Activity

Jay Villasoto STEM

1.) RLE PLAN OF ACTIVITIES (CLINICAL AREA)

TIME ACTIVITY

5:45 AM – 6:00 AM  CHECKING OF DUTY

UNIFORM AND DUTY BAG
PRAY THE NURSES’ PRAYER
ALTOGETHER
6:00 AM – 6:30 AM  LISTENING TO THE
ENDORSEMENT
 PRAY THE ENDORSEMENT
PRAYER ALTOGETHER
6:30 AM – 7:00 AM BREAKFAST BREAK
7:00 AM—8:00 AM  GREET PATIENT
 HAVE PATIENT
INTERACTION
 CONVERSE WITH FOLKS
AND INTERACT
8:00 AM – 8:15 AM  CHECK THE PATIENT’S
CHART AND FILL UP THE
VITAL SIGNS CHART AND
IV SHEET FORM
8:15 AM – 8:30 AM  CHECK THE PATIENT’S
MEDICATION AND
ADMINISTER IF NEEDED
8:30 AM – 9:00 AM BREAK
9:00 AM – 12:00 PM  CHECK THE PATIENT’S
VITAL SIGNS (q2 or q4)
 FILL UP THE VITAL SIGNS
SHEET FORM AND
MEDICATION SHEET FORM
 PREPARE FOR FDAR
CHARTING (FOCUS,
DIAGNOSIS, ACTION AND
RESPONSE)
 LET THE CLINICAL
INSTRUCTOR
COUNTERSIGN THE
PATIENT’S CHART
12:00 PM – 1:00 PM LUNCH BREAK
1:00 PM – 2:00 PM  CHECK ON PATIENT’S
VITAL SIGNS AND IV LINE
 FILL UP THE VITAL SIGNS
SHEET, MEDICATION SHEET
AND IV FLOW SHEET
FORMS
 LET THE CLINICAL
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Jay Villasoto STEM

COUNTERSIGN
 OFF DUTY
2:00 PM – 4:00 PM  WARD CLASS,
PRESENTATION OF
INDIVIDUAL AND GROUP
REPORTS, COMPLETION
OF REQUIREMENTS,
SIGNING OF DUTY
CALENDARS AND
COLUMNARS

4:00 PM – 5:00 PM DISMISSAL

2.) Patient Diagnosis

PT. A. N 41 years old came in with a chief complaint of Cold clammy extremities
With a working diagnosis of Cardiogenic Shock. Cardiogenic shock is a condition
caused by the inability of the heart to pump blood sufficiently to meet the
metabolic needs of the body due to the impaired contractility of the heart. Clients
usually manifest signs of low cardiac output, with adequate intravascular volume.
It is usually associated with myocardial infarction (MI), cardiomyopathies,
dysrhythmias, valvular stenosis, massive pulmonary embolism, cardiac surgery, or
cardiac tamponade. It is a self-perpetuating condition because coronary blood flow
to the myocardium is compromised, causing further ischemia and ventricular
dysfunction.
3.) FDAR
Focus Data, Action, Response
Chest Pain D: Reports of sharp pain on the chest
“masakit gamay akon dughan” with a
pain scale of 3 out of 10
A: Administered Trimetazidine 35
miligrams as ordered.
Kept patient comfortable and safe.
R: Patient reports pain was relieved
Vip score : 0

4.) Diagnostic Procedure/ Laboratory Examinations

Cardiogenic shock is usually diagnosed in an emergency setting. Doctors will
check for signs and symptoms of shock, and will then perform tests to find the
cause.
Blood pressure measurement. People in shock have very low blood pressure.
Electrocardiogram (ECG or EKG). This quick, noninvasive test records the
electrical activity of your heart using electrodes attached to your skin. If you have
Activity
Jay Villasoto STEM

damaged heart muscle or fluid buildup around your heart, the heart won't send
electrical signals normally.
Chest X-ray. A chest X-ray shows the size and shape of your heart and whether
there's fluid in your lungs.
Blood tests. You'll have blood drawn to check for organ damage, infection and
heart attack. An arterial blood gas test might be done to measure oxygen in your
blood.
Echocardiogram. Sound waves produce an image of your heart. This test can help
identify damage from a heart attack.
Cardiac catheterization (angiogram). This test can reveal blocked or narrowed
arteries. A doctor inserts a long, thin tube (catheter) through an artery in your leg
or wrist and guides it to your heart. Dye flows through the catheter, making your
arteries more easily seen on X-ray.
Biochemical profile
Measurement of routine biochemical parameters, such as electrolytes, renal
function (eg, urea and creatinine levels), and liver function tests (eg, bilirubin,
aspartate aminotransferase [AST], alanine aminotransferase [ALT], and lactate
dehydrogenase [LDH]), are useful for assessing proper functioning of vital organs.

Complete blood cell count

A CBC is generally helpful to exclude anemia. A high white blood cell (WBC)
count may indicate an underlying infection, and the platelet count may be low
because of coagulopathy related to sepsis.

Cardiac enzymes
The diagnosis of acute myocardial infarction (MI) is aided by a variety of serum
markers, which include creatine kinase (CK) and its subclasses, troponin,
myoglobin, and LDH. The value for the isoenzyme of creatine kinase with muscle
and blood subunits is most specific, but it may be falsely elevated in persons with
myopathy, hypothyroidism, renal failure, or skeletal muscle injury.

The rapid release and metabolism of myoglobin occurs in persons with MI. A
fourfold rise of myoglobin over 2 hours appears to be a test result that is sensitive
for MI. The serum LDH value increases approximately 10 hours after the onset of
MI, peaks at 24-48 hours, and gradually returns to normal in 6-8 days. The LDH
fraction 1 isoenzyme is primarily released by the heart, but it also may come from
the kidneys, stomach, pancreas, and red blood cells.

Troponins
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Jay Villasoto STEM

Cardiac troponins T and I are widely used for the diagnosis of myocardial injury.
Troponin elevation in the absence of clinical evidence of ischemia should prompt a
search for other causes of cardiac damage, such as myocarditis.

Troponin T and I can be detected in serum within the first few hours after onset of
acute MI. Troponin levels peak at 14 hours after acute MI, peak again several days
later (biphasic peak), and remain abnormal for 10 days. This characteristic could
make troponin T (in combination with CK-MB) useful for retrospective diagnosis
of acute MI in patients who seek care very late.

Troponin T is an independent prognostic indicator of adverse outcomes and can be

used as a patient risk-stratifying tool in patients with unstable angina or non–Q-
wave MI.

Arterial blood gases

ABG values indicate overall acid-base homeostasis and the level of arterial blood
oxygenation. (Acidosis can have a particularly deleterious effect on myocardial
function.) A base deficit elevation (reference range, +3 to –3 mmol/L) correlates
with the occurrence and severity of shock. A base deficit is also an important
marker to follow during resuscitation of a patient from shock.

Lactate
An elevated serum lactate level is an indicator of shock. Serial lactate
measurements are useful markers of hypoperfusion and are also used as indicators
of prognosis. Elevated lactate values in a patient with signs of hypoperfusion
indicate a poor prognosis; rising lactate values during resuscitation portend a very
high mortality rate.

Brain natriuretic peptide

Brain natriuretic peptide (BNP) may be useful as an indicator of congestive heart
failure (CHF) and as an independent prognostic indicator of survival. A low BNP
level may effectively rule out cardiogenic shock in the setting of hypotension;
however, an elevated BNP level does not rule in the disease.

5.) Drug Study

Drug Action Indication/ Nursing
Contraindication Responsibilities
Generic Name: Mechanism of Indication:  Observice 12
Trimetazidine Action: Trimetazidine is rights of
Brand Name: rimetazidine is indicated for use in medication
Vastarel an anti-ischemic angina pectoris.  Assess
(anti-anginal) location
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Jay Villasoto STEM

Classification: metabolic Contraindication: density,and

3-ketoacyl agent, which  Trimetazidine intensity of
coenzyme A improves is no longer angina pain
thiolase (3- myocardial indicated for  Monitor BP
KAT) inhibitors glucose the and Pr before
(anti-anginal) utilization symptomatic after
through treatment of administering
Dosage: inhibition of vertigo, the drug
35 miligrams long-chain 3- tinnitus and  Notify
1tab bid ketoacyl CoA visual field prescribing
thiolase disturbances. signs of heart
Route: activity, which  Trimetazidine failure such
Oral results in a is as swelling
reduction in contraindicated of the hands
fatty acid in patients with and feet or
oxidation and a Parkinson shortness of
stimulation of disease, breath
glucose Parkinsonian  Instruct to
oxidation. High symptoms, avoid
fatty acid tremors, strenuous or
oxidation rates restless leg hazardous
are detrimental syndrome, and activities
during ischemia other related requiring
due to an movement alertness to
inhibition of disorders. prevent risks
glucose of falls and
oxidation injury
leading to
uncoupling of
glycolysis and
an increase in
proton
production,
which has the
potential to
accelerate
sodium and
calcium
overload in the
heart. This leads
to an
exacerbation of
ischemic injury
and decreased
cardiac
efficiency
during
reperfusion.
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Jay Villasoto STEM

Drug Action Indication Nursing

Contraindication Responsibilities
Generic Name : Mechanism of Indications:  Observe 12
Carvedilol action: Coreg is a rights of
Brand Name: Carvedilol works prescription medication
Corerg, Coreg CR by blocking the medicine used to  Monitor BP
action of certain treat the and pulse
Classification: natural substances symptoms of heart frequently
Beta blockers, in your body, such failure and high during dose
Alpha activity as epinephrine, on blood pressure adjustment
the heart and (hypertension). period and
Dosage: blood vessels. Coreg may be periodically
6.25 Miligrams This effect lowers used alone or with during
1 tab BID your heart rate, other medications. therapy.
blood pressure,  Monitor
Route and strain on your Contraindications: intake and
Oral heart. Carvedilol Carvedilol is output
belongs to a class contraindicated in ratios and
of drugs known as patients with daily
alpha and beta- bronchial asthma weight.
blockers. or related
bronchospastic
conditions,
decompensated
NYHA functional
class IV heart
failure requiring
intravenous
inotropic therapy,
severe liver
impairment,
second- or third-
degree
atrioventricular
block, sick sinus
syndrome (unless
a permanent
pacemaker is in
place),
cardiogenic shock,
severe bradycardia
or known
hypersensitivity to
the drug.

Drug Action Indication/ Nursing

Contraindication Responsibilities
Generic Name: Mechanism of Indication:  Observe 12
Lactulose action Lactulose is indicated rights of
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Jay Villasoto STEM

Brand Name: Lactulose is a for use as a laxative in medication

Enulose, synthetic the treatment of  Assess
Generlac disaccharide chronic constipation amount,
derivative of in adults and geriatric colour and
Classification: lactose that patients. consistency
Osmotic consists of one  Chronic of stool.
Laxatives molecule of constipation.  Advise to
galactose and  Systemic drink plenty
Dosage: one molecule of encephalopathy of fluid
30cc BID fructose. in patients with while taking
Saccharolytic hepatic disease. this
Route bacteria present medicine.
Oral in the large  Patients
intestine Contraindication with
subsequently  Galactose-free constipation
break the diet should be
substance down  Surgery advised on
into organic  Diabetes prevention
acids like lactic mellitus such as
acid and small  Geriatric eating a
amounts of balanced
 Pregnancy
formic and diet
acetic acids. containing
Such resultant fibre, fresh
volatile fatty fruit and
acid metabolites, vegetables.
in combination
with hydrogen
and methane
that is also
generated
consequently
enhance
intraluminal gas
formation,
peristaltic gut
motility, and
elicit an osmotic
effect that
facilitates an
increase in the
water content of
stool as well as
associated stool
softening. All of
these actions
ultimately assist
in facilitating
and increasing
the frequency of
bowel
movements in
patients
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Jay Villasoto STEM

experiencing
constipation,
although it may
take 24 to 48
hours after using
the medication
for this laxative
effect to become
evident.