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Brief Description Ischemic or ischemic heart disease (IHD), or myocardial ischemia, is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking, hypercholesterolemia (high cholesterol levels), diabetes, hypertension (high blood pressure) and is more common in men and those who have close relatives with ischemic heart disease. Myocardial ischemia is a disorder that is usually caused by a critical coronary artery obstruction, which is also known as atherosclerotic coronary artery disease (CAD). CAD is the
leading cause of death worldwide, and it is the second most common cause of emergency department visits in the United States. More than $140 billion are spent each year for the diagnosis and management of CAD. B. Statistics a) International
Diagnosing myocardial ischemia prior to a heart attack is important because ischemic heart disease is responsible for approximately 14% of all deaths worldwide. Approximately 1.5 million Americans will have a heart attack this year as a result of myocardial ischemia; about 500,000 of those will be fatal. Angina occurs more frequently in women than in men, and in blacks and Hispanics more than in whites. It also occurs more frequently as people age--25% of women over the age of 85 and 27% of men who are 80-84 years old have angina. Number one killer in the United States and worldwide. Every minute, an American dies of coronary heart disease. Coronary heart disease afflicts over 13 million Americans.
b.) Local MORTALITY: TEN LEADING CAUSES BY SEX Number, Rate/100,000 Population and Percent Distribution Philippines, 2004
Source: The 2004 Philippine Health Statistics * Percent share from total deaths, all causes, Philippines ** External Causes of Mortality Last Update: February 11, 2008
A. General Objectives At the end of the clinical exposure, we should be able to attain and enhance our knowledge, skills and attitude to provide nursing care to our patient with chronic kidney failure. B. Specific Objectives During the exposure, we should be able to: Cognitive: ➢ Give brief discussion or description about the case of the patient. ➢ Understand Myocardial Ischemia, its causes and pathophysiology.
➢ Design a plan of care for patient with Myocardial Ischemia. ➢ Discuss the different data gathered for the patient’s health assessment. ➢ Discuss the different nursing intervention. ➢ To be able to set priorities and goal outcomes in collaboration with the patient. ➢ To be able to document patient responses to care and verbal reports, if any. Skills: ➢ Conduct physical assessment and organize data efficiently. ➢ Perform nursing procedures effectively and correctly to attain his optimum level of wellness. Attitude: ➢ To be able to establish rapport with the patient and folks. ➢ To be able to develop respect and trust.
ANATOMY AND PHYSIOLOGY OF THE DISEASE CARDIOVASCULAR SYSTEM
Your heart and circulatory system make up your cardiovascular system. Your heart works as a pump that pushes blood to the organs, tissues, and cells of your body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from your heart to the rest of your body through a complex
network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules and veins. If all the vessels of this network in your body were laid end-to-end, they would extend for about 60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth more than twice! The one-way circulatory system carries blood to all parts of your body. This process of blood flow within your body is called circulation. Arteries carry oxygen-rich blood away from your heart, and veins carry oxygen-poor blood back to your heart. In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to your heart. In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vessels that carry oxygen-poor blood are colored blue. Twenty major arteries make a path through your tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and nutrients to your cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to your heart to pick up oxygen. Coronary Arteries. Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.
Superior Vena Cava. The superior vena cava is one of the two main veins bringing deoxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart. Inferior Vena Cava. The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart. Aorta. The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body. Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart. Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart. Right Atrium. The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. Right Ventricle. The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs. Left Atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle. Left Ventricle. The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body. Papillary Muscles. The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close. Chordae Tendineae. The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease
in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings." Tricuspid Valve. The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery. Mitral Value. The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta. Pulmonary Valve. The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart. Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.
The Nervous System
The nervous system is a network of specialized cells that communicate information about an animal’s surroundings and its self; it processes this information and causes reactions in other parts of the body. It is composed of neurons and other specialized cells called glia, that aid in the function of the neurons. The nervous system is divided broadly into two categories; the peripheral nervous system and the central nervous system. Neurons generate and conduct impulses between and within the two systems. The peripheral nervous system is composed of sensory neurons and the neurons that connect them to the nerve cord, spinal cord and brain, which make up the central nervous system. In response to stimuli, sensory neurons generate and propagate signals to the central nervous system which then process and conduct back signals to the muscles and glands. The neurons of the nervous systems of animals are interconnected in complex arrangements and use electrochemical signals and neurotransmitters to transmit impulses from one neuron to the next. The interaction of the different neurons form neural circuits that regulate an organism’s perception of the world and what is going on with its body, thus regulating its behavior. Nervous systems are found in many multicellular animals but differ greatly in complexity between species The central nervous system (CNS) is the largest part of the nervous system, and includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while the head contains and protects the brain. The CNS is covered by the meninges, a three layered protective coat. The brain is also protected by the skull, and the spinal cord is also protected by the vertebrae. Brain is a part of the Central Nervous System, it plays a central role in the control of most bodily functions, including awareness, movements, sensations, thoughts, speech, and memory. Some reflex movements can occur via spinal cord pathways without the participation of brain structures. The cerebrum is the largest part of the brain and controls voluntary actions, speech, senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which are termed fissures. Some fissures separate lobes. The convolutions of the cortex give it a wormy appearance. Each convolution is delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum links the hemispheres. The right hemisphere controls voluntary limb movements on the left side of the body, and the left hemisphere controls voluntary limb movements on the right side of the body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four lobes, or areas, which are interconnected.
The frontal lobes are located in the front of the brain and are responsible for voluntary movement and, via their connections with other lobes, participate in the execution of sequential tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory. The parietal lobes are located behind the frontal lobes and in front of the occipital lobes. They process sensory information such as temperature, pain, taste, and touch. In addition, the processing includes information about numbers, attentiveness to the position of one’s body parts, the space around one’s body, and one's relationship to this space. The temporal lobes are located on each side of the brain. They process memory and auditory (hearing) information and speech and language functions. The occipital lobes are located at the back of the brain. They receive and process visual information (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
VITAL INFORMATION Name (initials): A.L Age: 67 years old Sex: Male Address: Panit.an, Capiz Civil Status: Widow Religion: Roman Catholic Occupation: Businessman Date and Time admitted: November 5, 2009 at 4:00 pm Ward: ICU- D Chief Complaint: Difficulty of Breathing Admitting Diagnosis: DM Type II, Pneumonia, Myocardial Wall Ischemia Final Diagnosis: Myocardial Ischemia Attending Physician/s: Dr. M. B.
CLINICAL ASSESSMENT A. Nursing History
Mr. AL is an excessive alcohol drinker. He stays on his shop often because of his business. One day prior to admission, he has onset of whitish productive cough and difficulty of breathing and chest pain. He has high blood pressure of 130/90 mmhg. B. Past Health Problem / Status Past Illnesses: Mr. A.L. is a 67 year old male suffering from hypertension, diabetes mellitus type – 2. He also experienced chickenpox and measles during his childhood. Allergies: He has no known allergies to food or drugs. Previous Hospitalization: Previous hospitalization was May 2006 due to difficulty of breathing with a diagnosis of Myocardial Infarction. C. Family History of Illness Upon interview, Mr. AL was diagnosed of Diabetes Mellitus Type II in the year 2004, and he is taking Glibenclamide as his medication, according to his daughter he is also fond of eating foods which are rich in fat and cholesterol. She has also that Mr. AL cannot eat without putting extra salt on her food. Both of his parents have hypertension, diabetes mellitus type -2 and a history of bronchial asthma, eventually, he may acquire these diseases. Some of his siblings have it too, and also to his children especially bronchial asthma.
HPN DM-type II
HPN, PTB, Myocardial IschemiaCCCCCCCC HPN HPN BA
Deceased male Deceased female BA Indicates patient
Living male Living female
BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND A. Educational Background Mr. AL is a college graduate. B. Occupational Background He is working as a business man. C. Religious Background He is a Roman Catholic and attends mass on Sundays and prays the rosary at night together with his children. D. Economic Status They belong to a middle class type of family and most of his children are professionals and have a job of their own.
CLINICAL INSPECTION A. Vital Signs Temperature Pulse Rate Respiration Blood Pressure Cardiac Rate Upon Admission 36.8C 88 bpm 30 bpm 140/90 mmHg 120 bpm During Care 36.5°C 95 bpm 36 bpm 130/80 mmHg 130 bpm
B. Height, Weight, BMI – no data C. Physical Assessment General Patient is wearing a hospital gown, with unkempt hair, appears weak; conscious and coherent. He is lying on bed with an ongoing IVF of #4 PLRS 1 L xKVO 5 µgtts/ min infusing well on the right metacarpal vein currently at 770 cc level. Oxygen inhalation at 2/L min via nasal cannula. Skin, Hair, Nails Dry skin, uniform in color. Hair is black with visible white hair, no lice and dandruff and dry scalp. Fingernails are trimmed, (+) cyanotic nailbeds, toenails are not trimmed and unclean.
Head, Face, Lymphatics (+) Headache. No head injuries, round in shape and oily face.
HEENT Upon the assessment of the client, most of the findings are of normal findings characterized by pupils which are equally round in shape, reactive to light and accommodation, with her right eyebrows evenly distributed and symmetrically aligned. With eyelashes of normal growth, there are no purulent or any discharges seen on the client’s eyes. No periorbital edema noted, cornea is transparent and shiny. Ears are of normal findings. Nose is also of normal findings. Lips that are dark and gums
Neck and Upper extremities No lumps or swollen glands. No reports of neck pain and stiffness. Arms able to move freely. Presence of palpitation in his wrist. Chest, Breast and Axilla Abnormal respiration upon admission with RR of 30 bpm and 36 bpm during care. Presence of chest pain, (+) history of bronchial asthma, (+) crackles, (+) wheezing. Respiratory System (Chest and Lungs) Thorax is symmetric. (+) history of bronchial asthma, RR is above normal. (+) dyspnea, (+) wheezing.(+) difficulty of breathing (+) productive cough with presence of whitish phlegm.CXR results: (+)PTB, both upper lobe with regression and Atheromatous Aorta
Cardiovascular System (+) history of hypertension with blood pressure of 140/90 upon admission and during care with the BP of 130/80 mmHg. (+) dyspnea, (+) tachycardia, (+) chest pain with discomfort. Cardiac rate is above normal with AR of 130 bpm and respiration of 36 bpm. Gastrointestinal System During Bowel Elimination Frequency: Once a day Pattern: Every morning Consistency: Normal Stool Color: Light Brown Odor: Normally foul stool odor Genito – Urinary System Quantity: 1000cc to 1200cc per shift Color: Lt. Yellow
(+) weakness, (+) limitation of motion or activity,
D. General Appraisal Speech: He speaks clearly, attentive and conversive. Language: The patient knows how to speak English, Tagalog, Bisaya. Hearing: The patient’s hearing is good. Mental Status: The patient is alert and attentive when asked but sometimes he is grumpy, depending on his mood. Emotional status: He is worried about his condition and thinks that he brings problem to his family due to his situation.
LABORATORY AND DIAGNOSTIC DATA A. Hematology Hematology is the branch of biology (physiology), pathology, clinical laboratory, internal
medicine, and pediatrics that is concerned with the study of blood, the blood of forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases. Test Result Normal Significance Values Date: 11/05/09 18.3x10^9/L 4.5-11.0 4.78x10^12/L 4.2-5.4 140g/L 0.42vol.fr 86.0cu.u 28.5uug 33.0g/dL 120-160 0.37-0.47 80-96 27-31 32-36
WBC count RBC count Hemoglobin Hematocrit Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin (MCH) Mean Corpuscular Hemoglobin the Concentration (MCHC) RDW Neutrophils Eosinophils Basophils Lymphocytes
↑ Susceptible to infection The result is Within Normal Range. The result is Within Normal Range. The result is Within Normal Range. The result is Within Normal Range. The result is Within Normal Range. The result is Within Normal Range.
12.8% 65.0% 4.0% 0.0% 11.0%
11-16 50-70 0-3 0-1 20-45 0-8 15000-35000 10-15 sec
The result is Within Normal Range. The result is Within Normal Range. ↑ Allergic reactions The result is Within Normal Range. ↓ It signifies severe debilitating illnesses. The result is Within Normal Limits. The result is Within Normal Limits. The result is within Normal Limits.
Monocytes 0.0% Platelet 118000 Protrombin Time 14.6sec A. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly performed on sick or aging patient. A blood sample is collected from the patient. The blood is then separated into a cell layer and serum layer by spinning the sample at high speeds in a machine called centrifuge. The serum layer is drawn off and a variety of compounds are then measured. These measurements aid the veterinarian in assessing the function of various organs and body systems. Test Glucose Sodium Magnesium Creatinine Cholesterol Normal Values Date: 11/07/09 678 mmol/L 4.10 – 5.90 140.0 mmol/L 137.0 – 145.0 1.10 mmol/L 129.3 mmol/L 9.34 mmol/L .70 – 1.00 71.0 – 133.0 0.00 – 5.20 Result Significance ↑ Hyperglycemia The result is Within Normal Limits. The result is Within Normal Limits. ↑ Impaired renal ↑ function, shock Elevation
indicates increase Direct HDLC LDL .45 mmol/L 7.40 1.00 – 1.60 1.71 – 4.60 ↓ ↑ risk in CAD Indicates risks in CAD Elevation indicates risk in VLDL 1.52 0.00 – 1.03 ↑ CAD Elevation indicates increase Potassium 3.8 3.5 – 5.10 risk in CAD The result is Within Normal Limits. A. Radiology It provides a radiographic image of the organs or tissues, to detect abnormality such as tumor, perforation, abscess, infection, foreign body or fracture. Test Date: 11/05/09 Chest PA (mobile) B. Serology and Immunology It is the science that deals with the properties and reactions of serums, especially blood serum. It analyzes the contents and properties of blood serum. Serum Specimen Troponin – 1 Determination Result/s Normal Value Date: 11/07/09 (+) Positive 3.13 ug/L <0.01ug/L Significance Indicates Myocardial Infarction. upper lobes. X – ray Findings Impression
Shows regression of TB infiltrates in both PTB, both upper lobe with regression Atheromatous aorta.
HbA1c is a test that measures the amount of glycated hemoglobin in your blood. Glycated hemoglobin is a substance in red blood cells that is formed when blood sugar (glucose) attaches to hemoglobin Serum Specimen Hba1C Result/s Normal Value Date: 11/07/09 (+) Positive 12.0% 4.2-6.2% Significance It means that your diabetes control may not be as good as it should be. High values mean you are at
greater risk of diabetes complications.
I. PATHOPHYSIOLOGY Non modifiable Factors: Age Sex Family History
Modifiable Factors: Abnormal lipids Smoking Hypertension Diabetes mellitus Abdominal obesity Too much alcohol Lack of regular exercise
Formation of plaque deposits
Occlusion by Major blood vessel
If not Vascular wall managed: becomes Lyses a moved weakened and thrombus from fragile the vessel.
Leaking of blood from the vessel wall
Mass of blood from and grows
Isospasm of tissue and anterior
Impaired distribution of oxygen and glucose
Tissue hypoxia and cellular starvation
MEDICAL MANAGEMENT A. Drug Study
Name of the Drug with Dosage Vastarel Mr 35mg/tab 1 tab BID Generic Name Action Mechanism of Action Trimetazidine Antianginal Drugs Acts by directly counteracting all the major metabolic disorders occurring within the ischemic cell. The actions of trimetazidine include limitation of intracellular acidosis, correction of disturbances of transmembrane ion exchanges, and prevention of excessive production of free radicals.decrease myocardial oxygen requirement by Long treatment of coronary insufficiency, angina pectoris. Nausea and vomiting slight weakness and head ache. Hypersensitivity to Trimetazidine Use cautiously with renal dysfunction. Assess patient for chest pain or what its type of severity. Instruct the client to take drugs only for 3 times and refer physician if frequent angina attack will occur. Monitor VS and refer if there is an abnormality Take the medicine with a full glass of water. Administer before meals. Caution patient to swallow capsules whole—not to open, chew, or crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and have patient drink immediately; fill cup with water and have patient drink this water. Do not Indications Side Effects Contraindications Nursing Responsibilities
A. Other Treatments
ECG Electrocardiography (ECG or EKG) is a transthoracic interpretation of the electrical activity of the heart over time captured and externally recorded by skin electrodes. It is a noninvasive recording produced by an electrocardiographic device. The etymology of the word is derived from electro, because it is related to electrical activity, cardio, Greek for heart, and graph, a Greek root meaning "to write". Electrical impulses in the heart originate in the sinoatrial node and travel through the intimate conducting system to the heart muscle. The impulses stimulate the myocardial muscle fibres to contract and thus induce systole. The electrical waves can be measured at electrodes placed at specific points on the skin. Electrodes on different sides of the heart measure the activity of different parts of the heart muscle. An ECG displays the voltage between pairs of these electrodes, and the muscle activity that they measure, from different directions, also understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in different parts of the heart muscle. It is the best way to measure and diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue that carries electrical signals, or abnormal rhythms caused by electrolyte imbalances. In a myocardial infarction (MI), the ECG can identify if the heart muscle has been damaged in specific areas, though not all areas of the heart are covered. The ECG cannot reliably measure the pumping ability of the heart, for which ultrasound-based (echocardiography) or nuclear medicine tests are used. Placement of electrodes Ten electrodes are used for a 12-lead ECG. They are labeled and placed on the patient's body as follows ELECTRODE LABEL (in the USA) V1 V2 V3 V4 In the fourth intercostal space (between ribs 4 & 5) to the right of the sternum (breastbone). In the fourth intercostal space (between ribs 4 & 5) to the left of the sternum. Between leads V2 and V4. In the fifth intercostal space (between ribs 5 & 6) in the midclavicular line (the imaginary line that extends down from the midpoint of the clavicle V5 (collarbone). Horizontally even with V4, but in the anterior axillary line. (The anterior axillary line is the imaginary line that runs down from the point midway ELECTRODE PLACEMENT
between the middle of the clavicle and the lateral end of the clavicle; the V6 lateral end of the collarbone is the end closer to the arm.) Horizontally even with V4 and V5 in the mid-axillary line. (The mid-axillary line is the imaginary line that extends down from the middle of the patient's armpit.) Limb leads In both the 5- and 12-lead configuration, leads I, II and III are called limb leads. The electrodes that form these signals are located on the limbs—one on each arm and one on the left leg. The limb leads form the points of what is known as Einthoven's triangle. • • • Lead I is the signal between the (negative) RA electrode (on the right arm) and the (positive) LA electrode (on the left arm). Lead II is the signal between the (negative) RA electrode (on the right arm) and the (positive) LL electrode (on the left leg). Lead III is the signal between the (negative) LA electrode (on the left arm) and the (positive) LL electrode (on the left leg). Precordial leads The electrodes for the precordial leads (V1, V2, V3, V4, V5, and V6) are placed directly on the chest. Because of their close proximity to the heart, they do not require augmentation. Wilson's central terminal is used for the negative electrode, and these leads are considered to be unipolar (recall that Wilson's central terminal is the average of the three limb leads. This will approximate ground). The precordial leads view the heart's electrical activity in the so-called horizontal plane. The heart's electrical axis in the horizontal plane is referred to as the Z axis. Waves and intervals
A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P wave, a QRS complex and a T wave. A small U wave is normally visible in 50 to 75% of ECGs. The baseline voltage of the electrocardiogram is known as the isoelectric line. Typically the isoelectric line is measured as the portion of the tracing following the T wave and preceding the next P wave. P wave During normal atrial depolarization, the main electrical vector is directed from the SA node towards the AV node, and spreads from the right atrium to the left atrium. This turns into QRS the P wave on the ECG. The QRS complex is a recording of a single heartbeat on the
complex PR interval ST
ECG that corresponds to the depolarization of the right and left ventricles. The PR interval is measured from the beginning of the P It is usually 120 to 200 ms
wave to the beginning of the QRS complex. long. The ST segment connects the QRS complex and the T wave. It has a duration of 0.08 to 0.12 sec (80 to 120 ms).
segment T wave The T wave represents the repolarization (or recovery) of the ventricles. The interval from the beginning of the QRS complex to the apex of the T wave is referred to as the absolute refractory period. The last half of the T wave is referred to as the relative refractory period (or vulnerable QT interval U wave period). The QT interval is measured from the beginning of the QRS complex to the end of the T wave. The U wave is not always seen. It is typically small, and, by definition, follows the T wave.
Normal values for the QT interval are between 0.30 and 0.44 seconds.
An echocardiogram uses sound waves to produce images of your heart. This common test allows your doctor to see how your heart is beating and pumping blood. Your doctor can use the images from an echocardiogram to identify various abnormalities in the heart muscle and valves. Depending on what information your doctor needs, you may have one of several types of echocardiograms. Each type of echocardiogram has very few risks involved. Your doctor may suggest an echocardiogram if he or she suspects problems with the valves or chambers of your heart or your heart's ability to pump. An echocardiogram can also be used to detect congenital heart defects in unborn babies. Depending on what information your doctor needs, you may have one of the following kinds of echocardiograms: Types Transthoracic echocardiogram. This is a standard, noninvasive echocardiogram. A technician (sonographer) spreads gel on your chest and then presses a device known as a transducer firmly against your skin, aiming an ultrasound beam through your chest to your heart. The transducer records the sound wave echoes your heart produces. A computer converts the echoes into moving images on a monitor. If your lungs or ribs obscure the view, a small amount of intravenous dye may be used to improve the images. Transesophageal echocardiogram. If it's difficult to get a clear picture of your heart with a standard echocardiogram, your doctor may recommend a transesophageal echocardiogram. In this procedure, a flexible tube containing a transducer is guided down your throat and into your esophagus, which connects your mouth to your stomach. From there, the transducer can obtain more detailed images of your heart. Doppler echocardiogram. When sound waves bounce off blood cells moving through your heart and blood vessels, they change pitch. These changes (Doppler signals) can help your doctor measure the speed and direction of the blood flow in your heart. Doppler techniques are used in most transthoracic and transesophageal echocardiograms. Stress echocardiogram. Some heart problems — particularly those involving the coronary arteries that feed your heart muscle — occur only during physical activity. For a stress echocardiogram, ultrasound images of your heart are taken before and immediately after walking on a treadmill or riding a stationary bike. If you're unable to exercise, you may get an injection of a medication to make your heart work as hard as if you were exercising. Risks
There are minimal risks associated with a standard transthoracic echocardiogram. You may feel some discomfort similar to pulling off an adhesive bandage when the technician removes the electrodes placed on your chest during the procedure. If you have a transesophageal echocardiogram, your throat may be sore for a few hours afterward. Rarely, the tube may scrape the inside of your throat. Your oxygen level will be monitored during the exam to check for any breathing problems caused by the sedation medication. During a stress echocardiogram, exercise or medication — not the echocardiogram itself — may temporarily cause an irregular heartbeat. Serious complications, such as a heart attack, are rare. During the procedure An echocardiogram can be done in the doctor's office or a hospital. After undressing from the waist up, you'll lie on an examining table or bed. The technician will attach sticky patches (electrodes) to your body to help detect and conduct the electrical currents of your heart. If you'll have a transesophageal echocardiogram, your throat will be numbed with a numbing spray or gel. You'll likely be given a sedative to help you relax. During the echocardiogram, the technician will dim the lights to better view the image on the monitor. You may hear a pulsing "whoosh" sound, which is the machine recording the blood flowing through your heart. Most echocardiograms take less than an hour, but the timing may vary depending on your condition. During a transthoracic echocardiogram, you may be asked to breathe in a certain way or to roll onto your left side. Sometimes the transducer must be held very firmly against your chest. This can be uncomfortable - but it helps the technician produce the best images of your heart. After the procedure If your echocardiogram is normal, no further testing may be needed. If the results are concerning, you may be referred to a heart specialist (cardiologist) for further assessment. Treatment depends on what's found during the exam and your specific signs and symptoms. You may need a repeat echocardiogram in several months or other diagnostic tests, such as a cardiac computerized tomography (CT) scan or coronary angiogram. Results Information from the echocardiogram can reveal many aspects of your heart health, including:
Heart size. Weakened or damaged heart valves, high blood pressure or other diseases can cause the chambers of your heart to enlarge. Your doctor can use an echocardiogram to evaluate the need for treatment or monitor treatment effectiveness. Pumping strength. An echocardiogram can help your doctor determine your heart's pumping strength. Specific measurements may include the percentage of blood that's pumped out of a filled ventricle with each heartbeat (ejection fraction) or the volume of blood pumped by the heart in one minute (cardiac output). If your heart isn't pumping enough blood to meet your body's needs, heart failure may be a concern. Damage to the heart muscle. During an echocardiogram, your doctor can determine whether all parts of the heart wall are contributing equally to your heart's pumping activity. Parts that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may indicate coronary artery disease or various other conditions. Valve problems. An echocardiogram shows how your heart valves move as your heart beats. Your doctor can determine if the valves open wide enough for adequate blood flow or close fully to prevent blood leakage. Abnormal blood flow patterns and conditions such as aortic valve stenosis — when the heart's aortic valve is narrowed — can be detected as well. Heart defects. Many heart defects can be detected with an echocardiogram, including problems with the heart chambers, abnormal connections between the heart and major blood vessels, and complex heart defects that are present at birth. Echocardiograms can even be used to monitor a baby's heart development before birth.
NURSING MANAGEMENT A. Concept Map of Nursing Problems
1. Ineffective airway clearance2. Acute to related (Chest) Pain r/t myocardial presence of secretions in the resulting from coronary artery ischemia tracheobronchial tree. occlusion with loss/restriction of blood flow to an area of the myocardium and Objective/s: necrosis of the myocardium. (+) Crackles, (+) Whitish productive cough, (+) Chest Pain, (+) DOB, (+) Tachycardia, (+) Objectives: Weakness, (+) Confusion, RR= 36 bpm, CXR- (+) Facial grimacing, (+) (+)Restlessness, PTB, both lobe with regression Atheromatous Fatigue, (+) Peripheral cyanosis, (+) Cold and aorta clammy skin, (+) Palpitations (+) Shortness of breath, (+) Pain scale of 8/10
` 6. Deficient Knowledge r/t new diagnosis and lack of understanding of medical condition.
Objectives: (+)Lack of improvement of previous regimen (+)Inadequate follow-up on instructions given. (+)Anxiety (+)Lack of understanding
CC: Difficulty of Breathing Medical Diagnosis: Myocardial Ischemia
3. Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and consumption as evidenced by shortness of breath.
5. Low self-esteem r/t chronic illness specifically myocardial ischemia. Objective/s: (+) indecisive nonassertive behavior, (+) Weakness, Lack of eye contact, Refusal to participate in hospital procedures, increasingly dependent on her wife
4. Infection r/t invasion of bacterial microorganism in the lungs Objective/s: Based on the Laboratory results: Eosinophils = 4.0% (0-3%), WBC = 18.3X10^9/L (4.5 – 11.0 X 10 ^ 9/L), CXR results: PTB, both upper lobe with regression Atheromatous aorta (+) whitish productive cough,
Objectives: (+)Increased heart rate 130 bpm. (+)Increased blood pressure130/80 (+)Difficulty of breathing (+)Pallor (+)Fatigue and weakness (+)Ischemic ECG changes
B. Nursing Care Plan
Subjective: “Nabudlayan ako mag ginhawa” as verbalized. Objective/s: • • • • • • • • • (+) Crackles (+) Whitish productive cough (+) Chest Pain (+) DOB (+)Tachycardia (+) Weakness (+) Confusion RR= 36 bpm CXR- PTB, both lobe with regression Atheromatous aorta
Ineffective airway clearance r/t presence of secretions in the tracheobronchial tree.
After 8 hours of nursing intervention, Mr. AL will be able to expectorate secretions and have normal respiratory rate.
Independent: 1. Assist the Mr. AL in performing coughing and breathing maneuvers. cough 1. This improves the productivity of
Faye Abdellah’s theory of 21 Nursing Problems (Problem Solving to move the patients towards health.) Faye Abdellah’s theory
Goal partially met. After 8 hours of nursing interventions, Mr. AL secretions are mobilized and cough out but the airway is not totally free from excessive secretions AEB abnormal lung sounds or crackles.
2. Instruct the Mr. AL in the following: • Optimal positioning (semi fowlers) • Use of pillow or Hand splints when coughing. • Use of abdominal muscle for more forceful cough • Temperance of ambulation and frequent position change.
2. Controlled coughing techniques help mobilize secretions from smaller airways to larger airways because coughing is done at varying times.
of 21 Nursing Problems (Doing the for the patient what they cannot do for themselves.) Virginia Henderson’s theory of 14 Components of Nursing Care (Process or movements from dependence to independence.) Florence Nightingale’s theory of Environment (Alleviate unnecessary source of pain and
1. Provide back Tapping to patient.
3. To loosen Secretions
suffering) Dorothy Johnson’s theory of Human
Dependent: 1. Administer 02 therapy as ordered 2L/minute via nasal cannula 2. Nebulization of salbutamol 1neb x 3doses/15min 2. To promote softening of secretions for better expectoration of secretions 1. For effective oxygenation
Behavioral System (Medicine focus: Cure) Lydia Hall’s theory of Components of Nursing Caring (Core and Cure -shared with other health care providers.)
Objective/s: Based on the Laboratory results: ○ ○ Eosinophils WBC 4.0% (0-3%) 18.3X10^9/L (4.5 – 11.0 X 10 ^ 9/L) ○ Chest X-ray reveals: PTB , both upper lobe with regression Atheromatous Aorta • (+) whitish productive cough
Infection r/t invasion of bacterial microorganism in the lungs
Mr. AL is free of infection as evidenced by laboratory results are within normal limits throughout hospital stay.
Independent: 1. Note for physical evidence of infection 1. Infections Ernestine Weidenback (Nurse meets through identification of needs) Dorothea Orem’s theory of Nursing Concepts (Identifies what Nursing Care is needed) Dorothea Orem’s theory of Nursing Concepts (Identifies what Nursing Care is needed.) must be treated to stop the immune response and glomerular inflammation. 2. Implement appropriate measures to protect the patient from potential infection sources. 3. Obtain a recent history for signs and symptoms of infection or exposure to infected individual. 2. Hand washing by all people in contact with the patient is the primary method to reduce the risk of infection. 3. Symptoms of Acute glomerulonephritis appear 10 to 14 days after initial streptococcal illness.
Goal Partially met. After nursing intervention Mr. AL is still having abnormal laboratory results AEB Chest X-ray reveals: PTB , both upper lobe with regression Atheromatous Aorta but Eosinophils and WBC are within normal limits.
Objective/s: • (+)indecisive nonassertive behavior • • • (+) Lack of eye Refusal to Weakness contact participate in hospital procedures • Increasingly dependent on his grandson.
Low self-esteem r/t chronic illness specifically myocardial ischemia.
After 8 hours of nursing intervention, Mr. AL will manifests more positive self-esteem and positively respond to medical and nursing interventions without any refusal.
Independent: 1. Actively listen to and respect Mr. AL 1. Listening and respect increase the development of therapeutic relationship with the client. Imogene King’s theory of Nurse – Patient interactions (Integrating personal system; interpersonal system; social system) 2. The nurse patient 2. Assist Mr. AL in Identifying the major areas of concern r/t altered self-esteem. relationship can provide a strong basis for implementing other strategies to assist the patient and family with adaptation. Hildegard Peplau’s theory of Interpersonal / Interactive (therapeutic interaction between Nurse and Patient)
Goal met. After 8 hours of nursing intervention Mr. REB was able to participate in all the nursing procedure without any refusal as evidence by presence of smile on his face and conversant attitude towards the health care provider.
3. As Mr. REB’s 3. Assist Mr. AL in Incorporating changes condition worsen with Myocardial Ischemia, it
Hildegard Peplau’s theory of Interpersonal /
in health status into activities of daily living, social life, interpersonal relationships, and occupational activities.
is more difficult to engage in even routing activities.
Interactive (Orientation, Identification)
4. Denial and anger 4. Allow Mr. REB’s time to voice concerns and express anger related to having a chronic condition. are anticipated responses to the diagnosis of a chronic illness.
Jean Watson’s theory of Interpersonal nature of caring (Help persons / patients achieve a degree of harmony within themselves.)
Collaborative: 1. Use case managers and social workers as necessary.
1. They can provide psychological support and assist in financial arrangement.
Lydia Hall’s theory of Components of Nursing Caring (Core and Cure -shared with other health care providers.) Dorothy Johnson’s
2. Refer to psychiatric consultant as necessary
2. Most patient experiences some degree of emotional
theory of Human Behavioral System (Nursing focus: The
imbalance. With professional psychiatric consultation, most patients can gradually accept changed selfesteem
behavior of the person threatened with illness or is ill.)
Lydia Hall’s theory 3. Encourage use of support groups. 3. Groups that come together for mutual goals can be most helpful. of Components of Nursing Caring (Core and Cure -shared with other health care providers.)
DISCHARGE PLANNING M – edications
Medications prescribed by the physician should be taken properly, to help the patient lessen unusual condition. The following are take home medications prescribed by the physician: Vastarel mr 35mg/tab Clovipaz 75mg/tab Aldactone 25 mg subcutaneous Transderm patch 5 mg Lipitor 80 mg/tab Lanoxin 0.25 mg/tab Accupril 5.0 mg/tab Rivotril 2 mg/tab Insulatard 15 units prebreakfast 12 units presupper Clarithomycin 500 mg.tab
E – xercise and Activity Encourage Mr. AL to have an active range of motion exercises thrice daily to maintain his muscle strength. T – reatment Continue monitoring blood pressure and ECG results and comply with the medications given prescribed by the attending physician to prevent further complications that may occur and to have a faster recovery. H – ome Teaching/s 1. Instruct the client/folks on how to monitor fluid status, as well as, the signs and symptoms in order to determine existing problems and to prevent further complications. 2. Teach/ educate the client and folks on infection prevention. 3. Instruct the client on how to delay weights and how to interpret the relationship of weight loss/gain to need for sodium and water. 4. Instruct the client and folks about the medication metabolism. 5. Teach the client and folks about the dietary regimens such as low salt, low fat and high fiber. 6. Importance of follow-up and physician appointment.
O – ut patient follow up
After discharge, Mr. R.E.B will have a regular follow-up check up with the physician to check and monitor the patient’s medical condition and have a dialysis thrice a week to remove waste products from the body and to prevent future complications. D – iet Maintain a low salt, low fat, and high fiber diet as prescribed by the attending physician. Advice the patient not to eat foods that is high in cholesterol such as the fatty portion of the pork that may increase the level of his blood pressure but to eat more green and leafy vegetables. S – pirituality and Sexuality In order to improve his spiritual aspects, he may attend holy masses or listen to gospel readings and pray the holy rosary or he may seek for divine providence to the Lord. Assist the patient that may include spiritual resources to help him deal with it.
Anticipating the unknown is something that is scary. This is one of my usual thoughts when we will be assigned to another ward. There will be different patient, different attitude and behavior, and lastly with different personality. I haven’t even experience some of the procedures that might be performed. I fear o doing wrong things or mistakes that might disappoint everyone especially to my patient. I was expecting that the staffs would be mean to us and the doctors might be a bit of intimidated. I was expecting to be very busy and that came true. I was wrong. The staff nurses were glad and welcomed us with a smile. It was a satisfaction working with them when they teach us and correct the things that we’ve been doing. They seem to be our CI because they ask questions about the drugs, procedures and IV which I find it more interesting. These enhanced my knowledge, skills and attitude toward my patient. I am enjoying every step of this journey, both the challenges and the success, because I know that I control of my future. Failures are merely learning experiences that lead to the next success. There would come times that they would be stricter to us but it is for our own good. There would be learning if you would learn from your mistakes. I am thankful to my CI, Mrs. Edrelyn Venturanza and Ms. Jimmelle Ellen Olilang, for being so patient and kind to us. I like the manner she tries to emphasize our responsibilities and obligations to our patients. She always carries a smile on her face which tells me deep inside that I must enjoy the field of profession that I choose in every chooser carrier, there is always hardship, sacrifices and trials that will come across the way. These 3 elements made me stronger enough the challenge to be a successful nurse someday. I also learned that you must grab every opportunity when you are still a student nurse, in this way we would be able to develop skills in performing different procedure. This includes skin test, IV follow-up, OTF feeding and subcutaneous injections. The days of duty has seems to end so fast. I didn’t notice and feel that I will soon leave the ICU. In our duty, I am always reminded that the life of your patient depends on my hands. I have given the responsibility to take good care of my patients. This month stay here in ICU would be cherished and reminisced in my life. I learned many values, learning and procedure that would help me in rendering care to my patient. Doing the case of my patient seems so hard yet full of learning. Even though it’s hard, I just think that it would contribute to gain further knowledge. Doing what you love is success. Success is not defined by fortune alone. It doesn't come while you're looking for it. It comes unexpectedly while you're filling the needs of your clients. It arrives in the moment you discover the key to your case and put the last piece of the puzzle in place.