Cardiovascular Diseases and Dengue

CARDIOVASCULAR DISEASES AND DENGUE
_______________
A Seminar Manuscript Presented to

The Faculty of the Nursing Department
Jocelyn A. Cataraja, RN, MN
_______________
In Partial Fulfillment of
Requirements in SEM – 101
SEMINAR IN NURSING
By:
Karen Quisha P. Banal St.N
Hazel A. Masion, St.N
Crisel Mae O. Mayangao, St.N
Raven Shin J. Maybanting, St.N
Jester Ryan D. Oducayen, St.N
Leoneil B. Oliveros, St.N
Jill Aira R. Ondap, St.N
Angel Rebb D. Ongcay, St.N
Henrikke Hannah L. Picar, St.N
Athena Marie R. Plaza, St.N
Quisha Kaila V. Salazar, St.N
BSN 4K - Group 3
February 8, 2023
TABLE OF CONTENTS
I. Introduction ……………………………………………………………………….1
II. Objectives …………………………………………………………………………3
III. Congestive Heart Failure ……………………………………………………….4
A. Definition ………………………………………………………………….4
B. Anatomy and Physiology ………………………………………………5
C. Symptomatology ………………………………………………………..12
D. Etiology …………………………………………………………………..14
E. Pathophysiology ………………………………………………………..21
F. Medical Management …………………………………………………..28
G. Surgical Management ………………………………………………….65
H. Nursing Management ………………………………………………….68
I. Literature …………………………………………………………………81
IV. Myocardial Infarction …………………………………………………………...84
A. Definition …………………………………………………………………84
B. Anatomy and Physiology ……………………………………………..84
C. Symptomatology ………………………………………………….…….87
D. Etiology ……………………………………………………………….….89
E. Pathophysiology ……………………………………………….…….…94
F. Medical Management ………………………………………….…….…98
G. Surgical Management ……………………………………………..…121
H. Nursing Management ……………………………………………..… 123
I. Literature ……………………………………………………………….135
V. Hypertension ……………………………………………………………………137
A. Definition ……………………………………………………………….137
B. Anatomy and Physiology ……………………………………………138
C. Symptomatology ………………………………………………………142
D. Etiology …………………………………………………………………144
E. Pathophysiology ……………………………………………………,..149
F. Medical Management …………………………………………………152
G. Surgical Management ………………………………………………..179
H. Nursing Management ………………………………………………...180
I. Literature ……………………………………………………………….192
VI. Dengue ………………………….……………………………………………….195
A. Definition ……………………………………………………………….195
B. Anatomy and Physiology ……………………………………………196
C. Symptomatology ………………………………………………………200
D. Etiology …………………………………………………………………202
E. Pathophysiology ………………………………………………………206
F. Medical Management …………………………………………………212
G. Surgical Management ………………………………………………..222
H. Nursing Management ………………………………………………..223
I. Literature ……………………………………………………………….232
VII. References ………………………………………………………………………234
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I. Introduction
The circulatory system or blood-vascular system are other names for the cardiovascular
system. It comprises the heart, a muscle pump, and a closed network of arteries, veins, and
capillaries that carry blood. The heart pumps blood throughout the circulatory system. As the
word "circulation" suggests, the blood moves through the "circulations" of the body in a circle
or circuit of vessels. For the circulatory system to maintain homeostasis, blood must move
through the tens of thousands of kilometers of capillaries that connect every cell in the body
in a steady, controlled way. So that blood can get to where it needs to go in the body, the
cardiovascular system's different parts and activities must be coordinated, controlled, and
integrated. These processes ensure each cell has a stable internal environment, even if the
amount of food it needs or the amount of waste it makes changes.
Conditions affecting the heart or blood vessels are collectively referred to as

cardiovascular disease (CVD). It is frequently associated with atherosclerosis, a buildup of
fatty deposits inside the arteries that increases the risk of blood clots. According to studies,
up to 90% of CVD may be avoidable. To lower risk factors, eat well, exercise often, don't
smoke, and don't drink too much alcohol. Given how common CVD is, nurses working
anywhere along the continuum of care, such as at home, in the office, in hospitals, long-term
care facilities, or in rehabilitation centers, must be able to evaluate the cardiovascular
system.
According to the World Health Organization (2021), CVDs are the leading cause of death
globally. 17.9 million deaths worldwide in 2019 were attributable to CVDs, or 32% of all
fatalities. Heart attack and stroke deaths accounted for 85% of these fatalities. The majority
of CVD fatalities occur in low- and middle-income nations. In 2019, non-communicable
diseases led to 17 million early deaths (before age 70), and CVD caused 38% of those
deaths. Most cardiovascular diseases can be prevented if people stop doing things that put
them at risk, like smoking, eating poorly, being inactive, and drinking too much alcohol. Also,
the World Health Organization says that CVDs cause one-third of all deaths in the
Philippines. CVDs are a subset of the larger category of non-communicable diseases
(NCDs), which would cause 72% of deaths in the Philippines in 2021, according to the
Philippine Statistics Office (PSA). Furthermore, according to Statista (2023), out of the more
than 6.4 thousand deaths that occurred in the entire Davao area of the Philippines in 2020,
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heart disease deaths were the leading cause of death in Davao City. On the other hand, 200
heart disease-related deaths were documented in the city of Mati during the same period.
This seminar will enhance the understanding of student nurses in nursing education.
This seminar aims to help nursing students and other healthcare professionals better
understand this illness. Additionally, it will help them improve the medical care and health
information given to patients with these disorders regarding the disease's etiology,
treatment, and preventive measures. This lecture emphasizes the gap between theory and
practice in nursing that student nurses encounter daily on the ward. It will also help you learn
to think critically about patients with congestive heart failure, myocardial infarction,
hypertension, and dengue. It will also prepare you to give the best nursing care a patient
deserves. It will also help future researchers learn more about the disease and use it as a
point of reference in nursing research, allowing future researchers, nursing students, and
other healthcare professionals.
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II. Objectives
General Objectives
At the end of the 4 - hours virtual seminar, the BSN 4K Group 3 student nurses will
be able to conduct a comprehensive seminar regarding common diseases of the
cardiovascular system and dengue and apply the knowledge, theories and skills required in
nursing care.
Specific Objectives
To achieve the general objectives, the speakers specifically aim to:
a. briefly discuss the cardiovascular disease and provide statistical data;

b. explain what is congestive heart failure, hypertension, myocardial infarction, and
dengue;
c. review the anatomy and physiology of the affected parts;
d. create an accurate and understandable disease process;
e. identify the signs and symptoms related to the disease;
f. determine the predisposing and precipitating factors;
g. enumerate all possible medical, pharmacological and surgical management;
h. construct possible nursing diagnosis related to the case;
i. present the RRLs (Review of Related Literature) that relates to the case; and
j. cite books, references, and websites used for sources of information in APA format.
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III. Congestive Heart Failure

A. Definition
According to Hare, J., et.al. (2019), the term “heart failure” doesn’t mean that the
heart stops working but actually means that the heart is not pumping as it normally should.
Heart failure is a term used to describe a heart that cannot keep up with its workload which
leads to the body not getting enough oxygen. At first the heart will make up for this by
enlarging its size to contract more strongly and keep up with the demand of the body to
pump more blood. It also tries to pump faster. Eventually the heart and body just can’t keep
up, and the person experiences common symptoms of heart failure such as fatigue and
breathing problems. As the heart weakens, blood begins to back up and force liquid through
the capillary walls. The term “congestive” then refers to the resulting buildup of fluid in other
parts of the body such as the ankles, feet, and lungs..
This can also be supported by Malik, A., et.al (2020) on which he defined Congestive
Heart Failure as a complex clinical syndrome that results from a functional or structural heart
disorder impairing ventricular filling or ejection of blood to the systemic circulation. It is by
definition a failure to meet the systemic demands of circulation. This condition is usually
triggered by conditions like coronary artery disease and myocardial infarction.
Moreover, according to Moore, K. (2020), there are 4 types of Heart failure. The first
type is the Left-side heart failure which is the most common type of heart failure. This occurs
when the left ventricle doesn’t pump efficiently, preventing the body from getting enough
oxygen-rich blood. The blood backs up into the lungs instead, which causes build-up of fluid.
The second type is the right sided heart failure, the accumulation of blood in the lungs
caused by left-sided heart failure makes the right ventricle work harder. This can stress the
right side of the heart and cause it to fail. The third type is Diastolic heart failure, which
occurs when the heart muscle becomes stiffer than normal. The stiffness, which is usually
due to heart disease, causes the heart to not easily fill-up with blood leading to the lack of
blood flow to the rest of the organs in the body. Lastly is the Systolic heart failure, which
happens when the heart muscle loses its ability to contract leading to the inability to pump
enough blood.
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B. Anatomy & Physiology
The cardiovascular system is also known as the blood-vascular system or simply

the circulatory system. It is made up of the heart, a muscular pumping device, and a closed
system of vessels known as arteries, veins, and capillaries. As the name implies, blood in
the circulatory or cardiovascular system is pumped by the heart around a closed circle or
circuit of vessels as it passes repeatedly through the body's various "circulations."
HEART
The heart is the main organ of the cardiovascular system which is a network of blood
vessels that pumps blood throughout the body. It is a four-chambered muscular organ,
shaped and sized roughly like a man's closed fist with two-thirds of the mass to the left of
midline. The four (4) main functions of the heart are the following:
● It pumps blood throughout the body;

● Supplies oxygen and nutrients to the tissues and removes carbon dioxide and waste
from the blood;
● Controls heart rate; and
● Maintains blood pressure.
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LAYERS OF THE HEART
The heart has three (3) layers or linings:
● Endocardium is made up of epithelium and connective tissue with many elastic and
collagenous fibers. It also contains blood vessels and specialized cardiac muscle
fibers known as Purkinje fibers. It is the inner lining of the heart.
● The thick myocardium is mostly made of cardiac muscle tissue and richly supplied by
blood capillaries, lymph capillaries, and nerve fibers. It pumps blood out of the
chambers of the heart. It is the muscular middle layer of the heart.
● The pericardium consists of connective tissue and some deep adipose tissue, and it
protects the heart by reducing friction. It is the outer membranous sac surrounding
the heart.
CHAMBERS AND VALVES OF THE HEART
The inside of the heart is divided into four hollow chambers, with two on the left and
two on the right. The upper chambers are called atria/atrium and receive blood returning to
the heart. They have auricles, which are small projections that extend anteriorly. The lower
chambers are called ventricles and receive blood from the atria, which they pump out into
the arteries . The left atria and ventricle are separated from the right atria and ventricle by a
solid wall-like structure called septum.
This keeps blood from one side of the heart from mixing with blood from the other
side. The atrioventricular valve (AV valve), which consists of the mitral valve on the left and
the tricuspid valve on the right, ensures one-way blood flow. Chordae tendineae (tendinous
strands) attach and secure the cusps of the AV valves to enlarged papillary muscles that
project from the ventricular walls. It allows the AV valves to close during ventricular
contraction, but prevents their cusps from getting pushed up into the atria. The other two
valves, the aortic and pulmonary valves, move blood to the lungs (Pulmonary valve) and the
rest of the body (Aortic valve) through the ventricles. When the heart valves open and close,
they create sounds we know as our heartbeat.
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CONDUCTION SYSTEM OF THE HEART.
The autonomic nervous system controls the rate and rhythm of the heartbeat. It is
normally generated by specialized neuromuscular tissue of the heart that is capable of
causing cardiac muscle to contract rhythmically. This tissue of the heart comprises the
sinoatrial node, the atrioventricular node, and the atrioventricular bundle.
● Sinoatrial node (SA node) is called the pacemaker of the heart, the SA node is
located in the upper wall of the right atrium, just below the opening of the superior
vena cava. It consists of a dense network of Purkinje fibers (atypical muscle fibers)
considered to be the source of impulses initiating the heartbeat. Electrical impulses
discharged by the SA node are distributed to the right and left atria and cause them
to contract.
● Atrioventricular Node (AV Node) is located beneath the endocardium of the right
atrium, the AV node transmits electrical impulses to the bundle of His (atrioventricular
bundle).
● Atrioventricular Bundle (Bundle of His) forms a part of the conduction system of
the heart. It is a collection of heart muscle cells specialized for electrical conduction
that transmits the electrical impulses from the AV node to the point of the apex of the
fascicular branches. The bundle of His branches into the two bundle branches that
run along the interventricular septum. The bundles give rise to thin filaments known
as Purkinje fibers. These fibers distribute the impulse to the ventricular muscle.
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Together, the bundle branches and Purkinje network comprise the ventricular
conduction system.
CARDIAC OUTPUT
Cardiac Output is the amount of blood ejected by each ventricle in one minute. It is the
product of the Heart rate (HR) and stroke volume (SV) and is measured in liters per minute.
● HEARTBEAT- contraction of the heart to pump blood to the lungs and the rest of the
body.
● STROKE VOLUME - amount of blood pumped by each ventricle with each heartbeat
4 Determinants of Cardiac Output
● Heart Rate - the number of times the heart beats within a certain time period, usually
a minute.
● Preload (End Diastolic Volume) - occurs during diastole. It is the initial stretching of
the cardiac myocytes (muscle cells) prior to contraction. It is related to ventricular
filling.
● Afterload - occurs during systole. It is the force or load against which the heart has
to contract to eject the blood out of the aorta or into the pulmonary trunk.
● Contractility - is the inherent strength and vigor of the heart's contraction during
systole.
BLOOD FLOW IN THE HEART
The right side of the heart pumps

oxygen-poor blood to the lungs, and the left
side pumps oxygen-rich blood toward the
body tissues. This happens through the
process of diffusion. The unoxygenated
blood from the body enters the right atrium
through the inferior vena cava and superior
vena cava. Then the tricuspid valve opens
to let blood travel from the right atrium to
the right ventricle. Going to the pulmonary
valve then blood through the pulmonary
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artery to the lungs, where it gets oxygen. After absorbing oxygen, the oxygen rich blood
returns to the heart through the pulmonary veins, then to the mitral valve to send blood from
the left atrium to the left ventricle, passing through the aortic valve into the aorta before
leaving the body through the tissues.
BLOOD
Blood is a specialized body fluid. It has four main components: plasma, red blood cells,
white blood cells, and platelets. It has many different functions, like transporting oxygen and
nutrients to the lungs and tissues, forming blood clots to prevent excess blood loss, carrying
cells and antibodies that fight infection and regulating body temperature. Red blood cells
are by far the most numerous cells in the blood. It contains hemoglobin, a protein that
contains iron and helps transport oxygen by reversibly attaching to it and considerably
enhancing its solubility in blood. In contrast, carbon dioxide is almost entirely transported
extracellularly dissolved in plasma as bicarbonate ions. White blood cells help to resist
infections and parasites, and platelets are important in the clotting of blood.
BLOOD VESSELS
The blood vessels of the

human body carry blood to
every type of tissue and
organ. There are five general
classes of blood vessels in the
cardiovascular system:
arteries, arterioles, capillaries,
venules, and veins. The
arteries carry blood away
from the heart, and veins
carry blood towards the heart.
With the exception of
pulmonary blood vessels, arteries carry oxygenated blood and veins carry deoxygenated
blood. Arterioles helps control blood flow from arteries to capillaries by vasoconstriction or
vasodilation. Capillary has a membrane allowing nutrients, gasses, and wastes to be
exchanged between blood and tissue fluid. Venule connects capillaries to veins. The artery
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wall consists of three distinct layers: tunica interna, tunica media and tunica externa. The
innermost tunica interna is made up of a layer of simple squamous epithelium known as
endothelium. It helps prevent blood clotting and in regulating blood flow. The middle tunica
media makes up most of an arterial wall, including smooth muscle fibers and a thick elastic
connective tissue layer. The outer tunica externa (tunica adventitia) is thinner, mostly made
up of connective tissue with irregular fibers attached to the surrounding tissues.
In the case of heart failure, the heart works

less efficiently than normal due to various
causes like high blood pressure or triggering
conditions such as myocardial infarction and
coronary artery disease. As a result, the heart
is unable to supply enough oxygen and
nutrients to the body. The heart chambers
may respond by stretching to hold more blood
to pump through the body, or by stiffening and
thickening. This helps to keep the blood
flowing, but the heart muscle walls may
weaken and become unable to pump as
efficiently over a period of time as a
consequence. In response, the kidneys may
cause the body to retain fluid (water) and salt.
The body becomes congested when fluid
accumulates in the arms, legs, ankles, feet, lungs, or other organs which result in congestive
heart failure.
Respiratory system is the network of organs and tissues that aids in breathing. It includes
the airways, lungs and blood vessels. These parts work together to move oxygen throughout
the body and clean out waste gasses like carbon dioxide. The following are parts of the
respiratory system:
● Lungs - is a spongy, pinkish organ that looks like two upside-down cones in the
chest. The right lung is made up of three lobes. The left lung has only two lobes to
make room for the heart. It brings oxygen into the body (called inspiration, or
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inhalation) and sends carbon dioxide out (called expiration, or exhalation). This
exchange of oxygen and carbon dioxide is called respiration.
Upper respiratory system
● Nose & Nasal Cavity - The function of this part of the system is to warm, filter and
moisten the incoming air
● Pharynx - Here the throat divides into the trachea (windpipe) and esophagus (food
pipe). There is also a small flap of cartilage called the epiglottis which prevents food
from entering the trachea.
● Larynx- This is also known as the voice box as it is where sound is generated. It
also helps protect the trachea by producing a strong cough reflex if any solid objects
pass the epiglottis.
Lower Respiratory System
● Trachea - Also known as the windpipe, this is the tube which carries air from the
throat into the lungs. The inner membrane of the trachea is covered in tiny hairs
called cilia, which catch particles of dust which we can then remove through
coughing. The trachea is surrounded by 15-20 C-shaped rings of cartilage at the
front and side which help protect the trachea and keep it open. They are not
complete circles due to the position of the esophagus immediately behind the
trachea and the need for the trachea to partially collapse to allow the expansion of
the esophagus when
● Bronchi - The left bronchi is narrower, longer and more horizontal than the right.
Irregular rings of cartilage surround the bronchi, whose walls also consist of smooth
muscle. Once inside the lung, the bronchi split several ways, forming tertiary
bronchi.
● Bronchioles - Tertiary bronchi continue to divide and become bronchioles, very
narrow tubes, less than 1 millimeter in diameter. There is no cartilage within the
bronchioles and they lead to alveolar sacs.
● Alveoli - Individual hollow cavities contained within alveolar sacs (or ducts). Alveoli
have very thin walls which permit the exchange of gasses, oxygen and carbon
dioxide. They are surrounded by a network of capillaries, into which the inspired
gasses pass. There are approximately 3 million alveoli within an average adult lung.
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● Diaphragm - The diaphragm is a broad band of muscle which sits underneath the
lungs, attaching to the lower ribs, sternum and lumbar spine and forming the base of
the thoracic cavity.
The heart and lungs work together to make sure the body has
the oxygen-rich blood it needs to function properly.
● The Pulmonary Loop. The right side of the heart

picks up the oxygen-poor blood from the body and
moves it to the lungs for cleaning and re-oxygenating.
● The Systemic Loop. Once the blood is reoxygenated,
the left side of the heart moves the blood throughout
the body so that every part receives the oxygen it
needs.
The close connection between the heart and lungs means that
breathing problems can be caused by issues in either the
heart or lungs, or both.
C. Symptomatology
SIGNS & SYMPTOMS RATIONALE
Shortness of breath Shortness of breath occurs because blood in

the body backs up in the blood vessels,
which return blood from the lungs to the
heart, due to the heart not pumping blood
out of the heart effectively. This causes fluid
to leak into the lungs, also known as
congestion.
Irregular heartbeat When you have heart failure, your heart tries
to compensate for its lack of pumping power
by beating faster (tachycardia) to keep up
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the same flow of blood around your body.

This increased heart rate may sometimes be
irregular and cause palpitations, which feel
like your heart is racing or throbbing.
Chest pain Chest pain caused by poor blood flow to the

heart. This is often caused by the buildup of
thick plaques on the inner walls of the
arteries that carry blood to the heart. These
plaques narrow the arteries and restrict the
heart's blood supply, particularly during
physical activity.
Fatigue As heart failure becomes more severe, the

heart is unable to pump the amount of blood
required to meet all of the body's needs. To
compensate, blood is diverted away from
less-crucial areas, including the arms and
legs, to supply the heart and brain. As a
result, people with heart failure often feel
weak (especially in their arms and legs),
tired and have difficulty performing ordinary
activities.
Persistent cough As the lungs become congested, due to

CHF, excess fluid can start to leak into the
air sacs (alveoli). Coughing is the body’s
natural response to this airway blockage,
cuing you to clear the bronchial passages in
an attempt to relieve the congestion.
Swelling A weak heart pumps less blood to your

kidneys and causes fluid and water
retention, resulting in swollen ankles, legs,
and abdomen (called edema) and weight
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gain. This can also cause an increased need

to urinate during the night as your body
attempts to get rid of this excess fluid.
Bloating in your stomach may cause a loss
of appetite or nausea.
D. Etiology
PREDISPOSING FACTOR RATIONALE

Age As a person grows older, their heart gets rigid
and fragile. People over 65 have a higher risk
of developing heart failure. Additionally, older
people are more vulnerable to various
medical conditions that cause heart
failure.(National Heart, Lung, and Blood
Institute, 2022).
Family history of cardiomyopathy Conditions that affect the myocardium are
referred to as cardiomyopathy (heart muscle).
Cardiomyopathy can produce scar tissue,
make your heart stiffer, larger, or thicker. Your
heart is unable to adequately pump blood
towards the rest of the body as a result.
Your heart may eventually become weaker,
and cardiomyopathy may result in congestive
heart failure (Cleveland clinic, 2021)
Gender Your likelihood of having congestive heart
failure is influenced by your gender. Older
women are particularly at risk for this
illness. More than 2.5 million women are
affected by congestive heart failure, which
frequently leads to hospitalization. Your
chances of developing heart failure increase
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even further if you are a woman and have the

other risk factors indicated. (Modern heart
and vascular, 2022)
Ethnicity Congestive heart failure can affect anyone,
however particular racial groups are at
greater risk. For instance, compared to
Caucasians, African Americans have a 30%
higher chance of dying from heart disease.
You can also be more susceptible to high
blood pressure depending on your ethnicity.
(Modern heart and vascular, 2022)
Congenital Heart Disease Congenital heart disease is a term used to
describe birth problems in the structure or
function of the heart. Further heart issues
brought on by these defects may weaken the
cardiovascular system and make it incapable
of delivering adequate blood throughout the
body. Heart failure may result due to this in
return. (Modern heart and vascular, 2022)
PRECIPITATING FACTOR RATIONALE

Obesity First, individuals who are overweight typically
have more blood in their bodies, which
causes the heart to work harder and
eventually can cause heart failure. Ventricular
hypertrophy is a condition in which the heart's
muscle size expands as a result of increased
workload. Second, there is a connection
between fat and sleep apnea, which can
result in lung issues, high blood pressure,
and ultimately heart failure. (National Heart
and Lung Institute, 2022)
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Sedentary lifestyle Staying sedentary might cause fatty deposits

to form in your arteries (the blood vessels that
carry blood to your organs). A heart attack
may result from blocked and damaged
arteries that deliver the heart's blood. A
stroke may result if this occurs in the arteries
that supply blood to the brain. (British Heart
Foundation, 2022)
History of alcohol abuse The heart's capability to pump blood is
impaired by long-term alcohol usage because
the heart muscle becomes thinner and
weaker. All of your body's essential
processes are disrupted when your heart is
unable to pump blood effectively. Heart failure
and other potentially fatal medical conditions
can result from this. (Healthline, 2018)
Smoking Your blood's capacity to carry oxygen is
influenced by the carbon monoxide in
cigarette smoke. In order to provide your
body enough oxygen, your heart must work
harder. Additionally, it causes chronic
obstructive pulmonary disease, which
manifests as shortness of breath and other
signs of heart failure. Smoking narrows blood
arteries throughout your body, including those
in your heart (narrow). Your heart failure
symptoms will worsen as a result.
(Kamimura, 2018)
Hypertension The heart needs to work harder to pump your
blood as a result of chronic high blood
pressure. Congestive Heart failure could
result from your heart muscle becoming thick
and fragile. Due to hypertension, your blood
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vessel walls could also thicken, which can be

harmful when cholesterol builds up inside of
the blood vessels. Your risk of having a heart
attack or stroke increases. (Mayo clinic,
2022)
Diabetes Your body and your heart may suffer if you
have diabetes. Your blood vessels and
nerves can become damaged over time by
diabetes' elevated sugar levels. Your risk of
heart disease and, eventually, heart failure
increases the longer you have diabetes. A
significant risk factor for heart failure is
diabetes. (Heart.org, 2019)
Heart Valve Disease The blood flow into and out of the heart is
regulated or controlled by the valves opening
and closing. When the heart beats, leaflets on
a healthy heart valve can fully open and close
the valve, but diseased valves may not. If the
heart valves are damaged, the heart must
work harder to pump blood around the body,
either against a restricted opening or while
blood leaks back into the chamber. This might
result in cardiac failure. (CDC, 2019)
Existing Heart Illness Heart failure can appear suddenly (acute) or
gradually as your heart becomes less healthy
(chronic). One or both of your heart's sides
may be affected. Heart failure that occurs on
the left or right side may have several
causes. The majority of the time, another
cardiac problem or a medical condition that
harms your heart is what causes heart failure.
(National Heart and Lung Institute, 2022)
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Systemic Infection During systemic, the immune system of the

body is activated by infection, resulting in
inflammation which can rupture plaque and
cause blockages that result in heart attack
and stroke. Long after they have recovered
from infection, patients frequently still retain
high levels of inflammatory markers in their
bloodstream. (Cleveland Heartlab, 2022)
Arrhythmia Heart failure can result from atrial fibrillation
because the heart is pumping so quickly that
it never fully fills with blood to pump to the
body. Cardiomyopathy and congestive heart
failure can result from the muscular
weakening that can happen when the heart
beats excessively quickly for an extended
length of time. Oxygen-rich blood is not being
delivered to the body and brain, causing
physical and mental exhaustion and
decreased stamina. Fluid also can build up in
the feet, ankles, and legs, causing
heart-failure related weight gain. When atrial
fibrillation causes heart failure, fluid in the
lungs can cause fatigue and shortness of
breath. (Heart.Org, 2018)
Medications(NSAIDs, Antihypertensives, By preventing the formation of
Diabetes medications) prostaglandins, NSAIDs can compromise
renal function in patients with a reduced
effective circulation volume. As a result, these
patients' unstable cardiovascular
homeostasis may be impacted, as may
increases in renal blood flow and glomerular
filtration rate, as well as sodium and water
retention. Urological agents have the
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potential to develop mild heart failure over

time. These medications stimulate trigger 1
receptors, raising levels of renin and
aldosterone. Major heart failure brought on by
the biguanide metformin might have a
delayed or fast onset due to changes in renal
function. (Saleh, 2021)
Sleep apnea or a variety of reasons, sleep apnea results in
irregular heart rhythms that induce abrupt
cardiac death. When the upper airway closes
due to sleep apnea, the heart is put under
mechanical stress because oxygen levels
drop, the fight-or-flight response is triggered,
and the chest pressure changes. It might
promote inflammation and lead to undesirable
alterations in blood vessels. (Cleveland clinic,
2020)
Excessive water and salt intake Your body's water content may rise as a
result of consuming too much salt or drinking
too much liquid, which can strain your heart.
This may aggravate or perhaps start your
CHF. Excessive salt consumption contributes
to elevated blood pressure and is associated
with water retention. Both high blood
pressure and an excessive salt intake pose
significant risks for developing heart failure as
well as for complicating the condition in
people who already have it. (Januzzi, 2018)
Cardiac infection and inflammation Infective endocarditis (IE) is an inflammation
of the lining of your heart chambers and
possibly your heart valves which can be fatal.
This happens when bacteria from other parts
of your body enter your bloodstream, cling to
20
the lining of your heart valves and chambers,

and start attacking them. Infectious
endocarditis extends outside of your heart
and blood arteries, forms growths
(vegetations) on the valves, and releases
toxins and enzymes that kill and degrade
tissue to create holes in the valve. (Cleveland
clinic, 2022)
21
E. Pathophysiology
22
23
24
25
26
Narrative
The above-mentioned factors, mainly the predisposing and precipitating factors

contribute a lot to the mechanism of congestive heart failure. For the predisposing factors, it
includes >65 years old, sex, family history of heart failure, Black and African American. For
the precipitating factors, it includes systemic infection, coronary artery disease, heart attack,
heart valve disease, hypertension, arrhythmia, diabetes, medications (NSAIDs,
anti-hypertensive, diabetes medications), alcohol use, smoking, cardiac infection and
inflammation, excessive water and salt intake, and obesity.
Initially in early stages, cardiac physiology attempts to adapt via several

compensatory mechanisms to maintain cardiac output and meet the systemic demands.
These include the Frank-Starling mechanism, changes in myocyte regeneration, myocardial
hypertrophy, and myocardial hypercontractility. With increased wall stress, the myocardium
attempts to compensate which further worsens the loading conditions and wall stress.
Furthermore, with increased wall stress, from a hemodynamic standpoint, heart failure can
arise from worsening systolic or diastolic function or, more frequently, a combination of both.
When this systolic/diastolic dysfunction happens, it can lead to the following forward and
backward effects. First, in backward effects, with the decreased emptying of Left Ventricle
due to the systolic and diastolic dysfunction it can lead to increase volume and end-diastolic
pressure in Left Ventricle which further Increase the volume in Left Atrium and volume in
pulmonary capillary bed. With this increasing volume, it can result to transudation of fluid
from capillaries into interstitial spaces of alveoli in which there will be rapid filling of alveolar
space which in turns lead to pulmonary edema which can be manifested as having dyspnea,
crackles, decreased 02 saturation, increased respiratory rate, orthopnea, and paroxysmal
nocturnal dyspnea and bronchoconstriction which is accompanied by wheezing. Second, in
forward effects, due to systolic and diastolic dysfunction, it can lead to decreased cardiac
output which can be manifested in physical finding as pulsus alternans. Then, the decreased
cardiac output can result in decreased perfusion of tissues of the body in which patients may
experience easy fatigability, weakness, dizziness, and pale cold sweaty skin. Furthermore,
with the decreased tissue perfusion, there will be decrease blood flow to the kidneys and
glands which increases reabsorption of Na & H20 Vasoconstriction which in turn can lead to
increase secretion of Na & H20 – retaining hormones, with this mechanism, it can increase
extracellular fluid volume which increases the total blood volume and increases systemic BP
in which 4th heart sound can be heard.
27
With these forward and backward effects, it can lead to further mechanism in which
the right ventricle when chronically exposed to high afterload, there will be right ventricle wall
tension that led to harder ejection of blood out of the right ventricle which can lead to
decrease right ventricular stroke volume. This process can further lead to blood backing up
to the right atrium which increases volume and pressure in systemic circulation, in which
there will be increased pressure in the great veins and distensible organs which further
leads to pressure in peritoneal vessels that can be manifested as ascites. With the
increasing pressure in the great veins and distensible organs, jugular vein distention and
hepatosplenomegaly happens. Furthermore, peripheral edema may also happen from the
increasing pressure in capillary vessels. In contrary, the decrease right ventricular stroke
volume can further lead to decrease blood volume from the right ventricle to the lungs which
in turn lead to decrease return to left atrium and subsequent decrease in cardiac output that
led to decrease systemic blood flow and pressure and further affects the tissue perfusion to
other organs such as the kidneys.
In addition, commonly right-sided heart failure generally develops as a result of

advanced left-sided heart failure, and is then treated in the same way. In relation, to
treatments and diagnostic tests chest x-ray, ECG, 2d Echo, basic metabolic panel, CBC,
BUN, Creatinine, CBG, serum electrolytes, ultrasound of the whole abdomen, lipid profile,
BNP test, SGPT test and CVP are usually being measured and done. Pharmacologic
therapies include the use of diuretics, vasodilators, inotropic agents, anticoagulants, beta
blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers
(ARBs), calcium channel blockers (CCBs), digoxin, nitrates and other specific medications
mentioned above. Nursing interventions which focus on decreased cardiac output, fluid
volume excess, impaired gas exchange is also a top priority when encountering patients
with heart failure. If treated, it will lead to a good prognosis. If not treated, complications of
heart failure depend on the severity of heart disease, possible complications can include
kidney failure, heart valve problems. heart rhythm problems, liver damage/ failure and
further leads to shock and then death. In the patient’s case, the group came up with a poor
prognosis considering the age, the presenting symptoms, test results and the patient was
also diagnosed with Class III Heart Failure by the doctor.
28
F. Medical Management
Diagnostic Tests
TEST NORMAL RESULT RATIONALE
Complete Blood Count CBC is one of the common

with Differential/Platelet tests that experts prescribe
WBC 4.0 - 10.5
to treat a patient's health. It
RBC 4.10 - 5.60 primarily provides
information on the three
Hemoglobi 12.5 - 17.0
blood cell components:
n
platelets, which provide
Hematocrit 36.0 - 50.0 immunity, WBC, which
transports oxygen, and RBC
MCV 80 - 98
(helps in blood clotting).
MCH 27.0 - 34.0 Additionally, it gives details

about the shape, size, and
MCHC 32.0 - 36.0 number of these cells'
physical characteristics. You
RDW 11.7 - 15.0
also learn about haematocrit
Platelets 140 - 415 and hemoglobin, which are
blood proteins that deliver
Neutrophils 40 - 74
oxygen (proportion of R.B.C.
Lymphs 14 - 46 to blood plasma count).
Monocytes 4 - 13 Since CBC can identify

anemia, which is known to
promote CHF and produce
symptoms that are similar to
those of CHF, it is used as a
technique to detect
congestive heart failure
(CHF).
29
CBC assessments of a
patient's platelet,
hemoglobin, haematocrit,
and white blood cell count
aid to reduce risks of
coronary heart defects and
the likelihood of a heart
attack.
Fasting Blood Sugar Less than 100 mg/ dL Fasting blood sugar (FBS)
measures blood glucose
after you have not eaten for
at least 8 hours. It is often
the first test done to check
for prediabetes and
diabetes. Random blood
sugar (RBS) measures
blood glucose regardless of
when you last ate.
Lipid Profile The blood fats are

measured by a cholesterol
Cholesterol Less than
test, often known as a lipid
200 mg/ dl
panel or lipid profile. The
Triglyceride Less than measures can be used to
s 150 mg/ dL calculate your risk of
or less than developing heart disease or
1.7 mmol/L having a heart attack.
Usually, the test comprises
HDL 60 mg/ dL
the following
Cholesterol (1.06
measurements:
mmol/L)
30
Total Cholesterol. This is

LDL Less than
the level of cholesterol in the
Cholesterol 100 mg/ dL
blood. Heart disease risk
can rise at a high level.
Low-density lipoprotein
(LDL) is also referred to as
"bad" cholesterol. Too much
LDL cholesterol in the blood
causes plaque to build up in
the arteries, which reduces
blood flow. These plaque
deposits sometimes rupture
and lead to major heart and
blood vessel problems.
High-density lipoprotein
(HDL) cholesterol.
Because it aids in removing
LDL ("bad") cholesterol,
keeping arteries open and
blood flowing more easily,
this is frequently referred to
as the "good" cholesterol.
Triglycerides. Another form

of fat seen in the blood is
called triglycerides. High
triglyceride levels usually
mean you regularly eat
more calories than you burn.
High levels can increase the
risk of heart disease.
31
Basic Metabolic Panel A basic metabolic panel

measures the following
Sodium 135 - 147
substances in your blood:
mmol/ L
Potassium 3.5 - 5.2 Glucose. This is a type of

mmol/ L sugar that provides energy
for your body and brain.
Chloride 95 - 107
Glucose is also known as
mmol/ L
blood sugar. Elevated blood
CO2 22 - 30 glucose is often a sign of
mmol/ L diabetes.
Blood Urea 7 - 20
Calcium. Calcium is one of
Nitrogen mmoL/ mL
the most important and
Creatinine 0.5 - 1.2 common minerals in your
mg/ dL body. While most of your

calcium is stored in your
Glucose 60 - 100 bones, you need calcium in
mg/ dL your blood as well. Blood
calcium is essential for
proper functioning of your
nerves, muscles and heart.
It also helps with blood
clotting when you’re injured.
BUN (blood urea

nitrogen). This is a
measurement of urea, which
is a waste product that your
kidneys help remove from
your blood.
Creatinine. This is a
32
byproduct of muscle activity.

It’s a waste product that
your kidneys filter and
remove from your blood.
A BMP also measures the

following four electrolytes.
Electrolytes are minerals
that carry an electric charge
when they are dissolved in a
liquid. These electrolytes in
your blood control nerve and
muscle function and
maintain the acid-base
balance (pH balance) of
your blood and your water
balance.
Sodium. Most of your

sodium comes from the food
you eat, and your kidneys
help regulate your body’s
sodium levels.
Potassium. Potassium
comes from the food you eat
and is present in all tissues
of your body.
Bicarbonate. Bicarbonate
indicates the amount of
carbon dioxide (CO2) in
your blood.
33
TEST RATIONALE
Chest X Ray A chest X-ray is an imaging test that uses X-rays to look at
the structures and organs in the chest. It can help the
healthcare provider see how well the lungs and heart are
working. It can show the healthcare provider the size,
shape, and location of the Heart, Lungs, Bronchi, Aorta,
Pulmonary arteries, Middle chest area (mediastinum) and
Bones of the chest.
ECG If the test is normal, it should show that your heart is

beating at an even rate of 60 to 100 beats per minute. An
electrocardiogram (ECG) is a simple test that can be used
to check your heart's rhythm and electrical activity. Sensors
attached to the skin are used to detect the electrical signals
produced by your heart each time it beats.
Echocardiogram A non-invasive test used to analyze the functioning and

assess the sections of your heart. This test gives images of
the different parts of the heart with the help of sound
vibrations.It assists in checking damages, blockages, and
blood flow rate. A normal result is when the heart's
chambers and valves appear typical and work the way they
should. More specifically, this means that: There are no
visible blood clots or tumors in the heart. The heart valves
open and close properly.
Cardiac Computerized Cardiac computed tomography (CT) is a non-invasive test

Tomography (CT Scan) that can be used to evaluate various parts of the heart. A
CT scan, also known as a CAT scan, is a noninvasive test
where an X-ray machine rotates around a patient’s body
while they lie on a table.
34
Unlike traditional X- rays, a CT scanner makes highly

detailed images of the internal organs and, in many cases,
is able to distinguish healthy tissue from diseased tissue. A
heart computerized tomography (CT) scan is used to find
calcium deposits in plaque of people with heart disease.
Magnetic Resonance A procedure that uses radio waves, a powerful magnet,

Imaging (MRI) and a computer to make a series of detailed pictures of
areas inside the body. A contrast agent, such as
gadolinium, may be injected into a vein to help the tissues
and organs show up more clearly in the picture. Magnetic
resonance imaging may be used to help diagnose disease,
plan treatment, or find out how well treatment is working.
MRI plays a pivotal role in various aspects of cardiac

failure. It is useful in establishing the diagnosis and
etiology. It enables risk stratification, provides prognostic
information, and determines suitability for surgical/
interventional procedures.
The diagnosis of cardiac failure is typically based on
clinical symptoms and signs and investigations, including
echocardiography.
Coronary Angiogram A coronary angiogram is a procedure that uses x-ray

imaging to see your heart's blood vessels. The test is
generally done to see if there's a restriction in blood flow
going to the heart.
Myocardial Biopsy Heart biopsy, also called myocardial biopsy or cardiac

biopsy, is an invasive procedure to detect heart disease. It
entails using a bioptome (a small catheter with a grasping
device on the end) to obtain a small piece of heart muscle
tissue that is sent to a laboratory for analysis.
35
Drug Study
Generic Name Spironolactone
Brand Name Aldactone
Drug Classification Aldosterone Receptor Antagonist. Clinical:

Potassium-sparing diuretic,
antihypertensive
Pregnancy Category: C
Mechanism of Action Interferes with sodium reabsorption by

competitively inhibiting action of
aldosterone in distal tubule, promoting
sodium and
water excretion, increasing potassium
retention. May decrease the effect of
aldosterone on arteriolar smooth muscle.
Therapeutic Effect: Produces diuresis,
lowers B/P.
Indication Management of edema in cirrhotic pts

when edema is unresponsive to fluid and
sodium restriction. Heart failure (NYHA
class III–IV and reduced ejection fraction) to
increase survival, manage edema, and to
reduce need for hospitalization for HF.
Management of hypertension (unresponsive
36
to other therapies). Treatment of primary

hyperaldosteronism. OFF LABEL:
Treatment of edema, hypertension in
children, female acne, female hirsutism.
Ascites due to cirrhosis.
Suggested Dose and Frequency PO: ADULTS, ELDERLY: (Tablet): Initially,

12.5–25 mg/day. May double the dose
q4wks if serum potassium remains less
than 5 mEq/L and renal function remains
stable. Maximum: 50 mg/day. in 1 or 2
divided doses.
Contraindications Contraindications: Hypersensitivity to

spironolactone. Hyperkalemia, Addison’s
disease, concomitant use with eplerenone.
Cautions: Dehydration, hyponatremia,
concurrent use of supplemental potassium,
elderly pts, mild renal impairment, declining
renal function, ACE inhibitors or angiotensin
receptor blockers.
Side Effects Frequent: Hyperkalemia (in pts with renal

insufficiency, those taking potassium
supplements), dehydration, hyponatremia,
lethargy. Occasional: Nausea, vomiting,
anorexia, abdominal cramps, diarrhea,
headache, ataxia, drowsiness, confusion,
fever. Male: Gynecomastia, impotence,
decreased libido. Female:Menstrual
irregularities (amenorrhea, postmenopausal
bleeding), breast tenderness. Rare: Rash,
urticaria, hirsutism.
Adverse Effects Severe hyperkalemia may produce

37
arrhythmias, bradycardia, ECG changes

(tented T waves, widening QRS complex,
ST segment depression). May proceed to
cardiac standstill, ventricular fibrillation.
Cirrhosis pts at risk for hepatic
decompensation if dehydration,
hyponatremia occurs. Pts with primary
aldosteronism may experience rapid weight
loss, severe fatigue during high-dose
therapy.
Drug Interaction DRUG: ACE inhibitors (e.g., captopril,

lisinopril), angiotensin receptor blockers
(e.g., valsartan), eplerenone,
potassium-containing medications,
potassium supplements may increase risk
of hyperkalemia. May decrease the
therapeutic effect of digoxin. NSAIDs (e.g.,
ibuprofen, ketorolac, naproxen) may
decrease antihypertensive effect. HERBAL:
Herbals with hypertensive properties (e.g.,
licorice, yohimbe) or hypotensive properties
(e.g., garlic, ginger, ginkgo biloba) may alter
effects.
Nursing Responsibilities 1. Compare the Medication

Administration Record to the
patient’s wristband and use two
patient identifiers to confirm the
patient.
Rationale: To improve medication
safety by ensuring you have
selected the correct patient
2. Obtain the patient’s past health
38
history and current health status.

Rationale: To check if the drug is
contraindicated to the patient,
3. Obtain the patient’s medication
history and current medications.
Rationale: To check if there are
drug interactions with other
medications and to know if extra
precautions are needed to be taken.
4. Monitor intake and output ratios and
daily weight.
Rationale: Weight is an indicator of
fluid overload.
5. Check for baseline vital signs, note
the pulse and regularity..
Rationale: To detect unusualities.
6. Assess dizziness that might affect
gait and balance.
Rationale: To avoid falls and
traumas.
7. Assess heart rate, ECG, especially
during activity
Rationale: to know if there are
rhythm disturbances or arrhythmias
8. Assess blood pressure periodically.
Rationale: To document
antihypertensive effects.
9. Inform pt to expect an increase in
urination.
Rationale: Spironolactone is a
diuretic, and causes pts to pee
more.
10. Advise the patient to avoid tasks
39
that require alertness, and motor

skills until response to drug is
established.
Rationale: It may cause drowsiness
therefore, may put the patient at risk
for accidents.
Generic Name Lisinopril
Brand Name Prinivil
Drug Classification Angiotensin-converting enzyme (ACE)

inhibitors
Pregnancy Category D
Mechanism of Action Competitive inhibitor of angiotensin-

converting enzyme (ACE) (prevents
conversion of angiotensin I to angiotensin II,
a potent vasoconstrictor; may
inhibit angiotensin II at local vascular,
renal sites). Decreases plasma angio-
tensin II, increases plasma renin activity,
decreases aldosterone secretion.
Therapeutic Effect: Reduces blood
pressure.
40
Indication Treatment of hypertension in adults and

children 6 yrs and older. Adjunctive therapy
to reduce signs/symptoms of systolic
HF. Treatment of acute MI within 24 hrs
in hemodynamically stable pts to improve
survival.
Suggested Dose and Frequency PO: ADULTS, ELDERLY: Initially, 2.5–5

mg/day. May increase by no more than
10 mg/day at intervals of at least 2 wks

lisinopril, other ACE inhibitors. History of
angioedema from treatment with ACE
inhibitors, idiopathic or hereditary
angioedema. Concomitant use with
aliskiren in pts with diabetes.
Co-administration with or within 36 hrs of
switching to or from a neprilysin inhibitor
(e.g., sacubitril). Cautions: Renal
impairment, unstented unilateral/bilateral
renal artery stenosis, volume depletion,
ischemic heart disease, cerebrovascular
disease, severe aortic stenosis,
hyper-trophic cardiomyopathy, HF, systolic
B/P less than 100, dialysis, hyponatremia;
before, during, or immediately after major
surgery. Concomitant use of potassium
supplements.
Side Effects Frequent (12%–5%): Headache, dizziness,

postural hypotension. Occasional (4%–2%):
Chest discomfort, fatigue, rash, abdominal
pain, nausea, diarrhea, upper respiratory
41
infection. Rare (1% or less): Palpitations,

tachycardia, peripheral edema, insomnia,
paresthesia, confusion, constipation, dry
mouth, muscle cramps.
Adverse Effects Excessive hypotension (first-dose syncope)

may occur in pts with HF, severe
salt/volume depletion. Angioedema
(swelling of face and lips), hyperkalemia
occur rarely. Agranulocytosis, neutropenia
may be noted in pts with collagen vascular
disease (scleroderma, systemic lupus
erythematosus). Nephrotic syndrome may
be noted in pts with a history of renal
disease.
Drug Interaction DRUG: Aliskiren may increase

hyperkalemic effect. May increase potential
for allergic reactions to allopurinol.
Angiotensin receptor blockers (e.g.,
losartan, valsartan) may increase adverse
effects. May increase adverse effects of
lithium, sacubitril. HERBAL: Herbals with
hypertensive properties (e.g., licorice,
yohimbe) or hypotensive properties (e.g.,
garlic, ginger, ginkgo biloba) may alter
effects.

patient.
42

selected the correct patient.
contraindicated to the patient.
4. Explain the medication, and give the
patient time to ask questions.
Rationale: To help minimize patient
anxiety and let the patient know
what the drug is for.
5. Check blood pressure and pulse
before each administration of
Lisinopril.
Rationale: To ensure that the blood
pressure of the pt has not dropped
too low.
6. Monitor the patient’s daily bowel
activity.
Rationale: To check if pt is
experiencing constipation due to the
medication, and to be able to inform
the physician immediately.
7. Assist patient in supine position with
feet slightly elevated if excessive
reduction in BP occurs.
Rationale: Placing the pt’s legs in a
43
slightly elevated position helps with

excessive low blood pressure.
8. Raise the pt’s side rails.
Rationale: To avoid pt falls, and
injuries.
9. Instruct the patient to go from lying
to standing slowly if excessive low
blood pressure is present.
Rationale: To reduce the
hypotensive effect.
10. Educate the patient to:
a. Limit salt intake
b. Maintain adequate hydration
c. Report vomiting, diarrhea,
diaphoresis, swelling of
face/lips/tongue, difficulty in
breathing, and persistent
cough.
d. Report decreased urinary
output, dark-colored urine,
swelling of the hands and
feet.
Rationale: Patient health
teaching helps expand the
pt’s knowledge, and allows
them to know what signs
need to be watched out for.
Generic Name Losartan

44
Brand Name Cozaar
Drug Classification Angiotensin II receptor blockers (ARBs)

Clinical: Antihypertensive
Pregnancy Category: D
Mechanism of Action Blocks vasoconstrictor, aldosterone

secreting effects of angiotensin II, inhibiting
binding of angiotensin II to AT1 receptors.
Therapeutic Effect: Causes vasodilation,
decreases peripheral resistance, decreases
B/P.
Indication Treatment of hypertension in adults and

children 6 yrs and older. Used alone or in
combination with other antihypertensives.
Treatment of diabetic nephropathy with an
elevated creatinine and proteinuria (in pts
with type 2 diabetes and history of
hypertension), prevention of stroke in pts
with hyper-tension and left ventricular
hypertrophy. OFF-LABEL: Slow rate of
progression of aortic root dilation in children
with Marfan’s syndrome. HF in pts intolerant
of ACE inhibitors.
Suggested Dose and Frequency ADULTS, ELDERLY: Initially, 25–50 mg

once daily. May increase as needed to 100
mg/day in 1–2 divided doses

losartan. Concomitant use of aliskiren in pts
with diabetes. Cautions: Renal/hepatic
impairment, unstented renal arterial
stenosis, significant aortic/mitral stenosis.
45
Concurrent use of potassium supplements.

Pts with history of angioedema.
Side Effects Frequent (8%): Upper respiratory tract

infection. Occasional (4%–2%): Dizziness,
diarrhea, cough. Rare (1% or less):
Insomnia, dyspepsia, heartburn, back/leg
pain, muscle cramps, myalgia, nasal
congestion, sinusitis, depression.
Adverse Effects Overdosage may manifest as hypotension

and tachycardia. Bradycardia occurs less
often. Institute supportive measures.
Drug Interaction DRUG: NSAIDs (e.g., ibuprofen, ketorolac,

naproxen) may decrease effects. Aliskiren
may increase hyperkalemic effect. May
increase adverse/toxicity of ACE inhibitors
(e.g., benazepril, lisinopril). May increase
levels/effects of lithium. HERBAL: Herbals
with hypertensive properties (e.g., licorice,
effects.

patient.
46

5. Raise the pt’s side rails, and help
them ambulate when needed.
Rationale: To guard the pt against
falls, and injuries.
6. Watch for and report signs of
impaired renal function, including
decreased urine output, cloudy
urine, or sudden weight gain due to
fluid retention.
Rationale: To avoid further
complications on the pt.
7. Monitor symptoms of high plasma
potassium levels (hyperkalemia),
including bradycardia, fatigue,
weakness, numbness, and tingling.
Rationale: To check for unusualities
because severe cases can lead to
life-threatening arrhythmias and
paralysis.
8. Do not abruptly discontinue
47
medication.
Rationale: Abruptly stopping your
medication may render the
medication less effective. Warn
about possible.
9. Explain to patients that they must
adhere to the medication regimen
but if they miss a dose do not
double dose.
Rationale: Double dosing can
temporarily boost the amount of
medication in a patient's system,
causing an increase in both
symptoms and side effects.
10. Advise the patient to avoid tasks
that require alertness, and motor
skills until response to drug is
established.
Rationale: It may cause fatigue,
and lightheadedness therefore, may
put the patient at risk.
Generic Name Metoprolol
Brand Name Lopressor
Drug Classification Beta Adrenergic Blocker

Clinical: Antianginal, antihypertensive, MI
adjunct
48
Mechanism of Action Selectively blocks beta1-adrenergic

receptors. Therapeutic Effect: Slows heart
rate, decreases cardiac output, reduces
B/P. Decreases myocardial ischemia
severity
Indication Immediate-Release: Treatment of

hemodynamically stable acute myocardial
infarction (AMI) to reduce CV mortality.
Long-term treatment of angina pectoris.
Management of hypertension. Extended
Release: Long term treatment of angina
pectoris. Management of hypertension.
Treatment of stable symptomatic HF of
ischemic, hypertensive, or cardiomyopathic
origin to reduce rate of hospitalization in pts
receiving ACE inhibitors, diuretics, and/or
digoxin. Injection: Treatment of
hemodynamically stable acute myocardial
infarction (AMI) to reduce CV mortality.
OFF-LABEL: Treatment of ventricular
arrhythmias, migraine prophylaxis, essential
tremor, aggressive behavior, prevent
reinfarction post-MI, prevent/treat atrial
fibrillation/atrial flutter, hypertrophic
cardiomyopathy, thyrotoxicosis.
Suggested Dose and Frequency PO: (Extended-Release): ADULTS: Initially,

12.5–25 mg/day. May titrate gradually by
doubling dose q2wks or longer up to target
dose of 200 mg/day.
Contraindications Hypersensitivity to metoprolol. Second- or

49
third-degree heart block.

Immediate-Release: MI:Severe sinus
bradycardia (HR less than 45 beats/min),
systolic B/P less than 100 mm Hg,
moderate to severe HF, significant
first-degree heart block. Immediate
Release: HTN/Angina: Sinus bradycardia,
cardiogenic shock, overt HF, sick sinus
syndrome (except with pacemaker), severe
peripheral arterial disease.
Extended-Release: Severe bradycardia,
cardiogenic shock, decompensated HF, sick
sinus syndrome (except with functioning
pacemaker). Cautions: Arterial obstruction,
bronchospastic disease, hepatic
impairment, peripheral vascular disease,
hyperthyroidism, diabetes mellitus,
myasthenia gravis, psychiatric disease,
history of severe anaphylaxis to allergens.
Extended-Release: Compensated HF.
Side Effects Metoprolol is generally well tolerated, with

transient and mild side effects. Frequent:
Diminished sexual function, drowsiness,
insomnia, unusual fatigue/weakness.
Occasional: Anxiety, diarrhea, constipation,
nausea, vomiting, nasal congestion,
abdominal discomfort, dizziness, difficulty
breathing, cold hands/feet. Rare: Altered
taste, dry eyes, nightmares, paresthesia,
allergic reaction (rash, pruritus).
Adverse Effects Overdose may produce profound

bradycardia, hypotension, bronchospasm.
50
Abrupt withdrawal may result in

diaphoresis, palpitations, headache,
tremulousness, exacerbation of angina, MI,
ventricular arrhythmias. May precipitate HF,
MI in pts with heart disease, thyroid storm in
those with thyrotoxicosis, peripheral
ischemia in those with existing peripheral
vascular disease. Hypoglycemia may occur
in pts with previously controlled diabetes
(may mask signs of hypoglycemia).
Antidote: Glucagon
Drug Interaction DRUG: Alpha2 agonists (e.g., clonidine)

may increase AV-blocking effect. Strong
CYP3A4 inducers (e.g., carBAMazepine,
phenytoin, rifAMPin) may decrease
concentration/effect. Dronedarone,
fingolimod, rivastigmine may increase
bradycardic effect. May increase
vasoconstriction of ergot derivatives (e.g.,
ergotamine). HERBAL: Herbals with
hypertensive properties (e.g., licorice,
effects.

patient.
51

5. Assess B/P, apical pulse
immediately before drug
administration.
Rationale: To monitor if pulse is
60/min or less or systolic B/P is less
than 90 mm Hg, withhold
medication, contact physician).
6. Measure B/P near the end of the
dosing interval.
Rationale: To determine if B/P is
controlled throughout day
7. Raise the pt’s side rails.
Rationale: To avoid the risk of injury
or falls.
8. Do not abruptly discontinue
medication.
Rationale: Abruptly stopping your
medication may render the
52
medication less effective. Warn

about possible.
9. Report excessive fatigue, and
drowsiness.
Rationale: To inform the physician
for them to check if medication
needs to be discontinued.
10. Educate the patient to restrict salt,
and alcohol intake.
Rationale: Dietary and lifestyle
changes are vital for the pt’s
recovery.
Generic Name Digoxin
Brand Name Lanoxin
Drug Classification Cardiac glycoside, Clinical: Antiarrhythmic

Mechanism of Action Inhibits sodium/potassium ATPase pump in

myocardial cells. Promotes calcium influx.
Supraventricular arrhythmias: Suppresses
AV node conduction. Therapeutic Effect:
HF: Increases contractility. Supraventricular
arrhythmias: Increases effective refractory
53
period/decreases conduction velocity,

decreases ventricular heart rate of fast atrial
arrhythmias.
Indication Treatment of mild to moderate HF. Control

ventricular response rate in pts with chronic
atrial fibrillation. OFF-LABEL: Fetal
tachycardia with or without hydrops;
decrease ventricular rate in supraventricular
tachyarrhythmias.
Suggested Dose and Frequency PO: ADULTS, ELDERLY: 0.125–0.25 mg

once daily.

digoxin. Ventricular fibrillation. Cautions:
Renal impairment, sinus nodal disease,
acute MI (within 6 mos), second or
third-degree heart block (unless functioning
pacemaker), concurrent use of strong
inducers or inhibitors of P-glycoprotein
(e.g., cyclosporine), hyperthyroidism,
hypothyroidism, hypokalemia,
hypocalcemia.
Side Effects Dizziness, headache, diarrhea, rash, visual

disturbances.
Adverse Effects The most common early manifestations of

digoxin toxicity are GI disturbances
(anorexia, nausea, vomiting), neurologic
abnormalities (fatigue, headache,
depression, weakness, drowsiness,
confusion, nightmares). Facial pain,
personality change, ocular disturbances
54
(photophobia, light flashes, halos around

bright objects, yellow or green color
perception) may occur. Sinus bradycardia,
AV block, ventricular arrhythmias noted.
Antidote: Digoxin immune FAB
Drug Interaction DRUG: Amiodarone may increase

concentration/toxicity. Beta blockers (e.g.,
metoprolol), calcium channel blockers (e.g.,
dilTIAZem) may have an additive effect on
slowing AV nodal conduction.
Potassium-depleting diuretics (e.g.,
furosemide) may increase toxicity due to
hypokalemia. Ketoconazole, vemurafenib
may increase concentration/effect.
Sucralfate may decrease
absorption/concentration. HERBAL: Licorice
may increase adverse effects.

patient.
55

5. Monitor apical pulse for 1 full min
before administering.
Rationale: Withhold dose and notify
health care professionals if pulse
rate is <60 bpm in an adult, <70
bpm in a child, or <90 bpm in an
infant.
6. Monitor BP periodically in patients
receiving IV digoxin.
Rationale: Strict monitoring of BP
should be done because it might
suddenly drop or increase.
7. Monitor intake and output ratios and
daily weights.
Rationale: Assess for peripheral
edema meaning there is a problem
in the blood volume.
8. Observe signs and symptoms of
toxicity. In adults and older children,
first symptoms of toxicity usually
include abdominal pain, anorexia,
nausea, vomiting, visual
disturbances, bradycardia, and other
arrhythmias. In infants and small
children, the first signs of overdose
56
are usually cardiac arrhythmias.

Rationale: If signs of toxicity occur
and are not severe, discontinuation
of digoxin may be all that is
required.
9. Emphasize the importance of taking
digoxin exactly as prescribed.
Rationale: Warn about possible
toxicity from taking too much and
decreased effectiveness from taking
too little.
10. Teach the patient how to take her
pulse, and instruct her to do so
before each dose. Urge her to notify
the prescriber if the pulse falls below
60 beats/minute or suddenly
Increases.
Rationale: To let the patient join in
the management and promote
independence.
Generic Name Furosemide

57
Brand Name Lasix
Drug Classification Loop Diuretics

Mechanism of Action Inhibits reabsorption of sodium, chloride in

the ascending loop of Henle and
proximal/distal renal tubules. Therapeutic
Effect: Increases excretion of water,
sodium, chloride, magnesium, calcium.
Indication Treatment of edema associated with HF

and renal/hepatic disease; acute pulmonary
edema. Treatment of hypertension (not
recommended as initial treatment).
Suggested Dose and Frequency PO: ADULTS, ELDERLY: Initially, 20–80

mg/dose; may increase by 20–40 mg/dose
q6–8h. May titrate up to 600 mg/day in
severe edematous states.
Contraindications Hypersensitivity to furosemide. Anuria.

Cautions: Hepatic cirrhosis, hepatic coma,
severe electrolyte depletion, prediabetes,
diabetes, systemic lupus erythematosus.
Pts with prostatic hyperplasia/urinary
stricture.
Side Effects Expected: Increased urinary

frequency/volume. Frequent: Nausea,
dyspepsia, abdominal cramps, diarrhea or
constipation, electrolyte disturbances.
Occasional: Dizziness, light-headedness,
headache, blurred vision, paresthesia,
photosensitivity, rash, fatigue, bladder
58
spasm, restlessness, diaphoresis. Rare:

Flank pain.
Adverse Effects Vigorous diuresis may lead to profound

water loss/electrolyte depletion, resulting
in hypokalemia, hyponatremia, dehydration.
Sudden volume depletion may result in
increased risk of thrombosis, circulatory
collapse, and sudden death. Acute
hypotensive episodes may occur,
sometimes several days after beginning
therapy. Ototoxicity (deafness, vertigo,
tinnitus) may occur, esp. in pts with severe
renal impairment. Can exacerbate diabetes
mellitus, systemic lupus erythematosus,
gout, pancreatitis. Blood dyscrasias have
been reported.
Drug Interaction DRUG: Bile acid sequestrants (e.g.,

cholestyramine), sucralfate may decrease
absorption/effect. May increase the
hyponatremic effect of desmopressin. May
increase QT interval–prolonging effect of
dofetilide. Amphotericin B, nephrotoxic
ototoxic medications (e.g., lisinopril, IV
contrast dye, vancomycin) may increase
risk of nephrotoxicity. May increase risk of
lithium toxicity. Other medications causing
hypokalemia (e.g., HCTZ, laxatives) may
increase risk of hypokalemia. HERBAL:
Herbals with hypertensive properties (e.g.,
licorice, yohimbe) or hypotensive properties
(e.g., garlic, ginger, ginkgo biloba) may alter
effects.
59

patient.
5. Instruct the patient to change
positions slowly, such as lying to
standing up slowly.
Rationale: To minimize orthostatic
hypotension.
6. Advise diabetic patients to monitor
blood glucose closely.
Rationale: Furosemide may cause
increased blood glucose levels.
7. Administer diuretics in the morning.
60
Rationale: To prevent nocturia or

the condition that causes you to
wake up during the night to urinate.
8. Instruct the patient to take
furosemide as directed, and to take
missed doses as soon as possible
but to not double dose
Rationale: Double dosing may
cause the side effects to be twice as
bad along with other problems.
9. Instruct the patient to notify the
health care professional of all Rx or
OTC medications, vitamins, or
herbal products being taken and to
consult health care professional
before taking any OTC medications
concurrently with this therapy.
Rationale: For the physician to be
informed and to check if the
medicine being taken has bad
interaction
10. Emphasize the importance of
routine follow-up examinations.
Rationale: The success of the
patient's treatment plan depends on
prompt follow-up of the patient.
Generic Name Nitroglycerin

61
Brand Name Nitrostat
Drug Classification Nitrate, Antianginal, Antihypertensive,

Coronary vasodilator
Mechanism of Action Dilates coronary arteries, improves

collateral blood flow to ischemic areas
within myocardium. Therapeutic Effect:
Decreases myocardial oxygen demand by
decreasing preload. Reduces left
ventricular preload (LVDP). Improves
collateral flow to ischemic areas.
Indication Treatment/prevention of angina pectoris.

Extended-release, topical forms used for
prophylaxis, long-term angina
management. IV form used in treatment of
HF, acute MI, perioperative hypertension,
induction of intraoperative hypotension.
Off Label: Short-term management of
pulmonary hypertension, esophageal
spastic disorders, uterine relaxation,
treatment of
sympathomimetic vasopressor
extravasation.
62
Suggested Dose and Frequency Angina, CAD Sublingual: Adults, Elderly:

One tablet (0.3–0.4 mg) under tongue. If
chest pain fails to improve or worsens in
3–5 min, call 911. After the call, may take
additional tablet. A third tablet may be
taken 5 min after the second dose
(maximum of 3 tablets).
Contraindications Contraindicated in patients that have

reported allergic symptoms to the
medication. Known history of increased
intracranial pressure, severe anemia,
right-sided myocardial infarction, or
hypersensitivity to nitroglycerin are
contraindications to nitroglycerin therapy.
Side Effects Frequent: Headache (possibly severe;

occurs mostly in early therapy, diminishes
rapidly in intensity, usually disappears
during continued treatment), transient
flushing of face/neck, dizziness (esp. if pt
is standing immobile or is in a warm
environment), weakness, orthostatic
hypotension.
Sublingual: Burning, tingling sensation at
the oral point of dissolution.
Adverse Effects Discontinue the drug if blurred vision, or

dry mouth occurs. Severe orthostatic
hypotension may occur, manifested by
syncope, pulselessness, cold/clammy skin,
and diaphoresis. Tolerance may occur with
repeated, prolonged therapy; minor
tolerance may occur with intermittent use
63
of sublingual tablets. High doses tend to

produce severe headaches.
Drug Interaction Antihypertensives (e.g., amlodipine,

lisinopril, valsartan), and vasodilators may
increase the risk of orthostatic
hypotension. Concurrent use of sildenafil,
tadalafil, and vardenafil (PDE5 inhibitors)
produces significant hypotension.
HERBAL: Ephedra, ginger, ginseng, and
licorice may increase hypertension. Black
cohosh, goldenseal, hawthorne may cause
hypotension.

patient.
precautions are needed to be
taken.
4. Explain the medication, and give
64
the patient time to ask questions.

Rationale: To help minimize
patient anxiety and let the patient
know what the drug is for.
Nitroglycerin.
Rationale: Blood pressure can
drop precipitously after a single
dose.
6. Monitor the patient’s vital signs
when the drug is being
administered.
Rationale: To check changes in
patient conditions, recognize early
patient deterioration, and prevent
harm or errors that may occur.
7. Teach the patient that Nitroglycerin
sublingual tablets should not be
chewed, crushed, or swallowed
and that they should place the
tablet under the tongue or between
the cheek and gum, and let it
dissolve.
Rationale: Nitroglycerin works
faster when absorbed through the
lining of the mouth.
8. Educate the patient not to take
sildenafil, tadalafil, or vardenafil
(PD5 inhibitors)
within 48 hours.
Rationale: To prevent acute
hypotensive episodes.
65
9. Instruct the patient that they should

not take alcohol soon after taking
nitroglycerin
Rationale: To avoid intensifying
hypotensive effects.
inform the physician or nurse if
adverse effects such as blurred
vision and dry mouth occur.
Rationale: To prevent further
complications and to inform the
physician in order for them to
adjust the dose appropriately.
G. Surgical Management
Ventricular Assist Device This device will help pump blood from the heart to the rest
of the body. It is a permanent implant to ease the
symptoms of those people who are not candidates for
heart transplant. During the surgery, the pump is
connected to the lower left chamber of the heart. The
pump is connected to the aorta through a tube. The pump
may be positioned inside or outside of the body by the
surgeon. The surgeon will create a small cut in the belly
part if the pump is to be inserted inside the body. A tiny
cable is then inserted through the cut. The pump and
control system are connected by the cable. Other cables
attached the control system and battery packs. Majority of
the people wear a belt and shoulder strap to carry the
battery packs and control system (Beckerman, 2021).
66
Implantable Cardioverter ICD is an automated implantable cardioverter defibrillator

Defibrillator (ICD) which is a device that can pace the heart, perform
cardioversion, and defibrillation. The device will
continuously monitor the heartbeat and produce electric
shocks to help return to a normal rhythm. It is a battery
operated device that is inserted under the skin to monitor
the heart rate. The size of the devices is almost the same
as a pocket watch. ICDs usually last for 5 to 7 years or
longer, depending on usage and the type of device. The
patient will be able to Important precautions after ICD is
inserted including keeping the incision dry, pat it dry after
every shower, always washing hands before touching the
wound (Beckerman, 2021).
Cardiac Resynchronization It helps the heart beat at the proper rhythm. To get the
Therapy (CRT) heartbeat back to its usual rhythm, a pacemaker is used.
The timing of the lower and upper cardiac chambers is
synchronized by the CRT pacemaker. A pacemaker will be
inserted during the surgery, typically placed just below the
clavicle. The device’s three lead wires will continuously
monitor the heartbeat to look for anomalies and send out
brief electrical pulses to fix them. Basically, it helps the
heart in resynchronizing. The procedure usually lasts
around 3-5 hours. The patient will stay in the hospital for a
day or two and the doctor will order tests before you are
discharged (American Heart Association, n.d).
Coronary Artery Bypass This surgery creates a new path for blood to flow around a
blocked or partially blocked artery in the heart. A healthy
blood vessel is removed during surgery from the leg or
chest region. The vessel is connected below the heart
artery blockage to help direct the blood flow. The new
route enhances the flow of blood to the heart muscle. The
surgery commonly lasts for about 3-6 hours. After the
67
surgery, the patient will stay in the hospital for 7 days to

have a close monitoring. Precautions after coronary
bypass include avoid lifting heavy objects, pushing or
pulling through the arms, limit elevation of the arms to 90
degrees and when coughing support the sternum with a
cushion or the arms in a self-hugging position. (Whitworth,
2019).
Heart Transplantation It is a surgical procedure where a donor heart from

someone else is used to replace your own heart. The
person should be critically ill despite medical treatment
and in need of a new heart to survive in order to qualify for
a heart transplant. The criteria for qualifying a heart
transplant includes being diagnosed with advanced heart
failure, besides their heart they should be relatively
healthy, no history of drug abuse, attain the required BMI
and age. The receiver and the donor should have a
matching blood type and similar body size. Heart
transplants are risky and challenging procedures, just like
other organ transplant surgeries. To avoid organ rejection
and other complications after the transplant, the patient
should have medical attention for the rest of their life. The
patient will also need to take medicine that will suppress
the immune system for the rest of their life (Brown, et. al,
2022)
Heart Valve Repair or This surgery is performed to repair or replace the

Replacement Surgery damaged heart valves if the cause of the heart failure
involves defective heart valves. It is an open-heart surgery
through the breastbone into the chest. In valve repair
surgery, it fixes the defective valve while preserving its
tissue. Valve replacement surgery removes the faulty
valve and changes it with a biological heart such as the
pig/cow/human tissue, or it could be a mechanical (metal
68
or carbon) valve. All valve replacements are

biocompatible, so the immune system won’t reject the new
valve. The healing process usually takes 4-8 weeks after
the surgery (Beckerman, 2022).
H. Nursing Management
NURSING DIAGNOSIS GOAL INTERVENTION
Decreased cardiac output Within 8 hours of nursing INDEPENDENT

related to altered contractility intervention, the patient will 1. Assess heart rate,
as evidenced by irregular be able to demonstrate blood pressure,
heartbeat and fatigue adequate cardiac output cardiac rhythm, and
and specifically be able to: hemodynamic
Rationale: Cardiac output is a. Display a heart rate measurements.
the amount of blood being and rhythm within Rationale: Low
pumped by the heart per the normal range cardiac output can
minute. It is calculated by b. Display strong stimulate the
multiplying the stroke volume. peripheral pulses sympathetic
A decrease in the stroke c. Participate in nervous system.
volume due to the loss of activities that This is to
cardiac contractility or muscle reduce cardiac compensate for the
compliance results in reduced workload decreased cardiac
filling or ejection of the output and can
ventricles. This reduced output result in increased
decreases blood flow to other heart rates and
organs making it difficult to initially an
circulate the blood to all parts increased blood
of the body thus, may cause pressure. Patients
with heart failure
69
altered heart rate and fatigue. benefit from

(Vaqar, 2019) continuous cardiac
monitoring via
telemetry.
Moreover, Unstable
patients may need
hemodynamic
monitoring to
maintain adequate
perfusion.
2. Monitor oxygen
saturation and
ABGs.
Rationale:
Baseline oxygen
saturation is useful
in establishing the
diagnosis and
severity of heart
failure in acute
settings.
Additionally, this
provides
information
regarding the
heart’s ability to
perfuse distal
tissues with
oxygenated blood.
3. Assess For
peripheral pulses,
including capillary
refill.
70
Rationale: Weak
pulses are present
in reduced stroke
volume and cardiac
output. Capillary
refill is sometimes
slow or absent.
4. Monitor urine
output, noting
decreasing output
and concentrated
urine. Rationale:
Kidneys respond to
reduced cardiac
output by retaining
water and sodium.
Urine output is
usually decreased
during the day
because of fluid
shifts into tissues
but may be
increased at night
because fluid
returns to
circulation when the
patient is
recumbent.
5. Check for any
alterations in level
of consciousness.
Rationale:
Decreased cerebral
71
perfusion and
hypoxia are
reflected in
irritability,
restlessness, and
difficulty
concentrating.
Aged patients are
particularly
susceptible to
reduced perfusion.
6. Inspect skin for
pallor.
Rationale: Pallor is
indicative of
diminished
peripheral perfusion
secondary to
inadequate cardiac
output,
vasoconstriction,
and anemia.
7. Assist the patient in
assuming a high
Fowler’s position.
Rationale: Allows
for better chest
expansion, thereby
improving
pulmonary capacity.
In this position, the
venous return to
the heart is
72
reduced, pulmonary
congestion is
alleviated, and
pressure on the
diaphragm is
minimized.
Additionally, heart
failure with
pulmonary
congestion can
cause a chronic
nonproductive
cough worsening in
the recumbent
position
8. Assess for reports
of fatigue and
reduced activity
tolerance.
Rationale: Fatigue
and exertional
dyspnea are
common problems
with low cardiac
output states. Close
monitoring of the
patient’s response
serves as a guide
for optimal
progression of
activity.
DEPENDENT
9. Give supplemental
73
oxygen as indicated
by the patient’s
symptoms, oxygen
saturation and
ABGs.
Rationale: Patients
with low oxygen
saturation may
need supplemental
oxygen due to the
heart’s inability to
pump oxygen-rich
blood to the body.
10. Administer
medications as
prescribed such as
Hydralazine.
Rationale:
Vasodilators open
arteries and veins
to allow for
decreased vascular
resistance,
increasing cardiac
output and reducing
ventricular
workload.
Angiotensin
receptor blockers
(ARBs) lower blood
pressure and make
pumping blood
easier for the heart.
74
Morphine and
anti-anxiety
medications help
with relaxing and
calming the patient
which can reduce
cardiac workload.
Excess fluid volume related Within 8 hours of nursing INDEPENDENT

to decreased renal perfusion intervention the patient will 1. Assess vital signs
as evidenced by pitting edema be able to demonstrate and auscultate
of the ankles, weight gain and stabilized fluid volume and lungs to find any
oliguria. specifically be able to crackles or
a. Demonstrate wheezes.
Rationale: Due to decreased balanced intake Rationale: Heart
cardiac output, the blood flow and output failure, especially
to the kidneys also decreases b. Reduced grading of left-sided HF may
which stimulates the edema from 2+ to lead to pulmonary
renin-angiotensin-aldosterone 1+ congestion, as
system. With this, it sets off a c. Display stable evidenced by
chain of events – weight crackles or
vasoconstriction, leading to wheezes on
increased aldosterone release, auscultation of the
causing sodium and water lungs.
retention and, in turn, 2. Assess for
increasing blood volume. distended neck and
Finally, sodium and water peripheral vessels.
retention becomes excessive, Note the presence
resulting in signs of systemic of edema.
venous congestion and fluid Rationale:
overload thus may cause Excessive fluid
symptoms such as edema and retention may be
oliguria. (Miller, 2020) manifested by
75
venous
engorgement and
edema formation.
3. Monitor patient’s
serum electrolytes
and renal function
to the physician as
needed.
Rationale: The use
of diuretics may
result to excessive
fluid shifts and
electrolyte loss
4. Monitor and
calculate 24-hour
intake and output
(I&O) balance.
Rationale: Diuretic
therapy may result
in a sudden
increase in fluid
loss (circulating
hypovolemia), even
though edema or
ascites remains.
5. Instruct the patient
regarding fluid
restrictions as
appropriate
Rationale: To not
aggravate and to
reduce extracellular
volume
76
6. Weigh the patient

on a daily basis.
Rationale:
Diuretics are
needed to manage
heart failure, but
may put the patient
at risk for sudden
fluid loss, which is
reflected through
his/her weight.
7. Elevate the
patient’s legs when
sitting
Rationale: This
increases venous
return to the heart
8. Instruct and
encourage the
patient to follow the
recommended
dietary restrictions
to maintain a
balanced fluid
volume.
Rationale: A diet
low in sodium is
recommended to
avoid aggravating
the patient’s
condition.
DEPENDENT
9. Administer
77
medications as
prescribed by the
physician
Rationale:
Medications such
as diuretics
effectively decrease
the patient’s fluid
volume by
urination.
10. Consider the need
for an external or
indwelling urinary
catheter.
Rationale:
Treatment focuses
on diuresis of
excess fluid.
Urinary catheters
provide a more
accurate
measurement of
the response to
diuretics.
Acute pain related to Within 3 hours of nursing INDEPENDENT

decreased myocardial blood intervention, the patient will 1. Assess patient pain
flow as evidenced by pain demonstrate relief of pain for intensity using a
score of 9 out of 10, as evidenced by pain rating scale,
verbalization of pressure-like a. a pain score of 0 location, and
chest pain, guarding sign on out of 10 precipitating
the chest, blood pressure level b. Vital signs within factors.
of 180/90, and restlessness normal range Rationale: To
78
c. Participation on identify intensity,

Rationale: In CHF, fluid builds activities and precipitating
up within the heart and causes behavior that will factors, and
it to pump inefficiently resulting prevent the location to assist in
in inadequate blood flow to recurrence of pain accurate diagnosis.
meet the heart’s oxygen 2. Monitor vital signs,
demands, the area may especially pulse
become ischemic and injured and blood pressure,
which then results in the every 5 minutes
stimulation of the neural pain until pain subsides.
receptors. (Malik, 2021) Rationale:
Tachycardia and
elevated blood
pressure usually
occur with angina
and reflect
compensatory
mechanisms
secondary to
sympathetic
nervous system
stimulation.
3. Assess the
response to
medications every
5 minutes
Rationale:
Assessing
response
determines the
effectiveness of
medication and
whether further
79
interventions are
required.
4. Elevate the head of
the bed
Rationale:
Elevation improves
chest expansion
and oxygenation.
5. Place the patient in
complete bed rest
during angina
attacks. Teach the
patient on stress
management, deep
breathing
exercises, and
relaxation
techniques.
Rationale: Stress
causes a persistent
increase in cortisol
levels, which has
been linked to
people with cardiac
issues. The effects
of stress are likely
to increase
myocardial
workload.
6. Provide comfort
measures.
Rationale: To
provide
80
non-pharmacologic
al pain
management.
7. Establish a quiet
environment.
Rationale: A quiet
environment
reduces the energy
demands on the
patient.
8. Teach patient
relaxation
techniques and
how to use them to
reduce stress.
Rationale: Anginal
pain is often
precipitated by
emotional stress
that can be relieved
by
non-pharmacologic
al measures such
as relaxation.
DEPENDENT
9. Administer
supplemental
oxygen, as
prescribed.
Discontinue if SpO2
level is above the
target range, or as
ordered by the
81
physician.
Rationale: To
increase the
oxygen level.
10. Administer
prescribed
medications that
alleviate the
symptoms of acute
chest pain.
Rationale: Aspirin
may be given to
reduce the ability of
the blood to clot, so
that the blood flows
easier through the
narrowed arteries.
Nitrates may be
given to relax the
blood vessels.
Other medications
that help treat
angina include
anti-cholesterol
drugs, and beta
blockers, calcium
channel blockers.
I. Literature
82
Title: Exposure to ambient air pollution and the incidence of congestive heart failure
and acute myocardial infarction: A population-based study of 5.1 million Canadian
adults living in Ontario
Longitudinal cohort study has shown that long-term exposure to air pollution causes
harm to the cardiovascular system. While experimental studies suggest that being exposed
to air pollution leads to oxidative stress, systemic inflammation and vasoconstriction which
leads to increased blood pressure and results in atherosclerosis, increasing the risk of
cardiovascular disease. However, effects of the air pollution towards the incidence of major
cardiovascular disease with acute myocardial infarction (AMI) and congestive heart failure
(CHF) is still unclear. This study aims to know the correlation of long-term exposure to air
pollution and incidence of CHF and AMI.
The study was conducted in Ontario which is the most populous province in Canada
to evaluate the risk of incidence of CHF and AMI related to long-term exposure to fine
particles and oxidant air pollutants. Participants were at ages 35 to 85 years of age who are
not diagnosed with CHF or AMI. Participants who have a history of AMI or CHF are
excluded from the study. Information such as age, sex, postal code, household income from
the participants are gathered. Exposure assessment was done and investigation for any
potential effect modification such as age group, sex, income level and selected
comorbidities with air pollutants was done.
Results of the study where long-term exposure to fine particles and oxidant air
pollutant ozone has a significant effect on increasing the risk for CHF and AMI incidence.
While exposure to nitrogen dioxide increases the risk of having CHF. With these results it
gives a better understanding towards the different roles of air pollutants on development of
cardiovascular events.
Title: Detection of Congestive Heart Failure Based on LSTM-Based Deep Network via
Short-Term RR Intervals.
Congestive heart failure is defined as an inadequate blood filling function which fails
to meet the needs of body metabolism. It is proven that with heart rate variability (HRV)
based on the RR interval is an effective predictor of CHF. In health care applications
short-term HRV has been used to monitor patient’s health, especially in combination with
83
mobile phones and smart watches. With this the study aims to further evaluate the use of
HRV which could help clinicians detect CHF using short-term assessment of heartbeat.
The common way to diagnose CHF in hospital is through an echocardiography and

ECG. Plenty of studies even require long-term RR interval to determine possibilities of CHF,
this however is not possible for health-care situations outside hospital, as heart rate testing
applications are currently being developed. They conducted a study in which the LSTM
network was used to detect time series signals, including RR interval signals. It is then
compared to other studies, however those studies use different datasets. With blind testing it
evaluates the performance of the method better. The proposed system or the LSTM based
inception, installation of these would be in low-cost ECG devices and serve as a diagnostic
tool for places where cardiologists have limited access. With this tool diagnostic results
would be easier to attain and save the clinicians and cardiologist time, more so in this way
misdiagnoses would decrease.
This study concluded that having an automated classifier for CHF detection resulted
in good performance. Using short term HRV signals in detecting CHF is important for
healthcare applications, specifically for smartphones and smart watches. This will help
clinicians on monitoring CHF patients outside the hospital. With this study it could help or
provide technical support in identification and managing CHF patients based on mobile
phones. With this in future work it would turn out as a useful automatic tool that will increase
the detection rate of patients with CHF.
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IV. Myocardial Infarction
A. Definition
“Myo” means muscle, “cardial” refers to the heart, and “infraction” means death of
tissue as there is a lack of blood supply. Myocardial Infarction or also known as heart
attack, occurs when the blood flow to the heart gradually or suddenly cuts off. Our heart
is the main organ that facilitates sufficient transport of oxygen and nutrients to the body.
This consists of different types of blood vessels having arteries as the most important
vessel. When the arteries get blocked or narrowed these results in a decreased flow of
oxygen towards the heart muscles therefore causing tissue damage. The sudden cut off
of blood flow or narrowing can be due to the buildup of plaque, a substance made of fat,
cholesterol, and cellular waste products which accumulates and then blocks the pathway
of blood (Macon, 2021). Prominent symptoms of Myocardial infarctions are chest pain
that radiates to chest, back, jaw and other areas of the upper body and difficulty of
breathing. This requires immediate treatment that might involve medication or having a
minimal invasive procedure. Without proper treatment, myocardial infarction might lead
to death (Newman, 2020).
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The cardiovascular system also called circulatory system includes the heart, blood
vessels and blood. It is located in the middle and slightly to the left side of the thoracic cavity
on the diaphragm between 3rd and 5th ribs. The heart helps control the blood supply,
produce blood pressure, ensure that blood flows in one direction, transport oxygen and
nutrients in the entire body, and remove waste. It has 3 layers which includes the
epicardium, myocardium, and endocardium. Epicardium is the outermost layer, the
myocardium is the thickest layer, and the endocardium is the innermost layer. Other major
components of the cardiovascular system include valves, chambers, and blood vessels.
HEART VALVES
The heart has four valves that permits the blood flow through the heart chambers
allowing it flow in one direction only, from the atria through the ventricles and out of the
major arteries leaving the heart. The atrioventricular valve is responsible for restricting blood
from returning to the atria as the ventricles contract. The mitral valve will control the blood
flow from the upper left chamber into the lower left chamber. The tricuspid valve allows the
blood flow from the body into the heart to the right ventricles, where it is pumped to the lungs
86
for oxygen. The semilunar valves protect the bases of the two major arteries as they leave
the ventricular chambers.
CHAMBERS OF THE HEART WITH GREAT VESSELS

It consists of four chambers including the right and left atria, and right and left
ventricles. Atria is the receiving chamber, which is responsible for assisting in filling the
ventricles. While the Ventricles are the discharging chambers, which eject the blood from the
heart and into the circulation when they contract. A heart valve between the top and bottom
of these chambers is in charge of opening and shutting to permit correct blood flow and
guarantee that it only flows in one direction. The left ventricle and aorta, which transports
blood throughout the body, are connected by aortic valves. The left atrium and left ventricle
are connected via the mitral valve. The pulmonary valve connects the right and pulmonary
arteries, which carry blood to the lungs. Connecting the right atrium and right ventricle is the
tricuspid valve.
Although the heart chambers have constant blood flow within the heart, the
myocardium is not nourished by this blood. The right and left coronary arteries are
responsible for supplying oxygen and nourishing the myocardium. The left coronary artery
supplies blood to the left side of the heart. There are two branches of left coronary arteries
which are the left anterior descending artery and circumflex artery. The left anterior
descending artery supplies the blood to the front of the left side of the heart, while the
circumflex artery supplies the outer and back side of the heart. The right coronary artery
supplies the right ventricle, right atrium, SA and AV nodes. There are two branches of the
right coronary artery: the right posterior descending and acute marginal artery, which are
responsible for supplying blood to the septum of the heart.
BLOOD VESSELS
Blood is carried through blood arteries throughout the body. Arteries are responsible
for carrying oxygen rich-blood away from the heart; Capillaries are thin blood vessels that
connect veins and arteries; and Veins are responsible for carrying oxygen-poor blood from
the body’s tissues back to the heart. Body cells and tissues are surrounded by capillaries
that transport and absorb nutrition, oxygen, and other chemicals. Additionally, the capillaries
link the vein and artery branching together. The tunica externa, tunica media, and tunica
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intima are the three different layers that make up the walls of the majority of blood arteries.
The lumen, the hollow interior through which blood flows, is encircled by these layers.
BLOOD CIRCULATION
The right side of the heart works as the pulmonary circuit pump. The superior and
inferior vena cava receives deoxygenated blood from the veins and pumps it out through the
pulmonary trunk. The pulmonary trunk is divided into the right and left pulmonary arteries,
which is responsible for carrying blood to the lungs, where oxygen is picked up and carbon
dioxide is unloaded. Oxygen-rich blood drains from the lungs and is returned to the left side
of the heart through the four pulmonary veins. This circuit is called pulmonary circulation.
Then oxygen-rich blood returned to the left atrium flows into the left ventricle and is pumped
out into the aorta. After the oxygen is delivered to the tissues, oxygen-poor blood circulates
from the tissues back to the right atrium through the systemic veins, which empties their
cargo either in the superior or inferior vena cava. This secondary circuit is called the
systemic circulation, which runs from the left ventricle through the body tissues and back to
the right atrium. It supplies oxygen and nutrient-rich blood to all the body organs.
In the case of Myocardial Infarction, when the blood supply to the heart is
significantly impeded or blocked, a heart attack happens. It is an irreversible damage to the
cardiac muscle fibers due to prolonged ischemia. The accumulation of fat, cholesterol, and
other chemicals in the heart's (coronary) arteries is typically what causes the obstruction.
The coronary arteries play a major role in supplying blood. A heart attack can result in death
and lasting heart damage if blood flow is not rapidly restored.
C. Symptomatology
Pain (Chest, Jaw, Neck & Back) The majority of heart attacks are characterized
by chest pain on the left or center sides that last
for more than a few minutes, or that disappears
and reappears. The discomfort may feel like
painful pressure, squeezing, fullness, or other
unpleasant sensations. (CBC 2022)
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When arteries become overly narrowed by

excessive plaque buildup, pain may result.
Plaque is made of accumulated cholesterol.
Narrowed arteries prevent blood from reaching
the heart muscle and other body parts, resulting
in pain. It is often poorly localized but is
classically in the area behind the breastbone and
associated with a pressure-like sensation.
Fatigue Unexpected symptoms of exhaustion or fatigue

may be a sign of a heart attack. The heart is put
under more stress because of the increased
work and fatigue, resulting in the heart having to
work harder to pump blood through a blocked
artery. Even when not exercising themselves,
someone who has had a myocardial infarction
may experience fatigue or a heavy feeling in the
chest while doing ordinary tasks like making the
bed or sweeping. Even when one is exhausted, it
may be difficult to fall asleep.
(Krans,2020)
Shortness of Breath Dyspnea, also known as shortness of breath or

breathlessness, is a condition where oxygenated
blood from the lungs is trying to return to the
heart through restricted heart arteries when
blood backs up in the veins. The accumulation of
fluid in the lungs makes it difficult to breathe
normally.
Dyspnea consequently happens while

exercising, shortness, or doing other activities.
As the condition worsens, shortness of breath
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may occur while resting or sleeping.

(UCSF, 2021)
Sweating Even if you aren't moving, excessive sweating

can be a symptom of heart issues. Since the
heart has to work harder to pump blood through
clogged arteries, the body creates more sweat to
keep itself warm while exerting more. This
happens because the sympathetic nervous
system, a type of fight-or-flight reaction, which is
a defense mechanism, is activated (Krans, 2020)
Nausea & Vomiting The digestive process is affected when the

heart's blood flow declines because less blood
reaches the digestive tract. This happens
because clogged arteries make it difficult for the
heart to pump blood throughout the body.
Vomiting and nausea are triggered by blood
being diverted from the digestive system and into
more critical organs like the brain. (Minton, 2019)
D. Etiology
PREDISPOSING FACTORS RATIONALE
Family History Several genetic variants are associated with

increased risk of AMI and family history of AMI in
a first-degree relative doubles AMI risk. If a father
develops heart attack before the age of 55 and
mother before the age of 65 years, this positive
family history becomes very significant for the
next generation and mere presence of parental
and maternal history for premature myocardial
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infarction may increase the risk to 7 folds in

descendants (Chung & Brown, 2019).
Hypertension Both systolic and diastolic hypertension increase

the risk of a myocardial infarction. The higher the
pressure, the greater the risk. The excess strain
and resulting damage from high blood pressure
causes the coronary arteries serving the heart to
slowly become narrowed from a buildup of fat,
cholesterol and other substances that together are
called plaque. When an artery becomes blocked,
the flow of blood through the heart muscle is
interrupted, starving the muscle of oxygen and
nutrients causing heart attack (American Heart
Association, 2016).
Age As you age, your chance of heart attack goes up.

The average age men have their first heart attack
is 65. For women, that age is 72, but menopause,
which women tend to go through around age 50,
lowers the amount of estrogen in your body.
Estrogen helps keep arteries flexible, so your
heart attack risk goes up once estrogen starts to
drop.
Diabetes High blood sugar can damage blood vessels and

the nerves that control your heart. People with
diabetes are also more likely to have other
conditions that raise the risk for heart disease.
High blood pressure increases the force of blood
through your arteries and can damage artery
walls. Having both high blood pressure and
diabetes can greatly increase your risk for heart
disease. Too much LDL (“bad”) cholesterol in your
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bloodstream can form plaque on damaged artery

walls. High triglycerides (a type of fat in your
blood) and low HDL (“good”) cholesterol or high
LDL cholesterol is thought to contribute to
hardening of the arteries.
Gender Men are at higher risk for heart failure than

women, but the overall prevalence rate is similar
in both sexes, since women survive longer after
the onset of heart failure. Women tend to be older
when diagnosed with heart failure and more often
have diastolic dysfunction than men (a failure of
the heart muscle to relax normally)
Obesity Excess weight can lead to fatty material building

up in your arteries (the blood vessels that carry
blood to your organs). If the arteries that carry
blood to your heart get damaged and clogged, it
can lead to a heart attack.
Physical Inactivity People who are not active have a greater risk of
heart attack than do people who exercise
regularly. Exercise burns calories to help maintain
a healthy weight, helps to control cholesterol
levels and diabetes, and may lower blood
pressure. Exercise also strengthens the heart
muscle and makes the arteries more flexible
PRECIPITATING FACTORS RATIONALE
Smoking Tobacco use is a major risk factor for heart

attack and stroke. Nicotine, one of the
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chemicals in cigarettes and e-cigarettes,

causes your heart to beat faster and blood
pressure to rise. Smoking makes clots more
likely to form. It can also promote the buildup of
plaque in arteries.
Alcohol Too much alcohol intake can increase the risk

of heart failure. High blood pressure puts strain
on the heart muscle and can lead to
cardiovascular disease (CVD), which increases
your risk of heart attack and stroke. Alcohol can
contribute to obesity and the long list of health
problems that can go along with it. Alcohol is a
source of excess calories and a cause of weight
gain that can be harmful in the long term.
Stress Chronic life stress, social isolation and anxiety

increase the risk of heart attack and stroke.
Acute psychological stress also is associated
with increased risk for coronary heart disease,
and it has been reported that intense grief in the
days after death of a significant person may
trigger the onset of myocardial infarction. The
pathophysiological mechanism of acute
emotional stress remains unclear, but it is
assumed to be related to hemodynamic stress
in the coronary arteries and rupture of an
atherosclerotic plaque, with consequent
thrombosis.
Strenuous Physical Activity Physical exertion may trigger infarction in

several ways. First, hemodynamic stress may
trigger the disruption of a vulnerable, but not
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necessarily stenotic atherosclerotic plaque.

Second, in the presence of endothelial
dysfunction, vasoconstriction rather than
dilatation may occur with physical as well as
emotional stress. Narrowing of stenotic
segments may lead to increased shear forces
and platelet deposition. Third, in patients with
coronary artery disease, exercise may induce a
prothrombotic state characterized by platelet
activation and a reduced fibrinolytic response
and reduced prostacyclin release (Tofler,
Mittleman, & Muller, n.d.).
Heavy Meal When you eat large amounts of food in one

sitting, it leads to higher levels of the stress
hormone norepinephrine in your body. That can
raise your blood pressure and heart rate, and it
may trigger heart attacks in some people. Very
fatty meals can also cause a sudden jump in a
kind of fat in your blood, and that may
temporarily damage some blood vessels as
well.
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E. Pathophysiology
95
96
97
Narrative
Narrative
Myocardial infarction has become predominant nowadays as most people are living
their lives in sedentary conditions. This lifestyle precipitates people to have illnesses due to
their habits. Furthermore the predisposing factors pose an increased risk of suffering from
myocardial infarction. Excess weight can lead to fatty material building up in the arteries
(the blood vessels that carry blood to your organs). These arteries are clogged up and
damaged. Men are at higher risk for heart failure than women, but the overall prevalence
rate is similar in both sexes, since women survive longer after the onset of heart failure due
to their cleaner lifestyle compared to men.. Women tend to be older when diagnosed with
heart failure and more often have diastolic dysfunction than men (a failure of the heart
muscle to relax normally). Several genetic variants are associated with increased risk of
AMI and family history of AMI in a first-degree relative doubles AMI risk. If a father develops
a heart attack before the age of 55 and mother before the age of 65 years, this positive
family history becomes very significant for the next generations. As you age, your chance of
heart attack goes up. The average age men have their first heart attack is 65. For women,
that age is 72, but menopause, which women tend to go through around age 50, lowers the
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amount of estrogen in your body. Estrogen helps keep arteries flexible, so your heart attack
risk goes up once estrogen starts to drop.
The clinical manifestation of Myocardial Infarction starts with an imbalance in the

oxygen supply and demand. This may be caused by atherosclerosis, arterial vasospasm, or
thrombus formation which leads to a decrease in blood flow to the myocardium. When
blood flow decreases, oxygen delivery also decreases, a decrease in the oxygen delivery to
the heart leads to myocardial ischemia then physiologic symptoms appear. Since the oxygen
demand is greater than the oxygen supply then the delivered oxygen is not sufficient for the
myocardial cells to function causing the cells to be oxygen deprived. Therefore, the cells
may become injured, a prolong in the ischemia longer than 35-45 minutes becomes an
irreversible damage as its tissue (cardiac tissues) dies this is the actual Myocardial
infarction. Cells normally use oxygen for its metabolism but once the oxygen is depleted
then anaerobic metabolism occurs. In anaerobic metabolism, the lactic acid is produced.
Cells rupture due to the buildup of toxic waste products with protein as the by-product
leaking to the bloodstream circulating. With the heart having decreased in contractility, the
cardiac output also decreases and it is characterized by the pain felt in the chest that
radiates to the chest jaw, neck, or back that may last from a few minutes to several hours.
The pain may also feel like indigestion sometimes which leads to nausea and vomiting.
Sclerosis decreases myocardial contractility, when the contractility decreases then the
cardiac output also decreases which may result in the activation of the sympathetic nervous
system which compensates for sweating, increased heart rate, and restlessness. The
oxygen perfusion also decreases leading to fatigue, paleness, and coldness of skin.
Diagnostic Exam
PROCEDURE RATIONALE
Electrocardiogram (ECG or EKG). This first test done to diagnose a heart

attack records electrical signals as they
travel through the heart. Sticky patches
(electrodes) are attached to the chest and
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sometimes the arms and legs. Signals are

recorded as waves displayed on a monitor
or printed on paper. An ECG can show if
you are having or have had a heart attack.
Blood tests Certain heart proteins slowly leak into the

blood after heart damage from a heart
attack. Blood tests can be done to check for
these proteins (cardiac markers).
CBC measurements of platelet, haematocrit

and hemoglobin values along with W.B.C
count help to assuage risks related to
coronary heart defects and chances of
heart attack in a patient.
Echocardiogram Sound waves (ultrasound) create images of

the moving heart. This test can show how
blood moves through the heart and heart
valves. An echocardiogram can help
identify whether an area of your heart has
been damaged.
Chest X-ray. There was good correlation between the

presence and extent of lung crepitations
and the presence of pulmonary oedema on
the chest x-ray film.It is suggested that the
chest x-ray film is a useful additional index
of the severity of heart failure in myocardial
infarction. Also, chest X-ray shows the
condition and size of the heart and lungs.
Cardiac biomarkers/enzymes The American College of

Cardiology/American Heart Association
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(ACC/AHA) guidelines on unstable

angina/NSTEMI (non–ST-segment
elevation myocardial infarction) recommend
that in patients with suspected myocardial
infarction, cardiac biomarkers should be
measured at presentation
Coronary catheterization (angiogram) A long, thin tube (catheter) is inserted into

an artery, usually in the leg, and guided to
the heart. Dye flows through the catheter to
help the arteries show up more clearly on
images made during the test.
Cardiac CT or MRI. These tests create images of the heart and

chest. Cardiac CT scans use X-rays.
Cardiac MRI uses a magnetic field and
radio waves to create images of your heart.
For both tests, you usually lie on a table
that slides inside a long tubelike machine.
Each test can be used to diagnose heart
problems. They can help show the severity
of heart damage.
Troponin test A troponin test measures the levels of

troponin T or troponin I proteins in the
blood. These proteins are released when
the heart muscle has been damaged, such
as occurs with a heart attack. The more
damage there is to the heart, the greater
the amount of troponin T and I there will be
in the blood.
Creatine kinase (CK) levels: Elevated serum levels of CK–MB are

therefore specific for myocardial cellular
injury, but not for acute myocardial
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infarction. Following onset of symptoms of

myocardial infarction CK and CK–MB
increase in serum within 3 to 6 hours; the
peak levels occur between 16 and 30
hours.
Myoglobin levels Myoglobin is released more rapidly from

infarcted myocardium than is troponin; urine
myoglobin levels rise within 1-4 hours from
the onset of chest pain
Drug Study
Generic Name Morphine
Brand Name MS Contin, Astramorph, Depodur, Duramorph, Infumorph,

Kadian, MorphaBond, Mitigo
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Drug Classification
Opioid Analgesics
Mode of Action Binds with opioid receptors within CNS, inhibiting ascending
pain pathways. Therapeutic Effect: Alters pain perception,
emotional response to pain.
Indication This medication is used to treat severe pain. Morphine

belongs to a class of drugs known as opioid analgesics. It
works in the brain to change how your body feels and
responds to pain.
Suggested dose and injectable suspension, extended-release, liposomal

frequency (DepoDur): 10mg/mL
tablet, extended-release (MS Contin):

15mg, 30mg, 60mg, 100mg, 200mg
Contraindications Morphine is also contraindicated in the following conditions:

heart failure secondary to chronic lung disease; cardiac
arrhythmias; increased intracranial or cerebrospinal
pressure; head injuries; brain tumor; acute alcoholism; and
delirium tremens. The use of bisulfites is contraindicated in
asthmatics.
Side Effects Ambulatory pts, pts not in severe pain may experience
nausea, vomiting more frequently than pts in supine position
or who have severe pain.
Frequent: Sedation, decreased B/P (including orthostatic

hypotension), diaphoresis, facial flushing, constipation,
dizziness, drowsiness, nausea, vomiting.
103
Occasional: Allergic reaction (rash, pruritus), dyspnea,

confusion, palpitations, tremors, urinary retention, abdominal
cramps, vision changes, dry mouth, headache, decreased
appetite, pain/burning at injection site.
Rare: Paralytic ileus.
Adverse Effects Overdose results in respiratory depression, skeletal muscle

flaccidity, cold/clammy skin, cyanosis, extreme drowsiness
progressing to seizures, stupor, coma. Tolerance to
analgesic effect, physical dependence may occur with
repeated use. Prolonged duration of action, cumulative
effect may occur in those with hepatic/renal impairment.
Antidote: Naloxone (see Appendix J for dosage).
Drug Interaction DRUG: Alcohol, other CNS depressants (e.g., LORazepam,

gabapentin, zolpidem) may increase CNS effects,
respiratory depression, hypotension. MAOIs (e.g.,
phenelzine, selegiline) may produce serotonin syndrome.
(Reduce dosage to 1/4 of usual morphine dose.)
HERBAL: Gotu kola, kava kava, St. John’s wort, valerian

may increase CNS depression. FOOD: None known.
LAB VALUES: May increase serum amylase, lipase.
Nursing Responsibilities 1. Monitor vital signs 5-10 minutes after IV

administration, 15-30 mins after SQ, IM.
: Morphine can decrease heart rate, blood pressure,
and venous return. Morphine can also stimulate local
histamine-mediated processes.
2. Be alert for decreased respirations and B/P
R: Morphine can also affect the cardiovascular
104
system and reportedly can cause flushing,

bradycardia, hypotension, and syncope. It is also
important to note that patients can experience
pruritus, urticaria, edema, and other skin rashes.
3. Check for adequate voiding
R: Morphine was identified as the cause of urinary
retention
4. Record onset of pain relief
R: To assess whether the medication give relief or
not
5. Report if pain is not adequately relieve
R: To formulate better intervention.
6. Instruct px to avoid consumption of alcohol
R: When morphine is taken with alcohol, the
combination can be dangerous. Combination alcohol
with opoids can lead to side effects such as: Nausea
and vomiting.
7. Encourage px rest and avoid motor skills activity
R: Morphine medicine may make you dizzy, drowsy,
confused, or disoriented.
8. Change position slowly
R: To avoid orthostatic hypotension
Generic Name Aspirin

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Brand Name APC-ASA Coated Aspirin, Aspir-Low, Aspirtrin, Bayer

Aspirin, Walgreens Aspirin Adult
Drug Classification PHARMACOTHERAPEUTIC: Nonsteroidal salicylate.

CLINICAL: Anti-inflammatory, antipyretic, anticoagulant.
Mode of Action Blocks pain impulses in CNS, reduces inflammation by

inhibition of prostaglandin synthesis; antipyretic action
results from vasodilation of peripheral vessels; decreases
platelet aggregation.
Indication Treatment of mild to moderate pain, fever. Reduces

inflammation related to rheumatoid arthritis (RA), juvenile
arthritis, osteoarthritis, rheumatic fever. Used as platelet
aggregation inhibitor in the prevention of transient ischemic
attacks (TIAs), cerebral thromboembolism, MI or
reinfarction. Durlaza: Reduce risk of MI in pts with CAD or
stroke in pts who have had TIA or ischemic stroke. OFF
LABEL: Prevention of preeclampsia; alternative therapy for
preventing thromboembolism associated with atrial
fibrillation when warfarin cannot be used; pericarditis
associated with MI; prosthetic valve thromboprophylaxis.
Adjunctive treatment of Kawasaki’s disease. Complications
associated with autoimmune disorders, colorectal cancer.
Suggested dose and MI, Stroke (Risk Reduction) PO: ADULTS, ELDERLY:
106
frequency Durlaza: 162.5 mg once daily.
Contraindications Hypersensitivity to salicylates, NSAIDs. Aspirin triad

(asthma, rhinitis [with or without nasal polyps], aspirin
intolerance). Asthma, rhinitis, nasal polyps; inherited or
acquired bleeding disorders; use in children (younger than
16 yrs) for viral infections. Do not use for at least 7 days
after tonsillectomy or oral surgery. Cautions:
Platelet/bleeding disorders, severe renal/hepatic
impairment, dehydration, erosive gastritis, peptic ulcer
disease, sensitivity to tartrazine dyes, elderly (chronic use of
doses 325 mg or greater). Avoid use in pregnancy,
especially third trimester.
Side Effects GI distress (including abdominal distention, cramping,

heartburn, mild nausea); allergic reaction (including
bronchospasm, pruritus, urticaria).
Adverse Effects High doses of aspirin may produce GI bleeding and/or

gastric mucosal lesions. Dehydrated, febrile children may
experience aspirin toxicity quickly. Reye’s syndrome,
characterized by persistent vomiting, signs of brain
dysfunction, may occur in children taking aspirin with recent
viral infection (chickenpox, common cold, or flu). Low-grade
aspirin toxicity characterized by tinnitus, generalized pruritus
(may be severe), headache, dizziness, flushing, tachycardia,
hyperventilation, diaphoresis, thirst. Marked toxicity
characterized by hyperthermia, restlessness, seizures,
abnormal breathing patterns, respiratory failure, coma.
Drug Interaction DRUG: Alcohol, NSAIDs may increase risk of GI effects

(e.g., ulceration). Antacids, urinary alkalinizers increase
excretion. Anticoagulants, (e.g. enoxaparin, warfarin),
heparin, thrombolytics, rivaroxaban, ticagrelor increase risk
of bleeding.
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HERBAL: Avoid cat’s claw, dong quai, evening primrose,

feverfew, garlic, ginger, ginkgo, ginseng, green tea, horse
chestnut, red clover (possess antiplatelet activity). FOOD:
None known.
LAB VALUES: May alter serum ALT, AST, alkaline

phosphatase, uric acid; prolongs prothrombin time (PT)
platelet function assay. May decrease serum cholesterol,
potassium, T3 , T4 .
Nursing Responsibilities 1. 1. Check the doctor’s order.

R: To give the right medication to the patient.
2. 2. Monitor and check vital signs.
R: To assess the wellbeing before administering
medications
3. Assess sensitivity to the drug.
R: To prevent any unwanted drug reactions
4. Observe 10 rights of drug administration.
R: To prevent errors when giving medication.
5. 5. Inform for possible adverse and side effects to the
patient.
R: To prevent untoward complications that may affect
the condition.
6. Instruct the patient to stop taking Aspirin and notify if
any symptoms occur like bloody or tarry stools and if
the patient is coughing up blood.
R: It may indicate that stomach or intestinal bleeding,
stop immediately.
7. Encourage patient to avoid activities that may cause
injury. Advise the use of soft toothbrush and electric
razor
R: To avoid gum and skin injuries.
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8. Advise patient to check aspirin before use if it has 71

a strong vinegar-like odor.
R: This odor could possibly mean that aspirin is
breaking down and is starting to decompose.
9. Inform that if behavioral changes, persistent vomiting
is observed it may indicate early signs of Reye’s
syndrome, contact physician.
R: Cautioned use when giving aspirin especially to
children or teenagers avoids damage to
mitochondria.
10. Instruct to not chew, crush, dissolve or divide
enteric-coated tablets.
R: It is best to swallow the tablet to prevent any side
effects.
Generic Name
Clopidogrel
Brand Name Plavix
Drug Classification Antiplatelet agents, Cardiovascular
Mode of Action Clopidogrel is an inhibitor of platelet activation and

aggregation through the irreversible binding of its active
metabolite to the P2Y12 class of ADP receptors on platelets
Indication Indicated to reduce the rate of myocardial infarction and

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stroke in patients. Reduce formation of blood clots for

patients with acute coronary syndrome
Suggested dose and For prevention of heart attack Tablet:

frequency - 75mg prevention of stroke; once a day
- 300mg adults; single dose
- Children - determined by doctor
Contraindications Hypersensitivity to clopidogrel or from the component

Active pathological bleeding such as peptic ulcer or
intracranial hemorrhage
Side Effects ●Collection of blood under the skin

●Deep, dark purple bruise
● Itching
● Pain
● Redness
● Swelling
● Nausea
● Confusion
Adverse Effects ● Blistering

● Chest pain
● Feeling of discomfort
● Indigestion
● Cold sweats
● Blurred vision
● Joint or muscle pain
Drug Interaction ● Risk for bleeding - NSAIDS, Warfarin, Antidepressants,

Aspirin, Rifampin
● Reduces the effectivity of clopidogrel -
Omeprazole/Esomeprazole, Opioids
● Eat fewer food with vitamin K as this will counteract the
effect of clopidogrel
110
● Citrus fruits interferes the metabolization of the medication
Nursing Responsibilities Assess vital signs

R: To ensure baseline data
Prevent getting wounds
R: To have lesser chance of having blood clot
Monitor bleeding
R: Antiplatelet also prevent aggregation that may
cause increase bleeding
Check for bruise
R: Patients may have bruise while taking
clopidogrel
Should not be taken with blood thinners
R: It prevents platelets from sticking together
and forming a dangerous blood clot
Monitor signs and symptoms of bleeding
R: Taking this drug has an increase risk of blood
clot
Monitor side effects
R: To provide immediate interventions
Discontinue use 5-7 days before surgery
R: Clopidogrel cessation less than 7 days before
an abdominal operation significantly increases
the risk of postoperative bleeding requiring
transfusion.
Generic Name Alteplase

111
Brand Name Activase, Tissue plasminogen activator, t-PA
Drug Classification Thrombolytics
Mode of Action Convert plasminogen to plasmin, which is then able to

degrade fibrin present in clots. Therapeutic effects: Lysis of
thrombus causing ischemic stroke, reducing risk of
neurologic sequelae.
Pharmacokinetics:
A – complete after IV administration
D – unknown
M – liver
E - Urine
Indication Acute myocardial infarction

Acute massive pulmonary emboli
Acute ischemic stroke
Occluded central venous access devices
Suggested dose and Acute MI IV Infusion:

frequency ADULTS WEIGHING MORE THAN 67 KG: Total dose: 100
mg over 90 min, starting with 15-mg bolus over 1–2 min,
then 50 mg over 30 min, then 35 mg over 60 min.
112
ADULTS WEIGHING 67 KG OR LESS: Total dose: Start

with 15-mg bolus over 1–2 min, then 0.75 mg/kg over 30
min (maximum: 50 mg), then 0.5 mg/kg over 60 min
(maximum: 35 mg).
Maximum total dose: 100 mg.
Contraindications Internal bleeding

History of CVA
Recent intracranial or intraspinal injury or trauma
Intracranial neoplasm, AV malformation or aneurysm
Severe uncontrolled hypertension
Hypersensitivity
Side Effects Decreased B/P, Allergic reaction
Adverse Effects Severe internal hemorrhage, intracranial hemorrhage, lysis

may produce atrial or ventricular arrhythmias or stroke
Drug Interaction Drugs – Drugs

NSAIDS, warfarin, heparin, Low-molecular-weight heparins
= concurrent use may increase the risk of bleeding 73
Antifibrinolytic agents= effects may be decreased
Herbal: Anise, chamomile, clove, dong quai, feverfew,

ginger, ginkgo, licorice = increases anticoagulant effect and
bleeding risk
Nursing Responsibilities 1. Monitor vital signs.

R: To check for baseline data. BP should be monitored
strictly, hypertension may occur due to the drug,
hemorrhage, or shock.
2. Assess for signs of bleeding.
R: Check every 15 minutes during the first hour of therapy,
113
every 30 minutes during the next 8 hours and at least every

4 hours.
3. Check for signs of hypersensitivity reaction.
R: Rash, dyspnea, fever, changes in facial color, swelling
around the eyes, and wheezing may occur. Keep
epinephrine, antihistamine and resuscitation equipment
close for anaphylactic reaction.
4. Assess for neurological status.
R: Neurologic changes may be a sign of intracranial
bleeding.
5. Have blood available and obtain blood type and
crossmatch, as ordered.
R: Blood should be always available in case of 74
hemorrhage.
6. If local bleeding occurs, apply pressure. If severe internal

bleeding, discontinue infusion.
R: This can be signs of toxicity or overdose. If occurs, infuse
whole blood, packed RBCs, fresh frozen plasma, or
cryoprecipitate, as ordered. Can administer aminocaproic
acid (Amicar) as an antidote.
7. Advise the need to rest and avoid unnecessary
procedures such as shaving and toothbrushing.
R: To avoid injury and possible bleeding.
8. Explain the purpose of medication and the need for close
monitoring.
R: To allow coordination of the patient and the family and to
attend to the patient if an emergency happens.
114
Generic Name Captopril
Brand Name Capoten
Drug Classification Angiotensin-converting enzyme
Mode of Action Selectively suppresses renin-angiotensin-aldosterone

system;inhibits ACE;prevents conversion of angiotensin I to
angiotensin II
Indication Captopril is used to treat high blood pressure

(hypertension), congestive heart failure, kidney problems
caused by diabetes, and to improve survival after a heart
attack.
Suggested dose and Acute MI or post-MI Adult: PO 6.25-12.5 mg tid,increase

frequency 25mg tid gradually
Contraindications History of angioedema related to ACE treatment, hereditary

or idiopathic angioneurotic oedema. Concomitant use with
aliskiren esp in patients with diabetes mellitus or renal
impairment (GFR <60 mL/min/1.73m2) and neprilysin
inhibitor (e.g. sacubitril). Pregnancy.
Side Effects Renal: About one of 100 patients developed proteinuria

Hematologic: Neutropenia/agranulocytosis has occurred
115
(see WARNINGS). Cases of anemia, thrombocytopenia, and

pancytopenia have been reported.
Dermatologic: Rash, often with pruritus, and sometimes with
fever, arthralgia, and eosinophilia, occurred in about 4 to 7
(depending on renal status and dose) of 100 patients,
usually during the first four weeks of therapy. It is usually
maculopapular, and rarely urticarial.
Cardiovascular: Hypotension may occur; see WARNINGS
and PRECAUTIONS: DRUG INTERACTIONS for discussion
of hypotension with captopril therapy.
Adverse Effects Body as a whole: Anaphylactoid reactions (see WARNINGS:

Anaphylactoid and possible related reactions and
PRECAUTIONS: Hemodialysis).
General: Asthenia, gynecomastia.
Cardiovascular: Cardiac arrest, cerebrovascular
accident/insufficiency, rhythm disturbances, orthostatic
hypotension, syncope.
Dermatologic: Bullous pemphigus, erythema multiforme

(including Stevens-Johnson syndrome), exfoliative
dermatitis.
Gastrointestinal: Pancreatitis, glossitis, dyspepsia.
Hematologic: Anemia, including aplastic and hemolytic.
Hepatobiliary: Jaundice, hepatitis, including rare cases of
necrosis, cholestasis.
Metabolic: Symptomatic hyponatremia.
Musculoskeletal: Myalgia, myasthenia.
Nervous/Psychiatric: Ataxia, confusion, depression,
nervousness, somnolence.
Respiratory: Bronchospasm, eosinophilic pneumonitis,
rhinitis.
Special Senses: Blurred vision.
116
Urogenital: Impotence.
Drug Interaction Aliskiren, certain drugs that weaken the immune

system/increase the risk of infection (such as everolimus,
sirolimus), lithium, drugs that may increase the level of
potassium in the blood (such as ARBs including
losartan/valsartan, birth control pills containing
drospirenone), sacubitril
Nursing Responsibilities 1. Carefully monitor the patient's blood pressure,especially

at the beginning of treatment and medication increase. 62
R:Although rare, excessive hypotension can occur for
captopril, occurs in hypertensive patients used in patients
with heart failure, undergoing renal dialysis,If hypotension
occurs, keep the patient supine.
2. Monitor the patient's blood pressure;administer
electrolytes to the patient regularly other drugs
renin-angiotensin system R:Hypotension and hyperkalemia
can occur.
3. Ask the patient to slowly stand up from a sitting or lying
position.
R:Minimize orthostatic hypotension.
4. Warn the patient not to stop taking the drug suddenly.
R:Stopping this medicine abruptly can cause it serious side
effects
5. Assess for skin rashes,pruritus
R:The rashes are signs of iron deficiency anemia and
aplastic anemia, respectively. Both types of anemia can be
dangerous, but they are easily treated.
6. Advise patients not to use salt substitutes contains
potassium, consult a prescribing physician before increasing
potassium intake
R:To avoid increased risk of hyperkalemia
7. Instruct the patient to take captopril 1 hour before meal.
117
R:Captopril is best administered empty stomach, 30 minutes

before meals, increased effect. Food in the digestive tract
may decrease reabsorption.
8. Assist with ambulation if dizziness occurs.
R:Ambulation increases circulation, which can aid in the
prevention of stroke-causing blood clots.
9. Notify your prescribing physician if pregnancy occurs.
R:Pregnant women should stop taking drugs
10. Inform the patient of drowsiness especially in the first
few days. R:To minimize the effect of lightheadedness and
to report occurrence to prescriber immediately.
Generic Name Nitroglycerin
Brand Name Minitran, Nitro-Bid, Nitro-Dur, Nitrolingual,

Nitrostat, Nitro-Time, Trinipatch, Pliva
Drug Classification Nitrate, Antianginal, Antihypertensive, Coronary vasodilator
Mode of Action Dilates coronary arteries, improves collateral blood flow to

ischemic areas within myocardium. IV form produces
118
peripheral vasodilation. Decreases myocardial oxygen

demand. Reduces left ventricular preload, afterload.
Indication Treatment/prevention of angina pectoris. Extended-release,

topical forms used for prophylaxis, long-term angina
management. IV form used in treatment of HF, acute MI,
perioperative hypertension, induction of intraoperative
hypotension. Off Label: Short-term management of
pulmonary hypertension, esophageal spastic disorders,
uterine relaxation, treatment of sympathomimetic
vasopressor extravasation.
Suggested dose and Angina, CAD Sublingual: Adults, Elderly:

frequency One tablet (0.3–0.4 mg) under tongue. If
chest pain fails to improve or worsens in 3–5
min, call 911. After the call, may take
additional tablet. A third tablet may be taken
5 min after second dose (maximum of 3
tablets).
Contraindications Contraindicated in patients that have reported allergic

symptoms to the medication. Known history of increased
intracranial pressure, severe anemia, right-sided
myocardial infarction, or hypersensitivity to nitroglycerin are
contraindications to nitroglycerin therapy.
Side Effects Frequent: Headache (possibly severe; occurs mostly in early

therapy, diminishes rapidly in intensity, usually disappears
during continued treatment), transient flushing of face/neck,
dizziness (esp. if pt is standing immobile or is in a warm
environment), weakness, orthostatic hypotension.
Sublingual: Burning, tingling sensation at the
oral point of dissolution.
Adverse Effects Discontinue the drug if blurred vision, or dry mouth occurs.
119
Severe orthostatic hypotension may occur, manifested by

syncope, pulselessness, cold/clammy skin, and diaphoresis.
Tolerance may occur with repeated, prolonged therapy;
minor tolerance may occur with intermittent use of
sublingual tablets. High doses tend to produce severe
headaches.
Drug Interaction Antihypertensives (e.g., amlodipine, lisinopril, valsartan),

and vasodilators may increase the risk of orthostatic
hypotension. Concurrent use of sildenafil, tadalafil, and
vardenafil (PDE5 inhibitors) produces significant
hypotension.
HERBAL: Ephedra, ginger, ginseng, and licorice may
increase hypertension. Black cohosh, goldenseal,
hawthorne may cause
hypotension.
Nursing Responsibilities 1. Compare Medication Administration

Record to patient wristband and use
two patient identifiers to confirm
patient.
safety by ensuring you have selected
the correct patient.
2. Obtain the patient’s past health history
and current health status.
3. Obtain the patient’s medication history
and current medications.
Rationale: To check if there are drug
interactions with other medications
and to know if extra precautions are
needed to be taken.
120

anxiety and let the patient know what
the drug is for.
Nitroglycerin.
Rationale: Blood pressure can drop
precipitously after a single dose.
6. Monitor the patient’s vital signs when
the drug is being administered.
Rationale: To check changes in
patient conditions, recognize early
patient deterioration, and prevent
harmor errors that may occur.
7. Teach the patient that Nitroglycerin
sublingual tablets should not be
chewed, crushed, or swallowed and
that they should place the tablet under
the tongue or between the cheek and
gum, and let it dissolve.
Rationale: Nitroglycerin works faster
when absorbed through the lining of
the mouth.
8. Educate the patient not to take
sildenafil, tadalafil, vardenafil (PD5
inhibitors)
within 48 hours.
Rationale: To prevent acute
hypotensive episode.
not take alcohol soon after taking
121
nitroglycerin
Rationale: To avoid intensifying
hypotensive effects.
10.Instruct the patient that they should
inform physician or nurse if adverse
effects such as blurred vision and dry
mouth occurs.
Rationale: To prevent further
complications and to inform physician
in order for them to adjust the dose
appropriately.
Treatment
PROCEDURE RATIONALE
Percutaneous coronary interventions Percutaneous coronary intervention (PCI)

(PCI) refers to a family of minimally invasive
procedures used to open clogged coronary
arteries (those that deliver blood to the
heart). By restoring blood flow, the
treatment can improve symptoms of
blocked arteries, such as chest pain or
shortness of breath.
Coronary angioplasty Angioplasty can improve symptoms of

blocked arteries, such as chest pain and
shortness of breath. Angioplasty is also
often used during a heart attack to quickly
open a blocked artery and reduce the
amount of damage to the heart. It is often
combined with the placement of a small
122
wire mesh tube called a stent. The stent

helps prop the artery open, decreasing its
chance of narrowing again. Most stents are
coated with medication to help keep the
artery open (drug-eluting stents). Rarely,
bare-metal stents are used.
Physical therapy For most stroke patients, rehabilitation

mainly involves physical therapy. The aim of
physical therapy is to have the stroke
patient relearn simple motor activities such
as walking, sitting, standing, lying down,
and the process of switching from one type
of movement to another.
Procedure Rationale
Percutaneous Transluminal Coronary A minimally invasive treatment termed

Angioplasty (PTCA) percutaneous transluminal coronary
angioplasty (PTCA), also known as
percutaneous coronary intervention (PCI),
is used to unblock stenosed or blocked
coronary arteries, allowing free flow of
blood to the myocardium. The lipid-rich
plaque in the arteries causes the
obstructions, which reduce blood flow to
the heart. To prevent myocardial injury,
immediate PTCA is frequently needed
(Malik & Tivakaran, 2022).
Coronary Artery Bypass Grafting (CABG) A treatment used to treat coronary artery
123
disease is coronary artery bypass graft

surgery (CABG). The blood channels that
carry oxygen and nutrients to the heart
muscle are known as the coronary
arteries, and coronary artery disease
(CAD) is the narrowing of these blood
vessels. Fatty substance accumulating in
the artery walls is what leads to CAD.
This accumulation makes the inside of the
arteries smaller, which reduces the
amount of oxygen-rich blood that can
reach the heart muscle. Bypassing the
blocked section of the coronary artery
with a piece of a healthy blood vessel
from another part of your body is one
method of treating the blocked or
restricted arteries. Pieces of a leg vein or
a chest artery may be utilized as blood
arteries, or grafts, during the bypass
treatment. Another option is to use an
artery from the wrist. The graft is attached
with one end above the blockage and the
other below the blockage by a doctor. To
get to the heart muscle, blood travels
through the new graft and around the
obstruction. In order to cure a blockage or
narrowing of one or more coronary
arteries and restore the blood supply to
your heart muscle, a doctor may perform
CABG.
124
Acute pain related to Within 2 hours of nursing

● Administer
myocardial tissue damage care the patient will be
medications as
from inadequate blood supply able to relief/control of
prescribed such
as evidenced by guarding chest pain as evidenced
as Analgesic
behavior and chest pain with a by:
(Morphine)
pain scale of 4/5 associated
a. Decrease pain to a R- Morphine is currently
with Myocardial Infarction.
level of 1/5 (Hurts used and recommended
little bit) or 2/5 for the treatment of
(Hurts little more) chest pain during

Rationale: myocardial infarction. It
from 4/5 (Hurts
whole lot). works by lessening the
When the heart's muscle cells
b. Display reduced pain effects associated
are not given enough blood, a
tension, relaxed with myocardial tissue
heart attack happens. The
manner, ease of ischemia and offers
decrease in blood flow to the
movement. anxiolytic effects that
heart is typically brought on by
c. Demonstrate use help inhibit the anxiety
a coronary artery blockage
of relaxation skills resulting from the
brought on by plaque
and diversional attack.
accumulation. Thus, chest
pain directly results from the activities.
d. Verbalization of ● Instruct the
heart muscle cells not
improvement in patient to do
receiving enough blood, thus
mood and coping. relaxation
manifesting a guarding
techniques such
behavior that is sought to
as deep and
prevent or alleviate pain
slow breathing.
(Nursing Diagnosis & Care
R – It helps in
Plan, 2022)
decreasing perception
and response to pain.
125
● Keep at rest in
semi-Fowler’s
position as
indicated.
R- To lessen the pain.
Gravity localizes
inflammatory exudate
into the lower abdomen
or pelvis, relieving
abdominal tension,
which is accentuated by
supine position.
● Reassess pain
routinely using
WONG- BAKER
FACES, noting
location,
characteristics,
severity (0–5
scale).
Investigate and
report changes
in pain as
appropriate.
R- Wong-Baker Face
Pain Rating Scale is the
pain scale most
preferred by physicians.
Changes in
characteristics of pain
may indicate developing
abscess or peritonitis,
126
requiring prompt
medical evaluation and
intervention.
● Determine
factors that
alleviate pain.
R- Ask clients to
describe anything they
have done to alleviate
the pain. These may
include, for example,
meditation, deep
breathing exercises,
praying, etc. Information
on these alleviating
activities can be
integrated into planning
for optimal pain
management.
● Monitor closely
the vital signs of
the patient.
R – Vital signs are
usually altered when the
pain is severe.
● Provide
diversional
activities such as
watching videos
or listening to
127
music.
R- Refocuses attention,
promotes relaxation,
and may enhance
coping abilities.
● Provide calm
environment.
R- It will help the patient
feel comfortable, relieve
from stress and helps
improve mood and
coping.
● Determine the
patient’s
anticipation for
pain relief.
R - Some patients may
be satisfied when pain
is no longer intense;
others will demand
complete elimination of
pain. This influences the
perceptions of the
effectiveness of the
treatment modality and
their eagerness to
engage in further
treatments.
● Encourage the
patient to
128
verbalize the
feelings about
pain.
R - Allowing to express
his feelings may lead to
decrease in anxiety and
provide emotional
support.
Activity intolerance related Within 8 hours of nursing

● Assess the
to imbalance between oxygen care the patient will be
patient’s
supply and demand as able to identify methods
baseline vital
evidenced by generalized and techniques to reduce
signs, and
weakness intolerance as evidenced
monitor vital
by:
signs such as -
a) Demonstrate respiratory rate

Rationale: and its depth,
decreased
physiological signs oxygen
An imbalance between
of intolerance such saturation, and
oxygen supply and demand
as Vital signs and use of accessory
can cause activity intolerance.
O2 saturation muscles for
Thus, tissue hypoxia occurs,
remained on respiration
and when that happens, it can
normal range (BP: before, during,
be related to generalized
120/80 mmhg, and after the
weakness and difficulty resting
HR/PR: 60 - 100 activity.
and sleeping. The body will
bpm, RR: 16 - 20 R - Closely monitoring
have insufficient physiological
cpm) patients for changes in
or psychological energy to
b) Determine vital signs provides
complete the required or
alternative ways to insight on the general
desired daily activities
maintain desired condition, and prevents
(RNpedia, 2020)
activity level such the development of
as sticking to complications.
129
planned activity
and prescribed ● Utilize
activity (sitting appropriate
when doing assistive devices
something). if needed.
c) Demonstrate R - Patients may have
techniques to decreased activity due
enhance activity to needing assistive
tolerance such as: devices (i.e. walker,
Having them place cane, etc.) that are not
their most used readily available to
items near them, them. Ensure these
Encourage them to devices are available
sit when doing and used when needed.
tasks, Work at slow
or gradual pace,
ROM exercises, ● Encourage rest
and undisturbed initially.
rest. Thereafter, limit
activity on basis
of pain and/or
adverse cardiac
response.
R - Reduces myocardial
workload and oxygen
consumption, reducing
risk of complications.
● Refrain from
performing
nonessential
activities or
procedures.
130
R - Patient with limited

activity tolerance need
to prioritize important
tasks first.
● Assist with ADLs

while avoiding
patient
dependency.
R - Assisting the patient
with ADLs allows
conservation of energy.
Carefully balance
provision of assistance;
facilitating progressive
endurance will
ultimately enhance the
patient’s activity
tolerance and
self-esteem.
● Have the patient

perform the
activity more
slowly, in a
longer time with
more rest or
pauses, or with
assistance if
necessary.
R - Helps in increasing
the tolerance for the
activity.
131
● Provide
emotional
support to
patient.
R - Patients can
become discouraged
with decreased activity
level that can further
hinder their ability and
desire to be active.
● Encourage
verbalization of
feelings
regarding
limitations.
Provide a
positive
atmosphere.
R - Verbalization of
feelings can help the
patient to cope and
minimizes frustration.
Acknowledge the
patient’s feelings about
activity intolerance as
this can be both
physically and
emotionally difficult.
Fear related to threat to Within 8 hours of nursing

● Open up about
well-being as evidenced by care the patient will be
132
restlessness, facial tension reduced fear as evidenced your awareness

and expressions of concern by: of the patient’s
about current and future fear.
a. Recognize feelings
events associated with R - This approach
Myocardial Infarction. b. Display reduce validates the feelings
restlessness and facial the patient is holding
tension and demonstrates
Rationale: recognition of those

c. Demonstrate use of feelings.
One of the fears it causes is a relaxation skills
fear of cardiovascular ● Instruct the
d. Verbalize reduction of
problems (poor heart health). patient to do
fear
Fear is a distressing emotion relaxation
caused by impending danger techniques such
or pain, whether the threat is as deep and
real or imagined. Other fears slow breathing.
are derived from a person's R – It helps in
life experiences, which decreasing perception
manifest as restlessness, and response to fear.
facial tension, and
expressions of concern about ● Discuss the
current and future events situation with the
(Nurseslabs, 2022) patient and help
differentiate
between real
and imagined
threats to
well-being.
R - This approach helps
the patient deal with
fear.
● Tell patient that

133
fear is a normal
and appropriate
response to
circumstances in
which pain,
danger, or loss
of control is
anticipated or
felt.
R - This reassurance
places fear within the
field of normal human
experiences.
● Maintain a
relaxed and
accepting
demeanor while
communicating
with the patient.
R - The patient’s feeling
of stability increases in
a peaceful and
non-threatening
environment.
● Provide accurate
information if
irrational fears
based on
incorrect
information are
present.
134
R - Replacing
inaccurate beliefs into
accurate information
reduces anxiety.
● If patient’s fear is
a reasonable
response,
empathize with
him or her. Avoid
false
reassurances
and be truthful.
R - Reassure patients
that asking for help is
both a sign of strength
and a step toward
resolution of the
problem.
● Use simple
language and
easy to
understand
statements
regarding
diagnostic
procedures.
R - The patient may find
it hard to understand
any given explanations
during excessive fear.
135
Simple, clear, and brief

instructions are
necessary.
● Allow the patient

to have rest
periods.
R - Relaxation improves
ability to cope. The
nurse needs to pace
activities, especially to
older adults to conserve
the patient’s energy.
● Initiate
alternative
treatments.
Provide verbal
and nonverbal
(touch and hug
with permission)
reassurances of
safety if safety is
within control.
R - Meditation, prayer,
music, Therapeutic
Touch, and healing
touch techniques help
lighten fear.
136
I. Literature
Title: New diagnostic and therapeutic strategies for myocardial infarction via
nanomaterials
Myocardial infarction occurs when coronary artery blood flow decreases for a variety
of reasons, depriving cardiomyocytes of oxygen and resulting in ischemic necrosis in the
supply area. There have been a number of attempts to improve its prognosis, among which
nanomaterial research offers an opportunity to address this problem at the molecular level
and has the potential to improve disease prevention, diagnosis, and treatment significantly.
Despite receiving anticoagulation, antiplatelet, thrombolysis, reperfusion, and other
treatments, some patients still continue to progress into heart failure. Hence, an effective
treatment is urgently needed to inhibit cardiomyocyte apoptosis and promote local
angiogenesis to stop the expansion of irreversible myocardial injury. With those demands,
nanomaterials provided a broad prospect for diagnosing and treating MI. According to
studies, nanomedicine refers to a highly selective diagnostic or therapeutic strategy against
diseases at the molecular scale by utilizing nano-objects with any external dimension at the
nanoscale (from 1 to 100 nm) or nanostructured materials with internal or surface structure
in the nanoscale. The properties of nanomaterials differ from those of conventional materials
since they can control or manipulate particles at the atomic level.
In this study, applications of nanomaterials in MI followed as diagnostic and

therapeutic strategies are reviewed. Among therapeutic strategies, there are injectable
hydrogels and organic nanofibers that can aid in angiogenesis or the formation of new blood
vessels from pre-existing vessels, formed in the earlier stage of vasculogenesis. Moreover,
many of the nanomaterials have an element associated with catalytic activity characterized
as nanozymes. This ultrahigh area to volume ratio, intrinsic stability, biocompatibility, and low
cytotoxicity enable nanomaterials to be used as drug delivery systems. As known, delivery
of drugs to the target site is particularly difficult on account of high shear stresses in the
cardiovascular system, limiting the clinical utility of drugs. With that, nanomaterials such as
liposomes are used. Encapsulation of drugs into liposomes can protect and control their
release and reduce systemic toxicity. With this it can significantly reduce the amount and
frequency of medication to decrease side effects and improve efficacy. On the other hand,
among its diagnostic strategies, due to physicochemical properties of nanomaterials, this
137
helps lower the detective limit of cardiac biomarkers, thus enabling a timely recognition of
potential patients.
Title: Myocardial Infarction During the COVID-19 Pandemic
The outbreak of coronavirus disease 2019 (COVID-19) has rapidly evolved into a
worldwide pandemic. In addition to respiratory complications, COVID-19 is associated with
significant direct and indirect cardiovascular consequences, with the latter being more
relevant, particularly in the context of time-dependent cardiovascular emergencies. In
particular, the risk of MI roughly doubles in the first seven days following a COVID-19
diagnosis. A growing amount of data suggests a dramatic decline in hospital admissions for
myocardial infarction worldwide during the COVID-19 pandemic. This is primarily due to the
fact that emergency medical systems were not activated because hospitals were perceived
as dangerous places regarding the infection risk.
In contrast, MI patients had significantly higher in-hospital mortality rates than

patients admitted prior to COVID-19. In this study, several mechanisms associated with
COVID-19 are presented. In type 1 MI, it can be triggered in patients with COVID-19 by a
pro-inflammatory state, which may promote destabilization of a coronary atherosclerotic
plaque, a phenomenon already observed during influenza outbreaks. Another potential
mechanism is the mismatch between reduced oxygen supply and increased myocardial
oxygen demand due to sympathetic system activation, tachycardia, hypotension, and
hypoxemia in the setting of acute respiratory insufficiency, which may be responsible for type
2 MI. Despite all the great efforts made by the international health authorities and national
governments to fight the infection, the patients with COVID-19 surge in demand for Intensive
Care Unit admission has been overwhelming. As a consequence, also Intensive Cardiac
Care Units have been dedicated to the treatment of patients with pneumonia and severe
acute respiratory syndrome. Thus, the tremendous pressure exerted on the healthcare
system by the viral pandemic compromised proven therapies for acute cardiovascular
emergencies and this accounts for negative effects for the outcomes of the patients.
V. Hypertension
138
A. Definition
The condition of hypertension, commonly referred to as high or rising blood

pressure, is characterized by a consistently elevated pressure in the blood arteries.
The vessels transport blood from the heart to every region of the body. The heart
pumps blood into the vessels with each beat. As blood is pumped by the heart, it
pushes against the walls of blood vessels (arteries), creating blood pressure. The
heart has to work harder to pump blood when the pressure is higher (World Health
Organization [WHO], 2019). Blood pressure is measured in millimeters of mercury
(mm Hg).
According to the The American Heart Association and the American College
of Cardiology classify blood pressure into four broad categories, the first being
Normal blood pressure which is 120/80 mm Hg or lower. Elevated blood pressure
ranges from 120 to 129 mm Hg and the bottom number is below, not above, 80 mm
Hg. For Stage 1 hypertension, the top number ranges from 130 to 139 mm Hg and
the bottom number is between 80 and 89 mm Hg. Stage 2 hypertension has a top
number that is 140 mm Hg or higher, and a bottom number that is 90 mm Hg or
higher. A hypertensive emergency or crisis is defined to have a blood pressure
reading of greater than 180/120 mm Hg and needing to immediately seek emergency
medical help (Mayo Clinic, 2022).
Furthermore, One in four adults, or one billion people, suffer from

hypertension, which is the leading cause of death worldwide. Hypertension is an
asymptomatic silent killer and frequently goes unnoticed until it is detected during
monitoring or manifests in a hypertension-related condition such as heart failure or
stroke. It is extremely difficult to treat, and undiagnosed and untreated hypertension
dramatically raises the risk of renal, heart, and brain damage. About half of all heart
disease and stroke-related deaths worldwide are attributed to it.

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The circulatory system, also called cardiovascular system, is a vital organ system
that delivers essential substances to all cells for basic functions to occur. Also commonly
known as the cardiovascular system, is a network composed of the heart as a centralized
pump, blood vessels that distribute blood throughout the body, and the blood itself, for
transportation of different substances.
THE HEART
The heart is a muscular pump that is the central component of the circulatory
system. It is divided into a right and left side by a muscular septum. Heart walls are the
muscles that contract, squeeze and relax to send blood throughout your body. A layer of
muscular tissue called the septum divides your heart walls into the left and right sides.
Heart walls have three layers:
● Endocardium: Inner layer.
● Myocardium: Muscular middle layer.
● Epicardium: Protective outer layer.
Heart chambers:
● Right atrium: Two large veins deliver oxygen-poor blood to your right atrium. The
superior vena cava carries blood from your upper body. The inferior vena cava brings
blood from the lower body. Then the right atrium pumps the blood to your right
ventricle.
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● Right ventricle: The lower right chamber pumps the oxygen-poor blood to your lungs
through the pulmonary artery. The lungs reload blood with oxygen.
● Left atrium: After the lungs fill blood with oxygen, the pulmonary veins carry the blood
to the left atrium. This upper chamber pumps the blood to your left ventricle.
● Left ventricle: The left ventricle is slightly larger than the right. It pumps oxygen-rich
blood to the rest of your body.
Heart valves
● Tricuspid valve: Door between your right atrium and right ventricle.
● Mitral valve: Door between your left atrium and left ventricle.
● Semilunar (SL) valves open when blood flows out of your ventricles. They include:
● Aortic valve: Opens when blood flows out of your left ventricle to your aorta (artery
that carries oxygen-rich blood to your body).
● Pulmonary valve: Opens when blood flows from your right ventricle to your
pulmonary arteries (the only arteries that carry oxygen-poor blood to your lungs).
Pulmonary circulation:
The pulmonary circuit begins with the right ventricle, which pumps deoxygenated
blood through the pulmonary artery. This artery divides above the heart into two branches,
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to the right and left lungs, where the arteries further subdivide into smaller and smaller
branches until the capillaries in the pulmonary air sacs (alveoli) are reached. In the
capillaries the blood takes up oxygen from the air breathed into the air sacs and releases
carbon dioxide. It then flows into larger and larger vessels until the pulmonary veins (usually
four in number, each serving a whole lobe of the lung) are reached. The pulmonary veins
open into the left atrium of the heart.
Systemic Circulation
The systemic circulation provides the functional blood supply to all body tissue. It
carries oxygen and nutrients to the cells and picks up carbon dioxide and waste products.
Systemic circulation carries oxygenated blood from the left ventricle, through the arteries, to
the capillaries in the tissues of the body.
The heart is continuously going through a series of contractions and relaxations.
Systole refers to when the ventricles of the heart simultaneously contract, diastole is when
the ventricles relax. During systole, blood is forcibly pumped out of the ventricles into the
outflow tracts of their corresponding circulation. The atria are filling with blood at the same
time. During diastole, the ventricles are relaxed, and blood flows from the atria into the
corresponding ventricles.
THE BLOOD
Blood, fluid that transports oxygen and nutrients to the cells and carries away carbon
dioxide and other waste products. Technically, blood is a transport liquid pumped by
the heart (or an equivalent structure) to all parts of the body, after which it is returned
to the heart to repeat the process.
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The blood has four main components:

● Plasma
About 55 percent of the blood is plasma. Plasma is what makes blood liquid.
Plasma moves blood cells through the body by way of the circulatory system. It also
carries hormones, nutrients, antibodies, and waste products.
● Red blood cells
Red blood cells, also called erythrocytes, make up about 40 to 45 percent of the
blood’s volume. These cells have no nucleus, which means they can easily change
shape as they move through the body’s arteries and veins. Red blood cells contain a
protein called hemoglobin. It carries oxygen from the lungs to the rest of the body
and returns carbon dioxide to the lungs, where it’s exhaled.
● White blood cells
White blood cells, also called leukocytes, make up just 1 percent of the blood. They
protect the body from infection..Types of white blood cells are granulocytes
(neutrophils, eosinophils, and basophils), monocytes, and lymphocytes (T cells and
B cells).
● Platelets
Platelets, also called thrombocytes, are cell fragments.
Platelets are essential for blood clotting. They stick to an injured blood vessel lining
to provide the basis for a clot. This stops bleeding and promotes healing.
Three main types of blood vessels:

● Arteries: Arteries are thin, muscular tubes that carry oxygenated blood away from
the heart and to every part of your body. The aorta is the body’s largest artery. It
starts at the heart and travels up the chest (ascending aorta) and then down into the
stomach (descending aorta). The coronary arteries branch off the aorta, which then
branch into smaller arteries (arterioles) as they get farther from your heart.
● Veins: These blood vessels return oxygen-depleted blood to the heart. Veins start
small (venules) and get larger as they approach your heart. Two central veins deliver
blood to your heart. The superior vena cava carries blood from the upper body (head
and arms) to the heart. The inferior vena cava brings blood up from the lower body
(stomach, pelvis and legs) to the heart. Veins in the legs have valves to keep blood
from flowing backward.
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● These blood vessels connect very small arteries (arterioles) and veins (venules).
Capillaries have thin walls that allow oxygen, carbon dioxide, nutrients and waste
products to pass into and out of cells.
Hypertension occurs when the body’s smaller blood vessels (the arterioles) narrow,
causing the blood to exert excessive pressure against the vessel walls and forcing the heart
to work harder to maintain the pressure. Although the heart and blood vessels can tolerate
increased blood pressure for months and even years, eventually the heart may enlarge (a
condition called hypertrophy) and be weakened to the point of failure. Injury to blood vessels
in the kidneys, brain, and eyes also may occur.
Blood pressure is actually a measure of two pressures, the systolic and the
diastolic. The systolic pressure (the higher pressure and the first number recorded) is the
force that blood exerts on the artery walls as the heart contracts to pump the blood to the
peripheral organs and tissues. The diastolic pressure (the lower pressure and the second
number recorded) is residual pressure exerted on the arteries as the heart relaxes between
beats. A diagnosis of hypertension is made when blood pressure reaches or exceeds
140/90 mmHg (read as “140 over 90 millimeters of mercury”).
C. Symptomatology
Signs and Symptoms Rationale

Blurry or double vision The walls of the blood vessels in the retina
may thicken if your blood pressure is too high.
Your blood vessels may narrow as a result of
this, which will limit the amount of blood that
can reach your retina. Blood vessels in the
retina can become damaged by high blood
pressure. High blood pressure over time can
harm the retina's blood vessels, restrict the
retina's ability to function, and put pressure on
the optic nerve, which can lead to vision
issues. (Healthline, 2021)
Fatigue Due to increased pressure on key organs
including the kidneys, heart, and brain caused
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by high blood pressure, fatigue is a common

side effect. Pressure exerted against blood
vessel walls can result in hidden damage if
left untreated. Stroke, heart attack, and renal
disease are just a few of the serious health
problems that can result from this injury.
(Lander, 2021)
Headache High blood pressure headaches often affect
both sides of the head. Headaches can result
from high blood pressure because it interferes
with the blood-brain barrier. Hypertension can
cause excessive pressure on the brain in
severe cases when blood pressure is very
high, which can lead to blood leakage from
the brain's blood vessels. Because the brain
is enclosed within the skull and has limited
room to grow, this leakage results in swelling,
or edema, which is dangerous. In addition to
increasing the pressure on the brain, the
swelling can result in headaches, nausea,
dizziness, weakness, confusion, seizures, and
blurred vision. (Kuruvilla, 2022)
Nosebleeds Nosebleeds are not caused by hypertension
by itself unless there is a hypertensive crisis.
This occurs when high blood pressure affects
the blood vessels, there would be an
increased chance of the nose blood vessels
being vulnerable to damage. Due to the
severe pressure damaging the delicate blood
vessels of the nose and causing them to
break and leak, high blood pressure can
result in nosebleeds. (Healthline, 2021)
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Shortness of breath The general diagnosis of pulmonary

hypertension indicates elevated blood
pressure in the pulmonary arteries. Your heart
and lungs' blood flow are interrupted. Your
pulmonary arteries become narrowed as a
result of high blood pressure. Your heart has
to work harder as a result to pump
oxygen-depleted blood to your lungs.
(Mayoclinic, 2022)
Nausea and/or vomiting Dizziness may accompany severe
hypertension-related nausea, which might
appear rapidly. Constipation or vomiting may
occur as a result of severe digestive
difficulties brought on by blood pressure
fluctuations. (MedlinePlus, 2022)
D. Etiology
Ages 45 and beyond Despite the fact that it can happen to younger
people, the risk of high blood pressure starts
to increase around the age of 45. The
vascular system, a network of blood vessels
in your body, alters as you get older. As
arteries stiffen, blood pressure increases.
(National Institute of Health, 2022)
Race African, Caribbean, or South Asian ancestry

increases the risk of getting high blood
pressure compared to the general population.
Additionally, type 2 diabetes, which increases
the risk of high blood pressure and other
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health issues like heart disease, stroke, renal

disease, and others, is more common in
South Asians. (AHA Journals, 2021)
Family History There is a familial tendency for hypertension.

People who have hypertension run a higher
risk of getting it themselves, especially if both
of their parents have it. The inheritance
pattern is uncertain, though. Rare genetic
varieties of hypertension inherit their
characteristics from their parents.
(MedlinePlus, 2019)
Excessive consumption of salt The body retains water when it consumes

salt. When intake of salt is too much, the
additional water in the blood puts more
pressure on the walls of the blood vessels,
causing blood pressure to rise. (Blood
pressure UK, 2021)
Smoking Smoking and other tobacco products

contain nicotine, which causes the blood
vessels to constrict and the heart to beat
more quickly, raising blood pressure.
Alcoholic Alcohol use can have an impact on the

blood vessel muscles. They might get
narrower as a result. The likelihood of
developing hypertension increases with
alcohol consumption. Regular drinking puts
their health at risk, especially if older than
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35. In addition to that, alcohol raises the

hormone renin levels in the blood, which
narrows the blood arteries. They thus
become smaller in diameter. Renin also
reduces the volume of fluid the body
excretes in urine. Blood pressure rises as a
result of the body's increased fluid retention
and its narrower blood vessels.(Health and
Safety Executive, 2022)
Stress There is no evidence that stress alone

causes persistently high blood pressure.
However, responding unhealthily to stress
can raise blood pressure and up the chance
of a heart attack or stroke. The following
actions have been connected to elevated
blood pressure: excessive alcohol or
caffeine use as a coping mechanism of
stress. (Mayoclinic, 2022)
Obesity Obesity and hypertension have a

well-established connection.
Obesity-induced hypertension is a prevalent
process in both children and adults, and it is
brought on by the buildup of extra adipose
tissue, which sets off a chain of events that
raises blood pressure.
Lack of Activity High blood pressure might result from a

sedentary lifestyle. Low levels of exercise
are directly related to weight gain, which
raises the risk of high blood pressure.
(WHO, 2022)
Too much Caffeine Caffeine may interfere with a hormone that

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keeps your arteries open. Additionally,

caffeine increases the amount of adrenaline
released by your adrenal glands, which
raises your blood pressure. (Mayoclinic,
2022)
High Cholesterol High cholesterol and high blood pressure

(hypertension) are related. Your arteries
harden and narrow as a result of cholesterol
plaque and calcium. As a result, pumping
blood through them requires significantly
more effort from your heart. Your blood
pressure goes up too much as a result.
(Clevelandclinic, 2022)
Sleep Apnea Due to reductions in blood oxygenation and

stress on the cardiovascular system during
apneic periods, sleep apnea can increase
blood pressure.(WebMD, 2021)
Pregnancy As a woman progresses in her pregnancy

there are changes in blood pressure
circulation and may return to pre-pregnancy
level. The blood volume of a woman can
increase by up to 45% when she is
pregnant. The heart must pump this
additional blood throughout the body.
(Healthline, 2019)
Cushing Syndrome Because cortisol increases vascular

sensitivity to catecholamine and angiotensin
II and accelerates salt reabsorption in the
kidneys, patients with Cushing's syndrome
(CS) are more likely to develop
hypertension. This explains why people with
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CS frequently have high blood pressure.

(Endocrine Abstract, 2015)
Diabetes Damage from diabetes results in kidney

scarring, which promotes salt and water
retention, which in turn raises blood
pressure. Small blood arteries are harmed
over time by diabetes, which causes their
walls to harden and function incorrectly.
These alterations are a factor in high blood
pressure.
(NeyYork-Presbyterian, 2019)
Chronic Kidney Failure Your kidneys are crucial to maintaining a

healthy blood pressure level. Kidney
disease affects its capacity to aid in blood
pressure control. Blood pressure rises as a
result. High blood pressure increases your
risk of developing cardiac issues and
worsening renal disease if you have chronic
kidney disease (CKD).
(National Kidney Foundation, 2018)
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E. Pathophysiology
151
152
Narrative
Hypertension is a condition where the blood pressure is high or above normal levels.
It is often characterized by a consistent elevated blood pressure exceeding the normal range
from 120/80 mm Hg. High blood pressure is often caused by excessive consumption of salt,
smoking, alcohol, stress, obesity, lack of activity, too much caffeine, high cholesterol, sleep
apnea, pregnancy, cushing syndrome, diabetes, and chronic kidney failure. While factors
like ages 45 years old above, race and family history are some factors that would likely
increase the likelihood of acquiring the condition.
With the precipitating and predisposing factor, this could lead into three ways which
can be Hyperactivation of the Sympathetic Nervous System (SNS), Hyperactivation of the
Renin Angiotensin Aldosterone Axis (RAAA), or Defects in renal sodium hemostasis. When
there is a hyperactivation of the SNS or the hyperactivation of the RAAA it could result in 4
ways. First would be the SA Node will have an increased heart rate leading to an increased
cardiac output. Second would be the ventricular myocardium will have an increased
contractility leading to increased cardiac output. Third would be the release of
norepinephrine on the smooth muscles leading to vasoconstriction and there would be an
increase of the peripheral vascular resistance. Fourth would be the increased production of
renin (angiotensinogen) followed by an increased production of angiotensin II leading to
increased antidiuretic hormone causing the increase of aldosterone resulting in increased
peripheral vascular resistance. While if the factors will lead to the defects in renal sodium
homeostasis it would lead to an inadequate sodium excretion causing for a renal sodium
retention leading to decreased filtration surface prompting for the increased blood volume
and resulting for the increased peripheral vascular resistance. The increased cardiac output
and the increased peripheral vascular resistance will then result in the increased blood
pressure resulting from hypertension. Signs and symptoms of hypertension would be blurry
or double vision, fatigue, headache, nosebleed, shortness of breath, and nausea and
vomiting. Diagnostic procedures such as urinalysis, fasting blood glucose, creatinine, kidney
function test, potassium blood test, sodium blood tests, lipid profile, thyroid function test,
blood pressure measurement, and echocardiogram would determine if the person has
hypertension.
Clients who have been diagnosed with hypertension would be managed with
medications such as diuretics, Angiotensin Receptor Blockers (ARBs), calcium channel
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blockers, alpha blockers, beta blocker, central agonists, and ace inhibitors. Some would be
advised for renal denervation, adrenalectomy. If a patient would have managed or followed
the recommended regimen it would lead to good prognosis. Wherein the person might have
a controlled blood pressure. But if the client mismanages or doesn’t follow its respective
treatment it could lead to bad prognosis and eventually death.
Laboratory Test
TEST Normal Range RATIONALE
Urinalysis Color: Yellow A urine sample can contain markers that

could point to secondary medical
Clarity: Clear or cloudy conditions that cause high blood pressure
and to look for damage to the kidneys as
pH: 4.5-8. a result of untreated hypertension wherein
the filtration system may leak, allowing
protein and sometimes blood to enter the
fluid that is filtered out to become urine.
When blood or protein is found in the
urine, it may indicate that damage due to
high blood pressure has occurred.
(Cleveland, 2021)
Fasting blood Normal: < 99 mg/dL Changes in blood sugar levels can have a
glucose direct effect on blood pressure. Increased
Prediabetes: 100 to 125 levels of sugar in the blood raises the
mg/dL levels of uric acid which in turn inhibit the
production of nitric oxide in blood vessels.
Diabetes: > 126 mg/dL Nitric oxide is responsible for vasodilation.
Without nitric oxide, vasoconstriction
happens which results in high blood
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pressure. (Weiss, 2021)
Creatinine Men: 0.74 to 1.35 mg/dL This test is used to determine if the
kidneys are functioning well in filtering
Women: 0.59 to 1.04 waste from the blood. When the blood
mg/dL exerts too much pressure against the
artery walls, it can lead to high blood
pressure. This will cause damage and it
weakens the blood vessels surrounding
the kidneys, affecting kidney function and
elevating creatinine levels (Schulman,
2019).
Kidney function Normal GFR: > 60 This test evaluates how well the kidneys
test Kidney disease: < 60 are working. When the kidneys are unable
Kidney failure: < 15 to receive enough blood, it responds by
releasing hormones that stimulate the
body to retain sodium and water. Blood
vessels will then fill with additional fluid
resulting in increased blood pressure.
(Harley, 2021)
Potassium blood 3.6 to 5.2 mmol/L A potassium blood test measures how
test much potassium is present in blood. It is
often part of the blood tests called an
electrolyte panel. This test examines the
potassium level in the fluid part of the
blood (serum). Potassium is a vital
electrolyte for healthy muscle and nerve
function. Decreased amount of potassium
into the blood can further elevate the
blood pressure as it is the one responsible
in relaxing the walls of the blood vessels
and helps lessen the effects of sodium.
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(Medline, 2022)
Sodium blood 135 to 145 mEq/L This test measures the concentration of
test sodium in the blood. Sodium plays a
significant role in regulating the balanced
amount of water in the body. However,
elevated levels disrupts the natural
sodium balance in the body thus causing
fluid retention and increases the pressure
exerted by the blood against blood vessel
walls. (Schulman, 2021)
Lipid profile Total cholesterol: below This test is a common blood test that is
200 mg/dl used to monitor and screen for risk of
cardiovascular disease. The panel
HDL: above 60 mg/dl includes three measurements of
cholesterol levels and a measurement of
LDL: below 100 mg/dl (for triglycerides. Increased levels of
people who have cholesterol and triglycerides have the
potential to build up in the arteries,
Diabetes: Below 70 mg/dl) clogging and narrowing the blood vessels
thus causing increased blood pressure.
Triglycerides: below 150 (Cleveland, 2021)
mg/dl.
Thyroid function 0.40 - 4.50 mIU/mL This test is performed to determine if the
test thyroid gland is functioning well by
measuring the amount of thyroid
hormones in the blood. If the thyroid gland
does not generate adequate thyroid
hormone or lacks production of thyroid
hormone, it can lead to high blood
pressure (Balingit, 2022).
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Diagnostic Test
Blood Pressure Blood pressure is measured in units of millimeters of mercury

Measurement (mmHg). The readings are always given in pairs, with the upper
(systolic) value first, followed by the lower (diastolic) value.
Systolic blood pressure is the measurement of the pressure as
the heart contracts and pumps oxygen-rich blood into the
arteries. When the heart relaxes, the pressure in the blood
vessels is known as the diastolic blood pressure (Falck, 2018).
High blood pressure value:
Blood Pressure Systolic Diastolic

Category
Prehypertension 120-139 80-89
Stage 1 140-159 90-99
Stage 2 > 160 > 100
Hypertensive > 180 > 120

Crisis
Echocardiogram This ultrasound test uses sound waves to produce images of

the heart. It enables physicians to see how the heart is working
as it fills with blood and pumps it to the rest of the body. The
images from the echocardiogram used to identify thickened
heart muscles or enlarged cardiac chambers, which could be
evidence of damage from high blood pressure (Cleveland,
2022).
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Drug Study
Generic Name Furosemide
Brand Name Lasix, Furocot
Drug Classification Loop diuretics

Pregnancy category: C
Suggested Dose Oral

Hypertension
Adult: 40-80 mg daily, adjusted according to patient response.
Usual maintenance dose of 20-49 mg daily.
Elderly: Initiate at lower doses.
Mechanism of Action Pharmacodynamics:

Furosemide is an anthranilic acid derivative and a potent diuretic.
It mainly inhibits the reabsorption of Na and chloride in the
ascending loop of Henle and in both the proximal and the distal
renal tubules. It also interferes with the chloride-binding
cotransport system, thereby causing its natriuretic effect.
Pharmacokinetics:
● Absorption: Incompletely but rapidly absorbed from the
gastrointestinal tract.
● Distribution: Crosses the placenta and enters breast milk.
● Metabolism: Undergoes minimal hepatic metabolism.
● Excretion: Mainly via urine (oral: 50%, IV: 80%) within 24
158
hours; feces (as unchanged drug).
Indication Furosemide is indicated for the treatment of edema associated

with congestive heart failure, cirrhosis of the liver, and renal
disease, including the nephrotic syndrome, in adults and pediatric
patients. Oral furosemide is indicated alone for the management of
mild to moderate hypertension or severe hypertension in
combination with other antihypertensive medications. Intravenous
furosemide is indicated as adjunctive therapy in acute pulmonary
edema when a rapid onset of diuresis is desired.
Contraindication Hypersensitivity to furosemide and sulfonamides, anuria, hepatic

coma, electrolyte disturbances (severe hyponatremia, severe
hypokalemia), hypovolaemia, dehydration, hypotension; comatose
or pre-comatose states associated with liver cirrhosis or
encephalopathy; addison’s disease, porphyria, digitalis
intoxication, lactation.
Side Effects Nausea, dizziness, hypotension, increased calcium excretion,

Hyponatraemia, hypokalaemia, hypomagnesaemia.
Adverse Effects Derm: Erythema multiforme, stevens-johnson syndrome, toxic

epidermal necrolysis, photosensitivity, pruritus, rash, urticaria.
EENT: hearing loss, tinnitus.
Endo: Hypercholesterolemia, hyperglycemia,
hypertriglyceridemia, hyperuricemia.
FandE: dehydration, hypocalcemia, hypochloremia, hypokalemia,
hypomagnesemia, hyponatremia, hypovolemia, metabolic
alkalosis.
GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia,
increased liver enzymes, nausea, pancreatitis, vomiting
GU: Increased BUN, excessive urination, nephrocalcinosis.
Hemat: Aplastic anemia agranulocytosis, hemolytic anemia,
leukopenia, thrombocytopenia.
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Drug Interaction
● May increase the risk of hypotension with
antihypertensives, nitrates, or acute ingestion of alcohol
● May increase risk of hypokalemia with other diuretics,
amphotericin B, stimulant laxatives, and corticosteroids
● Hypokalemia may increase risk of digoxin toxicity and
increase risk of arrhythmia in patients taking drugs that
prolong the QT interval.
● May increase risk of ototoxicity with aminoglycosides or
cisplatin.
● May increase risk of nephrotoxicity with cisplatin.
● May decrease therapeutic effects with NSAIDs.
Nursing 1. Assess the patient for skin rash frequently during therapy.
Responsibilities Discontinue furosemide at first sign of rash.
Rationale: This may be life-threatening. Stevens-Johnson
syndrome, toxic epidermal necrolysis, or erythema multiforme may
develop. Treat symptomatically; may recur once treatment is
stopped.
2. Assess blood glucose levels in patients with diabetes mellitus.
Rationale: Hyperglycemia is a well known adverse effect of
therapy with diuretics as it impairs glucose metabolism.
3. Assess patients receiving digoxin for anorexia, nausea,
vomiting, muscle cramps, paresthesia, and confusion.
Rationale: Patients taking digoxin are at increased risk of digoxin
toxicity because of the potassium-depleting effect of the diuretic.
4. Monitor liver and renal function tests
Rationale: to identify the need for possible dose adjustment and
toxic effects.
5. Monitor intake and output and voiding patterns
Rationale: to evaluate fluid balance and renal function.
6. Monitor dietary potassium intake. Watch for signs and

160
symptoms of hypokalemia.
Rationale: Diuretics cause the kidneys to excrete potassium along
with the extra fluid causing a depletion in potassium levels.
7. Administer diuretics in the morning.
Rationale: to prevent nocturia or the condition that causes you to
wake up during the night to urinate.
8. Instruct the patient to move slowly when rising.
Rationale: To avoid dizziness from sudden blood pressure
decrease.
9. Warn patients about an increased frequency of micturition. This

may last for up to six hours after a dose and should decrease after
they have taken furosemide for a few weeks.
Rationale: Diuretics are also known as water pills which are
medicines that help move extra fluid and salt out of the body
resulting in frequent urination.
10. Advise patients on antihypertensive regimen to continue taking
medication and reinforce the need to continue additional therapies
for hypertension (weight loss, exercise, restricted sodium intake,
stress reduction, regular exercise, moderation of alcohol
consumption, cessation of smoking).
Rationale: Furosemide controls high blood pressure but does not
cure it and therefore they need to continue with the medication
even if they feel well.
Generic Name Irbesartan

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Brand Name Avapro, Avalide, Ifirmacombi, Karvea, Karvezide
Drug Classification Angiotensin Receptor Blockers (ARBs)

Pregnancy Category: D
Suggested Dose Oral

Hypertension
Adult: 150 mg once daily, may increase to 300 mg once daily if
needed. Patient with intravascular volume depletion: Initially, 75 mg
once daily.
Mode of Action Pharmacodynamics:

Irbesartan is an angiotensin II receptor antagonist. It blocks the
vasoconstricting and aldosterone-secreting effects of angiotensin II
by binding to AT1 receptors.
Pharmacokinetics:
● Absorption: Rapidly absorbed from the GI tract.
● Distribution: Volume of distribution: 53-93 L.
● Metabolism: Undergoes hepatic metabolism via CYP2C9
isoenzyme to inactive metabolites.
● Excretion: Via bile and urine (as unchanged drug and
metabolites); urine (approx 20%, <2% as unchanged drug).
Indication Irbesartan is indicated to treat hypertension and diabetic

nephropathy in hypertensive patients with type 2 diabetes, elevated
serum creatinine, and proteinuria.
Contraindication Concomitant use w/ aliskiren in patients w/ diabetes and renal

impairment (GFR <60 mL/min), hypersensitivity to irbesartan,
losartan, or valsartan, pregnancy.
Side Effects ● Nausea

● Vomiting
● Headache
● Dizziness
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● Confusion
● Drowsiness
● Diarrhea
● Muscle weakness
● Palpitations
Adverse Effects CNS: Anxiety, nervousness, syncope.

CV: Tachycardia, chest pain
GI: Dyspepsia, abdominal pain.
EENT: conjunctivitis, vision disturbance, ear pain.
Respiratory: Upper respiratory infection, cough, pharyngitis,
rhinitis.
GU: albuminuria, renal failure
Metabolic: gout, hyperkalemia
Musculoskeletal: joint pain, back pain.
Skin: Rash.
Drug Interaction ● May antagonize hypotensive effects and increase risk of

nephrotoxicity w/ NSAIDs.
● May increase serum lithium levels and toxicity.
● Increased risk of hyperkalemia w/ K-sparing diuretics
(amiloride, triamterene, spironolactone), K supplements or
K-containing salt substitutes.
Nursing 1. Assess heart rate, ECG, and heart sounds, especially during
Responsibilities exercise
Rationale: This drug may cause rapid heart rate or signs of other
arrhythmias, including palpitations, chest discomfort, shortness of
breath, fainting, and fatigue/weakness.
2. Obtain baseline status for vital signs, overall skin condition and
girth measurements
Rationale: To have a baseline date and assess the patient for
sudden increase in body weight due to vasodilation or fluid
retention.
163
3. Monitor blood pressure regularly

Rationale: To evaluate patients response to the effectiveness to
drug
4. Monitor renal and hepatic function tests as well as signs of
impaired renal function, including decreased urine output, cloudy
urine.
Rationale: To alert the physician for possible development of renal
and/or hepatic failure as well as to signal need for reduced drug
dose.
5. Advise the patient to change positions slowly
Rationale: changing position slowly helps minimize orthostatic
hypotension.
6. Use caution during aerobic exercise and endurance conditioning.
Terminate exercise if the patient exhibits untoward symptoms such
chest pain and shortness of breath.
Rationale: This drug causes increased risk of cardiac arrhythmias
7. Caution the patient and family/caregivers to guard against falls
and trauma.
Rationale: This drug may cause dizziness that might affect gait,
balance, and other functional activities.
8. Administer drug with food .
Rationale: to prevent GI distress associated with drug intake.
9. Ensure that the patient is not pregnant and has appropriate
contraceptives available during therapy.
Rationale: Serious fetal damage has been associated with this
drug.
10. Educate patient on importance of healthy lifestyle choices
which include regular exercise, weight loss, smoking cessation, and
low-sodium diet
Rationale: to maximize the effect of antihypertensive therapy.
164
Generic Name Amlodipine
Brand Name Norvasc, Katerzia
Drug Classification Calcium channel blockers
Suggested Dose Oral

Hypertension
Adult: Initially, 5 mg once daily. Dosage is individualized and may be
increased after at least 1-2 weeks. Max: 10 mg once daily.
Child: 6-17 years Initially, 2.5 mg once daily, may increase to 5 mg
once daily after 4 weeks intervals according to clinical response.
Elderly: Initially, 2.5 mg once daily.
Mode of Action Amlodipine is a dihydropyridine calcium antagonist (calcium ion

antagonist or slow-channel blocker). It is considered a peripheral
arterial vasodilator that exerts its action directly on vascular smooth
muscle to lead to a reduction in peripheral vascular resistance,
causing a decrease in blood pressure.
Pharmacokinetics:
● Absorption: Well absorbed from the gastrointestinal tract.
● Distribution: Crosses placenta and enters breast milk.
● Metabolism: Extensively metabolized in the liver to inactive
metabolites.
● Excretion: Via urine (60% as metabolites, 10% as unchanged
drug).
Indication Amlodipine may be used alone or in combination with other

antihypertensive and antianginal agents for the treatment of
hypertension, coronary artery disease, chronic stable angina, and
165
vasospastic angina.
Contraindication Hypersensitivity, severe hypotension, cardiogenic shock, left

ventricular outflow tract obstruction such as high grade aortic
stenosis, and heart failure after acute myocardial infarction.
Side Effects ● Headache

● Dizziness
● Drowsiness
● Tiredness
● Stomach pain
● Nausea
● Swelling of ankle and feet
Adverse Effects CNS: Light-headedness, fatigue, weakness, lethargy

CV: peripheral edema, angina, bradycardia, hypotension,
palpitations
GI: Severe abdominal discomfort
Musculoskeletal: Muscle cramps, muscle pain or inflammation
Respiratory: Shortness of breath, dyspnea, wheezing
Skin: Rash, pruritus, urticaria, flushing
Drug Interaction ● Increased systemic plasma concentration with

immunosuppressants (ciclosporin, tacrolimus).
● Increased serum concentration of simvastatin. Increased
exposure with CYP3A4 enzyme inhibitors (protease
inhibitors, azole antifungals, erythromycin, diltiazem).
● Decreased plasma concentration with CYP3A4 inducers
(rifampicin).
Nursing 1. Assess heart rate, ECG, and heart sounds periodically.

Responsibilities
166
Rationale: : This drug can cause rhythm disturbances or symptoms

of increased arrhythmias, including palpitations, chest pain,
shortness of breath, fainting, and fatigue/weakness.
2. Assess blood pressure periodically, and compare it to normal
values. BP reduction is greatest after peak levels of amlodipine are
achieved 6–9 hours following oral doses.
Rationale: : To help document antihypertensive effects.
3. Assess for presence of edema using girth measurements. Report
any increased swelling in feet and ankles due to peripheral
vasodilation.
Rationale: : As the drug triggers the dilation of blood vessels, there's
increased blood flow, in turn, it intensifies the pressure within smaller
blood vessels, causing excess fluids to seep through the walls of the
vessels into surrounding tissues which results in edema.
4. Design and implement aerobic exercise and endurance training
programs as ordered.
Rationale: : To normalize blood pressure, improve coronary
perfusion, reduce angina, and improve myocardial pumping ability.
5. Use caution during aerobic exercise and other forms of
therapeutic exercise. Assess exercise tolerance frequently (heart
rate, fatigue levels).
Rationale: : There’s increased risk of cardiac arrhythmias and
angina pectoris. Termination of activity should be done immediately
if any untoward responses occur.
6. Instruct the patient to move slowly when assuming a more upright
position.
Rationale: To minimize orthostatic hypotension.
7. Provide a comfortable environment by adjusting lighting, noise,
and temperature and instruct the patient to eat frequent small meals.
Rationale: : To relieve symptoms such as nausea, vomiting and
headache which are common with amlodipine.
8. Instruct the patient to ask for assistance when standing or walking.
Rationale: : This drug may cause dizziness and fatigue that might
167
affect gait, balance, and other functional activities.

9. Educate the patient about additional interventions, including
regular exercise, weight loss, sodium restriction, stress reduction,
moderation of alcohol consumption, and smoking cessation.
Rationale: : To help control blood pressure and cardiac dysfunction.
10. Educate the patient to avoid drinking grapefruit juice.
Rationale: : It inhibits the hepatic metabolism of calcium channel

blockers and may lead to increased blood drug levels and increased
pharmacologic effects.
Generic Name Prazosin
Brand Name Minipress, Minizide, Prazin, Prazo
Drug Classification Alpha Blockers
Suggested Dose Oral

Hypertension
Adult: Initially, 0.5 mg bid or tid for 3-7 days to be taken in the
evening, then increase to 1 mg bid or tid for the next 3-7 days, if
tolerated. Then gradually increase up to Max 20 mg daily in divided
doses according to response. Alternatively, initial dose of 1 mg bid
168
or tid, then titrate dose up to 20 mg daily in 2-3 divided doses

according to response.
Elderly: Initiate at the lower end of the dosing range.
Mode of Action Pharmacodynamics:

Prazosin is an α-blocker that competitively inhibits postsynaptic
α1-adrenoceptors. This inhibition blocks the vasoconstricting
(narrowing) effect of catecholamines (epinephrine and
norepinephrine) on the vessels, leading to peripheral blood vessel
dilation and decrease in total peripheral resistance and blood
pressure.
Pharmacokinetics:
● Absorption: Readily absorbed from the gastrointestinal
tract.
● Distribution: Crosses the placenta, enters breast milk.
● Metabolism: Extensively metabolised in the liver via
demethylation and conjugation.
● Excretion: Mainly via faeces (5-11% as unchanged drug);
urine (<10%).
Indication It is indicated for the treatment of hypertension. Prazosin can be

given alone or given with other blood pressure-lowering drugs,
including diuretics or beta-adrenergic blocking agents. Moreover,
Prazosin does not negatively impact lung function, and therefore
may be used to manage hypertension in patients who are asthmatic
or patients with chronic obstructive lung disease (COPD)
Contraindication This drug is contraindicated in patients with known sensitivity to

quinazolines, prazosin, or any of the inert ingredients. Prazosin
should be used with caution in patients with angina pectoris
because severe hypotension may cause or worsen angina.
Side Effects ● Headache

● Drowsiness
● Tiredness
169
● Weakness
● Blurred vision
● Nausea
● Vomiting
● Diarrhea
● Dry mouth
● Fever.
Adverse Effects Significant: Syncope, orthostatic hypotension, priapism, prolonged

erections, angina, CNS depression, intraoperative floppy iris
syndrome.
Cardiac disorders: Palpitations.
Ear and labyrinth disorders: Vertigo.
Nervous system disorders: Headache, dizziness, drowsiness,
faintness.
Psychiatric disorders: Depression, nervousness.
Respiratory: Dyspnoea
Skin: Rash.
Nursing 1. Assess heart rate, ECG, and heart sounds, especially during
Responsibilities exercise.
Rationale: Report any rhythm disturbances or symptoms of
increased arrhythmias, including palpitations, chest pain,
shortness of breath, fainting, and fatigue/weakness.
2. Assess peripheral edema using girth measurements, volume
displacement, and measurement of pitting edema.
Rationale: Report increased swelling in feet and ankles or a
sudden increase in body weight due to fluid retention.
3. Periodically monitor blood pressure especially in elder
patients.
Rationale: Elderly patients may be more sensitive to the
drug's hypotensive effects
4. Monitor patients with preexisting low plasma volume (from
diuretic therapy or salt restriction), beta-adrenergic therapy,
170
and had recent stroke.

Rationale: within 90–120 min after the initial dose of
prazosin, there would be first dose phenomenon which is
characterized by a precipitous decline in BP, bradycardia,
and consciousness disturbances (syncope)
Be alert for signs of mental depression or other changes in mood
and behavior.
Rationale: Notify the physician if these changes become
problematic.
5. Make position and direction changes slowly and in stages.
Dangle legs and move ankles a minute or so before standing
when arising in the morning or after a nap.
Rationale: To avoid static hypotension.
6. Caution the patient and family/caregivers to guard against
falls and trauma.
Rationale: This drug may cause dizziness and weakness
that might affect gait, balance, and other functional activities
7. Avoid physical therapy interventions that cause systemic
vasodilation such large whirlpool ans Hubbard tank.
Rationale: Additive effects of this drug and the intervention
may cause a dangerous fall in BP.
8. Educate the patient about additional methods to lower blood
pressure such as low-sodium diet, decrease tobacco use
and decrease alcohol consumption.
Rationale: To maximize the effects of drugs. Full therapeutic
effect of drug is reached within 4-6 weeks
9. Inform the patient to report priapism or impotence.
Rationale: A change in the drug regimen usually reverses
these difficulties. Since acute episodes of priapism followed
by impotence spontaneously occur in men with sickle cell
anemia, another antihypertensive should be selected. In
these patients, drug-induced priapism is frequently
irreversible.
171
Generic Name Atenolol
Brand Name Tenormin
Drug Classification Beta-blocker; antihypertensive
Mode Of Action It blocks the stimulation of beta-adrenergic receptors within vascular

smooth muscle. It decreases cardiac output and cardiac oxygen
consumption, and depresses renin secretion.
Indication & Hypertension

Suggested Dose Adult: Initially 50 mg P.O daily alone or in combination with a
diuretic as a single dose. Increased to 100 mg once daily after 7-14
days. Dosages more than 100 mg daily are unlikely to produce
further benefit.
Child: 0.8-1 mg/kg/dose initially; range, 0.8-1.5 mg/kg/day; max 2

mg/kg/day PO.
Contraindication ● Pregnant women

● Hypersensitivity to beta-blockers
● Cardiogenic shock
● 2nd or 3rd degree heart block
● Sinus bradycardia
● Cardiac failure
Side Effects ● Frequent - hypotension manifested as cold extremities,

172
constipation, diarrhea, diaphoresis, dizziness, fatigue, headache,

nausea
● Occasional - insomnia, flatulence, urinary frequency, impotence
or decreased libido, depression.
● Rare - rash, arthralgia, myalgia, confusion (esp. in elderly),
altered taste.
Adverse Effects ● CV - profound hypotension, bradycardia, heart failure, cardiac

arrest
● Resp - bronchospasm, pulmonary edema
● Endo - hypo- and hyperglycemia
Drug Interaction ● Drug-drug

➢ Antihypertensive - increase hypotensive effect. Use together
cautiously
➢ Clonidine - may exacerbate rebound hypertension if clonidine is
withdrawn. Atenolol should be withdrawn first before Clonidine
by several days after clonidine stops.
➢ Prazosin - may increase the risk of orthostatic hypotension in
the early phases of use together.
➢ NSAIDs - decrease antihypertensive effects. Monitor BP
➢ Insulin, oral antidiabetics - alter dosage requirements in
previously stabilized diabetic patients. Observe the patient
carefully.
➢ Penicillins - reduce bioavailability of atenolol. Monitor BP
closely.
➢ Rivastigmine - enhances bradycardic effect of atenolol. Avoid
combination.
➢ Rifamycins - reduce effects of atenolol.
➢ Salicylates - reduce effects of atenolol. Lower salicylate dosage
or change to a nonsalicylate antiplatelet.
➢ Calcium channel blockers, hydralazine, methyldopa - may
cause additive hypotension effect. Use together cautiously.
➢ IV lidocaine - reduce hepatic metabolism of lidocaine,
173
increasing risk of toxicity. Give a bolus dose of lidocaine at a

slower rate and monitor therapy.
● Lab test
Increases: ALP, BUN, creatinine, LDH, potassium, AST, ALT,
uric acid levels, and platelet count.
Decreases: glucose level
Nursing ● Assess BP, apical pulse immediately before drug is given. If

Responsibilities pulse is 60/min or less, or systolic BP is less than 90mmHg,
withhold medication and contact physician.
● Monitor daily pattern of bowel activity, stool consistency.
Beta-blockers can cause constipation.
● Monitor intake and output. Increased weight, decreased urinary
output may indicate HF.
● Assist with ambulation if dizziness occurs. To prevent accidents.
● Assess extremities for pulse quality, changes in temperature. It
may indicate worsening peripheral vascular disease.
● Monitor hemodialysis patients closely because of hypotension
risk.
● Instruct the patient to report bradycardia, dizziness, confusion,
depression, fever.
● Beta-blocker may mask tachycardia caused by hyperthyroidism.
In patients with suspected thyrotoxicosis, withdraw beta blocker
gradually to avoid thyroid storm.
● Restrict salt and alcohol intake.
● Outpatients should monitor BP, pulse before taking the
medication, following correct technique. To know the
effectiveness of drugs.
174
Generic Name Clonidine
Brand Name Catapres
Classification Central agonists; antihypertensive
Mode Of Action It inhibits the sympathetic vasomotor center in CNS, which reduces
impulses in the sympathetic nervous system; blood pressure, pulse
rate, cardiac output are decreased.
Indication & Dose Hypertension

Adult: 0.1 mg bid then increase by 0.1-0.2 mg/day at weekly
intervals until desired response; max 2.4mg; range 0.2-0.6 mg/day
in divided days or transdermal every 7 days, start 0.1 mg and
adjust every 1-2 week PO.
Geriatric: 0.1 mg at bedtime PO. May increase gradually
Child: 5-10 mcg/kg/day in divided dose every 8-12hr, max 0.9

mg/day

● Hypersensitivity to the drug
● Patients using anticoagulants (blood thinners medications)
175
● Epidural form (bleeding disorder)

● Use cautiously in patients with severe coronary insufficiency,
conduction disturbances, recent MI, cerebrovascular accident,
chronic renal failure or impaired renal function.
Side effects ● CNS - drowsiness, dizziness, sedation, weakness, fatigue,

● EENT - taste change, dry eyes, dry mouth,
● GI - constipation, dry mouth, nausea, vomiting
● GU - urine retention, impotence, decreased libido
● ENDO - hyperglycemia
Adverse Effects ● CV - bradycardia, severe bound hypertension, ECG abnormalities

● Skin - rash, pruritus, excoriation (transdermal patches)
● MISC - withdrawal symptoms

➢ Amitriptyline. Amoxapine, clomipramine, desipramine,
doxepin, imipramine, mirtazapine, trimipramine - may
cause loss of BP control with life-threatening elevations in BP.
Avoid using it together.
➢ Beta-blockers- may cause life-threatening hypertension.
Closely monitor BP.
➢ CNS depressants - increase CNS depression. Use together
cautiously.
➢ Digoxin, verapamil - may cause AV block and severe
hypotension. Monitor BP and ECG.
➢ Diuretics - increase hypotensive effect. Monitor the patient
closely.
➢ Levodopa - reduce effectiveness of levodopa. Monitor the
patient.
● Drug-herb
➢ Capsicum and Ma huang - may reduce antihypertensive
effectiveness. Discourage using it together.
● Lab test
176
➢ a Decreases: urinary excretion of vanillylmandelic acid and

catecholamines. May cause a weakly positive Coombs test
result.
Nursing ● Monitor BP, pulse, mental status.

Responsibilities ● Monitor daily pattern of bowel activity, stool consistency. Since
one of the side effects of clonidine is constipation.
● If clonidine is to be withdrawn, discontinue concurrent
beta-blocker therapy several days before discontinuing
clonidine. Prevents clonidine withdrawal hypertensive crisis.
● Slowly reduce dosage over 2-4 days. To avoid withdrawal
symptoms.
● Assess for allergic reactions such as rash, fever, pruritus,
urticaria. Products should be discontinued if antihistamines fail to
help.
● Instruct the client to rise slowly from lying to standing to reduce
hypotensive effect.
● Restrict alcohol intake. To avoid high risk of CNS effects,
bradycardia, and orthostatic hypotension.
● Notify the physician if mouth sores, sore throat, swelling of
hands, chest pain, irregular heartbeat, and signs of angioedema
occur.
● Instruct the client to use hard candy, saliva product, sugarless
gum or frequently rinsing of mouth. This drug may cause dry
mouth.
177
Generic Name Captopril
Brand Name Capoten
Classification ACE inhibitors; antihypertensive
Mode Of Action It suppresses the renin-angiotensin-aldosterone system, preventing

the conversion of angiotensin I to angiotensin II, a potent
vasoconstrictor. Less angiotensin II decreases peripheral arterial
resistance, decreasing aldosterone secretion, which reduces
sodium and water retention, and lowers blood pressure.
Indication & Dose Hypertension

Adult: Initially dose is 12.5-25 mg bid-tid; may increase to 50 mg
bid-tid at 1-2 week intervals; usual range 25-150 mg bid-tid; max
450 mg/day PO.
Child: 0.3-0.5 mg/kg/dose, may titrate up to 6 mg/kg/day in 2-4

divided doses.

● Hypersensitivity to ACE inhibitor drugs
● History of angioedema
● Use cautiously in patient with renal impairment, serious
autoimmune disease especially SLE,
178
Side effects & ● CNS - fever, chills, dizziness, drowsiness, fatigue, headache,
Adverse Effects insomnia, weakness
● CV - hypotension, postural hypotension, tachycardia, angina
● GI - loss of taste, increased LFTs
● GU - impotence, dysuria, nocturia, proteinuria, nephrotic
syndrome, acute reversible renal failure, polyuria, oliguria, urinary
frequency
● Metabolic - neutropenia, agranulocytosis, pancytopenia,
thrombocytopenia anemia
● Skin - rash, pruritus
● MISC: angioedema, hyperkalemia
● Resp: bronchospasm, dyspnea, cough

➢ Aliskiren - increase risk of renal impairment, hypotension, and
hyperkalemia in diabetic patients and those with moderate to
severe renal impairment. Concomitant use is contraindicated in
diabetic patients and those with moderate to severe renal
impairment.
➢ Antacids - decrease captopril effect. Separate dosage times.
➢ Diuretics - may cause excessive hypotension. May need to
stop diuretic or reduce captopril dosage.
➢ Insulin, oral antidiabetics - may cause hypoglycemia when
captopril therapy is started. Monitor the patient closely.
➢ Lithium - may increase lithium level; symptoms of toxicity
possible. Monitor lithium level and patient closely.
➢ Potassium-sparing diuretics, potassium supplements - may
cause hyperkalemia. Avoid using them together unless
hypokalemia is confirmed.
➢ NSAIDs - may reduce antihypertensive effects. Monitor BP.
● Drug-herb
➢ Black catechu: may cause additional hypotensive effects.
● Drug-food
179
➢ Salt substitutes containing potassium: may cause

hyperkalemia. Monitor the patient closely.
● Lab test
Increase: ALP, bilirubin, BUN, serum creatinine, and potassium
levels.
Decrease: sodium, glucose, Hb levels, hematocrit, granulocyte,
RBC, and WBC count.
Nursing ● Obtain BP immediately before each dose in addition to regular

Responsibilities monitoring.
● If hypotension occurs, place the patient in supine position with
legs elevated. It increases cardiac output and raises blood
pressure.
● In patients with prior renal disease or receiving doses greater
than 150 mg/day, test urine for protein by dipstick method with
first urine of day before therapy begins and periodically
thereafter.
● In patients with renal impairment, autoimmune disease, or taking
drugs that affect leukocytes or immune response obtain CBC
before taking drugs, every 2 weeks for 3 months, then
periodically thereafter.
● Assess for skin rash, pruritus. This is a sign of allergic reaction.
● Assist with ambulation if dizziness occurs. To prevent accidents.
● Monitor urinalysis for proteinuria.
● Monitor serum potassium levels in patients on concurrent
diuretic therapy.
● Discontinue medication if angioedema occurs and contact the
healthcare provider immediately.
● Instruct the patient to report immediately if swelling of face, lips
or tongue, difficulty of breathing, vomiting, diarrhea, excessive
perspiration, persistent cough, sore throat, and fever occur.
180
Procedure Rationale
Blood Pressure Procedure (Renal The Blood Pressure Procedure, also known
Denervation) as RDN or renal denervation, is a
procedure that could help lower your blood
pressure. It targets specific nerves near the
kidneys that can become overactive and
cause high blood pressure. The procedure
works by delivering energy to these
overactive nerves to decrease their activity.
The procedure typically takes about an hour
to perform.
For those who are unable to control their

blood pressure through lifestyle changes or
medication alone, the procedure can be
highly beneficial.
Adrenalectomy is surgery to remove one or both of the

adrenal glands. The body's two adrenal
glands are located at the top of each
kidney. The adrenal glands are part of the
system that makes hormones, called the
endocrine system.
The body's two adrenal glands are located

at the top of each kidney. The adrenal
glands are part of the system that makes
hormones, called the endocrine system.
Although adrenal glands are small, they
make hormones that affect almost every
part of the body. These hormones control
181
metabolism, the immune system, blood

pressure, blood sugar and other important
body functions.
Acute pain related to After 3 hours of nursing 1. Monitor Vital

increased cerebrovascular intervention the patient will Signs
pressure as evidenced by be able to: Rationale: Vital
throbbing pain in suboccipital signs are
and reluctance to move head. a. report relief of measured to
pain/discomfort. obtain basic
b. verbalize methods indicators of a
Rationale: that provide relief. patient's health
Hypertensive crisis is a c. demonstrate use of status. If outside
medical emergency, as it can relaxation skills and of a normal range
lead to stroke, heart attack, diversional activities, of values they
kidney damage, memory loss, as indicated, for may point to
and other severe individual situations. dysfunction or a
complications. If your blood disease state.
pressure is 180/120 mm Hg or 2. Ask the client
higher. Hypertension appears about location,
to cause a headache with a characteristics,
hypertensive crisis. This occurs intensity,
when blood pressure soars to frequency and
180/120 mm Hg or higher and duration of pain.
is associated with symptoms of Rationale: It gives
end organ damage. (Nadel, full details of pain
2022) and helps in pain
management.
182
3. Encourage and
maintain bed rest
during the acute
phase.
Rationale:
Minimizes
stimulation and
promotes
relaxation.
4. Provide or
recommend non
pharmacological
measures to
relieve headache
such as cool cloth
to forehead; back
and neck rubs;
quiet, dimly lit
room; relaxation
techniques
(guided imagery,
distraction); and
diversional
activities.
Rationale:
Measures that
reduce cerebral
vascular pressure
and slow or block
sympathetic
response
effectively relieve
headaches and
183
associated
complications.
5. Provide a dim
and light but
providing good
ventilation.
Rationale: To add
comfort to the
patient.
6. Eliminate or
minimize
vasoconstricting
activities that may
aggravate
headache
(straining at stool,
prolonged
coughing,
bending over).
Rationale:
Activities that
increase
vasoconstriction
accentuate the
headache in the
presence of
increased
cerebral vascular
pressure.
7. Assist patient with
ambulation as
needed.
Rationale:
184
Dizziness and
blurred vision
frequently are
associated with
vascular
headaches. The
patient may also
experience
episodes of
postural
hypotension,
causing
weakness when
ambulating.
8. Provide more
liquids, and
advise to take a
soft diet. If nose
bleeding occurs,
provide nasal
packing.
Rationale: These
measures
promote general
comfort. Nasal
packing makes
the patient
breathe through
the mouth, so the
mucus membrane
becomes dry. To
avoid that,
provide mouth
185
care frequently.
9. Assist in self-care
activities as
tolerated.
Rationale: To
promote client
independence as
much as possible
and acquire
sense of function
10. Administer
medications as
ordered by
physician
(analgesics, etc)
Rationale:
Medications will
provide
synergistic effect
with
nonphramacologi
c interventions for
pain relief and
promote better
circulation by
aiding in
vasodilation for
better blood flow
to the brain and
altering
prostaglandin
synthesis to
decrease pain
186
Activity intolerance related to After 4 hours of nursing 1. Assess the vital

generalized weakness as intervention, the patient will signs or
evidenced by fatigue, dyspnea be able to: cardiopulmonary
and inability to perform response of any
activities of daily living. a. Identify factors physical activity
affecting activity of the patient
Rationale: intolerance and try to Rationale: Note
Hypertensive crisis is an reduce those factors' down the
umbrella term for hypertensive effects, whenever response before
urgency and hypertensive possible. activity, during
emergency wherein blood b. demonstrates activity and after
pressure spikes up to 180/120 physiological signs activity.
or higher. The main difference of intolerance 2. Note down the
between the two is that if organ c. participates in patient’s difficulty
damage is present or not. desired activities of in doing desired
Either way, both conditions his interest. activities
result with the heart not being Rationale:
able to pump blood effectively, Evaluate the
resulting in generalized activity, current
weakness and other symptoms limitations of the
such as headache client in
accompanied by confusion and performing those
blurred vision, shortness of activities. It gives
breath, anxiety, and severe baseline data
chest pain. This condition can about clients
lead to activity intolerance activity. It also
wherein there is insufficient helps to plan an
physiological or psychological effective
energy to endure various intervention to
activities. (Jimenez, n.d.) improve clients
activity tolerance
levels.
3. Advise patient to
187
take rest in
between
activities.
Rationale: It
reduces fatigue
4. Assist patient with
self-care activities
Rationale: The
intensity of the
activity can also
be reduced or
adjusted. It
reduces
overexertion.
5. Encourage the
patients to
express their
feelings during
and after the
activity. Provide
positive
reinforcement to
the patient
acknowledging
the difficult
situation of the
client.
Rationale:
Positive
reinforcement
helps to minimize
frustration and
rechannel energy.
188
6. involve patients
during the
planning of
activities.
Rationale: It gives
a chance to the
client to perform
the activity of
their choice
during the peak of
their energy.
7. Provide assistive
devices and
monitor the
patient while
performing any
activity with those
devices.
Rationale: It
provides smooth
mobility and
prevents injury.
8. Involve other
disciplines and
plan for graded
exercise or
rehabilitation
programmes for
the client.
Rationale: It
reduces
excessive
myocardial
189
workload and the

demand for
oxygen.
9. Inform the client
about his daily
and weekly
progression.
Rationale: It
sustains the
motivation of
doing the activity.
10. Identify
treatment-related
factors such as
medication or any
other therapy
which affect
activity.
Rationale: These
factors can also
affect the nature
and degree of
activity
intolerance.
Decreased cardiac output After 8 hours of nursing 1. Educate family

related to slow heart rate intervention, the patient will and patient about
associated with hypertension be able to: the disease,
complications of
Rationale: a. Verbalize future disease, and
Decreased cardiac output may self-care activities to information on
result in insufficient blood improve cardiac medications.
supply and compromise vital health Rationale: Early
190
reactions. This can result in b. Return to baseline recognition of

transition towards anaerobic activity level symptoms
metabolic pathways which lead c. Show adequate facilitates early
to production of lactic acid, cardiac output as problem solving
reduced cellular pH, enzyme evidenced by blood and prompt
denaturation, and altered pressure, heart rate, treatment.
membrane potential. If not and rhythm within 2. Educate patient
addressed, decreased cardiac normal limits. the need for and
output can lead to tissue and how to
organ damage. Impaired incorporate
cardiac function and decreased lifestyle changes.
cardiac output can be caused Rationale:
by hypertension, congestive Psychoeducation
heart failure and coronary al programs
disease. (King, 2020) including
information on
stress
management and
health education
have been shown
to reduce long
term mortality and
recurrence of the
disease.
3. Check heart rate
or auscultate for
any tachycardia
or bradycardia.
Rationale: to
clearly identify the
condition.
4. Monitor response
of the patient to
191
activity.
Rationale:
Sometimes the
cardiac output is
normal when the
patient is at rest.
Cardiac out
becomes
insufficient when
the patient is
involved in some
physical activities.
5. Assess heart rate
and blood
pressure.
Rationale: Most
patients have
compensatory
tachycardia and
significantly low
blood pressure in
response to
reduced cardiac
ouput.
6. Position patient in
semi-fowler’s to
high-fowler’s
position.
Rationale: Upright
position is
recommended to
reduce preload
and ventricular
192
filling when fluid

overload is the
cause.
7. If required, assist
the patient with
activities of daily
living.
Rationale:
Patients with
decreased
cardiac output are
restless and may
experience
lightheadedness.
This is to prevent
injury.
8. Provide a
comfortable
position to the
client on bed and
chair. Raise legs
20 to 30 degrees.
Rationale: It
decreases
oxygen
consumption and
reduces the
workload on the
myocardium.
9. Encourage
relaxation
techniques such
as deep breathing
193
exercise
Rationale: To
reduce anxiety
and conserve
energy
10. Instruct patient to
avoid or limit
activities that may
stimulate a
valsalva response
such as bearing
down during
bowel movement
Rationale: To
prevent changes
in cardiac
pressure and
impede blood
flow.
I. Literature
Title: A Role of Clinical Trial in Management of Hypertension and Medication of

Hypertension
Every year, new management and treatment in hypertension come out making the
patient's total health care elevated above standards. Hence, clinical trials are essential for
the progress of new treatments. Clinical trials are research reviews in which people
volunteer to attempt major treatments, interventions or experiments as a means to forbid,
detect, evaluate or manage assorted diseases or medical conditions. Some of these
investigations glance at how people react to a new arbitration and what side effects occur. In
addition to Research on new drugs and devices, clinical trials bring a scientific footing for
urge and treating patients. Blood pressure is a great way to measure the current health of a
194
person. The larger the blood pressure is, the larger the risk of health problems in the future.
If the blood pressure is higher than normal, it is putting extra work on the arteries, in turn,
overworking the heart. High blood pressure clouts your heart to work higher to pump blood
to the comfort of your body. This causes part of your heart (left ventricle) to congeal. A
congeal left ventricle high your risk of heart attack, heart failure and sudden cardiac death.
Heart failure and this may lead to death.
The fame of High blood pressure is world resounding. In fact, it endures a crucial
global disease of cardiovascular anguish and mortality. Scheme for evaluating hypertension
go on to derive as new illustrations become applicable from clinical drug trials or Conclusion
studies on hypertension treatment. As new hypertension codes become available, the quiver
of these trials become conspicuous from changes in the sanction of treatment, option of
drugs, options of treatment in like situations and ambition of therapy. The treatment of
hypertension goes on to derive and although some ambition for hypertension treatment is
planted on consensus, important are dependent on clues from large clinical drug trials or
review studies. The control of hypertension was made approximately 38 years ago and were
frequently new as new data and clues on hypertension treatment or diagnosis and
pathophysiology incline available 1 Hypertension, the dominant risk factor for cardiovascular
disease, arise from both genetic, environmental, and civil determinants. Environmental
factors consist of overweight/obesity, unhealthy diet, enormous dietary sodium, meager
dietary potassium, scant physical actions, and misuse of alcohol. avoidance and domination
of hypertension can be got through spotted and/or population-based blueprint. For control of
hypertension, the objective strategy commits interventions to high awareness, treatment,
and control in each other (J. Pharm. and Tech., June 2021).
Title: Hypertension and adiposity indices: commentary on the associations of

adiposity indices with hypertension in Brazil (Souza et al., 2021)
According to the statistics of WHO, hypertension is a major public health problem all
over the world with one billion people affected worldwide and a leading risk factor for
Coronary Vascular Disease (CVD). Hypertension is responsible for at least 45 and 51 %,
respectively, of mortality due to heart attack and stroke. Therefore, the early diagnosis and
appropriate management of hypertension to prevent the development of complications is
crucial. A simple method to determine the need to screen an individual for hypertension is by
195
evaluating his/her adiposity status. Among the key contributors to hypertension is

overweight and obesity, which has reached epidemic proportions globally.
With these, various instruments are used such as BMI, waist circumference (WC),
waist-to-hip ratio (WHR) and recently waist-to-height ratio (WHtR) are used to determine
overweight and obesity. WC, WHR and WHtR determine visceral or central obesity, which
better identifies cardiometabolic diseases such as hypertension and diabetes compared with
BMI, a known measure of general adiposity. Nevertheless, the optimal overweight and
obesity threshold which identifies cardiometabolic diseases by these instruments may vary
across populations. This is on account of differences in body composition across age,
gender and ethnicity.
Souza et al. emphasized the need for different optimal adiposity thresholds by age
group(5). However, it is important to maintain the ease of use of these adiposity instruments
by having a single threshold level, for each gender at most. These adiposity measures are
frequently used at primary care level by lower-level health-care workers. Multiple adiposity
threshold levels for different age groups may create confusion and be time consuming when
categorizing patients. This may lead to a reluctance to utilize measures that are otherwise
low cost and easy to perform. WC, WHtR and WHR require only a measuring tape while
BMI requires a scale as well. Nevertheless, with aging populations globally, research may be
required to determine the utility of current thresholds in the elderly and whether cut-off points
need to be adjusted accordingly.
WHtR has come into vogue over the last decade as an indicator of cardiometabolic
risk because of the simple message that it conveys: ‘your WC should be less than half of
your height’ (4,8). Furthermore, unlike the other measures of central obesity such as WC
and WHR, there is a single threshold for both genders and it has been found to be
appropriate for several ethnic groups. Souza et al. concluded that WHtR performed
comparably to WC and BMI in identifying hypertension.
196
VI. Dengue
A. Definition
A mosquito-borne viral disease called dengue virus has been rapidly spreading
throughout all regions in recent years. It has also been consistently emerging throughout the
tropics, with a local variation at risk of influence, such as rainfall, temperature, relative
humidity, and rapid urbanization. Severe dengue is a leading cause of serious illness and
death in some Asian and Latin American countries.
According to the WHO, Dengue is a mosquito-borne viral disease that has rapidly
spread to all regions of WHO in recent years. Dengue virus is transmitted by female
mosquitoes mainly of the species Aedes aegypti and, to a lesser extent, Ae. albopictus.
These mosquitoes are also vectors of chikungunya, yellow fever and Zika viruses. Dengue
is widespread throughout the tropics, with local variations in risk influenced by climate
parameters as well as social and environmental factors.
Dengue spreads to people through the bite of an infected mosquito. It does not
spread directly from person to person. However, a pregnant person can pass the infection
on to the baby. In rare cases, it can spread through a blood transfusion, organ transplant, or
needle stick injury.
About one in four people infected with dengue will get sick. For those who do get
sick, the infection can be mild or severe. The symptoms of dengue include high fever,
nausea and vomiting rash, aches and pains (eye pain, usually behind the eyes, and pain in
the muscles, joints, or bones) which usually last two to seven days.
Severe dengue is a serious form of the illness. About 1 in 20 people who get sick
with dengue will develop severe dengue. It can cause shock, internal bleeding, and even
death. People are more likely to develop severe dengue if they have had dengue before, are
pregnant, or are infants.
Severe dengue happens when your blood vessels become damaged and leaky. And
the number of clot-forming cells (platelets) in your bloodstream drops. This can lead to
shock, internal bleeding, organ failure and even death.
197
Warning signs of severe dengue fever — which is a life-threatening emergency — can

develop quickly. The warning signs usually begin the first day or two after your fever goes
away, and may include severe stomach pain, persistent vomiting, bleeding from your gums
or nose, bleeding under the skin which may look like bruising & irritability or restlessness.
Researchers are working on dengue fever vaccines. For now, in areas where dengue
fever is common, the best ways to prevent infection are to avoid being bitten by mosquitoes
and to take steps to reduce the mosquito population.
Liver
The human liver is the largest internal organ (the skin being the largest organ
overall) and the largest gland in the human body. It is a soft, pinkish-brown, triangular organ
typically weighing 1.44–1.66 kg (3.2–3.7 lb). It sits just below the diaphragm in the right
upper quadrant of the abdominal cavity. The liver is located to the right of the stomach and
sits on top of the gallbladder. The hepatic artery and portal vein are two large blood vessels
that connect to the liver. The hepatic artery transports blood from the aorta to the liver,
whereas the portal vein transports blood from the entire gastrointestinal tract and the spleen
and pancreas to the liver. These blood vessels subdivide into capillaries, which eventually
lead to a lobule.
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The liver regulates most chemical levels in the blood and excretes bile—this aids in
the removal of waste products from the liver. The liver filters all blood that leaves the
stomach and intestines. The liver processes this blood, breaking down, balancing, and
creating nutrients and metabolizing drugs into forms that are easier for the rest of the body
to use or that are nontoxic.
The liver is responsible for over 500 vital functions. The following are some of the
more well-known functions: (1) production of bile, which helps carry away waste and break
down fats in the small intestine during digestion, (2) production of specific proteins for blood
plasma, (3) production of cholesterol and special proteins to help carry fats through the
body, (4) conversion of excess glucose into glycogen for storage (glycogen can later be
converted back to glucose for energy) and to balance and make glucose as needed, (5)
regulation of blood levels of amino acids, which form the building blocks of proteins, (6)
processing of hemoglobin for the use of its iron content (the liver stores iron), (7) conversion
of poisonous ammonia to urea (urea is an end product of protein metabolism and is excreted
in the urine), (8) clearing the blood of drugs and other poisonous substances, (9) regulating
blood clotting, (10) resisting infections by making immune factors and removing bacteria
from the bloodstream, (11) clearance of bilirubin, also from red blood cells. If there is an
accumulation of bilirubin, the skin and eyes turn yellow. When the liver has broken down
harmful substances, its by-products are excreted into the bile or blood. Bile by-products
enter the intestine and leave the body in the form of feces. Blood by-products are filtered out
by the kidneys, and leave the body in the form of urine.
The liver is considered as an important target for DENV infection and is the most
common organ to be involved in the disease. Hepatic alterations are key characteristics
found in DENV cases. As observed in biopsies and autopsies of previously reported fatal
cases, hepatocytes and Kupffer cells are described as important targets during DENV
infection. Comparatively speaking to other organs, the disease most frequently affects the
liver. Through a variety of mechanisms, including direct viral effects on hepatocytes and
Kupffer cells, immunological hyperactivity caused by a T cell-mediated cytokine storm, and
circulatory failure that reduces hepatic perfusion, dengue damages the liver.
199
Kidney
On either side of the spine, near the base of the rib cage, are two kidneys, each
about the size of a fist. Up to a million nephrons, or functional units, can be found in each
kidney. A tubule and a glomerulus, a collection of microscopic blood arteries used for
filtration, make up a nephron. The glomerulus filters the blood as it enters, and the liquid that
is left then travels along the tubule. According to the body's requirements, chemicals and
water are either added to or subtracted from this filtered fluid in the tubule, with the result
being the urine we expel.
About 200 quarts of fluid are filtered and returned to the bloodstream by the kidneys
every 24 hours as part of their life-sustaining function. Two quarts of urine are excreted from
the body, and around 198 quarts are retrieved. The bladder has been holding onto the pee
we expel for anywhere between one and eight hours.
The body's fluid balance is maintained by the kidneys, which also eliminate drugs from the
body, filter waste products from the body, release hormones that control blood pressure,
make an active form of vitamin D that supports the development of strong, healthy bones,
and regulate the production of red blood cells.
200
It is now known that dengue virus infection affects the kidneys since proteinuria and
hematuria are so common—up to 80% of people have been said to have them. Although the
exact mechanisms causing dengue kidney problems are unknown, host immunity may play
an indirect role. Renal sections taken from post-mortem dengue cases were also taken into
consideration for investigation because of these information gaps.
Brain
The brain is a powerful organ that manages every bodily function as well as thought,
memory, emotion, touch, motor skills, vision, respiration, temperature, and hunger. The
central nervous system, or CNS, is made up of the spinal cord that emerges from the brain.
Cerebrum - The cerebrum (front of brain) comprises gray matter (the cerebral cortex) and
white matter at its center. The largest part of the brain, the cerebrum initiates and
coordinates movement and regulates temperature. Other areas of the cerebrum enable
speech, judgment, thinking and reasoning, problem-solving, emotions and learning. Other
functions relate to vision, hearing, touch and other senses.
Cerebral Cortex - Cortex is Latin for “bark,” and describes the outer gray matter covering of
the cerebrum. The cortex has a large surface area due to its folds, and comprises about half
of the brain’s weight.
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Brainstem - The brainstem (middle of brain) connects the cerebrum with the spinal cord. The
brainstem includes the midbrain, the pons and the medulla.
Cerebellum - The cerebellum (“little brain”) is a fist-sized portion of the brain located at the
back of the head, below the temporal and occipital lobes and above the brainstem. Like the
cerebral cortex, it has two hemispheres. The outer portion contains neurons, and the inner
area communicates with the cerebral cortex. Its function is to coordinate voluntary muscle
movements and to maintain posture, balance and equilibrium. New studies are exploring the
cerebellum’s roles in thought, emotions and social behavior, as well as its possible
involvement in addiction, autism and schizophrenia.
C. Symptomatology
Abdominal pain The most frequently reported symptom of DF

is abdominal pain. It is also a main warning
indication of dengue. It can be an indication of
a capillary leak, which occurs when blood
plasma escapes through tiny blood vessels
called capillaries and harms organs. In these
situations, prompt medical attention can help
prevent complications and hence save lives
(Mayo Clinic, 2023).
Diarrhea Dengue fever, whose mosquito vectors

reproduce in stored water containers, may be
epidemiologically connected to diarrheal
disorders resulting from tainted drinking water
as a result of subpar water collecting and
storage procedures. As a result, the two
diseases can be connected by the containers
used to hold water (National Center for
202
Biotechnology Information [NCBI], n.d.)
High Fever Dengue virus is a mosquito-transmitted

disease that affects tropical and subtropical
Headache
regions of the world. Interferons, a tiny protein
that is a member of the larger family of
proteins known as cytokines, are produced
and released by infected cells. Interferons can
prevent viral replication and stimulate the
innate and adaptive immune systems. They
aid in the immune system's recognition of
dengue-infected cells and aid in preventing
infection of uninfected cells. As the immune
system fights the dengue infection, the person
experiences a high fever, and headache as
well. The severe variety of dengue fever, also
known as dengue hemorrhagic fever, can
result in fatalities as well as significant
bleeding, a sharp drop in blood pressure, and
shock (Mayo Clinic, 2022).
Pain in joints, muscles and/or bones Early in the course of the illness, symptoms
including muscle discomfort, tenderness, and
minor swelling are common. Even in the
absence of any weakening, the pain frequently
affects the proximal muscles in the legs and
the back, making it difficult to walk. Muscle
discomfort is most likely caused by a direct
viral invasion of the muscles, followed by
inflammatory alterations that develop as a
result (Trivedi & Chakravarty, 2022).
Retro-orbital pain It is unclear how exactly the eye becomes

involved in dengue virus infection. Viral
203
agents, immunological mediation, capillary

leakage, stress, and bleeding are a few of the
possible causes. When the platelet count is at
its lowest and when it starts to rise, eye
involvement is typically observed. The most
common complaint, while symptoms are non
pathognomonic, is blurred vision, however,
there are many different ways it might present.
In addition to complex examinations,
funduscopy, and ophthalmological evaluation
are highly helpful (Yudhishdran et al., 2019).
Vomiting Vomiting is the body's method of removing

harmful substances from the stomach, yet it
can also be a reaction to something that has
irritated the digestive tract (National Health
Service, 2023).
D. Etiology
Age People of all ages are affected by dengue.

However, children under the age of 15 often
only show a nonspecific, self-limiting febrile
sickness. A high adult immunity prevalence in
endemic areas may prevent epidemics from
reaching children.
Geographical Area In tropical and subtropical areas, dengue is a

disease carried by mosquitoes. Aedes
mosquitoes reproduce in the peridomestic
environment and are the disease carriers.
204
America, Southeast Asia, and the Western

Pacific are the most severely impacted
regions, with Asia accounting for 70% of the
worldwide disease burden.
Previous Dengue Infection Dengue virus (DENV) is the term for the virus
that causes dengue. Since there are four
DENV serotypes, an individual may contract
the virus four times. Immunity against that
serotype is thought to last a lifetime following
infection recovery. Cross-immunity to the
other serotypes is only temporary and partial
following recovery. The risk of acquiring
severe dengue is increased by subsequent
infections (secondary infection) by various
serotypes.
Urbanization The rise or reemergence of vector-borne

diseases has been prompted by
urbanization, climate and environmental
change, more significant international travel
and trade, and other societal concerns. Since
urbanization fosters the survival of the Aedes
species, it is frequently linked to the
establishment and spread of vector-borne
diseases. Clogged street drains and gutters
collect water, which creates mosquito
breeding grounds. It can be found worldwide
in tropical and subtropical climates, primarily
in urban and semi-urban settings.
205
Travel History The spread of dengue fever has always been

aided by travel. For instance, the global
movement of troops and cargo ships during
World War II helped spread Aedes
mosquitoes, leading to extensive
development of the illness in Southeast Asia.
By visiting other countries, you could
unknowingly bring this virus with you. In
areas where this virus is widespread, this is
certainly relevant.
206
E. Pathophysiology
207
208
209
210
Narrative
The pathogenesis of dengue infection starts when an infected female Aedes Aegypti
mosquito bites a person for a blood meal. During mosquito feeding, the virus is injected into
the blood. The female Aedes mosquito needs blood for its egg maturation, and unlike other
mosquitoes, they are daytime feeders and commonly bite on the back of the neck and ankle
area. The primary reservoir of the virus is humans; when a non-infected Aedes mosquito
bites an infected person, the virus is transmitted into the mosquito, and it becomes infected,
and when this mosquito bites another non-infected person, the person also becomes
infected, this then becomes the primary method of viral transmission. Another source of
infection is any stagnant water in every home and a common breeding site for mosquitoes.
Moreover, environmental conditions such as open spaces with water are another source of
infection. In other hospitals, patients admitted with suspected dengue are encouraged to use
bed nets to prevent transmission during an outbreak because a dengue infection can spread
for around four to five days.
The virus enters the body through skin penetration during a mosquito bite. It infects
the immature dendritic cells (Langerhans cells) found in the skin's epidermis and serves as
the antigen-presenting cells. The infected dendritic cells then go to the lymphatic system
through the circulation to alert the system, leading to high amounts of virus in the
bloodstream (viremia). It will then travel to the lymph node, alerting the lymphatic system.
Furthermore, monocytes and macrophages are recruited to the lymph nodes to stop the
infection. These antibodies will also infiltrate the spleen and bone marrow; however, these
cells also become infected by the virus after the recruitment. These cells produce a large
number of cytokines, which facilitate the stimulation of white blood cells and pyrogen
production, resulting in dengue fever. Febrile phase usually lasts 2-7 days. Its symptoms
include sudden onset fever, headache, abdominal pain, vomiting, nausea, myalgia,
retro-orbital pain, and diarrhea and minor hemorrhagic manifestations including petechiae,
ecchymosis, purpura, epistaxis, bleeding gums, hematuria, or a positive tourniquet test
result. Various laboratory tests will be ordered by the physician which includes CBC, Dengue
NS1 antigen, Dengue IgM/IgG, MAC ELISA, Polymerase Chain Reaction,and Plaque
Reduction Neutralization Test. Dengue has no specific treatment and its management
includes giving of antipyretics every 4 hours, increasing fluid intake, hydration with IV fluids,
antiemetics as ordered by the physician, and applying hot and cold compress.
211
After becoming infected, monocytes and macrophages are unable to stop the viral
replication, leading to an increase in viral load while the host cells die through apoptosis.
The spleen, liver, and bone marrow will all get infected as a result of the increasing viral load
as it spreads through the bloodstream. Leukopenia and thrombocytopenia occur which is
caused by the virus’s direct destructive activity on red bone marrow precursor cells, thus the
patient will experience severe bone pain, also known as “break-bone pain”. Interventions in
break-bone pain include applying hot or cold compress, and giving pain relievers. Platelet
transfusion in thrombocytopenia is indicated in patients with significant bleeding. Then the
virus will target the parenchymal cells of the liver and spleen, where infection results in
apoptosis, causing hepatosplenomegaly which leads to dengue-hemorrhagic fever or severe
dengue. This will lead to increased number and pores of the capillaries, which results in fluid
leakage from the blood into the interstitial fluid. The critical phase of dengue usually starts at
defervescence and usually lasts for 24 to 48 hours. Due to extensive plasma leakage it can
lead to pleural effusions, ascites, and hemoconcentration. This phase requires close
monitoring because of the sudden changes in laboratory results such as increased
hematocrit, decreased WBC, and decreased platelet. Moreover, management such as
increasing OFI, limit staining with bowel movements and administration of crystalloid fluids,
diuretics and antipyretics can result if faster recovery, With this, the onset of the recovery
phase can be identified by improvement in WBC and hematocrit levels as well as the
gradual reabsorption of extravasated fluid such as from plasma leakage over 48–72 hours.
Consequently, this will lead to good prognosis, However, if it remains untreated, it can
progress and complications such as intense bleeding, pulmonary edema, severe
hypotension and hypovolemic shock can arise, resulting in poor prognosis.
212
Diagnostic Test
Diagnostic Test Rationale
Dengue NS1 RDT NS1 is a non-structural protein of dengue virus, this is present in
the blood during a dengue infection. This test is done when the
dengue virus is still in the acute phase or during the 0-7 days of
symptoms. If it exceeds 7 days NS1 is not recommended. A
positive NS1 indicates dengue infection however, it doesn’t
provide serotype information. Although it is not necessary for the
patient's care, NAAT is done for surveillance purposes.
MAC-ELISA On the dengue MAC-ELISA they would need the IgM antibodies
of the client on a microtiter plate with the use of anti-human-IgM
antibody and with an addition of dengue virus antigen. While the
immune system fights the infection, the IgM antibodies would be
detectable starting at 4-5 days after the onset of symptoms, they
would remain detectable for approximately 12 weeks. A positive
IgM indicates a presumptive, recent dengue virus infection.
Plaque Reduction Is done to precisely determine the cause of infection in patient

Neutralization Test who have an IgM positive result. This is to rule out the presence
(PRNT) of other viruses such as flaviviruses like zika or yellow fever. But
mostly used to determine what type of dengue virus serotype is
present. If the result of PRNT showcases neutralizing antibodies
on one dengue virus serotype it confirms the infection to that
serotype.
213
Polymerase Chain Patients who have persistent signs and symptoms of dengue,
Reaction (PCR) serum or plasma will be collected to determine the presence of
current dengue infection. Blood samples can also be used for
patients suspected with dengue who are taken 1-7 days after the
onset of fever. In cases when blood is taken after 7 days or more
from onset of symptoms, IgM antibody is done and also in cases
when the result of PCR came in negative IgM testing is
recommended.
Nucleic Acid Amplification NAAT is the preferred method of diagnosis of dengue infections,
Test (NAAT) since it provides confirmed evidence of infection. Patients who
are symptomatic for the first 1-7 days of illness, a serum sample
should be tested with a NAAT and IgM antibody as both test are
performed in serum. Performing both increases the chances of
confirming cases than performing one test. A positive result of
NAAT indicates dengue virus infection.
Complete Blood Count Blood will be drawn from the patient to look for signs of low
(CBC) platelet count, deceased levels of hemoglobin, hematocrit and red
blood cell. Decrease levels red blood cell could indicate blood
loss due to severe dengue fever.
Drug Study
Generic Name Paracetamol/Acetaminophen

214
Brand Name RiteMed Paracetamol
Classification Pharmacotherapeutic: Central analgesic

Clinical: Non-narcotic analgesic, antipyretic
Mechanism of Action Appears to inhibit prostaglandin synthesis in the CNS and, to a

lesser extent, block pain impulses through peripheral action. Acts
centrally on hypothalamic heat-regulating center, producing
peripheral vasodilation (heat loss, skin erythema, diaphoresis).
Indications Temporary relief of mild to moderate pain, headache, fever.
Suggested Dose and PO: ADULTS, ELDERLY, CHILDREN 13 YRS AND OLDER:
Frequency (Regular Strength) 325–650 mg q4–6h. Maximum: 3,250 mg/day
unless directed by a health care provider. (Extra Strength) 1000
mg q6h. Maximum: 3,000 mg/day unless directed by a health
care provider. CHILDREN 12 YRS AND YOUNGER: (Weight
dosing preferred; if not available, use age. Doses may be
repeated q4h. Maximum: 5 doses/day.)
Contraindications Severe hepatic impairment or active liver disease (IV)
Side Effects Hypersensitivity reaction.
Adverse Effects Early Signs of Acetaminophen Toxicity: Anorexia, nausea,

diaphoresis, fatigue within first 12–24 hrs.
Later Signs of Toxicity: Vomiting, right upper quadrant
tenderness, elevated LFTs within 48–72 hrs after ingestion.
215
Drug Interaction DRUG: Alcohol (chronic use), hepatotoxic medications (e.g.,

phenytoin), hepatic enzyme inducers (e.g., phenytoin, rifAMPin)
may increase risk of hepatotoxicity with prolonged high dose or
single toxic dose. May increase risk of bleeding with warfarin with
chronic, high-dose use.
HERBAL: St. John’s wort may decrease blood levels.
FOOD: Food may decrease the rate of absorption.
LAB VALUES: May increase serum ALT, AST, bilirubin;
prothrombin levels (may indicate hepatotoxicity).
Nursing Responsibilities ● Obtain baseline vital signs and monitor changes in

temperature.
● Assess for effectiveness or clinical improvement of
acetaminophen by assessing pain levels and fever
reduction.
● Advise patients not to take more than 4g/day.
● Monitor signs of hypersensitivity or bronchospasm such
as swelling of face, lips, eyelids, rash, difficulty breathing.
● IV acetaminophen should be infused over 15 minutes.
● Monitor for hematologic reactions, such as signs of
anemia and decreased red and white blood counts.
● Advise patient not to take avoid intake of alcohol while
administrating this drug.
● Promote for an increase of oral fluids.
● Document the given medication upon administration to
prevent doubling of dose
● Instruct patient to properly store the drug by protecting it
from light and excessive heat, store between 20-25°C for
oral meds while for IV injection store between 2-27°C. Do
not refrigerate
216
Generic Name Betamethasone
Brand Name RiteMED Betamethasone Dipropionate
Classification Pharmacotherapeutic: adrenocorticosteroid

Clinical: anti-inflammatory, immunosuppressant.
Mechanism of Action Controls rate of protein synthesis, depresses migration of

polymorphonuclear leukocytes/fibroblasts, reverses capillary
permeability, prevents or controls inflammation.
Indications Treat inflammatory & pruritic dermatoses that respond to

corticosteroids eg, atopic & contact dermatitis, neurodermatitis
(lichen simplex chronicus), lichen planus, eczema (including
nummular eczema, hand eczema, eczematous dermatitis),
intertrigo, dyshidrosis, seborrheic dermatitis, exfoliative
dermatitis, solar dermatitis, statis dermatitis, anogenital pruritus &
senile pruritus.
Suggested Dose and Topical: (Cream/Ointment):ADULTS, ELDERLY: 1–2 times daily.

Frequency: Foam: Apply twice daily (morning and night).
Contraindications Hypersensitivity to betamethasone. IM administration in idiopathic

thrombocytopenia purpura.
Side Effects Burning, stinging, pruritus.
Adverse Effects Overdose may cause systemic hypercorticism, adrenal

suppression.
217
Drug Interaction DRUG: Amphotericin may increase risk of hypokalemia. May

decrease effects of insulin, oral hypoglycemics (e.g., glimepiride,
metFORMIN, SITagliptin), potassium supplements. May increase
digoxin toxicity (due to hypokalemia). Hepatic enzyme inducers
(e.g., carBAMazepine, PHENobarbital, rifAMPin) may decrease
effect. Live virus vaccines may potentiate virus replication,
increase vaccine side effects, decrease pt’s antibody response to
vaccine.
HERBAL: Cat’s claw, echinacea possess immunostimulant
effects.
FOOD: None known.
LAB VALUES: May decrease serum calcium, potassium,
thyroxine. May increase serum cholesterol, lipids, glucose,
sodium, amylase.
Nursing Responsibilities 1. Examine area for infections and skin integrity before
application.
2. Wash your hands with soap and water before and after
using this medicine.
3. Administer cautiously to pregnant patients; topical
corticosteroids have caused teratogenic effects and can
be absorbed from systemic sites.
4. Report irritation or infection at the site of application
5. Report for some burning and stinging feeling few minutes
after applying the cream
6. Instruct patient to avoid using cosmetics or other skin care
products on the treated areas.
7. Use caution when occlusive dressings or tight diapers
cover affected area; these can increase systemic
absorption of the drug.
8. Instruct patient to avoid prolonged use near eyes, in
genital and rectal areas, and in skin creases.
218
9. Instruct patient to avoid exposure to infections; ability to

fight infections is reduced.
10. Protect the skin from water, clothing, or anything that
causes rubbing until the medicine has dried.
Generic Name Metoclopramide
Brand Name Reglan
Classification Antiemetic; GI stimulant
Mode of Action Stimulates motility of upper GI tract without stimulating

gastric, biliary, or pancreatic secretions; appears to sensitize
tissues to action of acetylcholine; relaxes pyloric sphincter,
which, when combined with effects on motility, accelerates
gastric emptying and intestinal transit; little effect on gallbladder
or colon motility; increases lower esophageal sphincter
pressure; has sedative properties; induces release of prolactin
Suggested Dose 10-15 mg PO up to 4 times/day 30 minutes before each meal

and at bedtime for 2-8 weeks
Route of Administration Oral, Intramuscular and Intravenous
Indication Metoclopramide is used to treat the symptoms of slow stomach

emptying (gastroparesis) in patients with diabetes. It works by
increasing the movements or contractions of the stomach and
intestines. It relieves symptoms such as nausea, vomiting,
219
heartburn, a feeling of fullness after meals, and loss of appetite.
Contraindication Allergy to metoclopramide, GI hemorrhage, Mechanical

obstruction or perforation, Pheochromocytoma, Epilepsy
Side Effects Chills, fever, nausea, vomiting, headache, diarrhea, drowsiness,

restlessness, increased sweating, itching, flushing, sore throat,
dry mouth, pale skin.
Adverse Effects Insomnia, seizure, anxiety, transient hypertension, visual

disturbance, confusion, hallucinations, irritability, muscle pain,
clay colored stools, dark urine.
Drug Interaction ● Decreased absorption of digoxin from the stomach

● Increased toxic and immunosuppressive effects of
cyclosporine
● Increased neuromuscular blocking effect of
succinylcholine
Nursing Responsibilities 1. Observe 10 rights in drug administration.

Rationale: Understanding and practicing the 10 Rights of
Medication Administration helps promote safe
administration of medications, prevent incidents and
harm, and support safe patient/client/resident care.
2. Assess for allergy to metoclopramide.
Rationale: This product may contain inactive ingredients,
which can cause allergic reactions or other problems.
3. Advise patient to avoid concurrent use of alcohol and
other CNS depressant while taking this medication
Rationale: This medicine will add to the effects of alcohol
and other CNS depressants
4. Do not drive or do anything else that could be dangerous
until you know how this medicine affects you.
Rationale: This medicine may make you dizzy, drowsy, or
have trouble with thinking or controlling body movements.
220
5. Monitor BP before and after administration of drug.

Rationale: Your blood pressure might get too high while
you are using this medicine. This may cause headaches,
dizziness, or blurred vision.
6. Advise patient to take this medicine on an empty
stomach, at least 30 minutes before meals and at
bedtime.
Rationale: Taking the drug after eating, sometimes the
drug has not had time to take effect, the patient has
nausea and vomiting. Therefore, oral antiemetics should
be taken before meals will be more effective than after
meals.
7. Advise patients to immediately inform their healthcare
provider if they experience a change in heart rate,
lightheadedness, or feel faint or have any signs and
symptoms of hypersensitivity reactions such as fever,
chills, rash, or breathing problems.
Rationale: To immediately provide nursing interventions.
8. Assess mental status of the patient after taking the
medicine
Rationale: One of the adverse effects of this medicine
can affect our mental status and it should be reported
immediately if there are any changes.
9. Instruct patient to report persistent vomiting and diarrhea.
Rationale: To immediately provide nursing intervention.
10. Instruct patient to take drug exactly as prescribed.
Rationale: A better health outcome is the most significant
benefit of using medication correctly as prescribed.
Treatment
221
Therapy Rationale
Platelet Transfusion Prophylactic platelet transfusions are deﬁned as

platelet transfusions given in the absence of clinical
bleeding, in contrast to therapeutic platelet
transfusions given to patients with clinical bleeding.
There is controversy as to the efficacy of
prophylactic platelet transfusions and the exact
trigger for platelet transfusion in dengue
Oral Rehydration Therapy Patients with severe dengue present with severe
dehydration. This is the most common complication
in dengue cases and also the main cause of death,
related to plasma leakage. Oral rehydration therapy
is recommended as the first line for patients who are
moderately dehydrated due to high fever and
vomiting.
Diet Therapy Patients with dengue are recommended with Diet

Therapy. It is a method of eating prescribed by a
physician to improve health. A number of conditions
are treated in part with therapeutic diets. Treatments
involve including foods that improve specific health
conditions, while avoiding foods that may make the
condition worse.
222
Dengue infections are increasing globally and account for significant morbidity and
mortality. Severe dengue results in microvascular changes and coagulopathy that may make
surgical intervention risky and the overall surgical management challenging. We outline the
potential surgical manifestations and complications following dengue infections and describe
the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients.
The main surgical presentations were acute cholecystitis, acute pancreatitis, acute
appendicitis, splenic rupture, bowel perforation, gastrointestinal bleeding, and hematomas.
Dengue may also mimic an acute abdomen without any true surgical complications. A
majority were treated nonoperatively. Misdiagnosis and unnecessary surgical intervention
resulted in poor outcomes. Better knowledge of the potential surgical complications would
help in early diagnosis, treatment, and referral to specialized centers and thus improve
outcomes. A high degree of suspicion of dengue fever is necessary when patients in a
dengue-epidemic area present with acute abdomen or bleeding manifestations. In endemic
areas, early dengue antigen testing and abdominal imaging before surgical intervention may
help in the diagnoses. Multidisciplinary team involvement with case-by-case
decision-making is needed for optimal care. A substantial number of cases of acute
abdomen seen in dengue are not because of true complications of dengue or dual pathology
but because of clinicians getting deceived by the presentation of dengue to misdiagnose as
an acute abdomen. Therefore, it is important for clinicians (both physicians and surgeons) to
be vigilant, specially in tropics, not only to avoid getting deceived by abdominal symptoms of
dengue but also not to miss true acute surgical concerns associated with dengue.
223
Acute pain related to right Within 3-4 hours of nursing ● Conduct a

abdominal pain as evidenced intervention, the patient will comprehensive pain
by patient scaling of pain 8 out be able to; assessment.
of 10. Rationale:
a. Report pain is Identifying the location,
Rationale: relieved/ controlled intensity, frequency, and
Pain modulation refers to the from a pain scale of characteristics of pain is
function of neural cells to 8 from 1 to 10; critical in determining the
inhibit, reduce, or dampen the underlying cause of
intrinsic modulatory activity of b. Verbalize reports abdominal pain and the
the central nervous system, that provide relief; effectiveness of the current
thus reducing the painful treatment regimen.
stimuli. Perception is the c. Demonstrate use of
conscious awareness, usually relaxation skills and ● Monitor vital signs
localized in certain areas of the diversional activities Rationale: Vital signs can
body. Level of pain perception as indicated for be altered because of pain.
depends on factors such as individual situations.
personal experiences, ● Provide a quiet and
immediate environment, and comfortable
socio-cultural influences. environment and
Dengue virus is transmitted comfort measures.
from human to human through Rationale: A comfortable
bites of Aedes aegypti and environment will help the
Aedes albopictus mosquitoes, process of relaxation.
and infections caused by
dengue virus can be ● Assist to a position of
asymptomatic or symptomatic. comfort.
Symptomatic infections could Rationale: Abdominal pain
be classical DF or dengue may be relieved with a
hemorrhagic fever (DHF), specific position that
224
which may or may not be promotes comfort. A

associated with shock. All ages knee-to-chest or side-lying
and both sexes are susceptible position tends to decrease
to DF, and children usually the intensity of abdominal
have a milder course pain. Raising the head of the
compared than adults . bed may also relieve
Following an average symptoms.
incubation period of 5–6 days,
classical symptoms of DF ● Teach the the patient
appear, including sudden onset how to do breathing
of high-grade fever with chills, exercise or
intense headache, abdominal relaxation technique.
joint pain. (Seetharam, P., & Rationale: When muscles
Rodrigues, G. (2020) are tense, they increase
pressure on our nerves,
which can make pain worse.
Breathing exercises can
help break this cycle. By
taking a moment to engage
with conscious breathing,
the body relaxes and the
tension around the pain site
is released.
● Teach Diversional
activities like
sleeping, talking with
company, reading
books
Rationale: Refocused
attention ; improve the ability
to cope with pain.
225
● Reassess pain level

after 30 minutes of
interventions.
Rationale: It is important to
reassess pain following
interventions to determine if
those actions were effective,
and the patient’s pain
control goals have been
met.
● Involve families in
nursing care
Rationale: Family will help

the healing process by
training the patient
relaxation.
● Administer analgesic
as needed and
prescribed by the
physician. Assess
effectiveness of pain
medication. Explain
action of analgesic,
time factors and
restrictions.
Rationale: Analgesics act
on higher brain centers to
reduce perception of pain,
promoting relaxation,
facilitating rest and sense of
well-being.
226
Hyperthermia related to the After 2 hours of nursing ● Monitor client

infection of dengue virus as intervention patient will be temperature—
evidenced [Increase in body able to maintain core degree and pattern.
temperature above normal temperature within normal Note
range range as evidenced by: shaking chills or profuse
a. body temperature is diaphoresis.
Rationale: Body temperature lowered to 37 Rationale: Temperature of
elevated above normal level degree celsius; 102.8°F to 106.8°F
that is usually caused by (38.9°C–41.1°C) suggests
several factors related to b. verbalize feeling acute severe infectious
illness. As inoculation occurs, more comfortable; disease process. Fever
proliferation of virus follows pattern may aid in diagnosis.
and once the virus starts to c. experience no Chills often precede
grow in number, it will soon associated temperature spikes.
reach its pathogenic level that complications.
will result into pyrexia or fever ● Adjust and monitor
as a defense mechanism of the environmental
body. factors like room
temperature and bed
linens as indicated.
Rationale: Room
temperature may be
Reference: Nurse’s pocket accustomed to near normal
guide by Marilyn Doeges10th body temperature and
edition blankets and linens may be
adjusted as indicated to
regulate temperature of
client.
● Apply tepid sponge

bath sponge bath.
Rationale: It could help in
reducing hyperthermia;
227
avoid using alcohol and iced

water which may even
produce chills and increase
client’s temperature.
● Loosen or remove
excess clothing and
covers.
Rationale: Exposing skin to
room air decreases heat and
increases evaporative
cooling.
● Encourage the client

to increase fluid
intake.
Rationale: Water regulates
body temperature.
● Educate client of
signs and symptoms
of hyperthermia and
help him identify
factors related to the
occurrence of fever;
discuss the
importance of
increased fluid intake
to avoid dehydration.
Rationale: Providing health
teachings to client could
help client cope with disease
condition and could help
228
prevent further
complications of
hyperthermia
● Start intravenous
normal saline
solutions or as
indicated by the
physician.
Rationale: To replenish fluid
losses.
● Administer
antipyretics as
prescribed by the
physician, utilizing
the 10 Rs in giving
medication.
Rationale: Antipyretics acts
on the hypothalamus,
reducing hyperthermia.
Deficient fluid volume related After an 8-hour of nursing ● Assess, document

to active fluid loss as interventions patient will be and monitor vital
evidenced by vomiting able to; signs.
Rationale: Getting the
a. demonstrate baseline vital signs will allow
adequate fluid you to compare and note the
Rationale: Deficient Fluid balance as progress in rehydration or
Volume (also known as Fluid evidenced by good decline to dehydration.
229
Volume Deficit (FVD), skin turgor, moist

hypovolemia) is a state or skin and mucous ● Note possible
condition where the fluid output conditions/ process
exceeds the fluid intake. It b. demonstrate that may lead to
occurs when the body loses behaviors to prevent deficits
both water and electrolytes development of fluid Rationale: To determine the
from the ECF in similar volume deficit. underlying cause of the
proportions. Common sources disorder.
of fluid loss are the c. free from
gastrointestinal tract, polyuria, dehydration ● Assess skin turgor
and increased perspiration. and mucous
Risk factors for deficient fluid membranes
volume are as follows: Rationale: Poor skin turgor
vomiting, diarrhea, GI and dry mucous membranes
suctioning, sweating, signal decreased fluid
decreased intake, nausea, volume
inability to gain access to
fluids, adrenal insufficiency, ● Note and record
osmotic diuresis, hemorrhage, intake and output
coma, third-space fluid shifts, regularly, noting for
burns, ascites, and liver the characteristics
dysfunction. Fluid volume and quality of urine
deficit may be an acute or output (i.e., color,
chronic condition managed in specific gravity,
the hospital, outpatient center, turbidity,
or home setting. One of the transparency, etc.).
complications of dengue is Rationale: Concentrated
dehydration which, if not urine usually is indicative of
carefully monitored and dehydration. A reduction of
treated, may lead to shock, urine output is also
particularly in those with indicative of a lower fluid
dengue haemorrhagic fever.n intake.
dengue, you feel extremely
230
dehydrated because the virus ● Observe and record

causes an outpouring of fluids capillary refill time
from your blood vessels into regularly.
your subcutaneous tissues. Rationale: Capillary refill
(Scott 2022) time is an indicator of
adequate circulation as well
as peripheral perfusion.
● Encourage to drink
prescribed amount of
fluid.
Rationale: To help restore a
normal fluid volume in the
body.
● Provide frequent oral

hygiene, at least
twice a day
Rationale:
Oral hygiene decreases
unpleasant tastes in the
mouth and allows the client
to respond to the sensation
of thirst.
● Administer
intravenous
hydration if needed
as prescribed by the
physician.
Rationale: Severely
dehydrated patients or
231
patients unable to take oral

hydration may require IV
hydration to maintain
appropriate hydration level.
● Administer
electrolyte
replacements as
needed/as ordered.
Rationale: Dehydration can
lead to electrolyte
abnormalities, it is important
the nurse monitors for this
and provides supplemental
replacements when needed.
● Educate patient on
the importance of
maintaining a proper
hydration and
nutrition status
regularly.
Rationale: Education will
help the patient to become
more independent upon
discharge and will help them
to understand what they can
do to prevent further
episodes of dehydration.
232
I. Literature
Title: Dengue & COVID-19: A Comparison and the Challenges at Hand.
Chowdhury et al. reported a case of co-infection that was initially suspected to be COVID-19
infection due to a positive RT-PCR test but was subsequently identified as co-infection
based on positive IgG and IgM antibody reactivity in the dengue duo test.
A case with flu-like symptoms that was thought to have been infected with
SARS-COV-2 was described by Bandeira et al. When the patient developed a
maculopapular rash that extended to the neck, chest, and limbs after receiving the
necessary treatment, the condition was reclassified as dengue fever. Skin rashes were
thought to be COVID-19 complications when the reverse transcriptase-polymerase chain
reaction (RT-PCR) report for SARS-COV-2 was positive. Subsequently, the authors came to
the conclusion that they misdiagnosed the patient as having dengue.
According to certain research, a false positive serological test for COVID-19 in

dengue patients and a false positive serological test for COVID-19 in dengue patients have
both been reported. This supports the notion that there is cross-reactivity. COVID-19 and
dengue fever are both significant risks to the global community. Their clinical presentations
are comparable, which could cause diagnoses to become confusing. Confusion results from
shared clinical symptoms between COVID-19 and dengue fever, including fever, dyspnea,
headache, cough, and skin signs.
This misunderstanding is also exacerbated by the rise in the number of false positive
serological test findings brought on by cross-reactivity and similar blood patterns. Incorrectly
diagnosing COVID-19 as dengue and failing to isolate those infected will cause outbreaks in
medical facilities. On the other side, failure to recognize dengue and provide supportive care
may result in deaths from dengue that may have been avoided. Patients in regions where
COVID-19 and dengue coexist should be screened for both illnesses.
Title: Sinococuline, a bioactive compound of Cocculus hirsutus has potent

anti-dengue activity
The traditional medical literature from around the world mentions the use of a number
of herbs in fever disorders like dengue. In their search for an anti-dengue remedy, they
consulted the Indian medical canon known as Ayurveda. In this effort, they previously
233
discovered an aerial methanolic extract of Cissampelos pareira that demonstrated both in

vitro and in vivo pan-anti-dengue activity.
They also discovered that Cocculus hirsutus' aerial methanolic extract is more
effective than C. pareira. An effort was made to increase C's anti-dengue effectiveness.
conditions are met by experimenting with various extraction methods and plant components,
which resulted in the creation of an aqueous extract of the C. stem. hirsutus to be the most
effective in both lab and real-world settings. When tested in vitro, Sinococuline showed
anti-DENV inhibitory properties. Additionally, the AQCH phytopharmaceutical chemical was
created, clinically tested, and determined to be extremely safe for human usage.
Due to the virus's ability to hide in tissues during the advanced stages of DENV
infection, sinococuline has the ability to reduce the tissue viral load in a variety of important
organs, which in turn lowers proinflammatory cytokines and increases tissue viral load.To
sum up, Sinococuline shown that it has the ability to stop severe DENV infections in vivo. To
meet the urgent demand for a dengue antiviral, sophisticated pre-clinical and clinical
development might be used to further investigate sinococuline as an anti-dengue chemical.
234
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Cardiovascular Diseases and Dengue

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CARDIOVASCULAR DISEASES AND DENGUE

A Seminar Manuscript Presented to

Conditions affecting the heart or blood vessels are collectively referred to as

To achieve the general objectives, the speakers specifically aim to:

a. briefly discuss the cardiovascular disease and provide statistical data;

III. Congestive Heart Failure

B. Anatomy & Physiology

The cardiovascular system is also known as the blood-vascular system or simply

● It pumps blood throughout the body;

LAYERS OF THE HEART

The heart has three (3) layers or linings:

CHAMBERS AND VALVES OF THE HEART

CONDUCTION SYSTEM OF THE HEART.

4 Determinants of Cardiac Output

BLOOD FLOW IN THE HEART

The right side of the heart pumps

The blood vessels of the

In the case of heart failure, the heart works

Upper respiratory system

Lower Respiratory System

● The Pulmonary Loop. The right side of the heart

SIGNS & SYMPTOMS RATIONALE

Shortness of breath Shortness of breath occurs because blood in

the same flow of blood around your body.

Chest pain Chest pain caused by poor blood flow to the

Fatigue As heart failure becomes more severe, the

Persistent cough As the lungs become congested, due to

Swelling A weak heart pumps less blood to your

gain. This can also cause an increased need

PREDISPOSING FACTOR RATIONALE

even further if you are a woman and have the

PRECIPITATING FACTOR RATIONALE

Sedentary lifestyle Staying sedentary might cause fatty deposits

vessel walls could also thicken, which can be

Systemic Infection During systemic, the immune system of the

potential to develop mild heart failure over

the lining of your heart valves and chambers,

The above-mentioned factors, mainly the predisposing and precipitating factors

Initially in early stages, cardiac physiology attempts to adapt via several

In addition, commonly right-sided heart failure generally develops as a result of

TEST NORMAL RESULT RATIONALE

Complete Blood Count CBC is one of the common

MCH 27.0 - 34.0 Additionally, it gives details

Lymphs 14 - 46 to blood plasma count).

Monocytes 4 - 13 Since CBC can identify

Lipid Profile The blood fats are

Total Cholesterol. This is

Triglycerides. Another form

Basic Metabolic Panel A basic metabolic panel

Potassium 3.5 - 5.2 Glucose. This is a type of

Creatinine 0.5 - 1.2 common minerals in your

mg/ dL body. While most of your

BUN (blood urea

byproduct of muscle activity.

A BMP also measures the

Sodium. Most of your

ECG If the test is normal, it should show that your heart is

Echocardiogram A non-invasive test used to analyze the functioning and

Cardiac Computerized Cardiac computed tomography (CT) is a non-invasive test

Unlike traditional X- rays, a CT scanner makes highly

Magnetic Resonance A procedure that uses radio waves, a powerful magnet,

MRI plays a pivotal role in various aspects of cardiac

Coronary Angiogram A coronary angiogram is a procedure that uses x-ray