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OBJECTIVES

A. General Objective After the discussion of this case presentation, the students will be able to deal and care for a patients with Aortic Aneurysm integrally by applying their knowledge, skills, and positive attitudes based on what they have learned out of the discussion.

B. Specific Objectives At the end of the case presentation, it is expected that the students will be able to: Skills 1. Deal patient with thoracic aortic aneurysm. 2. Provide proper care and intervention with limitation to stressful activities. 3. Conduct physical assessment and organize data efficiently. 4. Perform nursing procedures effectively and correctly to attain optimum level of wellness. Knowledge 1. Define Thoracic Aortic Aneurysm. 2. Have an overview about the diseases, including its causes and preventive measures. 3. Determine the signs and symptoms. 4. Review the anatomy and physiology of the organ affected. 5. Understand the pathophysiology of the disease. 6. Identify and enumerate the management needed depending on the severity and possible rupture of the aneurysm. 7. Formulate nursing care plans that will aid in the improvement of patient s condition. Attitudes 1. Develop a positive attitude in caring the patient with thoracic aortic aneurysm throughout the nursing Process. 2. To be able to establish rapport with the patient and folks. 3. To be able to develop respect and trust to the folks as well as in other health care team member in caring of clients with Thoracic Aortic Aneurysm.

INTRODUCTION
A. Definition
An Aneurysm is a localized dilation or out pouching of

vessel wall or cardiac chamber. The Law of Laplace can provide an understanding of the hemodynamic of an aneurysm. Presumably, in myocardial infarction, a ventricular wall aneurysm forms when intraventricular tension stretches the non contracting infracted muscle. The stretching produces

infarct expansion, a weak and thin layer of necrotic muscle, and fibrous tissue that bulges with each systole. Aneurysm forms in the arteries when there is disruption of the wall of the vessel associated with changes in collagen and elastin that make the vessel more vulnerable to intravascular pressures. The aorta is particularly susceptible to aneurysm formation because of the constant stress on the vessel wall and the absence of penetrating vasa vasorum in the media layer. Three fourths of all aneurysms occur in the abdominal aorta. Atherosclerosis is the most common cause of arterial aneurysms because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension also contributes to aneurysm formation by increasing wall stress. Dissection of the arterial walls occurs when there is a tear in the intima and blood enters the wall of the artery. Dissection can involve any part of the aorta and can disrupt flow through arterial branches, thus creating a surgical emergency.

A Ruptured Aneurysm may cause massive hemorrhage and death.

B. Statistics International:
The following statistics relate to the prevalence of Aortic aneurysm: 5 to 7% of people over 60 have thoracic aortic aneurysms in the US

Incidence (annual) of Aortic aneurysm: 2,966 annual cases in Victoria 2008.

Incidence Rate: approx 1 in 1,537 or 0.07% or 176,913 people in USA

Deaths from Aortic aneurysm: 15,807 annual deaths in 2007 USA.

The term 'prevalence' of Aortic aneurysm usually refers to the estimated population of people who are managing Aortic aneurysm at any given time. The term 'incidence' of Aortic aneurysm refers to the annual diagnosis rate, or the number of new cases of Aortic aneurysm diagnosed each year.

ANATOMY & PHYSILOGY


In a general sense, a Blood vessel is defined as a hollow utensil for carrying something: a cup, a bucket, a tube. Blood vessels, then, are hollow utensils for carrying blood. Located throughout your body, your blood vessels are hollow tubes that circulate your blood There are three major types of blood vessels: a. Arteries which carry the blood away from the heart

b. Capillaries which enable the actual exchange of water and chemicals between the blood and the tissues c. Veins which carry blood from the capillaries back toward the heart

The arteries and veins have different structures, veins having two layers and arteries having three:
a.

Tunica intima It is the thinnest layer: a single layer of simple squamous endothelial cells glued by a polysaccharide intercellular matrix, surrounded by a thin layer of

subendothelial connective tissue interlaced with a number of circularly arranged elastic bands called the internal elastic lamina. Also the inner layer of the vessel.

b.

Tunica media It is the thickest layer: circularly arranged elastic fiber, connective tissue, polysaccharide substances, the second and third layer are separated by another thick elastic band called external elastic lamina. The tunica media may (especially in arteries) be rich in vascular smooth muscle, which controls the caliber of the vessel. Also the middle layer of the vessel.

c.

Tunica adventitia It is entirely made of connective tissue. It also contains nerves that supply the vessel. Also the outer layer of the vessel.

Besides circulating blood, the blood vessels provide two important means of measuring vital health statistics: pulse and blood pressure. We measure heart rate, or pulse, by touching an artery. The rhythmic contraction of the artery keeps pace with the beat of the heart. Since an artery is near the surface of the skin, while the heart is deeply protected, we can easily touch the artery and get an accurate measure of the heart's pulse. When we measure blood pressure, we use the blood flowing through the arteries because it has a higher pressure than the blood in the veins

If you took all of the blood vessels out of an average child, and laid them out in one line, the line would be over 60,000 miles long! An adult's vessels would be closer to 100,000 miles long!

The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries, the common iliac. The aorta distributes oxygenated blood to all parts of the body through the systemic circulation.

The aorta gives off branches that go to the head and neck, the arms, the major organs in the chest and abdomen, and the legs. It serves to supply them all with oxygenated blood. The aorta is the central conduit from the heart to the body. The aorta is usually divided into five segments/sections:
a.

Ascending aorta - It is the section between the heart and the arch of aorta

b.

Arch of aorta - It is the peak part that looks somewhat like an inverted "U"

c.

Descending aorta - It is the section from the arch of aorta to the point where it divides into the common iliac arteries. Thoracic aorta It is the half of the descending aorta above the diaphragm

Abdominal aorta It is the half of the descending aorta below the diaphragm. The abdominal aorta is the largest artery in the abdominal cavity. As part of the aorta, it is a direct continuation of the descending aorta in the thorax.

THORACIC AORTIC ANEURYSM

A. Definition
An Aneurysm is a localized sac or dilation of an artery formed at a weak point in the vessel wall.

Types of Aortic Aneurysm: 1. Thoracic aortic aneurysm It is an aortic aneurysm that is present primarily in the thorax. 2. Abdominal Aortic Aneurysm It is a localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50 percent, and is the most common form of aortic aneurysm. 3. Cerebral / Intracranial Aneurysm It is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall.

Sites of Thoracic Aortic Aneurysm: 1. Aortic root 2. Ascending Thoracic Aorta 3. Arc aorta 4. Descending Thoracic Aorta

Characteristics of Aneurysm: 1. False Aneurysm It is actually a pulsating hematoma. The clot and connective tissue are outside the arterial wall. 2. True Aneurysm One, two, or all three layers of the artery may be involved.

3. Fusiform Aneurysm Symmetric, spindle shaped expansion of entire circumference of involved vessel.

4. Saccular Aneurysm A bulbous protrusion of one side of the arterial wall.

5. Dissecting Aneurysm This is usually a hematoma that splits the layers of the arterial wall.

B. Risk factors
Gender Age Occurs frequently between ages of 40 70 years. Men are more affected than women.

Congenital Primary connective tissue disorders including Marfan s syndrome and Ehlers Danlos syndrome. Infectious Bacterial, fungal, spirochetal infection.

Traumatic Penetrating arterial injuries, blunt arterial injuries, pseudoaneurysms.

Inflammatory (non infectious) Associated with arteritis; Takayasu s disease, systemic Lupus Erythematosus.

Cigarette Smoking The primary cause of atherosclerosis. Atherosclerosis is the most common cause of arterial aneurysms because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension. Contributes to aneurysm formation by increasing wall stress.

C. Signs/Symptoms Symptoms are variable and depend on how rapidly the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures. Yet, some do not produce symptoms.

From the Textbook Constant chest pain associated with a harsh breathing which may occur only in supine position. Dyspnea, cough (paroxysmal and brassy), or stridor

Manifested by the Patient 

Rationale It results from the disruption of normal circulation in the thoracic region.


Hoarseness, weak voice or aphonia Dysphagia

It is the result of pressure of aneurysm sac against trachea, a main bronchus, or the lung itself. Resulting from the pressure against the laryngeal nerve. Due to impingement on the esophagus by the aneurysm.

Edematous areas on chest wall Cyanosis

When large veins in the chest are compressed by the aneurysm, the superficial veins of the chest, neck, or arms become dilated.  A result of pressure against the cervical sympathetic chain.

Unequal pupils

D. Diagnostic Findings
Most thoracic aortic aneurysms are detected by tests performed for other reasons, it may include: Chest x-ray It is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures and can show presence of any masses in the thorax. Echocardiogram

It is important for the evaluation of the aortic valve and also can be used to evaluate the size of the ascending aorta. Chest CT scan

This can show the size of the aorta and the exact location of the aneurysm. Aortogram

It is a special set of x-ray images made when dye is injected into the aorta that can identify the aneurysm and any branches of the aorta that may be involved.

E. Prevention
To prevent atherosclerosis: Control your blood pressure and blood lipid levels. Do not smoke. Exercise regularly.

F. Medical management
Medical or surgical management depends on the type of aneurysm. For a ruptured aneurysm, prognosis is poor and surgery is performed immediately. When surgery is delayed, medical measures include: Strict control of blood pressure and reduction in pulsatile flow. Correcting risk factors. Systolic pressure maintained at 100 to 120 mm Hg with antihypertensive drugs, such as:   Nitroprusside (Nipride) Hydralazine (Apresoline)

Pulsatile flow reduced by medications that reduce cardiac contractility, such as:  Propranolol

G. Surgical Management
Removal of the aneurysm and restoration of vascular continuity with a graft is the goal of surgery and treatment of choice for aortic aneurysm. It is recommended if the aneurysm is larger than 5.5 cm (2 inches) in diameter or those that are enlarging. Intensive monitoring in the critical care unit is required. The surgical procedure includes: Thoracic Endovascular Grafting / stenting The endovascular grafts or stents are inserted into the t horacic aorta via various vascular access routes, including the femoral or iliac artery. This is a tiny metal or plastic tube that is used to hold an artery open and can be placed into the body without cutting the chest. Resection and Bypass Graft It involves removing theaneurysmal portion of the aorta and replacing it with an a rtificial Dacron tube. If the aortic valve is damaged it also need to be replaced or repaired. Replacement options include mechanical and tissue valves.

Pre operative assessment: Assessment is guided by the fact that the aneurysm may rupture Signs include persistent or intermittent back or abdominal pain that may be localized in the middle or lower abdomen or lower back. Establish functional capacity of all organ systems, recognizing possible cerebral, cardiovascular, pulmonary, and renal impairment due to atherosclerosis. Implement medical therapies to stabilize patient.

Post operative assessment Intensely monitor the pulmonary, cardiovascular, renal and neurologic systems. Monitor for complications: arterial occlusion, hemorrhage, infection, ischemic bowel, renal failure and impotence. Prescribe an exercise schedule after the recovery phase. Discouraged prolonged sitting

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H. Rupture of Aneurysm
Rupture or dissection of these aneurysms produces dramatic symptoms. A ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades is the most typical complaint during thoracic aortic dissection or rupture. Dizziness, difficulty walking and speaking can all accompany this acute event.

Patients with known aortic aneurysms experiencing such symptoms need to contact their physician or surgeon immediately and go to the nearest emergency room.

I. Nursing considerations
Smoking cessation Avoid carrying heavy objects to prevent pressure on the vessel wall. Strict compliance to antihypertensive medications to keep your blood pressure under control. Limit stressful physical activities Get regular exercise. Reduce cholesterol and fat in your diet.

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OVERVIEW of CONGESTIVE HEART FAILURE

Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to supply sufficient blood flow to meet the needs of the body. The most common causes of congestive heart failure are: Coronary artery disease Hypertension DM Obesity Longstanding alcohol abuse Disorders of the heart valves Unknown (idiopathic) causes, such as after recovery from myocarditis

Signs & Symptoms Right Sided Heart Failure Peripheral edema, Anasarca Nocturia Paroxysmal nocturnal dyspnea Ascites Fatigue Hepatomegaly Coagulopathy Cool extremities at rest. Confusion Left Sided Heart Failure Pulmonary congestion Dyspnea (SOB) Orthopnea Exercise intolerance Wheezing Dizziness

Diagnostic Examination Electrocardiogram (ECG) Is used to determine changes or variation in electrical activity of the heart.

Chest X-ray To detect previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs. Echocardiogram In which ultrasound is used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness.

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B-type natriuretic peptid level This level can vary with age and gender but is typically elevated from heart failure and can aid in the diagnosis, and can be useful in following the response to treatment of congestive heart failure Coronary angiography It is a procedure that uses a special dye or contrast material and x-rays to see how blood flows through your heart.

Prevention Do not smoke. Do not drink alcohol. Reduce salt intake. Exercise as recommended by your health care provider.

Treatment Coronary artery bypass graft surgery Is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the hear. Angioplasty Is a term describing a procedure used to widen vessels narrowed by stenoses or occlusion.

Single or dual chamber pacemaker To help with slow heart rates or certain other heart signaling problems.

Biventricular pacemaker To help the left and right side of your heart contract at the same time.

Implantable cardioverter defibrillator To correct or prevent severe arrhythmias.

Intra-aortic balloon pump (IABP) A temporary device placed into the aorta

Left ventricular assist device (LVAD) Which takes over the role of the heart by pumping blood from the heart into the aorta; it's most often used by those who are waiting for a heart transplant.

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Pharmacologic Treatment ACE inhibitors Such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Diuretics Including hydrochlorothiazide, chlorthalidone, chlorothiazide,furosemide, torsemide, bumeta nide, and spironolactone to help rid your body of fluid and salt (sodium) Digitalis glycosides To increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances. Angiotensin receptor blockers (ARBs) Such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors Beta-blockers Such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease.

Nursing Management Take the medications as directed. Carry a list of medications with you wherever you go. Limit salt intake. Smoking Cessation Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan based on the degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that the weight has gone up from fluid retention or if not feeling well. Lose weight if overweight. Provide enough rest, including after exercise, eating, or other activities. This allows the heart to rest as well. Keep your feet elevated to decrease swelling.

Here are some tips to lower your salt and sodium intake: Look for foods that are labeled low-sodium, sodium-free, no salt added, or unsalted.

Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.

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Don t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG). Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese. Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese. Use oil and vinegar, rather than bottled dressings, on salads. Eat fresh fruit or sorbet when having dessert.

Prognosis With the availability of newer drugs to potentially favorably affect the progression of disease, the prognosis in congestive heart failure is generally more favorable than that observed just 10 years ago. In some cases, especially when the heart muscle dysfunction has recently developed, a significant spontaneous improvement is not uncommonly observed, even to the point where heart function becomes normal

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OVERVIEW of ACUTE MYOCARDIAL INFARCTION

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia.

Etiology Atherosclerosis Age Sex Family history of premature coronary heart disease Male-pattern baldness Dyslipidemia Smoking or other tobacco use Diabetes mellitus Hypertension Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders Obesity Sedentary lifestyle and/or lack of exercise Psychosocial stress Poor oral hygiene Type A personality

Signs & Symptoms Pain, fullness, and/or squeezing sensation of the chest Jaw pain, toothache, headache Nausea, vomiting, and/or general epigastric discomfort Sweating Heartburn and/or indigestion Arm pain Upper back pain General malaise Shortness of breath

Diagnostic Studies Electrocardiogram(ECG) Is a recording of the electrical activity of the heart. Abnormalities in the electrical activity usually occur with heart attacks and can identify the areas of heart muscle that are deprived of oxygen and/or areas of muscle that have died.

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Blood tests Cardiac enzymes are proteins that are released into the blood by dying heart muscles. These cardiac enzymes are creatine phosphokinase (CPK) and troponin I, and their levels can be measured in blood. A series of blood tests for the enzymes performed over a 24-hour period are useful not only in confirming the diagnosis of heart attack, but the changes in their levels over time also correlates with the amount of heart muscle that has died.

Treatment Thrombolytic / fibrinolytic therapy Has been shown to reduce death from heart attacks similarly in men and women; however, the complication of strokes from the thrombolytic therapy may be slightly higher in women than in men. Percutaneous transluminal coronary angioplasty ( PTCA) Or coronary stenting for acute heart attack The use of a balloon-tipped catheter to enlarge a narrowed artery. Coronary Artery Bypass Graft (CABG) A surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.

Nursing Management Patients with active symptoms of ACS should be instructed to call emergency services and should be brought in by emergency medical services personnel, not by themselves, family, or friends. Patients should be instructed to come to the emergency department immediately if the suspected ACS symptoms last longer than 20 minutes at rest or are associated with near syncope or hemodynamic instability. If nitroglycerin is prescribed to a patient with suspected ACS, the patient should be instructed to take a dose if symptoms arise. If no relief is experienced 5 minutes after the first dose, the patient should contact emergency services. Educate post myocardial infarction patients about the role of a low-cholesterol and low-salt diet. Educate patients about the American Heart Association (AHA) dietary guidelines, including a lowfat, low-cholesterol diet. A dietitian should see and evaluate all patients post myocardial infarction prior to their discharge. Emphasize exercise training because current evidence demonstrates that cardiac rehabilitation post myocardial infarction results in lower rates of recurrent cardiovascular events.

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Following myocardial infarction, educate all patients regarding the critical role of smoking in the development of coronary artery disease. Smoking cessation classes should be offered to help patients avoid smoking after their myocardial infarction Prognosis Acute myocardial infarction is associated with a 30% mortality rate; half of the deaths occur prior to arrival at the hospital. An additional 5-10% of survivors die within the first year after their myocardial infarction. Approximately half of all patients with a myocardial infarction are rehospitalized within 1 year.

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OVERVIEW of HYPERTENSIVE ATHEROSCLEROSIS CARDIIOVASCULAR DISEASE

Athersclerotic cardiovascular disease is most commonly known as coronary heart disease. This condition involves the hardening of the heart arteries. Athersclerotic cardiovascular disease is attributed to the builds up of fat deposits, which essentially clog up the heart's arteries.

Treatment Dietary sodium restriction Regular moderate exercise Smoking cessation Weight reduction

Pharmacological Treatment ACE inhibitors Such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Digitalis glycosides To increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances. Angiotensin receptor blockers (ARBs) Such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors Beta-blockers Such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease.

Nursing Management Maintain the healthiest lifestyle possible. This means eating a healthy and nutritious diet. Getting a good amount of physical activity in your daily schedule Sodium restriction and low-fat diet Encourage to stop smoking

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VITAL IBFORMATION

Name Sex Age Address Civil Status Religion Occupation Educational Attainment Date & Time Admitted

J.B Male 60 years old North Natividad, Pilar, Capiz Married Roman Catholic Fisherman Elementary Graduate June 29, 2011 4:20 pm

Ward Chief complaint Admitting Diagnosis

St. Catherine Laboure SOB T/C CAP MR, T/C aortic aneurysm, CHF 2 AMI, HACVD, S/P AMI

Diet Attending Physicians

Full diet, low cholesterol Dr. M. B. Referral to: Dr. B.

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CLINICAL ASSESSMENT

A. Nursing History
For almost nine (9) years, Mr. J.B is very compliant to all of his medications as maintenance and regular check up to Dr. B. However, a month ago, Mr. J.B was not able to meet the recommended

medications for his maintenance due to lack of knowledge. He thought that he is fine since his blood pressure was always ranging to 130 / 80 to 140 / 90. He also stopped seeing his doctor for regular check up because of the long distance travel and has the belief of the routine medical advice. Pareho malang gyapon ang ginahimo kag ginareseta sa akon as verbalized. Moreover, three weeks prior to his admission, Mr. J.B. experienced sudden onset of shortness of breath especially if placed on supine position associated with harsh breathing. Also, he experienced occasional nape pain and full to heavy chest pain as described. These complaints continued until his admission to St. Anthony College Hospital. On the day prior to Mr. J.B s admission, June 29, 2011 at around 4:20 pm, he sought consultation with his attending physician, and was advised for intensive care unit admission. During this time, Mr. J.B needs an intensive care for he is suspected to have an aneurysm which is a medical emergency case.

B. Past Health Problem


Mr. J.B is a known chain smoker during his time; he can consume 3 packs of cigarettes (Hope) a day. He considers himself as a moderately alcoholic drinker : 5 to 6 shots of alcoholic beverage were enough for him just to relieve his fatigue from all the day s work. In addition, he also drinks coffee every morning. Furthermore, on the year 2001, Mr. J.B was admitted at St. Anthony College of Roxas, Inc. (Hospital) due to mild stroke with his attending physician, Dr. B. Because of that incidence, Mr. J.B stayed in the Intensive Care Unit (ICU) for almost five days. Following his stay in the ICU, he was transferred to a private room where in care was being rendered until optimum wellness was achieved. That incidence in his life forced him to totally stop smoking, drinking alcoholic and caffeinated beverage.

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C. Family Genogram

F.B

R.B

G.B

B.B

R.B

J.B

H.B

C.B

D.B

N.B

LEGEND:
Patient
J.B

Aortic Aneurysm, AMI, HACVD, Hypertension


J.B

Male
R.B

Diabetes Mellitus II

Female

Hypertension
F.B

Death
R.B

Aging

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PATTERNS OF FUNCTIONING

Nutritional History a. Drinking Patterns HOME Mr. J.B is fond of drinking water. He drinks water before and after meals, as well as when there is a feeling of dry mouth and thirst. Mr. J.B is not fond of drinking neither soft drinks nor coffee and a beverage at all. He can consume not less than 8 glasses of water a day. HOSPITAL His fluid intake was limited for he cannot tolerate large amount of fluids. He only consumes 350cc of water per shift during our care.

b. Eating Pattern HOME Mr. J.B had a very good appetite. He can tolerate large amount of food; is able to consume his meal and have extra rice every meal. Since Mr. J.B lives in Pilar, there viand most of the time is sea foods which is rich in sodium. Yet, he also likes to eat vegetables. His wife prepares vegetables 3 or 4 times a week and sometimes fruits. HOSPITAL Mr. J.B loses his desire for foods. He had a poor appetite and can only consume 1/3 of the meal served. Mr. J.B cannot tolerate large amount of foods. The meals being served to him was full diet and low in cholesterol.

c. Breathing Patterns HOME Mr. J.B experienced an episode of shortness of breath associated with harsh breathing when in supine position before he was admitted. HOSPITAL Mr. JB had oxygen of 1 L breaths per minute via nasal cannula. Sometimes, he complained of shortness of breath with a respiratory rate ranging from 22 24 breaths per minute.

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d. Circulation Temperature Pulse rate Respiration rate Blood pressure Apical rate 36C 88 bpm 24 bpm 160/100 mmHg 90 bpm IVF Left carpal vein Side Drip # 2 PNSS 1L x KVO AC Drip: 500 ml D5 water + 2 Apresoline + 2 Catapres @ 15 gtts / min (Maintain systolic blood pressure of 140 to 150, titrate 5 ugtts / min and stop side drip for Bp of 140).

Daily Activity Patterns: a. Rest and Sleeping Patterns HOME Mr. J. B usually sleeps at night after watching television news with long intervals. He slept at about 8 - 9 in the evening and wake up at 5 6 in the morning to have walking at the seashore. He also slept at noon time to rest in his small hut. HOSPITAL Mr. J.B has a difficulty in sleeping at night; he claimed that he can only slept at night in a short interval due to dizziness and coming in and out of nurses in the room. He slept at 10 - 11 pm and woke up at 6 in the morning.

b. Personal Hygiene HOME At home, Mr. J. B takes a bath every day and does his oral hygiene once a day by himself. HOSPITAL In hospital, Mr. J. B takes a bath occasionally and does his oral hygiene once a day after dinner with assistance from the student nurse assigned or the folks. Sponge bath is also rendered by his wife every day or when he did not take a bath.

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c. Elimination Patterns Bowel Movement FREQUENCY Home Hospital PROBLEMS / DIFFICULTIES Home Hospital

Once or twice a day every morning or after lunch

Once every 2 or 3 days and there is no BM during our care.

He experienced sometimes having constipation or diarrhea.

None

Urination FREQUENCY Home Hospital PROBLEMS / DIFFICULTIES Home Hospital

Urinates whenever feels the urge and approximately 5 times a day.

Urinates whenever feels the urge with a urine output approximately 620 cc during our 8 hour care.

None

None

A. Educational Background - Mr. J.B is an elementary graduate at Dulangan Elementary School. B. Occupational Background - Mr. J.B is a fisherman. C. Religious practices - Mr. J.B does not attend regular masses every Sunday except during Holy days of obligations. Yet, he said that he is praying before sleeping and before eating his meals. D. Economic status - They belong in the middle class of economic level in this society.

SOCIO-CULTURAL HEALTH A. Cultural Health Mr. J.B participates when they have their fiesta in their barrio. They also prepare foods for their visitors. He did not consider superstitious beliefs. Rather, he believes that everything happens in God s will.

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B. Recreational Pattern Mr. J.B loves to have walking every morning and during sunset in the seashore. For him, breathing fresh air is the best way that he could relax himself. Other than that, he is also fond of watching news in ABS-CBN and stay in his nipa hut to have rest. He also listens to the music or news in Bombo station through his favourite radio.

C. Environmental Pattern Their house is located in between of the road and coastal area. It is also at the front of basketball court and chapel. As what we have observed, the environment there is conducive to make Mr. J.B feel relax.

D. Interaction Pattern Through the help of his grandchildren, Mr. J.B forgot that he has health problem. When they are all in, they tend to have conversation with each other and have humours. Kasadya gid kong makita ko sila tanan , as what Mr. J.B told us. According to him, his family is his strengths and being with them, is the most treasure he had.

E. Coping Pattern Mr. J.B had no idea about his aneurysm; all he knew was that he is only suffering from a high blood pressure associated with a cardiac problems. From that information he had, he tried to maintain and lower down his blood pressure through a long period of rest, a strict compliance to all the medications, and avoiding stressful stimuli like noises. They have a strong bond in their family. All of her children as well as his wife participate in the plan of care for him. Actually, they monitor the blood pressure of Mr. J.B, taking good care of his feelings and asking him not to perform those activities that need effort. They also accompanied Mr. J.B when he likes to walk in the seashore. Because of his situation, they decided to keep the real status of Mr. J.B s condition.

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CLINICAL INSPECTION

Vital Signs
Upon Admission Temperature 36.1C Respiratory rate 25 bpm Apical pulse 105 bpm Radial pulse 100 bpm Blood pressure 220/140 & 230/150 mmHg

During our Care September 16, 2010 Time Temperature (C) Respiratory rate (bpm) (bpm) 7:00 8:00 9:00 10:00 11:00 12:00 1:00 2:00 36.1 22 86 82 36 24 90 88 160/100 150/100 160/100 160/100 150/100 140/100 140/100 140/100 (bpm) (mmHg) Apical pulse Radial pulse Blood pressure

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PHYSICAL ASSESSMENT

General Appearance Mr J.B is awake and consciously lying on bed at a high fowler s position which appears weak,

fatigue, with shortness of breath, and pale but still oriented and in an appropriate mood; with an ongoing IVF of #2 PNSS 1 L x KVO infusing well on the right carpal vein at the level of 500 cc, a secured AC drip of 500 ml D5 water + 2 Appresoline + 2 Catapres @ 15 ugtts / min; this is to maintain systolic blood pressure of 140 to 150 mmHg and to be titrated at 5 ugtts / min, and O2 inhalation of 1 LPM via nasal cannula. He is coherent, physically and mentally conscious wherein responsiveness to any stimuli is observed, and with non edematous lower & upper extremities are not noted.

Cephalocaudal
Body Parts Method of Assessment Skin Inspection Poor skin turgor Due to physiologic changes of aging; limited physical activity and range of motion. Findings Interpretation

Skin is warm and dry, (-) pallor, (-) cyanosis. Skin is intact and wrinkled Fair complexion. Skin is soft and no scar, bruise or petechiae noted.

Normal

Head

Inspection

Normocephalic, , hair is evenly distributed, black in color, straight, smooth and short Symmetrical feature of the face. Normal

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Facial grimace

(+) chest pain when in supine position; It results from the disruption of normal circulation in the thoracic region.

Palpation Absence of nodules Normal

Nails

Inspection

Capillary refill of 4 seconds

Due to the disturbance of circulation in the periphery.

(-) of clubbing with an angle of about 160 degrees. Eyes Inspection Pupil size R = 2mm L = 1.5 Sluggish pupil reaction Reddish sclera & conjunctiva Moderately reactive to light and accommodation.

Normal

A result of pressure against the cervical sympathetic chain.

Palpation Ears Inspection

(-) Tenderness and lumps Color same as facial skin Auricle is aligned with the outer cantus of the eye Responsive to moderate voices

Normal

Normal

Nose

Inspection

Symmetric with the nasal septum at the center O2 @ 1 liter per minute

Normal

Neck

Inspection

Coordinated, smooth movements with no discomfort No lumps or swollen glands

Normal

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Chest and Thorax

Inspection

RR= 24 bpm (+) Shortness of breath Nonproductive, intense cough

It is the result of pressure of aneurysm sac against trachea, a main bronchus, or the lung itself.

Auscultation

(+) Chest pain Pain scale = 5 to 6

It results from the disruption of normal circulation in the thoracic region.

(-) adventitious breath sounds Abdomen Inspection Abdominal wall is uniform in color and round.

Normal

Normal

Auscultation

No abdominal bowel sounds

Due to limited physical activity and bed rest.

Palpation

Soft bulgy abdomen (-) tenderness Liver is not palpable

Normal

Extremities

Inspection

Capillary refill of 4 seconds

Due to the disturbance of circulation in the periphery.

Lesions and wounds Cardiovascular Inspection Chest pain

Normal It results from the disruption of normal circulation in the thoracic region.

Bp = 160/100 mmHg

Due to atherosclerosis and continues decreased in the passage way of blood as a result of

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compression from aneurysm.

HR = 90 bpm PR = 88 bpm Genitourinary Inspection Voids freely in the comfort room with no complaints of pain and difficulties. The urine output during our care is 620 cc. Urine is clear and aromatic Musculuskeletal Inspection Able to ambulate with assistance Limited physical activity

Normal

Normal

Due to his condition. This is to provide rest and prevent stressors that could cause an increase in blood pressure result to rupture of aneurysm.

A. General Appraisal

i.

Speech

He is oriented and converses appropriately without any problem in his speech.

ii. Language He knows Ilonggo, Tagalong and a little in English.

iii. Hearing He can hear moderate sound and interpret auditory stimuli appropriately.

iv. Emotional status He is slightly worried about his condition. He all knows that he had only hypertension and he worries about it when his blood pressure is above normal. His medical condition was decided by Mr. J.B s family to keep it from him. This is the reason why he did not know about the extent of thoracic aortic aneurysm and the effects of it in his lifestyle. v. Mental status

He is conscious, alert, coherent, and able to comprehend instructions and commands. He is also oriented to person, time, place and events occurring in the environment and sometimes he asks about his condition.

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LABORATORY &DIAGNOSTIC DATA

Date: June 29, 2011 Chest X Ray View: Anterior Posterior Impression: Cardiomegaly. Mild Pulmonary congestion. Bibasal Pneumonia. Left hilar mass vs. Aortic Aneurysm. Atheromatous aorta. Hyperthrophic Degenerative Osteoarthropathy, thoracic spine.

Fluid Serum Test Result Normal Values Sodium Calcium Magnesium Creatinine 143 mmol/L 2.39 mmol/L .9 mmol/L 126.8 umol/L 136 145 2.12 2.52 .74 - .99 53 115 Normal Normal Normal Reduced blood flow to the kidney due to disturbed arterial circulation. Potassium 3.5 mmol/L 3.5 5.1 Normal Significance

Troponin I Determination (miniVIDAS) Normal: <0.01 ug/L Result: <0.01 ug/L

Hematology Test Result Normal Values Hematocrit Hemoglobin Red Blood Cell White Blood Cell Segmenters .70 50 60 % As a compensatory mechanism of the body to .46 vol. fr. 151 gms/L 5.36 x 10 ^ 12/L 10.9 x 10^ 9/L 0.42 0.52 120 160 4.6 6.2 4.5 11 Normal Normal Normal Normal Significance

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fight against the invasion of pathogens. Eosinophils Lymphocytes Monocytes Platelet .02 .25 .03 294 x 10 ^ 9 / L 1 4% 25 30 % 2 5% 150 350 Normal Normal Normal Normal

CT Scan Request: Chest (Plain) Interpretation: Pneumonitis, both lungs, not ruled. Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Bilateral minimal Infero Posterior pleural thickening. Thoracic hyperthrophic degenerative osteoarthropathy.

Date: June 30, 2011 Serum Test Test Result Normal Values Glucose 9.12 mmol / L 4.4 6.1 Due to decrease utilization of insulin from the pancreas, specifically the beta cells of the Islet of Langerhands. Significance

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PATHOPHYSIOLOGY

Predisposing Factors Male 60 years old

Precipitating Factors Hypertension HACVD

Degenerative Changes

DM

Cigarette smoking

Atherosclerosis

Plaque Formation

Losses elasticity and becomes weak

Arterial Spasm

Contractility of Out pouching of aorta the vessel

Aortic arc aneurismal dilatation

Blood flow to the body

Narrows the vessel

Blood & O2 supply (Kidney)

Blood & O2 supply (Myocardium)

Prolonged high blood pressure Creatinine of Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab O.D AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min Imdur 30 mg 1 tab OD Dilzem 60 mg 1 tab TID 126.8 umol/L Chest pain SOB

Rupture of Added strain to aorta Aneurysm

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MEDICAL MANAGEMENT

A. Drug Study
Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction Mechanism of Action Nursing Responsibilities Trimetazidine Vastarel MR Beta blocker 35 mg 1 tab BID Hypertension Hypersensitivity to the drug and any of its constituents. Nausea and vomiting It is known to depress renin secretion. Should be taken with food. Swallow whole, do not crush Monitor heart rate prior to administration

Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction

Isosorbide Mononitrate Imdur Nitrate 30 mg 1 tab OD Angina pectoris Hypersensitivity to nitrate, MI with low left ventricular filling pressure. Headache, dizziness, nausea and vomiting, flushing, weakness, orthostatic hypotension.

Mechanism of Action

May reduce cardiac oxygen demand by decreasing left ventricular end diastolic pressure (preload) and, to lesser extent, systemic vascular resistance (after load). Thus, increases blood flow through collateral coronary vessel.

Nursing Responsibilities

Monitor blood pressure, heart rate and rhythm, and intensity and duration of drug response. Do not give the drug during an 8 to 12 hour period daily. Give drug on empty stomach, either 30 minutes before or 1 to 2 hours after meals, and have him swallow tablets whole. Advise him to take drug regularly , as prescribed, and to keep it accessible at all times.

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Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction

Losartan potassium Cozaar ACE Inhibitor 50 mg 1 tab OD Hypertension Hypersensitivity Dizziness, syncope, headache, insomnia, hypotension, diarrhea, abdominal pain, nausea, cough, back pain, hyperkalemia.

Mechanism of Action

It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the rennin angiotensin system as well as the

release of aldosterone leading to decreased Bp. Nursing Responsibilities Administer without regard to meals. Monitor his blood pressure regularly and thereafter therapy to monitor drug s effectiveness. Regularly monitor creatinine and BUN to monitor kidney function. Give once daily dose in the morning to prevent insomnia. Tell patient to avoid sodium substitutes because they may contain potassium, which can cause hyperkalemia in patients taking drug.

Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction

Diltiazem Hydrochloride Dilzem Calcium Channel Blocker 60 mg 1 tab 1 tab TID Angina pectoris Allergy to diltiazem, heart block, cardiogenic shock, sick sinus syndrome. Lightheadedness, dizziness, headache, peripheral edema, arrhythmia, bradycardia, nausea, flushing.

Mechanism of Action

It inhibits calcium ion influx across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles.

Nursing Responsibilities

Monitor blood pressure when therapy starts and when dosage changes. Monitor ECG and heart rate, and rhythm regularly. Give the tablet before meals and at bedtime. Assist with ambulation during start of therapy because dizziness may occur. Immediate report if he experiences chest pain, shortness of breath,

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dizziness, palpitations, or swelling of the limbs. Minimize exposure to direct sunlight and to take precautions when in sun because of drug induced photosensitivity.

Generic Name Brand Name Drug class Dosage Indications Contraindications

Moxifloxacin Hydrochloride Avelox Fluoroquinolone 400 mg 1 tab TID Infection (pneumonitis, both lungs) Hypersensitivity to the drug, any of its components, or other fluoroquinolones. Use cautiously in patients with known or suspected CNS disorders and in patient with risk factors that may predispose them to seizures or lower the seizure threshold.

Adverse reaction

Vertigo, allergic, dyspnea, tachycardia, hypertension, peripheral edema, somnolence, tremor, anxiety, insomnia, headache, dizziness, paresthesia.

Mechanism of Action

Inhibits the enzymes needed for bacterial DNA replication, transcription, repair, and recombination.

Nursing Responsibilities

 Obtain specimen for culture and sensitivity test before first dose.  Monitor him for hypersensitivity reactions and symptoms of CNS toxicity, including seizures, prolonged QT interval, phototoxicity and tendon rupture.  Give with or without food. Give at the same time each day to provide consistent absorption.

Side Drips Medication: Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction Hydralazine Hydrochloride Appresoline Vasodilator 500 D5 water + 2 Appresoline + 2 Catapres @ 15 gtts / min Hypertension Hypersensitivity to drugs and its components, Coronary artery disease. Headache, palpitations, tachycardia, anorexia, nausea, vomiting, diarrhea, orthostatic hypotension, anorexia, dizziness, arrhythmia, rash. Mechanism of Action Acts directly on vascular smooth muscle to cause vasodilation, primarily arteriolar, decreasing peripheral resistance; maintains or increases renal and cerebral blood flow. Nursing Responsibilities  Instruct patient that he may experience dizziness and weakness as

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adverse affects of this drug. Lie down for a while if dizziness occurs.  Assist when changing patient s position.  Monitor patient s blood pressure before therapy and regularly thereafter.  Monitor CBC during therapy.  Tell patient to limit sodium intake.

Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction

Clonidine Hydrochloride Catapres Centrally Acting Sympatholytic 500 D5 water + 2 Appresoline + 2 Catapres @ 15 gtts / min Hypertension Hypersensitivity to drugs and its components. Anxiety, dizziness, drowsiness, fatigue, headache, somnolence, bradycardia, hypotension, orthostatic hypotension, constipation, dry mouth, vomiting, pruritis and dermatitis.

Mechanism of Action

It inhibits central vasomotor centers, decreasing sympathetic outflow to heart, kidneys, and peripheral vasculature, resulting in decreased peripheral vasculature resistance, decreased systolic and diastolic blood pressure, and decreased heart rate.

Nursing Responsibilities

Monitor blood pressure before therapy and thereafter therapy. Drug may be given to lower blood pressure rapidly in some in some hypertensive emergency situations. Monitor him closely, especially during the few days of therapy. Respiratory depression or deep sedation may occur. Caution him that drug can cause drowsiness, but that he will develop tolerance to these adverse effects.

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B. Medi Map
Risk factors:

Pathophysiology: Atherosclerosis is the most common cause of arterial aneurysm because plaque formation erodes the vessel wall and contributes to inflammation and release of proteinases that can further weaken the vessel. Hypertension also contributes to aneurysm formation by increasing wall stress. Thus, aneurysms form in arteries when there is disruption of the wall of the vessel associated with changes in clollagen and elastin that make the vessel more vulnerable to intravascular pressures.

Gender; man Age; 60 years old Cigarette smoking Hypertension

Laboratory and Diagnostic Test Chest X ray Troponin I Determination Hematology Chest CT Scan Capillary blood Glucose Serum K, Na, Ca, Mg Creatinine Clearance

Signs & symptoms: Chest pain when in supine position Shortness of breath Occasional cough Unequal pupils

THORACIC AORTIC ANEURYSM

Medical Management
Nursing interventions: Smoking cessation Avoid carrying heavy objects to prevent pressure on the vessel wall.
Drugs; Vastarel MR 35 mg 1 tab BID Imdur 30 mg 1 tab OD Losartan (Cozaar) 50 mg 1 tab OD Dilzem 60 mg 1 tab TID Avelox 400 mg 1 tab OD IV Therapy Bottle #2 PNSS 1 L x KVO AC Drip: 500 ml D5 water + 2 Appresoline + 2 Catapres @ 15 gtts / min (Maintain systolic blood pressure of 140 to 150, titrate 5 ugtts / min and stop side drip for Bp of 140) O2 Therapy: O2 @ 1 Lpm via nasal cannula

Prevention: Control your blood pressure and blood lipid levels. Do not smoke. Exercise regularly.

Strict compliance to antihypertensive medications to keep your blood pressure under control. Limit stressful physical activities Get regular exercise. Reduce cholesterol and fat in your diet.

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NURSING MANAGEMENT

40

A. Concept Map of Nursing Problems

2. Ineffective cardiac tissue perfusion r/t diminished arterial circulation to the cardiac muscle. 1. Decreased cardiac output r/t disturbed arterial circulation 2 to obstruction in the aortic

3. Ineffective renal tissue perfusion r/t t diminished arterial circulation to the kidney.

4. Chronic pain r/t the disruption of normal circulation in the thoracic region.

9. Risk for deficient fluid volume: hemorrhage r/t potential abnormal blood loss secondary to possible

Thoracic Aortic Aneurysm


Cc : SOB

5. Infection r /t to the invasion of pathogens.

8. Deficient knowledge r/t lack of information about current medical condition.

7. Sleep deprivation r/t coming in and out of staff nurses in the room.

6. Activity intolerance r/t limited physical activity 2 to possible rupture of aneurysm.

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1. Decreased cardiac output r/t disturbed arterial circulation 2 to obstruction in the aortic arc. Objectives: BP = 160 / 100 mmHg RR = 24 bpm Shortness of breath (+) Weakness (+) Fatigue Facial grimace Capillary refill of 4 seconds Creatinine clearance result: Creatinine = 126.8 umol/L Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta Cardiomegaly. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.

2. Ineffective cardiac tissue perfusion r/t diminished arterial circulation to the cardiac muscle. Subjective: Masakit akon dughan kung gahigda ko as verbalized. Objectives: BP = 160/100 mmHg RR = 24 bpm (+) Weakness (+) Fatigue (+) Shortness of breath Chest pain when in supine position Capillary refill of 4 seconds Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.

3. Ineffective renal tissue perfusion r/t diminished arterial circulation to the kidney. Objectives: BP = 160/100 mmHg (+) Weakness (+) Fatigue Capillary refill of 4 seconds Creatinine clearance result: Creatinine = 126.8 umol/L Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.

4. Chronic pain r/t the disruption of normal circulation in the thoracic region. Subjective: Masakit akon dughan , as verbalized. Objectives: BP = 160 / 100 mmHg With shortness of breath (+) Weakness (+) Fatigue (+) Chest pain with a pain scale of 5 to 6. (+) Facial grimace (+) Anorexia Chest X ray result: Left hilar mass vs Aortic Aneurysm. Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Dilzem 60 mg 1 tab. Imdur 30 mg 1 tab Oxygen inhalation at 1 Liter per minute.

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5. Infection r /t to the invasion of pathogens. Objectives:

6. Activity intolerance r/t limited physical activity 2 to possible rupture of aneurysm. Subjective: Daw nahapo ko kung sagad

7. Sleep deprivation r/t coming in and out of staff nurses in the room. Subjective: Wala ako nakatulog mayad kay sagad binalik balik sang nurse, as verbalized. Objective: (+) Weakness (+) Fatigue (+) Facial grimace (+) Anorexia Slowed reaction

9. Risk for deficient fluid volume: hemorrhage r/t potential abnormal blood loss secondary to possible rupture of aneurysm. Objectives: BP = 160 / 100 mmHg Shortness of breath Facial grimace (+) Weakness (+) Fatigue Capillary refill of 4 seconds Chest X ray result: Left hilar mass vs Aortic Aneurysm. Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Vastarel MR 35 mg 1 tab BID Losartan 50 mg 1 tab. AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD. O2 inhalation of 1 Liter per minute.

BP = 160 / 100 mmHg Shortness of breath (+) Fatigue

ko lakat, as verbalized.

Objectives: (+) Weakness (+) Nonproductive, intense cough Bp = 160 / 100 mmHg With shortness of breath (+) weakness Hematology result: Segmenters = 70 % high Chest X ray: Bibasal Pneumonia Avelox 400 mg 1 tab. (+) fatigue (+) facial grimace Chest X ray result: Left hilar mass vs Aortic Aneurysm. Chest CT Scan (Plain) Aortic arc aneurismal dilatation.

8. Deficient knowledge r/t lack of information about current medical condition Subjective: Wala pa siya namon ginsugiran sang iya condition. as verbalized by the folks. Objectives: Has no idea about his aortic aneurysm

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B. Nursing Care Plan


Assessment Objectives: BP = 160 / 100 mmHg RR = 24 bpm Shortness of breath (+) Weakness (+) Fatigue Facial grimace Capillary refill of 4 seconds Diagnosis Decreased cardiac output r/t disturbed arterial circulation 2 to obstruction in the aortic arc. Planning To provide adequate cardiac output as evidence by capillary refill < 3 seconds, blood pressure of 140 / 80 to 150 / 100 mmHg and decreased episodes of SOB with in the 8 hour shift Administered Losartan 50 mg 1 tab. It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action Creatinine clearance result: Creatinine = 126.8 umol/L blocks the vasoconstriction effect of the rennin angiotensin system as well as the release of Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly AC drip of 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / To provide a systemic effect of antihypertensive and directly lowers down aldosterone leading to decreased Bp. Intervention Dependent: Administered Vastarel MR 35 mg 1 tab BID It is known to depress renin secretion. Goal partially met. Adequate cardiac output was provided as evidenced by capillary refill of 3 seconds, blood pressure ranging from 140 / 100 to 160 / 100 millimeter of mercury, respiratory rate of 22 breaths per minute with no complaint of shortness of breath after 8 hours of care. Rationale Evaluation

44

min given by NOD. Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta Cardiomegaly. Provided O2 inhalation of 1 Liter per minute.

the blood pressure.

To supply supplemental oxygen needed by the body for metabolic demand.

Independent: Monitored vital signs; including blood pressure, heart rate, and respiratory rate. To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation.

Provided calm and quiet environment conducive for rest.

Rest helps lower arterial pressure and reduces the workload of the myocardium by diminishing the requirements for cardiac output.

45

Placed in a high back rest position.

Prevents compression in the thoracic region by the aneurysm. Thus, prevents further disturbances in the circulation.

Encouraged to immediately report ripping sensation within the chest accompanied by severe pain in the back between the shoulders.

This indicates rupture of aneurysm.

Encouraged to keep in bed rest and avoid if not possible, limit physical activity.

Stress could bring tension; and blood pressure may increase due to tension. Thus, adding pressure to the affected vessel.

Encouraged not to elevate the legs above the level of the heart.

Leg elevation decreases blood supply to the legs.

46

Monitored skin color and temperature of the skin.

Skin pallor and cold temperature of the skin signals poor circulation in the periphery.

Monitored intake and output.

Decreased cardiac output results in decreased perfusion of the kidney, with a resulting decrease in urine output.

Encourage to limit sodium intake or sodium containing foods.

Sodium attracts water and increases fluid volume in the body.

Assessment Subjective: Masakit akon dughan kung gahigda ko as verbalized.

Diagnosis Ineffective cardiac tissue perfusion r/t diminished arterial circulation to the cardiac muscle.

Planning To provide adequate cardiac perfusion as evidenced by the absence of shortness of breath, a decrease in episodes of

Intervention Dependent: Administered Vastarel MR 35 mg 1 tab BID

Rationale

Evaluation

It is known to depress renin secretion.

Goal met. Adequate cardiac tissue perfusion was provided as evidence by respiratory rate of 22 breaths per minute with no complaints

Objectives: BP = 160/100 mmHg

chest pain and blood pressure of 140 / 80 to 150

47

RR = 24 bpm (+) Weakness (+) Fatigue (+) Shortness of breath Chest pain when in supine position Capillary refill of 4 seconds

/ 100 mmHg within 8 hour shift.

Administered Losartan 50 mg 1 tab.

It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the rennin angiotensin system as well as the release of

of shortness of breath and blood pressure ranging from 140 / 100 to 160 / 100 millimeter of mercury after 8 hour of care.

Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly AC drip = 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly. Provided O2 inhalation of 1 Liter per minute. NOD.

aldosterone leading to decreased Bp.

To provide a systemic effect of antihypertensive and directly lowers down the blood pressure.

To supply supplemental oxygen needed by the cardiac muscle for metabolic demand.

48

Independent: Monitored vital signs; including blood pressure, heart rate, and respiratory rate.

To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation.

Provided a quiet environment conducive for rest.

It conserves energy and lowers tissue oxygen demand.

Placed on high back rest position.

Prevents compression in the thoracic region by the aneurysm. Thus, provides perfusion to the cardiac muscle and relieves chest pain.

Encouraged to immediately report ripping sensation within the chest accompanied by severe pain in the back between the shoulders.

This indicates rupture of aneurysm.

49

Encouraged to keep in bed rest and avoid if not possible, limit physical activity.

Stress could bring tension; and blood pressure may increase due to tension. Thus, adding pressure to the affected vessel.

Encourage to limit sodium intake or sodium containing foods.

Sodium attracts water and increase fluid volume in the body.

Assessment Objectives: BP = 160/100 mmHg (+) Weakness (+) Fatigue Capillary refill of 4 seconds

Diagnosis Ineffective renal tissue perfusion r/t diminished arterial circulation to the kidney.

Planning To provide adequate renal perfusion as evidence by blood pressure of 140 / 80 to 150 / 100 mmHg within 8 hours of care.

Intervention Dependent: Administered Vastarel MR 35 mg 1 tab BID

Rationale

Evaluation

It is known to depress renin secretion.

Goal partially met. Adequate renal tissue perfusion was provided as

Administered Losartan 50 mg 1 tab.

It selectively blocks the binding of angiotensin II to specific tissue receptors

evidenced by blood pressure ranging from 140 / 100 to 160 / 100 millimeter of mercury.

Creatinine clearance result: Creatinine = 126.8 umol/L

found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction

50

Chest X ray result: Left hilar mass vs Aortic Aneurysm. Atheromatous aorta. Cardiomegaly

effect of the rennin angiotensin system as well as the release of aldosterone leading to decreased Bp.

Chest CT Scan (Plain) Aortic arc aneurismal dilatation. Atherosclerotic aorta. Cardiomegaly.

AC drip = 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD.

To provide a systemic effect of antihypertensive and directly lowers down the blood pressure.

Provided oxygen inhalation of 1 Liter per minute.

To supply supplemental oxygen needed by the kidney for metabolic function.

Independent: Monitored vital signs; including blood pressure, heart rate, and respiratory rate. To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation.

51

Provided a quiet environment conducive for rest.

It conserves energy and lowers tissue oxygen demand.

Encourage to limit sodium intake or sodium containing foods.

Sodium attracts water and increases fluid volume in the body.

Assessment Subjective: Masakit akon dughan , as verbalized.

Diagnosis Chronic pain r/t the disruption of normal circulation in the thoracic region.

Planning To alleviate level of pain as evidence by a decreases in pain scale from 5 - 6 to a pain scale of 2 - 3 after 4 hours of nursing intervention.

Intervention Dependent: Administered Dilzem 60 mg 1 tab.

Rationale

Evaluation

It inhibits calcium ion influx across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles.

Goal met. The level of pain was alleviated as evidenced by pain scale of 2.

Objectives: BP = 160 / 100 mmHg With shortness of breath (+) Weakness (+) Fatigue (+) Chest pain with a pain scale of 5 to 6. (+) Facial grimace

Administered Imdur 30 mg 1 tab

May reduce cardiac oxygen demand by decreasing left ventricular end diastolic pressure (preload) and, to

52

(+) Anorexia

lesser extent, systemic vascular resistance (after

Chest X ray result: Left hilar mass vs Aortic Aneurysm.

load). Thus, increases blood flow through collateral coronary vessel.

Chest CT Scan (Plain) Aortic arc aneurismal dilatation.

Provided oxygen inhalation at 1 Liter per minute.

To provide supplemental oxygen needed by the cardiac muscle. Lack of oxygen in the myocardial tissue can cause chest pain.

Independent: Encouraged to perform relaxation technique like deep breathing exercise. To assist in muscle and generalized relaxation.

Provided comfort measures & an environment conducive for rest.

Promotes relaxation, and reduces muscle tension.

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Monitored vital signs.

To monitor and evaluate client s pain status. VS is elevated when suffering from pain

Placed on high back rest position.

This position makes him feel comfortable and helps in reducing pressure in the thoracic region which alleviates chest pain.

Assessment Objectives: BP = 160 / 100 mmHg Shortness of breath (+) Fatigue (+) Weakness (+) Nonproductive, intense cough

Diagnosis Infection r /t to the invasion of pathogens.

Planning To prevent or reduce further progression of infection with in hospital stay.

Intervention Dependent: Administered Avelox 400 mg 1 tab.

Rationale

Evaluation

Inhibits the enzymes needed for bacterial DNA replication, transcription, repair, and recombination.

Goal met. Mr. J.B shows improvement in his condition as evidenced by (-) cough, (-) weakness and

Independent: Monitored vital signs;

To check for the presence of hyperthermia, this is a common signs of infection.

is able to perform activities of daily living without difficulties.

Hematology result: Segmenters = 70 %

including temperature.

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high

Performed hand hygiene before and after every

To prevent transmission of microorganisms that could add to current infection.

Chest X ray: Bibasal Pneumonia

procedures.

Assessment Subjective: Daw nahapo ko kung sagad ko lakat, as verbalized.

Diagnosis Activity intolerance r/t limited physical activity 2 to possible rupture of aneurysm.

Planning To enhance activity tolerance within 8 hour shift.

Intervention Independent: Encouraged to perform active range of motion as tolerated.

Rationale

Evaluation

Inactivity rapidly contributes to muscle shortening and other factors contribute to

Goal met. Mr. J.B improved his activity tolerance as evidenced by ability to perform activity like sitting on chair, walking around the room and going to the

Objectives: Bp = 160 / 100 mmHg With shortness of breath (+) weakness (+) fatigue (+) facial grimace Instructed to stop activity immediately if experiencing chest tightness, unusual fatigue, dizziness and discomfort.

contracture and limitation of motion.

These are common symptoms of angina and are cause by a temporary insufficiency of coronary blood supply.

bathroom for personal necessities.

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Chest X ray result: Left hilar mass vs Aortic Aneurysm.

Promoted comfort measures and provided relief of pain.

It enhances ability to participate in activities.

Chest CT Scan (Plain) Aortic arc aneurismal dilatation.

Monitored vital signs; including blood pressure, heart rate and respiratory rate.

To evaluate tolerance in every activities being performed.

Allowed for periods of rest before and after activity.

Rest helps lower arterial pressure and reduces the workload of myocardium.

Assessment Subjective: Wala ako nakatulog mayad kay sagad binalik balik sang nurse, as verbalized.

Diagnosis Sleep deprivation r/t coming in and out of staff nurses in the room.

Planning To demonstrate an improvement in sleep/rest pattern within the shift.

Intervention Independent: Promoted adequate physical exercise activity as tolerated during day.

Rationale

Evaluation

It enhances expenditure of energy and release of tension so that client feels ready for sleep.

Goal met. Mr. J.B demonstrated an improvement in sleep/rest pattern as evidenced by a sleep with a long interval.

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Objective: (+) Weakness (+) Fatigue (+) Facial grimace (+) Anorexia Slowed reaction

Minimized coming in and out of the room by doing things at the same time as possible.

To prevent disturbing him and provides adequate rest periods.

Provided calm and quiet environment conducive for rest.

It provides resting environment to the client.

Placed in a high fowler s position.

Placing client in a comfortable position helps in facilitating periods of rest.

Assessment Subjective: Wala pa siya namon ginsugiran sang iya condition. as verbalized by the folks.

Diagnosis Deficient knowledge r/t lack of information about current medical condition.

Planning To provide understanding about his current condition and health maintenance without mentioning aortic aneurysm within the shift.

Intervention Independent: Used easy to understand language when giving information.

Rationale

Evaluation

To provide broad understanding about his health condition.

Goal met. Mr. J.B was able to understand his condition as evidenced by realization that his blood pressure had

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Objectives: Has no idea about his aortic aneurysm

Provided health and healthcare information relevant only to the condition.

To prevent overload of unnecessary information.

increased continuously due to decreased compliance in medication and regular check up, kinahanglan ko nagid emonitor akon

Discussed healthy lifestyle changes that promote wellness.

To improve preventive healthcare and enhance quality of life.

Bp as verbalized without knowing about his thoracic aortic aneurysm.

Informed to watch for ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades; and immediately bring him to the nearest hospital as possible.

To provide awareness that this symptom is an emergency situation. Thus, prompt action or intervention is necessary.

A medication which is more on antihypertensive

Discussed the importance of strict compliance to medication & regular check up.

drugs and antiangina is necessary to maintain blood pressure between its normal range and relieves chest pain.

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Emphasized the significance of controlling blood pressure without mentioning anything about his aortic aneurysm.

This may enhance the knowledge of the patient regarding the potential health problems that may occur due to a high blood pressure; and could motivate him to strictly comply to its treatment.

Assessment Objectives: BP = 160 / 100 mmHg Shortness of breath Facial grimace (+) Weakness (+) Fatigue Capillary refill of 4 seconds

Diagnosis Risk for deficient fluid volume: hemorrhage r/t potential abnormal blood loss secondary to possible rupture of aneurysm.

Planning To prevent the risk for deficient fluid volume within 8 hour shift.

Intervention Dependent: Vastarel MR 35 mg 1 tab BID

Rationale

Evaluation

It is known to depress renin secretion.

Goal met. The risk for deficient fluid volume was prevented as

Administered Losartan 50 mg 1 tab.

It selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and

evidenced by the absence of hemorrhage or abnormal blood loss due to rupture of the aneurysm.

Chest X ray result: Left hilar mass vs Aortic Aneurysm.

adrenal gland; this action blocks the vasoconstriction effect of the rennin

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angiotensin system as well Chest CT Scan (Plain) Aortic arc aneurismal dilatation. as the release of aldosterone leading to decreased Bp.

AC drip = 500 ml D5 water + 2 catapres + 2 Appresoline @ 15 gtts / min given by NOD.

To provide a systemic effect of antihypertensive and directly lowers down the blood pressure.

Independent: Monitored intake and output. A urine output of < 30 cc per hour is insufficient for normal kidney function and indicates hypovolemia or onset of renal damage.

Monitored vital signs.

To check for signs of hypovolemia; including low Bp and increased heart rate respiratory rate.

Encouraged to limit

To prevent stress and

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physical activity and perform it as tolerated.

tension. These can contribute to an increase in Bp that adds pressure into the aneurysm.

Provided calm and quiet environment conducive for rest.

Rest helps lower arterial pressure.

Placed on high back rest position.

Prevents compression in the thoracic region by the aneurysm.

Informed to watch for ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades; and immediately notify staff nurses or physician if it is being felt.

This is a sign of ruptured aneurysm and is an emergency situation.

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DISCHARGE PLANNING

edications
Encourage the patient to have a strict compliance with regards to the medication to attain therapeutic effects. Explain to the patient the use and side effects of the medications so that he will be aware of its effects. Give adequate instructions to the significant others about the importance of the following medications and dietary regimens so that the patient s condition can remain stable as soon as possible. 1. Hyzaar 100mg / 25 mg 1 tab at 6 am 2. Dilzem 60 mg 1 tab 3x a day 3. Vastarel MR 25 mg b.i.d p.c 4. Imdur 30 mg o.d 1 tab at 8 am 5. Avelox 400mg 1 tab p.c lunch 6. Neoform 1 tab o.d p.c breakfast 7. Lilac 30 cc HS if no BM. 8. Iterax tab HS 9. Lipitor 40 mg tab HS

xercise
Educate the patient about bed exercises such as leg exercise, since patient have limitations on his physical activity because of possible rupture of aneurysm. Instruct not to carry heavy objects. Teach how to perform range-of-motion exercises as tolerated to prevent muscle shortening and any factors that may contribute to limitation of motion. It also maintains or increases proper joint movement and flexibility. Encourage to have a regular exercise.

reatment
Aware the patient to avoid over work for the following days and must have adequate bed rest to regain energy or strength. By means of anticipating the needs on the course of healing and curing process, train the patient to focused to himself by not always depending on the interventions that are not highly needed just to ease or prevent any health problem regarding his condition.

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Encourage to comply on further treatment for the proper maintenance and gain of optimal health by means of anticipating the needs on the course of optimum wellness.

ome teaching
To promote adherence to the therapeutic programs. Teach the following:
Environmental sanitation is needed to provide a therapeutic way of curing himself. Teach the patient and family how to measure blood pressure. Encourage the folks to regularly monitor his blood pressure. Instruct not to carry objects or avoid stressful activities. Limit physical activities. Inform to watch for ripping sensation within the chest accompanied by severe pain in the back between the shoulder blades; and immediately bring him to the nearest hospital as possible. Discus the importance of strict compliance to medication & regular check up.

ut-patient
Remind the patient that he must come back to the hospital one week after, for the follow-up check-up to confirm if the patient s condition is really restored. Also to know if there are complications sited during the check up to know if patients condition have worsen or not. Advise patient and the family to report to the physician if any recurrence or severity of symptoms, any adverse effects to the medication, and any development of complications. Advise patient to comply with the medication strictly as well as to regular check up. Teach the patient about the importance of continuing medications that is prescribed by the physician.

iet
Advise to eat nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables Inform the client and the client s relatives on the specific types of food that may help speed

up the recovery from the condition; including low salt, low cholesterol and low fat.

pirituality
Encourage the patient to read the Bible and pray to God always, ask for guidance and pray for the healing and restoration of health. Ask the patient to reflect on the Bible Scripture, For I will restore health to you and heal you on your wounds. says the Lord. (Jeremiah 30:17). Always seek spiritual advice and go on Sunday masses.

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PROGNOSIS

Two weeks after our clinical care to Mr. J.B, July 17, 2011, during our after care visit at North Natividad, Pilar, Capiz; he was able to comply all his medications on time which includes: Hyzaar 100mg / 25 mg 1 tab at 6 am Dilzem 60 mg 1 tab 3x a day Vastarel MR 25 mg b.i.d p.c Imdur 30 mg o.d 1 tab at 8 am Avelox 400mg 1 tab p.c lunch Neoform 1 tab o.d p.c breakfast Lilac 30 cc HS if no BM. Iterax tab HS Lipitor 40 mg tab HS And last July 28, 2011 he went to his attending physician together with his wife and undergone different laboratories related to his condition.

As we have our follow-up care, we observed that Mr. J.B was capable of performing activities of daily living by himself. He is also walking in the seashore every morning and before the sun sets as one of his recreational activities. This habit of Mr. J.B becomes a routine activity of him, wherein it makes him feel unwind and calm.

His family also helps him by monitoring his blood pressure regularly. The seafoods and sodium rich foods that is being prepared every meal was also lessen and sometimes, he was discouraged to eat those mentioned foods and to carry heavy objects or exert much effort and pressure in every activities.

Moreover, Mr. J.B complained episodes of full to heavy chest pain in a tolerable level. There is no episodes of shortness of breath and slept in a high back rest position as described. According to his wife, is blood pressure ranges from 160 / 100 to 140 / 90 millimeter of mercury. Mr. J.B s latest vital signs were: Blood pressure of 150 / 100 millimeter of mercury Heart rate of 89 beats per minute Respiratory rate of 21 breaths per minute; and Pulse rate of 84 beats per minute.

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JOURNEY

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ACKNOWLEDGEMENT

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REFERENCE

http://www.nlm.nih.gov/medlineplus/ency/article/001119.htm Brunner & Suddarths Textbook of Medical Surgical Nursing, eleventh edition http://en.wikipedia.org/wiki/Thoracic_aortic_aneurysm http://www.slrctsurgery.com/Thoracic%20aortic%20aneurysms.htm http://www.mayoclinic.com/health/aortic-aneurysm/DS00017/DSECTION=lifestyle-and-homeremedies http://www.wrongdiagnosis.com/a/aortic_aneurysm/prevalence.htm http:/www.mims.com

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