ETIOLOGY

Decreased coronary blood flow

MODIFIABLE RISK FACTORS

NON-MODIFIABLE RISK FACTORS Lifestyle (Alcoholic)
Age Emotional stress
Gender Elevated Blood pressure
Past health Hx Hyperglycemia (DM)
Others: Others:
Family health Hx Obesity
High blood cholesterol
Race (hyperlipidemia)
Smoking
Sedentary lifestyle

PATHOPHYSIOLOGY
 CLINICAL
MANIFESTATIONS
MEDICAL DIAGNOSIS
 Chest pain Acute Pericarditis
 Epigastric Pain
 Increase BP MEDICAL & OR/ SURGICAL MANAGEMENT
 Tachycardia
Medical
 Fatigue
 IVF PNSS1L @
 Dyspnea
10gtts/min
 ISMO 60g
 Isordil 5g SL PRN
Past History:
 Zantac IVT now then
R/O Diabetes
q8h
Nephropathy, 1yr
 Troponine T now
PTC
 Transfuse 2’U’ PRBC
R/O Chronic Renal
 Tramadol 50mg IVT
Insufficiency, 1 yr
now
PTC
 Pantoprazole
(Ulcepraz) 40g IVT OD,
start now
 Please give captopril
25mg tab SL now
 Arixtra 25mg SC now
then OD
 Plavix 75mg 4 tabs
now then 1tab OD
 O2 inhalation 2L/min
 Lipitor 1 tab OD start
tonight
 Bepridil (Vascor) 10
mg. 1 tab now then OD
P.O.
 Give Isordil5mg tab SL
for 3 doses q 5 minutes
if chest pain is not
relieved  Increase O2
inhalation to 4L/min
 Therabloc 50mg 1tab
now then OD
DIAGNOSTIC TESTS
Hematology- are tests in the
blood, blood proteins and blood
producing organs. These tests can
evaluate a variety of blood
condition.
JUNE 29,2017, 11:43 pm
OR/Sugical •Troponin-T: Increased
 The combination of •Total RBC: 2.57X10^9/L (M: 5.0-
6.0x12/L)
a thrombolytic agent
and PTCA has been •Hgb: 10 g/dl (M: 13.5-17.5 g/dl)
used for acute •Hct: 28.0 (M: 42-52)
JULY 1,2017, 6:36 pm
reperfusion of
•Total RBC: 3.49x10^9/L (M: 5.0-
myocardial
6.0x12/L)
infarction in a large
•Hgb: 11.1 g/dl (M: 13.5-17.5
number of patients g/dl)
and is now •Hct: 32.5 (M: 42-52)
considered definitive Blood chemistry- measures the
treatment of choice amount of certain substances in
for many patients the body. It includes (electrolytes)
who have acute sodium, potassium, fats, proteins,
evolving myocardial glucose.
infarction, •Triglyceride: 221.64 mgs/dl
particularly anterior (<150 mgs/dl)
•HDL (High-density Lipoproteins):
wall infarction.
28.39 mgs/dl (40 mgs/dl)
 Percutaneous •LDL (Low-density Lipoproteins):
coronary 66.01 mgs/dl (<100 mgs/dl)
intervention Other diagnostic tests:
 Thrombolytic Chest X-ray. An X-ray image of
therapy your chest allows your doctor to
 Emergent check the size of your heart and
Percutaneous its blood vessels and to look for
Coronary fluid in your lungs.
Intervention Coronary catheterization
(angiogram). A liquid dye is
 Cardiac
injected into the arteries of the
Rehabilitation
heart.
 Coronary artery Echocardiogram. Sound waves
bypass surgery (ultrasound) create images of the
moving heart.
 SIGNIFICANCE/ PERTINENT FINDINGS
History of heavy drinker of alcohol during his adolescence and late adulthood
History of having hypertension
History of PRBC transfusion
Diagnosed of having Diabetes Nephropathy and Chronic Renal Insufficiency
Chest pain with complaints of acute epigastric pain, growing in character and on and
off.
Anorexic
Blood pressure: 180/60mmHg
Lipid profile: Elevated Triglycerides 221.64 (mgs/dl), Decreased HDL 28.39 mgs/dl
Hematology: Elevated Troponin- T
Hematology: Below normal range CBC with Total RBC of 2.57x 10^9/L on June 29,
2007, 11:43pm
Hematology: Below normal range CBC with Total RBC of 3.49 x10^ 9/L on July 1, 2007,
6:36pm
Decreased level of Lymphocytes with 15.4
Elevated level of Monocytes with 13.1
Creatinine (6.17 mgs/dl) above normal range

NURSING DIAGNOSIS

Acute Pain related to increase myocardial oxygen demand and

decrease myocardial oxygen supply (tissue ischemia - coronary
artery occlusion) as evidence by reports of chest pain with/out
radiation and changes in BP
 NURSING INTERVENTIONS
Independent

 Monitor and document characteristic of pain, noting verbal reports, nonverbal cues. Variation of
appearance and behavior of patients in pain may present a challenge in assessment. Most patients
with an acute MI appear ill, distracted, and focused on pain
 Obtain full description of pain from patient including location, intensity, and radiation. Assist patient to
quantify pain by comparing it to other experiences. Provides baseline for comparison to aid in
determining effectiveness of therapy, resolution and progression of problem.
 Instruct patient to report pain immediately. Provide quiet environment, calm activities, and comfort
measures. Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping
abilities and adjustment to current situation.
 Instruct patient to do relaxation techniques: deep and slow breathing, distraction behaviors,
visualization, guided imagery. Assist as needed. Provides a sense of having some control over the
situation, increase in positive attitude.
 Check vital signs before and after narcotic medication. Hypotension and respiratory depression can
occur as a result of narcotic administration. These problems may increase myocardial damage in
presence of ventricular insufficiency
Dependent

 Administer supplemental oxygen by means of nasal cannula or face mask, as indicated. Increases
amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated
with tissue ischemia.
 Administer medications as prescribed and indicated: Antianginals, Beta-blockers.

EXPECTED OUTCOME
After 30 mins of nursing intervention, the patient was able to;
Verbalized relief from pain as evidenced by decrease pain on chest area.
Displayed reduced tension, relax manner, and ease of movement as
evidence by decrease pain and irritability and facial grimace, and
guarding actions
Partially demonstrated use of relaxation techniques as evidenced by
effective regular breathing pattern
DISCHARGE PLAN

At home

 Check that you have a list of all the medicines you take. Take your medicines exactly as directed. Make
sure you've been given instructions about your medicines and how to take them. Make sure you have a
pharmacy so you can get the prescription filled.

 Don’t skip doses.

 Talk with your healthcare provider if your medicines aren't working for you. Together you can come up
with another treatment plan.

 Remember that recovery after a heart attack takes time. Plan to take it easy for at least 4 to 6 weeks
while you recover. Then return to normal activity when your doctor says it’s OK.

 Ask your doctor about joining a heart rehab program. This can help strengthen your heart and lungs
and give you more energy and confidence.

 Tell your doctor if you are feeling depressed. Feelings of sadness are common after a heart attack. But
it's important to speak to someone or seek counseling if you are feeling overwhelmed by these feelings.
These feelings most often pass within a month.

Lifestyle changes

 Your heart attack might have been caused by cardiovascular disease. Your healthcare provider will
work with you to make changes to your lifestyle. This will help the heart disease from getting worse.
These changes will most likely be a combination of diet and exercise.

Diet

 Your healthcare provider will tell you what changes you need to make to your diet. You may need to
see a registered dietitian for help with these diet changes. These changes may include:

 Cutting back on how much fat and cholesterol you eat

 Cutting back on how much salt (sodium) you eat, especially if you have high blood pressure

 Eating more fresh vegetables and fruits

 Eating lean proteins such as fish, poultry, beans, and peas, and eating less red meat and processed
meats

 Using low-fat dairy products

 Using vegetable and nut oils in limited amounts

  Limiting how many sweets and processed foods such as chips, cookies, and baked goods you eat

 Limiting how often you eat out. And when you do eat out, making better food choices.

 Not eating fried or greasy foods, or foods high in saturated fat

Exercise

 Your healthcare provider may tell you to get more exercise if you haven't been physically active.
Depending on your case, your provider may recommend an exercise program that is best for you.
Warm-up 5 to 10 minutes before exercising and cool-down 5 to 10 minutes after exercising.

NCP#1
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective data: Acute Pain Short term INDEPENDENT 1. Variation of Short term goal:
related to goal: 1. Monitor and appearance After 30 mins of
The patient increase After 30 document and behavior nursing
verbalizes that he myocardial minutes of characteristic of of patients in intervention, the
is experiencing oxygen nursing pain, noting verbal pain may patient was able
intermittent chest demand and intervention, reports, nonverbal present a to;
pains but doesn’t decrease the patient will: cues. challenge in
radiate on any myocardial assessment. 1. Verbalized
body organ. oxygen supply 1. Verbalize Most patients relief from pain
(tissue relief/control of with an acute as evidenced by
Objective data: ischemia - chest pain MI appear ill, decrease pain on
coronary within distracted, and chest area.
(+) Pain, chest is artery appropriate focused on
with acute occlusion) as time frame for pain.
epigastric pain evidence by administered
(+) Anorexia reports of medications. 2. Obtain full 2. Provides
(+) HPN chest pain description of pain baseline for
R/O: PUD; with/out Long term from patient comparison to Long term goal:
Diabetic radiation and goal: including location, aid in After 2 hours of
Nephropathy changes in BP After 2 hours of intensity, and determining nursing
nursing radiation. Assist effectiveness intervention the
VS: intervention the patient to quantify of therapy, patient was able
BP: 180/60 patient will: pain by comparing it resolution and to:
mmHg to other progression of
Temp: 36.6 C 1.Display experiences. problem.
PR: 54 bpm reduce tension, 1.Displayed
RR: 18 cpm relax manner, 3. Decreases reduced tension,
ease of external relax manner,
movement. 3. Instruct patient to stimuli, which and ease of
report pain may aggravate movement as
2. Demonstrate immediately. anxiety and evidence by
use of Provide quiet cardiac strain, decrease pain
relaxation environment, calm limit coping and irritability and
techniques. activities, and abilities and facial grimace,
comfort measures. adjustment to and guarding
current actions
situation.
2. Partially
 4. Provides a demonstrated
sense of use of relaxation
having some techniques as
4. Instruct patient to control over evidenced by
do relaxation the situation, effective regular
techniques: deep increase in breathing pattern.
and slow breathing, positive
distraction attitude.
behaviors,
visualization, guided
imagery. Assist as 5. Hypotensio
needed. n and
respiratory
depression
5. Check vital signs can occur as a
before and after result of
narcotic medication. narcotic
administration.
These
problems may
increase
myocardial
damage in
presence of
ventricular
insufficiency.
DEPENDENT
6. Administer
supplemental 6. Increases
oxygen by means of amount of
nasal cannula or oxygen
face mask, as available for
indicated. myocardial
uptake and
thereby may
relieve
discomfort
associated
with tissue
ischemia.

Administer
medications as
prescribed and
indicated:  Nitrates are
useful for pain
Antianginals control by
coronary
vasodilating
effects, which
increase
coronary blood
flow and
myocardial
perfusion.

Important
Beta-blockers second-line
agents for pain
 control
through effect
of blocking
sympathetic
stimulation,
thereby
reducing heart
rate, systolic
BP, and
myocardial
oxygen
demand.May
be given alone
or with
nitrates.

Analgesics Although
intravenous
(IV) morphine
is the usual
drug of choice,
other
injectable
narcotics may
be used in
acute-phase
and/or
recurrent
chest pain
unrelieved by
nitroglycerin to
reduce severe
pain, provide
sedation, and
decrease
myocardial
workload.
NCP#2
Assessmen Diagnosis Planning Intervention Rationale Evaluation
t
Subjective Risk for Short term goal: INDEPENDENT: 1. There are Short term goal:
data: decrease After 45 mins of 1. Assess, many After 45 mins of an
The client cardiac an effective document and conditions effective nursing
verbalizes tissue nursing report the associated with intervention the
easy perfusion intervention the patient’s chest patient was able to:
fatigability related to patient will be description of discomfort.
and muscle reduced able to: chest There are  Reported relief
weakness coronary discomfort, characteristics from any chest
blood flow  Patient will including the clinical finding discomfort
Objective have no chest location, of ischemic except a slight
data: discomfort intensity, pain and pain on the
(+) chest and no radiation, symptoms. affected area as
pain symptoms duration and evidenced by
(+) anorexic appear. factors that verbalization of
(+)  Patient will be affect it. comfort and
hypertension comfortable relief
R/O: PUD, and free from 2. Check for  Appeared
diabetic any signs and optimal fluid comfortable and
nephropathy symptoms balance. 2. Sufficient fluid free from other
Administer IV intake signs and
VS: fluids as maintains symptoms as
BP: 180/60 ordered. adequate filling evidenced by
mmHg pressures and decreased pain
Temp: 36.6 optimizes on the area and
C cardiac output effective regular
PR: 54 bpm needed for breathing.
RR: 18 cpm 3. Monitor intake tissue
Long term goal: and output perfusion. Long term goal:
After 3 hours of After 3 hours of an
an effective effective nursing
nursing 3. Reduce renal intervention the
intervention the perfusion may patient was able to:
patient will be 4. Ensure take place due  Respiratory rate,
able to: physical rest; to vascular cardiac rate and
head of the bed occlusion. blood pressure
 Respiratory elevated to return to normal
rate, cardiac promote 4. Physical rest level as
rate and blood comfort; diet as reduces evidenced by
pressure will tolerated; myocardial stable BP of
return to provide a oxygen 120/70 mmhg
normal level. restful consumption  Adequate
 Cardiac environment cardiac output
output will be as evidence by:
stabilized or - Stable/impro
will be 5. Obtain a 12 ving ECG
improving. lead ECG - Heart rate
 Patient will be recording 5. An ECG during and rhythm
free of during symptoms may - Blood
adverse effect symptomatic be useful in the
pressure
on the events, as diagnosis of
 No noted
medication. prescribed, to ongoing
adverse effects
assess for ischemia
from the
ongoing medication as
ischemia. evidence by free
from
DEPENDENT anaphylactic or
6. Administer 6. Oxygen allergic from the
oxygen as therapy drug being
prescribed increase the administered.
oxygen supply
to the
7. Administer myocardium.
medication
therapy as
prescribed, and 7. Medication
evaluate the therapy is the
patient’s first line of
response defense in
continuously preserving
myocardial
8. Submit patient tissue.
to diagnostic
testing as
indicated. 8. A variety of
tests are
available
depending on
the cause of
the impaired
tissue
perfusion.
Angiograms,
Doppler flow
studies,
segmental limb
pressure
measurement
such as ankle-
brachial index
(ABI), and
vascular stress
testing are
examples of
these tests.
 DRUG STUDY FOR MI
Agent Names Indications Pharmacodyn Common Side Nursing considerations
Categor Generic amics Effects
y/ (Brand)
Subcate
gory
Nitrates ISMO 60g Acute treatment Produce  dizziness,  Assess location,
Isordil 5g of anginal vasodilation  headache. duration, intensity, and
SL PRN) attacks (SL (venous  hypotension, precipitating factors of
only). greater than  tachycardia, anginal pain.
Prophylactic arterial).  paradoxic  Monitor BP and pulse
management of Decrease left  bradycardia, routinely during period
angina ventricular of dosage adjustment
 syncope
pectoris end-diastolic  PO:Swallow extended-
 nausea,
pressure and release capsules
left ventricular  vomiting
whole; do not break,
end-diastolic crush, or chew .
volume  Avoid eating, drinking,
(preload). Net or smoking until tablet
effect is is dissolved. Replace
reduced tablet if inadvertently
myocardial swallowed.
oxygen  Instruct patient to take
consumption. medication as directed,
Increase even if feeling better.
coronary blood Take missed doses as
flow by dilating soon as remembered;
coronary doses of isosorbide
arteries and dinitrate should be
improving taken at least 2 hr
collateral flow apart
to ischemic  Caution patient to
regions make position changes
slowly to minimize
orthostatic hypotension
Antiulcer Zantac Potent anti-ulcer Inhibits the  confusion,  Assess patient for
agents IVT now drug that action of  dizziness, epigastric or abdominal
then q8h competitively histamine at  drowsiness, pain and frank or occult
and reversibly the H2-  hallucinations, blood in the stool,
inhibits receptor site  headache emesis, or gastric
histamine action located  ARRHYTHMI aspirate.
at H2-receptor primarily in AS.  May cause false-
sites on parietal gastric parietal negative results in skin
 constipation
cells, thus cells, resulting tests using allergenic
 diarrhea,
blocking gastric in inhibition of extracts. Histamine
acid secretion. gastric acid  nausea
antagonists should be
Indirectly secretion discontinued 24 hr
reduces pepsin before the test.
secretion but  Inform patient that
appears to have smoking interferes with
minimal effect the action of histamine
on fasting and antagonists.
postprandial Encourage patient to
serum gastrin quit smoking or at least
concentrations not to smoke after last
or secretion of dose of the day.
 gastric intrinsic  May cause drowsiness
factor or mucus. or dizziness. Caution
patient to avoid driving
or other activities
requiring alertness until
response to the drug is
known.
Analgesi Tramadol Moderate to Binds to mu-  SEIZURES,  Assess type, location,
cs 50mg IVT moderately opioid  dizziness, and intensity of pain
now severe pain receptors.  headache, before and 2– 3 hr
(extended- Inhibits  anxiety, (peak) after
release reuptake of  confusion, administration.
formulations serotonin and  coordination  Assess BP and
indicated for norepinephrine disturbance, respiratory rate before
patients who in the CNS and periodically during
 euphoria,
require around- administration.
 malaise,
the-clock pain Respiratory depression
management).  nervousness,
has not occurred with
 sleep
recommended doses.
disorder,
 Explain therapeutic
 weakness
value of medication
before administration
to enhance the
analgesic effect.
 Regularly administered
doses may be more
effective than prn
administration.
Analgesic is more
effective if given before
pain becomes severe
Antiulcer Pantopra Erosive Binds to an  headache.  Assess patient
agents zole esophagitis enzyme in the  abdominal routinely for epigastric
(Ulcepraz associated with presence of  pain, or abdominal pain and
Proton- ) 40g IVT GERD. acidic gastric  diarrhea, for frank or occult
pump OD,start Decrease pH, preventing  eructation, blood in stool, emesis,
inhibitors now relapse rates of the final  flatulence or gastric aspirate.
daytime and transport of  Patients receiving
 hyperglycemi
nighttime hydrogen ions pantoprazole IV should
a
heartburn into the gastric be converted to PO
symptoms on lumen dosing as soon as
patients with possible.
GERD.  Monitor bowel function.
Pathologic Diarrhea, abdominal
gastric cramping, fever, and
hypersecretory bloody stools should
conditions be reported to health
care professional
promptly as a sign of
pseudomembranous
colitis. May begin up to
several weeks
following cessation of
therapy.
Antihyper Captopril Alone or with Angiotensin-  dizziness,  Hypertension: Monitor
tensives 25mg tab other agents in converting  fatigue, BP and pulse
SL now the enzyme (ACE)  headache, frequently during initial
ACE management of inhibitors block  insomnia. dose adjustment and
inhibitors hypertension. the conversion
 Management of of angiotensin  cough. periodically during
heart failure. I to the  hypotension, therapy. Notify health
Reduction of vasoconstrictor  chest pain, care professional of
risk of death, angiotensin II.  palpitations, significant changes
heart failure- ACE inhibitors  tachycardia  Assess patient for
related also prevent signs of angioedema
hospitalizations, the (dyspnea, facial
and degradation of swelling).
development of bradykinin and  Heart Failure: Monitor
overt heart other weight and assess
failure following vasodilatory patient routinely for
myocardial prostaglandins resolution of fluid
infarction. . ACE overload
Treatment of inhibitors  Administer 1 hr before
diabetic alsoqplasma meals or 2 hr after
nephropathy in renin levels meals. May be crushed
patients with andpaldostero if patient has difficulty
Type 1 diabetes ne levels. Net swallowing. Tablets
mellitus and result is may have a sulfurous
retinopathy systemic odor.
vasodilation.  Caution patient to
avoid salt substitutes
containing potassium
or foods containing
high levels of
potassium or sodium
unless directed by
health care
professional.
Anticoag Arixtra Prevention and Binds  confusion,  Assess for signs of
ulants 25mg SC treatment of selectively to  dizziness, bleeding and
now then deep vein antithrombin III  headache, hemorrhage; sudden
OD thrombosis and (AT III). This  insomnia. drop in BP. Notify
pulmonary binding  edema, health care
embolism potentiates the  hypotension. professional if these
neutralization occur.
 constipation,
(inactivation)  Fondaparinux cannot
 diarrhea,
of active factor be used
X (Xa).  nausea,
interchangeably with
 vomiting
heparin, low-
molecularweight
heparins, or
heparinoids as they
differ in manufacturing
process, anti-Xa and
anti-IIa activity, units,
and dose
 Advise patient to report
any symptoms of
unusual bleeding or
bruising, dizziness,
itching, rash, fever,
swelling, or difficulty
breathing to health
care professional
immediately.
 Instruct patient not to
take aspirin or NSAIDs
without consulting
 health care
professional during
therap
Antiplatel Plavix Reduction of Inhibits platelet  depression,  Assess patient for
et agents 75mg 4 atherosclerotic aggregation by  dizziness, symptoms of stroke,
tabs now events (MI, irreversibly  fatigue, peripheral vascular
then 1tab stroke, vascular inhibiting the  headache disease, or MI
OD death) in binding of ATP  chest pain, periodically during
patients at risk to platelet  edema, therapy
for such events receptors  Monitor patient for
 hypertension
including recent signs of thrombotic
MI, acute thrombocytic purpura
coronary  Administer once daily
syndrome without regard to food.
(unstable  Advise patient to notify
angina/non– Q- health care
wave MI), professional promptly if
stroke, or fever, chills, sore
peripheral throat, rash, or unusual
vascular bleeding or bruising
disease. occurs.
Lipid- Lipitor 1 Primary Inhibits 3-  amnesia,  Obtain a diet history,
lowering tab OD prevention of hydroxy-3-  confusion, especially with regard
agents start coronary heart methylglutaryl-  dizziness, to fat consumption
tonight disease coenzyme A  headache,  Monitor liver function
(myocardial (HMG-CoA)  insomnia, tests prior to initiation
infarction, reductase, an  memory loss, of therapy and as
stroke, angina, enzyme which clinically indicated.
 weakness.
and coronary is responsible  May be administered
 abdominal
revascularizatio for catalyzing without regard to food.
n) in an early step  cramps,
 constipation,  Avoid grapefruit and
asymptomatic in the grapefruit juice during
patients with synthesis of  diarrhea,
therapy; may increase
increased total cholesterol risk of toxicity
and low-density  Advise patient that this
lipoprotein medication should be
(LDL) used in conjunction
cholesterol and with diet restrictions
decreased high- (fat, cholesterol,
density carbohydrates,
lipoprotein alcohol), exercise, and
(HDL) cessation of smoking
cholesterol.
Cardiova Bepridil Indicated for the Selectively  ervousness,   Monitor cardiac status,
scular (Vascor) treatment of blocks calcium  dizziness,  as bepridil can induce
agent; 10 mg. 1 chronic stable ion influx  asthenia,  new arrhythmias,
calcium tab now angina (classic across the cell  headache. including ventricular
channel then OD effort- membrane of  muscle aches, tachycardia and
blocker P.O. associated cardiac muscle  fever, fibrillation, and CHF
angina).  and vascular  Monitor diabetics for
 nausea,
smooth muscle loss of glycemic
 vomiting,
without control.
changing  Assess safety and
serum calcium need for help with
concentrations ambulation or other
. Unlike other activities (dizziness is a
calcium common adverse effect
channel of this drug).
blockers, it  Report hypokalemia
 also blocks the immediately. The
sodium condition should be
channel and promptly corrected.
possibly the
potassium
channel,
resulting in
quinidine-like
effects.
Antiangin Therablo Long term Blocks  fatigue,  Monitor BP, ECG, and
als c 50mg management of stimulation of  weakness, pulse frequently during
Antihyper 1tab now angina pectoris beta1(myocard  anxiety, dosage adjustment
tensives then OD due to coronary ial)-adrenergic  depression, period and periodically
atherosclerosis. receptors.  dizziness, throughout therapy.
Management of Does not  drowsiness,  Monitor intake and
hypertension; usually affect output ratios and daily
 insomnia,
may be used beta2(pulmona weights. Assess
 memory loss,
alone or in ry, vascular, routinely for HF
combination uterine)-  mental status
(dyspnea,
with other receptor sites changes,
rales/crackles, weight
antihypertensive  nervousness,
gain, peripheral
drugs  nightmares edema, jugular venous
particularly with distention).
a thiazide-type  Take apical pulse
diuretic. before administering
drug. If 50 bpm or if
arrhythmia occurs,
withhold medication
and notify physician or
other health care
professional.
 Patients with diabetes
should closely monitor
blood glucose,
especially if weakness,
malaise, irritability, or
fatigue occurs