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II. Introduction The cardiovascular system is made up of the heart and blood vessels.

Its function is to circulate blood throughout the body and bring oxygen and nutrients to muscles and organs in order for it to function. This is one of the reasons why we are able to live our everyday life. However, a persons insalubrious lifestyle or even an unfortunate genetic predisposition can jeopardize the cardiovascular functional capability thus, tormenting not only the heart and the vessels but also putting the persons life at risk. Coronary Artery Disease or CAD is a type of cardiovascular disease wherein the arteries that supply blood to heart muscle (coronary artery) become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain (angina) or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage. According to World Health Organization, CVDs were the leading cause of Non-Communicable Disease deaths (17 million deaths) in 2008.In addition to this, the National Center for Health Statistics 2011 reported that cardiovascular disease (CVD) remains the leading cause of mortality in the United States in men and women. More than half of the deaths due to heart disease in 2009 were in men. In the Philippines, diseases of the heart have consistently been the top leading cause of death for the past ten years. Per 100,000 population, 78 deaths due to diseases of the heart were registered in 2000 for the whole country, ballooning to 102 deaths in 2008 and 109 deaths in 2009, respectively. Quite expectedly, among the regions, the highest prevalence rate is consistently that for the NCR (151 in 2009), the major center of economic activities in the country. As men are generally believed to be leading more dangerous, more stressful lives, there are many more males than females who die due to diseases of the heart - 129 males per 100 females in 2008, and 128 males per 100 females in 2009. Highest sex disparity is for ARMM. It is also estimated that by 2030, over 23 million people will die from cardiovascular diseases annually. The study on Coronary Artery Disease can be useful not only for nursing students but also for the community as a means of increasing awareness of the community people. To the students, this case study will give knowledge and skills on how to manage a patient suffering from CAD.

This case study focuses on Coronary Artery Disease, Left Ventricular Dysfunction secondary to Hypertension. As a case study, this discussion is centered to a certain client in Notre Dame Hospital. All data utilized in this study come from her course of stay in the hospital. It has served as a basis of instruction to present more realistic overview of the disease.

Our group has decided to take this case because we are alarmed of the increasing number of individual suffering from this disease. Also, we took this case in order for us to have additional inputs regarding the disease that hopefully in the future, we can be able to manage the disease better. Furthermore, the knowledge that we can gain in this study can help us apply it in the area as well as in our selves.

II. Objectives of the Study

General Objective: After the completion of this case study on Coronary artery disease with left ventricular dysfunction, secondary hypertension, the student nurses will be able to discuss comprehensively the patients state of health and all aspects contributing to and affect her condition.

Specific Objectives: Within the span of clinical exposure at Notre Dame Hospital, the student nurses will be able to: acquire pertinent data regarding the patient which are relevant to the case study; discuss patients history ( family health, past and present health history ) to show how these factors contribute to the occurrence of the disease; conduct a thorough cephalocaudal assessment and focus assessment of the Cardiovascular and Circulatory system; discus the Anatomy and Physiology of Cardiovascular and Circulatory systems to have basis of comparison from the assessment findings; discuss the pathophysiology of Coronary Artery Disease with left ventricular dysfunction, secondary hypertension and identify links that would connect the disease conditions together and discuss the causes of the signs and symptoms that occurred; discuss the courses of treatment given to the patient within the span of patients hospital stay; discuss how the diseases affect other body functions by understanding the significance of laboratory and diagnostic findings; and formulate specific, measurable, attainable, realistic and time-bound nursing care plans that would cover the entire time span of the patients hospital stay and even until discharge to ensure effective management of the diseases which will promote partial/full recovery of the patient (if possible)

III. Patients Data Name: SRS Bithdate: January 10, 1942 Birthplace: Maguindanao Age: 70 years old Sex: Female Address: San Vicente St. Cotabato City Status: Widowed Religion: Islam Occupation: None Highest Educational Attainment: High School Graduate Name of Spouse: TKH Fathers Name: RS Mothers Name: SS No. of Children: 7

IV. Health History A. Family History Patient _________ is 70 years old, a mother of 7 children. Her parents had already passed away a long time ago. Her father died due to untreated disease of the liver. On the other hand, her mother died of a complication brought by severe hypertension in a way that blood already drained from her ears and nose due to its severity, as described by the patient. Dates of their deaths can no longer remembered by the patient or the watchers. Among her siblings, she is the only one diagnosed with Coronary Artery Disease and Hypertension.

B. Past Medical history According to the patient, she underwent a surgical procedure on the past but she already forgot details about it. This was confirmed by the watcher saying that it was a surgical removal of a tumor from the patients liver. But, no records found in the patients chart about the cited surgery in the past. Patient _______ has no known allergies. She is not currently taking any medications, food supplements or herbal medicine. On the past, when experiencing common colds or cough, she just consults friends or family members on what to do and afterwards takes over-the-counter drugs to relieve the symptoms. She doesnt smoke and never drinks alcoholic beverages. She is also fond of consuming caffeinated drinks. Her usual diet is high in sodium. She admitted that she loves eating salted fish and bagoong but is not fond of eating fatty foods. She considers doing household chores as her daily exercise. C. History of Present Illness A day prior to admission, patient ______ complained difficulty of breathing after cleaning the backyard in the morning. According to her, she only experienced trouble in breathing without any other accompanying symptoms like dizziness, chest pain or nape pain. After hours of rest, she was relieved from dyspnea. She didnt take any medications to relieve the symptoms she experienced but she and her family decided to just seek medical attention from a hospital on the next day. On July 24, 2013, in the morning, she was admitted to Notre Dame Hospital and School of Midwifery by Dr. Peralta. Initial assessment was done to her and different diagnostic and laboratory tests were performed to her to come-up to an appropriate diagnosis.

V. GENERAL PHYSICAL ASSESSMENT

1. 2. 3. 4.

Age/ sex/race : 70 years old, female, Asian Body Build: Emaciated Posture: slouched Hygiene/grooming: unfixed hair, clean and well-trimmed nails without nail polish in both hands

and feet. 5. 6. 7. 8. 9. 10. Dress: wearing white shirt and red malong, appropriate to weather. Body odor: No body odor. Attitude: cooperative, interested and respectful. Affect/mood: approachable and appropriate to situation. Speech: moderate pace and with low pitch tone. Thought process: ideas are sometimes inappropriate and with sense of reality.

Vital Signs: (June 25, 2013)

TEMPERATURE: 36.4C RESPIRATORY RATE: 24 Bpm PULSE RATE: 74 Bpm CARDIAC RATE: 83 Bpm BLOOD PRESSURE: 140/100 mmHg

Height: 5 ft Weight: 43 kg

INTEGUMENTARY:

The skin is uniform in color; there is presence of scar due to the removal of tumor in the abdomen, there is presence of lesions on both leg and arm. The nail plate is pale and has a convex curve. When performing the blanch test of capillary refill it returns to usual color after 2 seconds. The hair in the head is evenly distributed, thick and silky. The face is brown in color, evenly distributed hair with symmetrical facial structure and no facial edema is present. The skull is smooth, uniform consistency, absence of nodules or mass. No lumps and lesions in the scalp. The nose is symmetrical and color is same as face, smooth, not tender, no lesions and absence of nodules. Both axillas appear dark, no infections and rashes noted upon inspection.

EARS:

External ears are equal in size, symmetrical in position, color same as facial skin, no lumps, no tenderness and deformities noted. Ear canal has no discharges, absence of swelling or redness and no foreign bodies noted. Upon checking the hearing ability the client was not always hear it clearly and cant always repeat words correctly.

MOUTH:

Lips are brown in color, soft, moist texture, symmetry of contour and ability to purse lip. Teeth are not complete and yellowish in color. Uvula and tonsils is normal, symmetrical and not enlarged.

CARDIOVASCULAR SYSTEM:

Upon auscultation, the heart rate is 75 beats per minute.

GI SYSTEM:

Brown in color, not symmetrical in size because of the suture in the abdomen, there is presence of stretch marks over abdomen, no masses palpated; umbilicus is sunken and centrally located.

RESPIRATORY: Upon inspection there is a rate of 24 beats per minute, there is no adventitious sound noted upon auscultation. MUSCULOSKELETAL: Equal size on the both sides of the body; can reflex each arm and feet. EYES AND VISION: Eyebrow is equally distributed, symmetrically aligned with equal movement and no discoloration noted. Short eyelashes equally distributed and curved outward. The eyelid closes symmetrically. No edema and tenderness on lacrimal gland. Pupils are 4mm, round, equal in size, 16 involuntary blinks per minute. TESTING EYE FUNCTION: Using a printed materials client was able to read about one meter nearer.

NEUROLOGIC SYSTEM: Patient can respond to verbal command, oriented in time, place and person. The patient was able to smell and distinguish taste like sour and sweet.

VI. FOCUS ASSESSMENT CARDIAC ASSESSMENT Inspection and Palpation of chest: Skin color is even throughout the body No rashes or lesions found Aortic Area: located at the second intercostal space to the right of the sternum; No vibration or pulsation. Pulmonic Area: Located at the second intercostals space to the left of the sternum; No vibration or pulsation. ERBS Point: Located at the third intercostals space to the left of the sternum; No vibration or pulsation. Tricuspid Area: Located at the Right ventricular area; No vibration or pulsation. Mitral Area: Located at the left ventricular area ( 5th intercostal space at the midclavicular line ) No vibration or pulsation. Point of maximal impulse is located at the left midclavicular line, 5th intercostals spac, just below the nipple. Auscultation of the chest: Cardiac rate is 60 bpm with irregular rhythm. No extra sounds or murmurs heard S1 sound is dull, low-pitched and longer than S2; less intense in aortic and pulmonic area and louder in tricuspid area and apical area. S2 is higher than S1; louder than S1 in aortic and pulmonic area and less intense in tricuspid area and apical area.

VII. Anatomy and Physiology CARDIOVASCULAR SYSTEM HEART The human heart is shaped like an upside-down pear and is located slightly to the left of center inside the chest cavity. About the size of a closed fist, the heart is made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of the body. The hearts duties are much broader than simply pumping blood continuously throughout life. The heart must also respond to changes in the bodys demand for oxygen. The heart works very differently during sleep, for example, than in the middle of a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can respond almost instantaneously to shifting situationswhen a person stands up or lies down, for example, or when a person is faced with a potentially dangerous situation. STRUCTURE OF THE HEART The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The hearts lower two chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood away from the heart. A wall of tissue separates the right and left sides of the heart. Each side pumps blood through a different circuit of blood vessels: The right side of the heart pumps oxygen-poor blood to the lungs, while the left side of the heart pumps oxygen-rich blood to the body. Blood returning from a trip around the body has given up most of its oxygen and picked up carbon dioxide in the bodys tissues. This oxygen-poor blood feeds into two large veins, the superior vena cava and inferior vena cava, which empty into the right atrium of the heart. HEART VALVES Four valves within the heart prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but when blood pushes against the valves in the opposite direction, the valves close. Two valves, known as atrioventricular valves, are located between the atria and ventricles. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve. The left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other two heart valves are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moon-shaped flaps of tissue. The right semilunar valve, between

the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. LAYERS OF THE HEART MYOCARDIUM. Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding of tough connective tissue to form the walls of the hearts chambers. The atria, the receiving chambers of the heart, have relatively thin walls compared to the ventricles, the pumping chambers. The left ventricle has the thickest wallsnearly 1 cm (0.5 in) thick in an adultbecause it must work the hardest to propel blood to the farthest reaches of the body. PERICARDIUM. A tough, double-layered sac known as the pericardium surrounds the heart. The inner layer of the pericardium, known as the epicardium, rests directly on top of the heart muscle. The outer layer of the pericardium attaches to the breastbone and other structures in the chest cavity and helps hold the heart in place. Between the two layers of the pericardium is a thin space filled with a watery fluid that helps prevent these layers from rubbing against each other when the heart beats. ENDOCARDIUM. The inner surfaces of the hearts chambers are lined with a thin sheet of shiny, white tissue known as the endocardium. The same type of tissue, more broadly referred to as endothelium, also lines the bodys blood vessels, forming one continuous lining throughout the circulatory system. This lining helps blood flow smoothly and prevents blood clots from forming inside the circulatory system. CARDIAC CYCLE Although the right and left halves of the heart are separate, they both contract in unison, producing a single heartbeat. The sequence of events from the beginning of one heartbeat to the beginning of the next is called the cardiac cycle. The cardiac cycle has two phases: diastole, when the hearts chambers are relaxed, and systole, when the chambers contract to move blood. During the systolic phase, the atria contract first, followed by contraction of the ventricles. This sequential contraction ensures efficient movement of blood from atria to ventricles and then into the arteries. If the atria and ventricles contracted simultaneously, the heart would not be able to move as much blood with each beat. During diastole, both atria and ventricles are relaxed, and the atrioventricular valves are open. Blood pours from the veins into the atria, and from there into the ventricles. In fact, most of the blood that enters the ventricles simply pours in during diastole. Systole then begins as the atria contract to complete the filling of the ventricles. Next, the ventricles contract, forcing blood out through the

semilunar valves and into the arteries, and the atrioventricular valves close to prevent blood from flowing back into the atria. As pressure rises in the arteries, the semilunar valves snap shut to prevent blood from flowing back into the ventricles. Diastole then begins again as the heart muscle relaxesthe atria first, followed by the ventriclesand blood begins to pour into the heart once more. CORONARY CIRCULATION Coronary circulation is the circulation of blood in the blood vessels that supply blood to and from the heart muscle itself. Although blood fills the chambers of the heart, the muscle tissue of the heart, or myocardium, is so thick that it requires coronary blood vessels to deliver blood deep into it. The vessels that deliver oxygen-rich blood to the myocardium are known as coronary arteries. The vessels that remove the deoxygenated blood from the heart muscle are known as coronary veins. The coronary arteries that run on the surface of the heart are called epicardial coronary arteries. These arteries, when healthy, are capable of autoregulation to maintain coronary blood flow at levels appropriate to the needs of the heart muscle. These relatively narrow vessels are commonly affected by atherosclerosis and can become blocked, causing angina or a heart attack. The coronary arteries that run deep within the myocardium are referred to as subendocardial. The coronary arteries are classified as "end circulation", since they represent the only source of blood supply to the myocardium: there is very little redundant blood supply, which is why blockage of these vessels can be so critical. CIRCULATORY SYSTEM The circulatory system is an organ system that moves nutrients, gases, and wastes to and from cells, and helps maintain homeostasis. This system may be seen strictly as a blood distribution network, but some consider the circulatory system as composed of the cardiovascular system, which distributes blood, and the lymphatic system, which distributes lymph. Heart is a hollow muscular organ that pumps blood through the body. The heart, blood, and blood vessels make up the circulatory system, which is responsible for distributing oxygen and nutrients to the body and carrying away carbon dioxide and other waste products. The heart is the circulatory systems power supply. It must beat ceaselessly because the bodys tissuesespecially the brain and the heart itselfdepend on a constant supply of oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood for more than a few minutes, death will result. The circulatory system includes: the pulmonary circulation, a "loop" through the lungs where blood is oxygenated; and the systemic circulation, a "loop" through the rest of the body to provide

oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, which consists of plasma that contains red blood cells, white blood cells, and platelets. Two types of fluids move through the circulatory system: blood and lymph. The blood, heart, and blood vessels form the cardiovascular system. The lymph, lymph nodes, and lymph vessels form the lymphatic system. The cardiovascular system and the lymphatic system collectively make up the circulatory system. The circulatory system pumps purple blood until it reaches the heart. The heart then pumps blue blood. You bleed red blood because when the blood hits oxygen, it turns red.

VIII. Pathophysiology i. Predisposing Factor: Heredity Increasing age Gender Diagram Precipitating Factor: Hypertension Physical inactivity Low HDL

Injury to the vascular endothelium

Presence of inflammation

Attraction of inflammatory cells (such as monocytes: macrophages)

Macrophages ingest lipids

Macrophages become foam cells

Transport of lipids into the arterial wall

Activated macrophages also release biochemical substances

Attracting platelets and initiating clotting

Smooth muscle cells within the vessel wall subsequently proliferate

Formation of fibrous cap over a core filled with lipid and inflammatory infiltrate

Formation of atheromas or plaques

Narrowing of the vessel


Obstruction of blood flow

Decreased oxygenation to the tissues

Impairs Left ventricular function

Decrease cardiac output

Left sided Congestive Heart Failure

Dyspnea

IX. Course in the Hospital Date and Time 06-24-2013 6:00 am 180/100 36.3C 76bpm 22bpm To ROC Pls. admit under the service of Dr. Peralta Doctors order carried out, referred patient to Dr. Peralta. Side Notes Doctors Order Progress Notes

Low salt, Low fat diet

Informed dietary unit about patients diet.

Vs q4h and record pls.

Vs monitored and recorded q4h

Start venoclysis with 1l PNSS @ KVO rate

PNSS 1L hooked and inserted. Then regulated IVF at KVO rate

>Labs

Lab request made and given to patient for scheduling and

1. CBC 2. UA 3. St RABS now (95mg/dl) 4. ECG 12 leads now 5. CXRAY PA VIEW 6. FBS, Lipid Profile, Creatinine in A.M. ( NPO POST MIDNIGHT

billing. It was also referred to the medical technologist.

The patient was also instructed not to eat anything beyond 12

except meds)

midnight except for meds.

>Meds

Prescription of medication was made and carried out.

1. Amiodarone 200mg tab OD 2. Candesartan 8mg 1 tab OD in A.M 3. Trimettazidine 35mg 1 tab OD @ night 4. Clopidogrel 75mg 1 tab OD in A.M (use plogrel) 5. ISMN 30mg 1 tab OD in A.M. O2 inhalation via nasal cannula @ 24lpm PRN

Then it was given to the patient and encouraged strict compliance to medications for faster recovery.

O2 inhalation 2 lpm was administered via nasal cannula when necessary.

CBR withot BRP, pls. provide bedside commode

Instructed patient that she is not allowed to go to the comfort room as ordered by the doctor. Bedside commode was provided and also instructed how to use it.

Avoid straining

Reminded the patient to avoid straining.

Mod-high back rest

Placed patient on moderate high back rest.

Pls. inform AP Captopril 25mg 1tab SL ROCO Presciption for Captopril 25mg 1tab was given.

Signed: Dr. Dela Pena

06-24-2013 8:00 A.M.

Monitor VS q1h till stable Continue other home meds ISMN (MONTRA) 30 mg 1tab in A.M.

Vs monitored and recorded hourly. Instructed patient to continuously comply with the medications.

Signed: Dr. Peralta

06-24-2013 1:00 P.M.

Candesartan 16mg 1 tablet after breakfast

Candesartan 16mg 1 tab was given to the patient after breakfast.

Use clopidogrel, plogrel 75mg 1tab OD

Clopidogrel (plogrel) 75mg 1 tab given OD

Captopril 25mg 1tab SL now strict BP > 100 q6h IVF @ KVO, 15gtts/min Lasix 20mg IV STAT

Captopril 25mg 1 tab given after taking blood pressure.

IVF regulated at 15gtts/min.

Lasix 20mg andministered thru IV immediately as

ordered.

Measure I and O qshift

Intake and output was accurately monitored, measured and recorded.

Signed: Dr. Peralta

6/26/2010 6:15 am (-) CP (-) SOB BP: 120/80

SFF Aldactone 50 mg 1 tab OD CBR without BRP Oxygen at 1-2 LPM if with SOB Administered Aldactone 50 mg 1 tab OD aseptically as ordered Stressed importance of CBR w/o BRP to patient and watchers; strict observance enforced

6/27/2013 6:00 am (-) CP (-) SOB BP: 130/80 Continue meds Meds continuously administered aseptically as ordered

X. Laboratory Studies CLINICAL CHEMISTRY (June 25,2013)

Determinants

Actual Value

Normal Value

Interpretation

Significance

Nursing Responsibility

FBS

4.39

4.11 5.89 mmol/L

Within normal range

Normal

Check the Doctors order. Positively identify the patient Inform the patient that he would be undergoing a test and state of its importance Note any recent procedure that can interfere with the test results.

Creatinine

68.2

M:59-104 umol/L F: 45-84 umol/L

Within normal range

Normal

Total Cholesterol

3.26

Up to 5.2 mmol/L

Within normal range

Normal

Triglyceride

0.80

Up to 2.3 mmol/L

Within normal range

Normal

HDL

1.11

M: >1.45 mmol/L F: >1.68 mmol/L

Decreased

HDL cholesterol is lower in patients with increased risk for Coronary Artery Disease

HEMATOLOGY June 24, 2013 Determinants Actual Values Normal Values Interpretations Significance Nursing Responsibility

Leukocyte

5.3

4.0-10.0 x 10^9/L

Within normal range

Normal

Check the Doctors order. Positively identify the patient

Erythrocytes

3.72

M: 4.5 5.0x10^12/L F: 4.0 5.0x10^12/L

Decreased

Decreased in all anemias,in leukemia and after hemmorhage when blood volume has been restored.

Inform the patient that he would be undergoing a test and state of its importance

Note any recent procedure that can interfere with the test results.

Monitor vital signs especially BP & RR Hemoglobin 118 M: 140 180 g/dL F: 120 160 g/dL Decreased Decreased in all various anemia, severe or prolonged hemorrhage, and with excessive fluid intake. Instruct pt to take extra care not to injure self. Instruct to move slowly. Instruct lie flat for a few

minutes if feel dizzy or lightheaded. Assist in ADL Hematocrit 0.35 M: 0.40 0.48 F: 0.37 - 0.45 Decreased Decreased in severe anemia, acute massive blood loss. Encourage to do light exercise Encourage to take a rest every after activity especially when tired. Reposition the pt every hour. Encourage to eat green leafy vegetables and cooked red meat. Encourage to drink 2-3 liters(8-12glasses) of liquid a day as ordered.

Neutrophil

0.62

0.45 0.77 %

Within normal range

Normal

Lymphocyte

0.24

0.20 0.40 %

Within normal range

Normal

Monitor for signs of infection such as fever, redness, etc.

Monocyte

0.10

0.03 0.08 %

Increased

Increased in viral infections, parasitic disease, collagen & hemolytic disorders decreased with use of corticosteroids.

Emphasize the importance of handwashing Encourage intake of protein- and calorie-rich foods. Instruct watchers to avoid direct contact with patient.

Eosinophils

0.04

0.005 0.05 %

Within normal range

Normal

Basophils

0.00

0.00 0.01 %

Within normal range

Normal

MCV(Mean Corpuscular Volume)

95.10

86 100 fl

Within normal range

Normal

MCH(Mean Corpuscular Hemoglobin) 31.70 26.0 31.0 pg Increased Increased in macrocytic anemias

MCHC(Mean Corpuscular Hemoglobin Concentration) 33.30 31 37 g/dL Within normal range Normal

URINALYSIS June 24, 2013 Determination Color Actual value Yellow Normal value Amber / Straw Interpretation Normal Significance Tea colored urine indicates a concentrated urine while a very light urine indicates a diluted urine Instruct the patient to void directly into a clean, dry container. Sterile, disposable Transparency Clear Clear to slightly hazy Normal A cloudy appearance may indicate an infection. Instruct the patient to catch the midstream urine about 1-2 ounces. Albumin Negative Negative Normal Larger amounts of protein in the urine may indicate a kidney problem. Cover all specimens tightly, label properly and send immediately to the laboratory. containers are recommended. Nursing responsibility Inform the patient about the procedure to be done

Observe standard precautions

Sugar

Negative

Negative

Normal

Glycosuria (excess sugar in urine) generally means diabetes mellitus.

when handling urine specimens.

If the specimen cannot be delivered to the laboratory or

Ph

Acidic

4.5 to 8

Normal

Abnormal pH levels may indicate a kidney or urinary tract disorder.

tested within an hour, it should be refrigerated or have an appropriate preservative added.

Specific Gravity 1.010 1.005 to 1.025 Normal indicates hydration and any measurement above it indicates relative dehydration

Refer the results to the physician Instruct the patient that abnormal results will be explained by the physician.

Diagnostic Test: Chest X-ray) Xray PA : There is prominence of the vascular markings Haziness in the right lung base is also seen. Heart is enlarged. Diaphragm and costophrenic sinuses are intact The bony thorax is unremarkable Impression : Cardiomegaly with Pulmonary Congestion Underlying Right Basal Pneumonia is also considered.

XI. Drug Studies

Generic Name T R I M E T A Z I D I N E

Brand Name C A R V I D O N

General Classification Anti-Anginal drugs

Mode of Actions Trimetazidine is a cellular acting anti-ischaemic agent. It has 3 main properties by which it acts as a cytoprotective agent. It inhibits the anaerobic glycolysis and fatty acid metabolism, thus allowing only aerobic glycolysis. This action helps to restore the energy balance in the cell. It inhibits acidosis and free radical accumulation in the cell. All these action help the cell to restore the normal ionic and metabolic balance. Absorption: Rapidly absorbed. Peak plasma concentration: within 2 hr (conventional tab); 5 hr (modified release). Excretion: Via urine, mainly as unchanged drug. Half life: 6 hr (conventional); 7 hr (modified release).

Indications -Angina pectoris -treatment of Meniere's disease

Contraindications -Hypersensitivity to the drug -Pregnancy and lactation.

Usual Dose 1 tab every morning and evening

Actual Dose 35mg 1 tab BID

Side Effects -GI disturbances such as nausea and vomiting

Nursing Responsibilities

-headache

Generic Name C L O P I D O G R E L

Brand Name P L O G R E L

General Classifications Anticoagulant/ Antiplatelet

Mode of Actions

Indications

Contraindications

Usual Dose

Actual Dose 75mg 1 tab OD in AM

Side Effects

Nursing Responsibilities

Clopidogrel is an irreversible inhibitor of platelet aggregation. It acts by irreversibly modifying the platelet adenosine 5'diphosphate receptor, thus selectively inhibiting the binding of ADP to its platelet receptor and the

- Prevention of atherosclerotic events in patients with history of recent myocardial infarction (MI)

- Known hypersensitivity to clopidogrel or any component in the formulation.

75mg 1 tab once daily

-GI disturbances such as diarrhea, abdominal pain, nausea and vomiting

-when patient experience nausea help her to relieve sensation of nausea by providing her ice chips, Dry toast or crackers

-Presence of active pathological

-when patient experience vomiting position patient semi fowlers(awake) and lateral position(unconscious)

- Non-ST segment elevation acute

bleeding (eg, peptic ulcer, intracranial hemorrhage)

subsequent activation of coronary the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. syndrome (unstable angina/non-Q wave MI) dermatological -coagulation disorders.

to avoid aspiration.

Consequently, platelets exposed to clopidogrel are affected for the remainder of their lifespan. Biotransformation of clopidogrel to its active metabolite is necessary to produce inhibition of platelet aggregation.

including patients who are managed medically with percutaneous coronary intervention (with or without stent) or coronary artery bypass graft (CABG).

reactions such as -encourage patient to rashes and pruritus, erythema multiforme. use antipruritic or anti bacterial soaps to lessen the spread of microorganisms and to aid in the itchiness.

Generic Name C A N D E S A R T A N

Brand Name C A N D E Z

General Classification Angiotensin II Antagonists

Mode of Actions

Indications

Contraindications

Usual Dose

Actual Dose 16mg 1 tab OD after meals

Side Effects Nursing Responsibilities -dizziness, Headache -Encourage patient to stay in bed and ask for assistance when doing ADLs to avoid injury. -Instruct watcher not to leave patient unattended.

Candesartan is an angiotensin-receptor blocker (ARB) that may be used alone or with other agents to treat hypertension. It is administered orally as the prodrug, candesartan cilexetil, which is rapidly converted to its active metabolite, candesartan, during absorption in the gastrointestinal tract.

-Management of HTN.

- Severe renal & hepatic impairment and or cholestasis.

Adult 8mg or 16mg once

-Used in heart failure in patients w/ impaired left ventricular systolic function -Pregnancy & lactation.

daily

-instructed watcher -fever to perform TSB and to turn off aircondition when performing TSB. -instructed watcher to wear light

C I L E

Candesartan lowers blood pressure by antagonizing the renin-angiotensinaldosterone system

X E T I L

(RAAS); it competes with angiotensin II for binding to the type-1 angiotensin II receptor (AT1) subtype and prevents the blood pressure increasing effects of angiotensinII.

clothings -encourage patient to increase OFI within the cardiac tolearance of the patient.

Generic Name I S O S O R B I D E

Brand Name M O N T R A

General Classifications Anti-Anginal Drugs

Mode of Actions

Indications

Contraindications

Usual Dose

Actual Dose 60mg 1 cap OD in AM

Side Effects

Nursing Responsibilities

Isosorbide-5mononitrate (ISMN), an active metabolite of isosorbide dinitrate, acts by relaxing vascular smooth muscles

Prophylaxis of

-Hypersensitivity

Adult: initially 30mg 1 cap once daily in the morning for the 1st 2-4days and may increased to 60mg 1cap once daily in the morning

-Headache

-Encourage patient to stay in bed and ask for assistance when doing ADLs to avoid injury. -Instruct watcher not to leave patient unattended.

anginal attacks to isosorbide-5in patients with chronic stable angina pectoris mononitrate -Acute circulatory failure associated with marked hypotension -angle-closure glaucoma -increased intracranial pressure -myocardial insufficiency due to obstruction obstructive

producing vasodilatation associated of both arteries and veins, with the latter effect predominating. By decreasing endwith coronary artery disease.

-encourage patient to -fever, flulike symptoms -encourage patient to -body malaise stay in bed and take a rest to regain energy and have a balanced increase vitamin C rich foods in her diet.

M O N O N

diastolic pressure and volume, ISMN decreases intramural pressure resulting in improvement in

I T R A T E

subendocardial blood flow. Thus, after administering ISMN, there is reduced cardiac workload and improved oxygen supply/demand balance in the myocardium.

hypertrophic cardiomyopathy; pericarditis; hypotension and/or cardiogenic shock; postural or orthostatic hypotension; severe anemia; -Dry mouth

diet to help gain enough calories.

-instruct patient to take sugar less lozenges or ice chip when experiencing dry help to aid in the dryness of her mouth.

Generic Name L E V O X F L O X A C I N

Brand Name L E V O X

General Classification Quinolones

Mode of Actions

Indications

Contraindications

Usual Dose

Actual Dose 500mg 1 tab after lunch

Side Effects

Nursing Responsibilities

Levofloxacin is the levorotatory isomer of ofloxacin which inhibits DNA topoisomerase, more commonly referred to as the DNA gyrase. DNA gyrase is necessary for bacterial DNA replication and some aspects of transcription, repair, recombination and transposition. Inhibition of DNA gyrase in susceptible microorganisms results in the inhibition of ATPdependent negative

-Acute bacterial sinusitis

-Hypersensitivity to levofloxacin or any other component of Levox.

250500mg 1tab once or BID

-edema

-influenza-like symptoms,

-encourage patient to increase vitamin C rich foods in her

-acute bacterial exacerbation of chronic bronchitis, -Patients with a history of tendon disorders related to fluoroquinolone -nosocomial pneumonia therapy. -malaise

diet.

-assist patient in doing ADLs to avoid injury.

-communityacquired pneumonia

-Dry mouth -instruct patient to take sugar less lozenges or ice chip

supercoiling of DNA, inhibition of ATPdependent relaxation of supercoiled DNA and promotion of doublestranded DNA breakage resulting in bacterial cell death.

-complicated skin and skin structure infections

when experiencing dry help to aid in the dryness of her mouth.

- chronic bacterial prostatitis

-urinary tract infection.

Generic Name F U R O S E M I D E

Brand Name L A S I X

General Classification Loop diuretics

Mode of Actions Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water,sodium, chloride, magnesium, potassium, and calcium. Decreased blood pressure. Diuresis and subsequent mobilization of excess fluid like edema.

Indications

Contraindications Usual Dose

Actual Dose Lasix 20 mg IVTT q 8 hrs

Side Effect

Nursing Responsiblities

Edema due to heart failure, hepatic impairment or renal disease.

>hypersensitivity >Hepatic coma or anuria

20-40 mg, may repeat in 1-2 hr

>observe 10 Rs in giving medication >dehydration >hypochloremia >hypokalemia >Monitor intake and output >Monitor electrolytes >Monitor BP and PR baefore

Use cautiously in:

and increase by 20 mg every 12 hr until response is obtained.

>hypomagnesemia and during administration >hyponatremia >aplastic anemia >Assess patient for tinnitus and hearing loss >Caution patient to change in > dizziness >headache >vertigo >hypovolemia position to prevent orthostatic hypotension >Asssess fall risk and implement fall prevention strategies

Hypertension. >severe liver disease >electrolyte depletion >Diabetes mellitus > hypotension and electrolyte imbalance.

Generic Name C A P T O P R I L

Brand Name C A P O T E N

General Classification Antihypertensives

Mode of Action Lowering of blood pressure in

Indication

Contraindication

Usual Dose

Actual Dose

Side Effects

Nursing Responsibility >Observe the 10 Rs in giving medication >Monitor BP & PR >Monitor frequency of prescription refills to determine adherence. >Monitor CBC with differential prior to initiation of therapy.

Reduction of risk of death or

>Hypersensitivity 12.5-25 >history of angioedema with prev. use of ACE inhibitors mg 2-3 times daily, may be

Captopril >cough 25 mg 1 tab SL every 6 hrs. >hypotesion >dizziness >drowsiness >fatigue >dyspnea >chest pain

hypertensive development patients. Improved symptoms in patients with CHF. of CHF following MI. Decreased progression of diabetic neuropathy. Management of hypertension.

increased >160 Use cautiously in: >Renal and heatic impairment >hypovolemia >hyponatremia >concurrent diuretic therapy at 1-2 weeks intervals up to 150 mg 3 times daily

>constipation >Administer 1 hr before or 2 hr after meals. May be crushed if the patient has difficulty swallowing >assess patient for resolution of fluid overload. >Notify health care professional of significant changes.

Generic Brand General Name A M I O D A R O N E Name C O R D A R O N E Classification

Mode of Action

Indication

Contraindication

Usual Dose

Actual Dose Side Effects

Nursing Responsibility >Observe 10 Rs in giving medication >Monitor heart rate >Monitor ECG >Report dyspnea, tachypnea, or rales/crackles. >Monitor BP. Hypotension usually occurs during first several hours. >Monitor liver and thyroid functions before & throughout therapy. > Advise patient to avoid drinking grapefruit during therapy.

Antiarrhythmics Prolongs action potential (Class III)

800-, Amiodarone >dizziness 1600 and refractory period. threatening cardiogenic mg/day 200 mg >fatigue in 1-2 Inhibits adrenergic ventricular shock doses OD in AM >malaise for 1-3 stimulation. Increases PR arrhythmias >Hypersensitivity wks, >headache then and QT intervals and unresponsive to Amniodarone 600>insomnia 800 decreases peripheral to less toxic or iodine mg/day >nausea in 1-2 vascular resistance. agents. >Bradycardia doses >vomiting in 1 (Vasodilation)Suppression Management month >constipation then of arrhythmias. of Use cautiously 400 >tremor mg/day supraventricu- in: maintenance lar >history of CHF dose tachyarrhythmias. >Thyroid disorders >Severe pulmonary or liver disease.

Life-

>Patients with

XII. Nursing Care Plans

XIII. Prognosis DETERMINA NTS Severity of the disease Very Good Good Fair Poor Very Poor The severity of the disease is marked as poor since the client is on advance age and if no medical and nursing intervention, her condition will probably lead to ischemia to Myocardial infection. Financial status The financial status is rated as fair since the client verbalized that her family can provide her medicines for her treatment course and they can eat three meals per day, given that her 2 out of 7 children have jobs. Patient Factor The patient factor is rated as fair because based on her after she had an idea about her condition, she said that she started to follow instructions given to her by the doctor and seek some advices to prevent her condition to worsen. Availability and accessibility of appropriate treatment In this portion, it is rated s good since the location of the patients home is accessible and near to the hospital in which approximate treatment can be rendered to the patient but the conflict was that, they dont prioritize treatment because its expensive to seek medical treatment. Justification

General Prognosis

The general prognosis is rated as poor because the client is currently taking medications for the improvement of her condition, even the condition is life threatening, if the patient will just follow and take all the medications and orders, she will be able to prevent worsening of her condition.

XIV. Discharge Plan Medications Medications should be complied, following the correct dosage and timing to ensure full recovery of the patient Exercise - The best way to control the symptoms of coronary artery disease and to help prolong your life is exercise and diet. Here is a list of exercises you can perform inside the comfort of your home. 1. Light Stretching 2. Light-weight lifting (no more than 5 lbs) When exercising, be sure to wear comfortable, unrestricting clothes. If your clothes restrict the blood flow to your limbs, your heart will have to work harder to pump the blood. It is very important that you don't overexert yourself, as this will place too much stress on your heart. Avoid activities that can potentially raise blood pressure Promote frequent position change ( every 2 hours ) on bed Patient should not be kept flat on bed for longer than 24 hours Treatment Refer promptly to health-care institution when there is any unusualities observed from the patient Hygiene Frequent bathing and changing of clean clothes of the patient Assist patient in doing ADLs Out-patient visit Scheduled follow-up visit with the physician needs to be complied Follow-up 2 weeks after discharge Diet The key to this diet is limiting salt, because too much sodium can lead to fluid retention. Although you should ask the doctor for specific dietary guidelines, these are some of the keys to a better diet: Cook with less salt. Avoid canned or processed foods Limit fats and cholesterol Drink sufficient amount of fluids for about 1-2 L per day Steaming, boiling and baking your food instead frying or grilling it.

XV. Recommendations I. For the Patient We recommend to the patient to comply with her treatment regimen indicated by the health care team and always include her Nutritional Therapy/Cardiac Diet consists of low salt and low fat diet. In addition, avoidance of drinking excessive amounts of fluid including alcohol to reduce work load of the heart. We recommend patient to eat fruits, vegetables, fresh and natural food instead of processed foods. Patient should also slight limit her physical activity, at least 10 minutes of exercise each day with ample rest periods and avoidance to strenuous activity to decrease oxygen demand. Encourage the patient not to stress-out herself instead, doing relaxation technique such as deep breathing exercise will help in the oxygenation and relaxation of the client. II. For the Family We recommend and encourage the family to support the patient to take her medications on time throughout the course of treatment regimen. They must guide and care for the patient not only financially and physically but also they should include emotional and spiritual aspect of the client. They should help follow restriction regarding her diet, activities, medication as prescribed by the doctor and compliance to the therapeutic medical regimen. If severe chest pain, rush the client to the nearest hospital to provide medical treatment as soon as possible. III For the community We encourage the community to be aware of the different diseases that may arise to them because those diseases may be prevented if early detection and treatment will undergo. We recommend the community to have regular check-up if given a chance to check their over-all health status and to prevent exacerbation of disease if present. IV For the Student Nurse We recommend and encourage our fellow student to give a quality nursing care and therapeutic intervention that are helpful for the patient; to review and apply assessment technique and concepts related to the case to have a better understanding to the disease process. to be sure to the different intervention and management that will be applied to the patient and keep in mind that patients health is indispensable.