R: Overexertion increases oxygen consumption/demand and can compromise myocardial function. 6. 7. Provide bedside 101 . CR= 43 bpm. promoting chest expansion.

spasmodic coughing. The culprit coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. Administer stool softeners as ordered. 13. rectal stimulation.oxygen available for 102 . vomiting. The infracted area in AMI will eventually heal and the necrotic myocardial cells will commode if unable to use bathroom R: Attempts at using bedpan can be exhausting and psychologically stressful. Avoid activities such as isometric exercises. as indicated R: Increases amount of . This occlusion will impede the flow of blood to the cardiac muscle and other parts of the body. 11. Caffeine is a direct cardiac stimulant that can increase heart rate.the coagulation cascade. 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. 12. Provide small or easily digested meals. R: These may stimulate valsalva response. Restrict caffeine intake R: Large meals may increase myocardial workload and cause vagal stimulation resulting in bradycardia or ectopic beats. Administer supplemental oxygen. thereby increasing oxygen demand and cardiac workload. Therefore there is inadequate blood pumped by the heart to meet the metabolic demands of the body.

which are often treated prophylactically. Early inclusion of ACE inhibitor therapy enhances ventricular output. increases survival and may slow progression of heart failure. Maintain IV access as indicated R: Patent line is important for administration of emergency drugs in presence of persistent dysrhythmias or chest pain. 14. myocardial uptake. This area cannot contribute to pumping except to maintain the integrity of the ventricular wall. 103 .Nursing Care Plan. 4th Edition by Doenges . 3rd Edition by Nowak Harrison’s Internal Medicine. Administer antidysrhythmic drugs and ACE inhibitors as ordered. reducing ischemia and resultant dysrhythmias.be replaced by dense fibrous connective tissue (scarring). 5th Edition Source: . except for PVCs.Nurse’s Pocket Guide. 15. Source: Pathophysiology: Concepts and Applications for Health Care Professionals. R: Dysrhythmias are usually treated symptomatically.

8th Edition by Doenges

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Name: Perfecto Pandacan Balili Age: 60 y.o. Sex: Male Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III Date and Time Cues Need Nursing Diagnosis Activity Intolerance related to decrease cardiac functioning as evidenced by irregular cardiac rate and rhythm secondary to CAD, AMIK II 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 thrombotic occlusion of a coronary artery

Room and Bed #: CCU bed 1 Attending Physician: Dr. Voltaire Egnora Institution: Davao Medical Center Objective 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 patient’s normal limits and skin warm, pink and dry. Nursing Intervention 1. Determine baseline vital signs R: Provide opportunities to track changes. 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 patient’s 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. Evaluation Goal Partially Met 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:

S: Novembe “Dali ko makapoy r 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

BP 3. 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

105

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,

P A T T E R N

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. 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

106

Pale nail beds noted . RR=23 cpm. Decrease cardiac functioning will lead to imbalance between myocardial oxygen supply and on the heart. which then converts fibrinogen to fibrin.Weakness noted . strength and overexertion increasing Yap. 5. Factors VII and X are activated.rough skin noted . This occlusion will impede the flow of blood to the cardiac muscles.Capillary refill of 1 second . 10. Review signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician R: Palpitations. Note response to activity R: Overexertion increases oxygen consumption/demand and can compromise myocardial function. Provide bedside commode if unable to use bathroom R: Attempts at using bedpan can be exhausting and 107 .Needing assistance upon changing positions noted . or dyspnea may indicate need for changes in exercise regimen or medication 8. Place on moderate high back rest R: Lowers diaphragm.Temp=35. Novelynne preventing Joy 7. and potential resistance to thrombolysis. development of chest pain. ultimately leading to the conversion of prothrombin to thrombin. CR= 57 bpm. The culprit coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. The coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. promoting chest expansion. BP= 90/70 mmHg activation. pulse irregularities. 9.

as indicated R: Increases amount of . Provide small or easily digested meals. psychologically stressful. Performing activities increases oxygen consumption from the body in which an individual with such imbalance will have difficulty performing the task. 5 Edition 13. Administer supplemental oxygen. Encourage patient to maintain positive attitude.oxygen available for 108 .demand wherein the heart is unable to meet the metabolic demands of the body. suggest use of relaxation techniques such as visualization or guided imagery as appropriate R: Enhance sense of wellbeing 14. Plan care with periods in between R: reduce fatigue rest Source: Pathophysiology: Concepts and Applications for Health Care Professionals. thereby increasing oxygen demand and cardiac workload. 11. Caffeine is a direct cardiac stimulant that can increase heart rate. 12. 3rd Edition by Nowak Harrison’s Internal th Medicine. Restrict caffeine intake R: Large meals may increase myocardial workload and cause vagal stimulation resulting in bradycardia or ectopic beats.

reducing ischemia and resultant dysrhythmias. 4th Edition by Doenges . Maintain IV access as indicated R: Patent line is important for administration of emergency drugs in presence of persistent dysrhythmias or chest pain.Nurse’s Pocket Guide.myocardial uptake. 15. 8th Edition by Doenges 109 .Nursing Care Plan. Source: .

The family also lacks the financial support that they would need for medical intervention and this is also with respect to the patient’s age. In addition. This implies that the condition of the patient continuously deteriorates every after the attack. it only indicates that the patient is unable to meet the necessary interventions to prevent having another attack. he always asks questions regarding it. Regardless of the patient’s 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. myocardial free wall rupture. Since the patient’s 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. Prognosis is highly variable and depends on a number of factors related largely on infarct size. and so on) were to occur. he is also aware of the Duration of illness √ Willingness to take medication √ Age √ Expectations to √ .) there is a higher risk for acquiring such illness. with more than half of deaths occurring in the prehospital setting. left ventricular function and the presence or absence of ventricular arrhythmias. The patient wanted to go home with ordered medications however. the prognosis is poor. Prognosis is significantly worsened if a mechanical complication (papillary muscle rupture. He had attacks in the past and his condition has complications already. This is for the reason that the patient’s condition has been transpiring for years. CRITERIA ACTUAL Poor Fair Good JUSTIFICATION The patient already had four attacks prior to the present hospitalization.o.PROGNOSIS MI may be associated with a mortality rate as high as 30%. Overall. He would ask for the purpose of his medicines before taking it. The patient is very willing to take all the available prescribed medications. The patient is not getting any younger and at his current age (60 y. In fact.

Perfecto would fully recover from his illness. The family is always there to provide assistance and support the patient. 111 . 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. He and his family still hopes that Mr. 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.illness Environment √ Family support √ reality that his condition is worsening. The patient lives in an air conditioned room and is provided with his oxygen tank.

Interventions and Rationales.tripod.org/C003758/Function/How%20Cardiac%20Muscle%20Contracts. Alice C.html http://circ.org/HIC/Anatomy/Anatomy.org/teen/your_body/body_basics/heart.html http://www.americanheart.net/cardiac_cycle.org/wiki/Cardiovascular_system http://www. Essentials of Anatomy and Physiology 4th Edition Suzanne C.thinkquest. Stephens. 9th Edition Marilynn E.htm http://en.html http://webschoolsolutions.php?content=health003 http://library. Pathophysiology Clinical Concepts of Disease Process 4th Edition Wilson. Brunner and Suddhart’s Textbook on Medical-Surgical 10th Edition Sylvia A.html http://biology.htm 112 .org/wiki/Myocardial_infarction http://circ. Mary Frances Moorehouse.com/EMERG/topic327.org/cgi/content/abstract/111/25/3481 http://training.com/diseasemanagement/cardiology/complications/complicati ons. Doenges.org/cgi/content/full/102/18/2284 http://supplements. Geissler-Murr.htm http://texasheart.com/library/organs/heart/blheartintro.htm http://www.geocities.gov/module_anatomy/unit7_1_cardvasc_intro. Alice C.ahajournals. Geissler-Murr.cfm http://www.com/~dgholgate/four. 3rd Edition Rod Seeleys.seer. Lorraine M.ahajournals.cancer. et al. Wilson.com/Heart%20Disease/HD002. Trent D.cwc. Price.com/baddarni/Myocardial-Infarction.wikipedia. Nursing Care Plan Guidelines for Individualizing Nursing Care 6th Edition Nowak. Bare.org/scientific/statements/1994/079402.edu/~dck3/heart/intro.htm http://www. Pathophysiology: Concepts and Application for Health Care Professionals.clevelandclinicmeded. Philip Tate. Diagnoses.kidshealth.htm http://en.net/mindandbody/main. Brenda G. Doenges. 12th Edition http://www.jdaross. Harrison’s Principles of Internal Medicine. Mary Frances Moorehouse.about.cvphysiology. Thomas.html http://filer.BIBLIOGRAPHY Harrison’s Internal Medicine Marilynn E. Nurses’ Pocket Guide.wikipedia.inq7.html http://members.case. Smeltzer.emedicine.htm http://www.com/patts/systems/heart.

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