Get Homework/Assignment Done

Homeworkping.com

Homework Help

https://www.homeworkping.com/

Research Paper help

https://www.homeworkping.com/

Online Tutoring

https://www.homeworkping.com/

click here for freelancing tutoring sites

Introduction

A heart beat signifies life, from the day it starts to beat in the womb, till it stops,

and where death conquers us. The heart beats not only to one tune but it also responds

to the tune of emotions and physical stress. As some of us may have also experience

moments of joy or sorrow and the heart may feel pain or pleasure.

In medicine, an acute disease is a disease with a rapid onset or a short course.

The term “Acute” may often be confused by the general public to mean “severe”,

however, this has a different meaning. Coronary, may refer to as “the heart” or “relating

1

to the heart”. While syndrome is defined as a set of signs and symptoms that tend to

occur together and which reflect the presence of a particular disease or an increased

chance of developing a particular disease.

Acute Coronary Syndrome is defined as a spectrum of conditions involving chest

discomfort or other symptoms caused by lack of oxygen to the heart muscle (the

myocardium). The unification of these manifestations of coronary artery disease under a

single term reflects the understanding that these are caused by a similar

pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or

rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary

arteries and impaired blood supply to the heart muscle.

According to the morbidity rate, taken from the records of the Department of

Health for region X, the occurrence of cardiovascular diseases per 100,000 populations

is 3,356. This data is taken from the 2001-2005, a 5 years average record. While the

occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373

per 100,000 populations.

2

OBJECTIVES OF THE STUDY

The study aims to explore the concepts about the condition and the quality of

nursing care being rendered to our client Mrs. F that was diagnosed with Acute

Coronary Syndrome.

In order to learn more about the health condition of the patient, the study wants

to fathom about the predisposing and precipitating factors, anatomy and physiology and

the pathophysiology of the condition experienced by the client. Basically the main goal

of this study in relation to knowledge is to identify the nursing interventions after the

condition of patient Mrs. F.

The study aims to critically analyze the qualitative and quantitative data gathered

in order to establish connection between the different manifestations experienced by the

patient with that of the disease process. To be able to improve skills, the students also

endeavors to come up with nursing care plans that will alleviate Mrs. F.’s condition. The

presentors also intend to compare and contrast the ideal management for Acute

Coronary Syndrome with that of the actual management. In addition, the study seeks to

disseminate essential information to everybody for awareness.

Furthermore, by this study, the provider will be able to exercise that attitude of

determination and in order to come up with a successful study.

3

SCOPE AND LIMITATIONS OF THE STUDY

This case study tackles about Acute Coronary Sydrome specifically on the case

of patient Mrs. F. It includes essential concepts in relation to the said condition such as

the patient’s profile and health history, nursing assessment and clinical manifestations,

drug study and diagnostic exams done. The anatomy and physiology is also included as

well as the pathophysiology of Acute Coronary Syndrome with its associated factors.

The Medical and Nursing Management along with the discharge plans with its referrals

are also being covered. The prognosis is also given.

The scope of the plan encompasses during the Recovery Phase which was on

February 12, 13, 14, 15, 16, 18 and 19 of year 2008 wherein the assigned students who

have assessed the client with cumulative interaction and good rapport to the patient and

significant others. Nursing Management covers the above mentioned dates which

encompasses the client’s Recovery Phase. Data gathering about the Laboratory results

covers from February 05 to February 16, 2008.

The areas of concerns are limited to the discussions of Acute Coronary

Syndrome and the quality of Nursing Care to the patient. The quantity and quality of the

information are limited to the data gathered from the client, significant others and his

medical records.

Immediate family background is limited because the patient has difficulty in

recalling necessary information that would aid in the data gathering. Data gathering was

limited in the confines of Maria Reyna Hospital, Cagayan de Oro City and Aluba,

Cagayan de Oro. Generally, the content of the report is limited to the elaboration of the

diagnosis given to the patient and the corresponding Nursing Management.

4

PATIENT’S PROFILE

Name: Mrs. FMrs. F

Age: 81 years old81 years old

Sex: Female

Birthday: June 3, 1926June 3, 1926

Birth rank: 2nd to the eldest

Number of siblings: 7

Religion: Roman Catholic

Civil Status: Married

Number of children: 13, with 10 living and 3 deceased

Nationality: Filipino

Height: 5 Ft.

Weight: 73 kg

Address: Baungon, Bukidnon

Occupation: House wife

Income: Php. 15,000/ mo.

Educational Attainment: 1st year H.S.

Date Admitted: February 05, 2008

Time Admitted: 12: 05 PM

Chief Compliant: Shortness of breath and chest pain

Date Discharged: February 16, 2008

Time Discharged: 4:15 PM

Final Diagnosis: Acute Coronary Syndrome, hypertension, Myocardial Infarction

5

Significance of the study

The study is significant to the following people, the client, the client’s family, the

researchers, nursing student, and future researchers.

The study is significant to the client, because it enlightens the client’s queries and

doubts regarding her condition. Allowing her to understand the situation of her present

state, this would allow her to be more aware of the importance of following the

treatment regimen.

Client’s family must also be aware of the condition of the client. With the study,

the client’s family will be able to participate in the client’s treatment, and they will be

able realize the importance of the support system in participating in the client’s care.

The study is also important to the researchers, since it allows them to explore the

client’s condition, giving them first hand experience in observing the manifestations of

the disease condition and allowing them to apply theoretical knowledge regarding

nursing managements for the manifested signs and symptoms.

Nursing students and future researchers may use the study for reference or basis

purposes in planning an intervention or understanding a condition which could be

similar or related to the study presented.

6

Health HistoryFamily History

History of hypertension was present to both paternal and maternal side, in

addition to the given data’s from the informant; there’s no history of CA on the clients

lineages. However, on her maternal side a history of diabetes mellitus and heart

problems was present.

Mrs. F.’s grandfather (father side) died due to liver abscess. It was known that

her grandfather was a chain tobacco smoker consuming 24 sticks or approximately

1pack of cigarette per day and drinks alcoholic beverages such as “tuba”. Additionally,

patient’s grandmother (father side) died due to normal aging with high blood pressure.

Patient’s maternal side history revealed that grandparents died due to aging.

Furthermore, patient’s father died due to normal aging with hypertension. It was

mentioned that her father was also a smoker, consuming 15-20 estimated sticks of

cigarette per day. He also drinks alcoholic beverages like “tuba”. Her mother died at her

88 years of age due to normal aging process.

On the siblings of the client’s father side, all had hypertension. Some of her

mother’s siblings had hypertension and one had CVA.

Personal Social history

Mrs. F. had her menarche at the age of 13 years old. At the age of 20 years old,

Mrs. F. met Mr. S. at Baungon, Bukidnon and got married. Mrs. F.’s reproductive profile

was G13, P13, T13, P0, A0, and L10. She has 13 children. Her first pregnancy was on

February 3, 1947 with their first child named Sohrab through Normal Spontaneous

Vaginal Hospital delivery. Sorab died on January 29, 1989 due to an accident. Second

delivery was a pregnancy uterine full term, normal Spontaneous delivery with a baby

7

boy named after his father, Santiago Jr. History divulges that the patient’s second child

died after birth. Third pregnancy was still a normal spontaneous vaginal delivery. The

baby was named Leopoldo, Leopoldo died due to measles at the age of 3months. Her

fourth pregnancy was still normal named her third child Elleonor with an educational

attainment of High School level who was born February 22, 1949. Mrs. F.’s 10

remaining pregnancies were all full term and were all delivered through normal

spontaneous vaginal delivery. The remaining 10 children were the following: Gemma

who was born on December 18 1950, married and with an educational attainment of

High School Grad, Rosalina born aug. 18, 1951 with an educational attainment of High

School graduate ,married (female), Efren born Sept. 18 1952 with an educational

attainment of High School level and is married (male), Salvacion born on Feb. 15, 1953

a High School level and is married (female), Marjorie born on Oct. 16, 1962 a High

School graduate and is married (female), Jose born on 0ct. 18, 1963 a High School

level and is single (male), Marites born on Dec. 10, 1964 a High School level and is

married (female), Nancy born on Aug. 22, 1966 a college graduate and is married

(female),Edgardo born on Nov. 2 1967 a High School Grad and is single(male).

Patient’s husband, Mr. S. was the Former vice Mayor of Baungon, Bukidnon. On

the year 1963- 1965.Being a wife of the vice mayor, she participated well in politics and

has a lot of programs and campaigns for her husband. She was also a member of the

Catholic Women’s League and has done a lot of outreach programs for the church.

Their family social status was at peak that time, but then a great downfall happened in

their lives. At the age of 39 years old, Mr. Santiago was stabbed due to political conflicts

which caused his death. She hardly accepted it because of the traumatic experience

they had.

After two years, Mrs. F. got married to Mr. V. He is a Cebuano who came to

Baungon, Bukidnon in search for work and found more than what he had expected. Mr.

V was afraid in marrying her because he has to face all of her children to ask for the

hands of their mother. Luckily, all of her children understood and accepted him and they

got married. Mr. V. and Mrs. F. were not blessed with children somehow blessed with

their adopted children who were Margie and Kristine.

8

They have their own house in Baungon, Bukidnon and took cared by her adopted

daughter Margie. When visiting in Cagayan de Oro wherein her sons and daughters are

residing in the same area, they stay in her daughter’s house Marites in Aluba, Coca-

cola compound where they are warmly welcomed. Our client’s source of income is only

P15,000 pesos a month from her pension pay.

Past medical History

On 1965, the year of Mr. S.’s death, Mrs. F. had traumatic experience that

caused her psychological and physical stress. It was claimed by the informant that at

the year 1984, patient was admitted to City Hospital due to her first stroke attack. That

admission lasts for a week and she was diagnosed to have Cerebro Vascular Accident

or CVA. Her, second attack was on year 1991 at Madonna Hospital Intensive Care Unit

(ICU). After a couple of years from her 2nd admission, patient suffered from persistent

chest pain thus gave way to her third admission at Maria Reyna Hospital the year 2006.

After that admission, patient was given home medications to be maintained which are:

Telmisartan (pritor) 40mg 1 tab/day, Clopidogrel (Plavix) 75mg 1 tab OD, Metroprolol

50mg ½ tab BID, Amniodarone (Cordarone) 200mg 1 tab TID, ASA 80mg 1 tab OD,

Atorvastatin (Lipitor) 80mg 1 TAB OD @ hs, SMN (imdur) 60mg 1 TAB BID.

One year after her third admission patient underwent surgery on her left eye. An

Extra Capsular Cataract Lens Extraction (ECCLE) was done on the year 2007.

History of Present Illness

One week prior to admission patient experienced blurring of vision and headache

which continue until the day of admission. She didn’t do anything because she thought

that it’s just a symptom of her cataract. 3days prior to adm. Client took Isodril for her

moderate chest pains radiating from the left shoulder to her back but wasn’t relieved.

Informant stated that, 1 day prior to admission, patient had shortness of breath with

9

inability to lie flat on bed and the night of the same date (February 4, 2008), patient

noted and complained for moderate chest pain radiating to her left shoulder and back.

On the 5th day of February 2008, Severe Chest pain suffered by the patient persisted

with difficulty in breathing and shortness of breath which prompt her admission at Maria

Reyna Hospital and was initially diagnosed with Hypertensive Cardiovascular disease.

The client was ruled with the final diagnosis of Acute Coronary Syndrome and was

under the observation and medical treatment of Dr. Alenton.

Chief Complaint

Shortness of breath

10

Developmental Data

GROWTH AND DEVELOPMENT

Patient: Mrs. F

Gender: Female

Age: 81 years old

Psychosocial Theory – Erik Erikson

Erik Erikson’s theory of psychosocial development is one of the best-known

theories of personality in psychology. His theory describes the impact of social

experience across the whole lifespan. In each stage, Erikson believed people

experience a conflict that serves as a turning point in development. In Erikson’s view,

these conflicts are centered on either developing a psychological quality or failing to

develop that quality. During these times, the potential for personal growth is high, but so

is the potential for failure.

In this theory, the patient has the task of Integrity vs. Despair which is the final

task of psychosocial theory which ranges at 65 years old until death. This phase occurs

during old age and is focused on reflecting back on life. Those who are unsuccessful

during this phase will feel that their life has been wasted and will experience many

regrets. The individual will be left with feelings of bitterness and despair. Those who feel

proud of their accomplishments will feel a sense of integrity. Successfully completing

this phase means looking back with few regrets and a general feeling of satisfaction.

These individuals will attain wisdom, even when confronting death.

The patient has developed a feeling of despair. She’s destructed by her worries

for things that might worsen her condition and for things that might happen to her

offspring. Patient was even afraid of facing death because she felt that she hasn’t done

11

her best yet for the future of her grown children for the reason that some of her children

didn’t have a stable job and others were unemployed. Another reason of despair was

that the client wasn’t able to prepare for the current health condition she is experiencing

brought by aging. For instance, the client wasn’t able to prepare by saving or by making

investments that could have had supported her health needs and maintenance.

Normally, it is usually anticipated by any person during younger years when she/he is

still able and strong. She verbalized that these emotions triggered her to have the

disease condition.

Developmental Task theory – Robert Havighurst

Havighurst (1972) defines a developmental task as one that arises at a certain

period in our lives. The successful achievement of which leads to happiness and

success with later tasks while, failure leads to unhappiness, social disapproval, and

difficulty with later tasks. These tasks provide a framework that a nurse can use to

evaluate a person’s general accomplishments. Robert Havighurst believed that learning

is basic to life and that people continue to learn throughout life. He believed that in each

stage in a person’s life, a person has different tasks to be learned.

In later maturity (61+) where the patient belongs, there are six (6) tasks to be learned,

as follows;

1. Adjusting to decreasing physical strength and health.

2. Adjusting to retirement and reduced income.

3. Adjusting to death of a spouse.

4. Adopting and adapting social roles in a flexible way.

5. Establishing satisfactory physical living arrangements.

6. Establishing an explicit affiliation with one’s age group.

These tasks are arranged in chronological order;

12

(1) Adjusting to death of a spouse. At an early age of 39, she became a widow and

left with 11 children. This was not an easy situation after the tragic death of her husband

especially raising the kids. Presently, patient is happily married with her second

husband Mr. V.

(2) Adopting and adapting social roles in a flexible way. She used to be the wife of a

vice mayor in their place. She attended most of the social functions her husband was

connected and interact very well to the constituents in the community. She remarried at

age 41 and she didn’t have a child with her present spouse. She was able to adopt her

second marriage for her husband loves her children as his and was also very

supportive.

(3) Adjusted to reduced income. Patient had stopped working at the age of 58. That

was the time when she was admitted in the hospital due to CVD. She used to work in an

eatery but due to her age and physical condition, her children advised her to stay at

home as they were grown up and would support her.

(4) Establishing physical living arrangements with her family. At present, the couple

is no longer working and is supported by the children. They are happily living together in

their house at Baungon, Bukidnon.

(5) Adjusting to decreasing physical strength and health due to her present health

condition and her old age.

(6) Establishing an explicit affiliation with one’s age group. Until now the patient has

casual communication with her age level. She still could recognize some of her friends

during her younger years and at present. Much as she wanted to be with them always

but her health and age condition would not allow anymore.

Interpersonal Theory – Harry Stack Sullivan

Harry Stack Sullivan was an American psychiatrist who extended theory of

personality development to include the significance of interpersonal relationships. He

13

thought that inadequate or nonsatisfying relationships produced anxiety, which he saw

as the basis for all emotional problems.

Sullivan saw interpersonal development as taking place over seven stages, from

infancy to mature adulthood. Personality changes can take place at any time but are

more likely to occur during transitions between stages.

In this theory, the patient falls under the final stage which is the adulthood stage

which starts from 23 years of age. This is the time when a person establishes a stable

relationship with a significant other person and develops a consistent pattern of viewing

the world. The struggles of adulthood include financial security, career, and family. With

success during previous stages, adult relationships and much needed socialization

become easier to attain. Without a solid background, interpersonal conflicts that result

in anxiety become more commonplace.

The patient has developed well according to this theory. In fact, two years after

the death of her first husband, she was able to find herself again, started a new life and

got married with her second husband. She was able to get over her first husbands

death in just 2 years.

The patient can also be considered as having a good coping mechanism

because she was able to adjust to possible crises in life. For instance, though they were

not living a lavish life, but they were able to adopt well a life that suits their resources.

As a couple, they were able to meet their basic needs in life.

14

Medical ManagementDoctors Orders

DATE ORDERS RATIONALE

February 05, 2008

2:30 pm

Pls. admit under the service of Dr. Alenton.

To render proper medical management

Secure consent to care. For legal purposes which pertains to medical treatment and procedures.

Temperature Pulse Respirations q 4 hrs.

To obtain baseline data.

Nothing Per Orem temporary To prevent the risk for aspiration.

Start venoclysis with D5W 500cc at 10cc/hr.

For saline lock; emergency IVTT drugs used.

Labs.

Complete Blood Count To check for any hematologic unusualities.

Sodium To check for serum sodium content in the body.

Potassium To check for potassium content in the body.

15

Creatinine To check for any tissue damage.

Serum Glutamic Pyrovic Transimenase

To check for liver functioning.

Trop T (quantitative) To detect and diagnose Myocardial infarction.

Creatinine Kinase-MB-stat! To immediately check for the degree of infarction

Electrocardiogram 12 Leads To monitor cardiac functioning.

Chest X-ray –Antero posterior (portable)

To detect mediastinal abnormalities

Fasting Blood Sugar

=Lipid Profile

To check for blood sugar level.

Med’s.

Nitroglycerin (Transderm) patches 5mg now x 12 OD.

Treatment of Angina

Aspirin 80mg 4 tabs now then 1 tab OD after(pc) lunch

Treatment and prophylaxis of Myocardial infarction

16

Clopidrogrel (Plavix) 75g 4 tabs now then once a day(OD)

Treatment of patients with acute coronary syndrome and myocardial infarction

Captopril 25g ½ tab now then three times a day (BID)

Treatment for Hypertension

Fondaparinux (Arixtra) 2.5mg Subcutaneous (SQ) now then OD

Prevents the formation of thrombus

Tramadol (Dolcet) 1 cap now then three times a day (TID)

Prophylaxis for pain

Tramadol (Dolcet) 1 cap now then three times a day (TID)

Prophylaxis for pain

Metoprolol (Neobloc) 80mg 1 tab now then twice a day (BID)

Prevention of reinfarction in Myocardial infarction

Oxygen inhalation at 2 liters/ minute via nasal cannula.

To provide supplemental oxygen.

Moderate high back rest To promote lung expansion

Complete Bed Rest without toilet privilege

To prevent increase workload of the heart.

Intake and Output every shift.

To determine fluid retention and dehydration.

17

Monitor vital signs every hour and record

To check for any unusualities

Will inform Attending Physician

For proper management and care.

Refer accordingly To aid for further medical intervention

5:13pm Add’s meds.

Atorvastatin (lipitor) 80mg 1 tab now then OD at

Treatment of elevated Low density lipoprotein

Lactulose 20cc OD at hs.

Prevent Constipation

Decrease Captopril to 25g ¼ tab now then every 8hour.

Reduce the risk of hypotension

Decrease Metoprolol to 50g ½ tab then BID

Reduce the risk of hypotension

Start Isoket drip: D5W 90cc +1 amp Isoket at 10cc/hr.

Treatment for left ventricular failure secondary to acute Myocardial infarction

Repeat ECG 12 Leads in morning

For comparison purposes and to check for the effectivity of drugs

Increase Aspirin to 80mg 2 tabs OD PC lunch

To attain drug efficacy level.

Remove transderm patch.

Chest pain subsides; not needed for treatment.

18

Attached to cardiac monitor.

To monitor cardiac functioning

7:03pm Ranitidine(Ulcin) 150g 2 tab BID PO

Treatment for sour stomach in adults

May have soft, low salt. Low fat diet.

To meet nutritional needs intended for MI patient

Shift ranitidine PO to 50mg IVTT q 8hrs.

For fast drug absorption.

8:07pm Soft diet To meet nutritional needs intended for MI patient.

12 lead ECG with long lead 2

To assess cardiac status

FBS lipid profile, uric acid, SGPT in am

Aid to diagnosed for hyperglycemia, hyperuricemia and M.I

Kalium durule 1 tab TIDx6 doses.

Treatment for hypokalemia

10:45pm Increased Isoket to15cc/hr To attain drug efficacy level

Give Tramadol 50mg IVTT now

Treatment for moderate to severe pain

10:50pm Increased Isoket to20cc/hr

To attain drug efficacy level.

19

Increased Isoket to25cc/hr

To attain drug efficacy level.

11:00pm Increased Isoket to30cc/hr

To attain drug efficacy level.

Give morphine 4mg IVTT now.

Relief of moderate to severe acute pain

11:30pm Shift ranitidine PO to 50mg IVTT q 8hrs.

For fast drug absorption

February 06, 2008

6:05 am

Pls. Follow-up repeat ECG with long lead 3 care of heart station.

For continuous monitoring.

To follow Isoket drip: D5 water 90cc. plus 1 amp. Isokit at 30cc. / min.

Left ventricular failure secondary to acute Myocardial infarction

Metformin (Imax) 500mg. 1 tab BID

Oral treatment for type 2 diabetes

Isoket drip to consume To obtain effectivity of medication

Imdur 60mg. 1 Tab BID Prophylaxis and treatment for angina pectoris.

4:30 pm IV follow-up with D5 Water 500cc.10cc/hour

For saline lock; emergency IVTT drugs used.

Add 1 banana per meal. Aid to increase serum potassium level.

20

February 07,2008

6:05pm

Limit visitors To promote rest and decrease fatigue.

Facilitate ECG with long lead 2 in a.m

For continuous monitoring.

February 08,2008

7:15 am

Summary of meds:

Isosorbide Mononitrate (Imdur) 60mg 1 tab OD

Left ventricular failure secondary to acute Myocardial infarction

Isosorbide Dinitrate (Isordil) 5mg 1 tab 5L PRN for chest pain

Treatment and prophylaxis of Myocardial infarction

Aspirin 80mg 2 tabs OD PC lunch

Treatment of patients with acute coronary syndrome and myocardial infarction

Clopidrogrel (Plavix) 750mg 1 tab OD

Treatment of patients with acute coronary syndrome and myocardial infarction

Captopril 25mg ¼ tab q 8hrs

Treatment for hypertension

Fondaparinux (Arixtra) 2.5mg OD SQ

Prophylaxis of Deep Vein thrombosis

21

Metoprolol 50mg ½ tab BID PO

Prevention of reinfarction in Myocardial infarction

Atorvastatin (lipitor) 80mg 1 tab OD at HS.

Treatment of elevated Low density lipoprotein

Lactulose 20cc at HS hold for BM >/= 2x/day

Prevent constipation

Metformin 500mg (Imax) 1 tab BID PO

Oral treatment for Type II diabetes mellitus

Ranitidine Hydrochloride (Zantac) 150mg 1 tab BID PO

Prophylaxis for GI irritation

Increase Imdur to 60mg 1tab BID

To attain drug efficacy level

Vastaril MR 1 tab BID

Prophylaxis and treatment for Angina pectoris.

Now give Isordil q 5 mins for 3 doses of chest pain if not relieved by first dose.

Treatment and prevention of angina pectoris

2:00pm IVF to follow with PNSS 500c at 10cc/hr.

For saline lock; emergency IVTT drugs used.

22

February 9, 2008

1:08am

Metoclopramide (plazil) 10mg IVTT now

Prevention of nausea and vomiting

Aluminum Magnesium Hydroxide (maalox) 10ml now then TID

Treatment for hyperacidity

5:40am IVF to ff: PNSS 500cc @ 10cc/hr

Saline lock; for emergency IVTT drugs used

8:40am Repeat ECG today For comparison purposes and to check for the effectiveness of the drug

Increase Maalox 10ml to QID before meals and HS

To attain drug efficacy level.

Inform IMROD for any recurrence of chest pain and SOB

For further medical management

4:00pm Off O2 – may have 02 PRN for dyspnea

To aid patient during SOB

200mg Cordarone 1 tab TID

Treatment of ventricular arrhythmias

February 11,2008

May sit on bed with dangle legs.

To determine pt. ability to sit upright in her own

23

February 12,2008

Summary of meds

Aspirin 80mg 2 tabs OD PC lunch PO

Treatment and prophylaxis of Myocardial infarction

Clopidogrel (Plavix) 75mg 1 tab OD PO

Treatment of patients with acute coronary syndrome and myocardial infarction

Captopril 25mg ¼ tab q 8h

Prophylaxis and treatment for hypertension

Fondaparinux (Arixtra) 2.5mg OD SL– Day 7 last dose at 6pm

Prophylaxis of Deep Vein thrombosis

Tramadol(dolcet) 1 tab TID prn for pain

Moderate to severe pain

Metoprolol 50mg ½ tab BID

Hypertension , Angina Pectoris, Prevention of reinfarction in Myocardial Infarction

Atorvastatin (Lipitor) 80mg 1tab OD @ HS

Treatment of Low density Lipoproteins

Lactulose 20cc OD, hold for BM > 2x/day

Prevent constipation

Metformin (I-max) 500mg 1tab BID

Oral treatment for Type II diabetes

Ranitidine (Zantac) 150mg 1tab BID

Prophylaxis for GI irritation

24

Isosorbide Mononitrite (Imdur) 60mg 1tab BID

Relieve and prevent angina

Aluminum Magnesium Hydroxide (Maalox) 10ml QID

Neutralizes gastric acidity

Amniodarone (cordarone) 200mg 1tab tid

Treatment of ventricular arrhythmias

10:20am Repeat ECG 12 leads now

For comparison purposes

DIET: decreased fat, decreased Na, hypertensive diet

To prevent hypertension( a precipitating factor)

May sit on bedside chair Ready for ambulation and slow assumption of activity daily living.

May walk @ bedside with assistance.

To promote exercise and prevent sudden orthostatic hypotension.

7:55pm ECG 12 lead now To assess cardiac status

Give metoclopramide(Plazil) 10mg IVTT now

Prevention of nausea and vomiting

Refer for recurrent of vomiting and save vomitus care of IMROD

For ocular inspection.

May decrease Aspirin 80mg 1 tab OD pc lunch

To prevent the risk of bleeding.

25

Hold Ranitidine Shift to new drug ordered Pantoprazole

26

Feb. 13, 2008 Start Pantoprazole (Pantoloc) 20mg 1 tab now then O.D P.O

Prophylaxis for epigastric hyperacidity

12:55p.m May walk inside the ward.

To promote exercise, and improved blood circulation

B/P and Cardiac rate after walking.

To monitor cardiac changes when doing certain activities.

Feb. 14, 2008

8:10p.m

Discontinue Maalox Epigastric hyperacidity subsides.

May walk to the bathroom with assistance

Enhances self care and prevent from sudden orthostatic hypotension

Give Domperidone(Motilium) 1 tab am then BID.

Treatment for flatulence

Feb.15, 2008

8:00am

I.V.F to consume then discontinue

Patient’s fluid status is stable, and in preparation for patients may go home.

May walk inside the ward

To promote exercise and blood circulation.

B/P and Cardiac rate after walking and record

To monitor cardiac changes when doing certain activities.

27

12:30pm Metoclopramide (plazil) 10mg. IVTT every 8 hours prn

Prevention of nausea and vomiting

Feb. 16,2008

11:02 am

MGH Patient may continue treatment at home

Home medications For treatment compliance regimen.

Telmisartan (Priton)40mg 1 tab O.D

Treatment of essential Hypertension

Clopidogrel (Plavix) 75mg 1 tab O.D

Treatment of patients with acute coronary syndrome and Myocardial infarction

Metoprolol 50mg ½ tab BID

o Treatment for hypertension

Atorvastatin (Lipitor) 80mg 1 tab OD @ H.S

Prophylaxis and treatment for hyperlipidemia

ISMN (Imdur) 60mg 1 tab BID

Prophylaxis and treatment for Angina pectoris

Amniodarone (Cordarone) 200mg 1 tab TID

Treatment of ventricular arrhythmias

Aspirin 80mg 1 tab OD pc lunch

Prophylaxis for MI

Metformin (Imax) Treatment for Type II

28

500mg 1 tab BID diabetes mellitus

Day Feb.20, 2008 at MRH clinic follow-up check-up.

To evaluate for the effectiveness of medical and nursing care.

Photocopy all labs. Results (2copies)

For legal and documentation purposes.

Blood Chemistry

02-05-08

Test Normal Range Results Implications

Creatinine .7 - 1.2 1.3 mg/dl Myocardial Infarction

Na 137 – 145 132 mmol/L Hyponatremia

K 3.5 – 5.1 3.4 mmol/L Hypokalemia

ALT 9 – 52 3.0 u/L liver functioning decrease r/t drugs adverse effect and

gerontologic consideration

CK-MB 0 – 18 7 u/L

29

Differential Count

02-05-08

Test Normal Range Results Implications

Segmenters 55 – 65 % 46 Suggest anemia

Lymphocytes 25 – 35 % 53 Anemia

Eosinophils 1 – 3 % 01 Reduced in Stress

Hematology

02-05-08

Test Normal Range Results Implications

HCT 35 – 50 % 29.4 Iron Deficiency Anemia

HGB 11 – 16.5 g/dl 9.8 Iron Deficiency Anemia

RBC 3.8 – 5.80 10/mm

WBC 5 – 10 10/mm 9,100

Platelet Count 140,000 – 440,000 333,000

30

Chest x-ray Report

02-05-08

Examination Desired: CCXR Port

Haziness seen in the left base

Heart I magnified

Aorta is calcified

Spurs seen at the margins of the thoracic spine.

Impression:

Probable left basal Pneumonia

Atherosclerotic Aorta

Thoracic Spondylosis

31

Fasting Blood Sugar Lipid Profile

02-06-08

Test Normal Range Results Implications

Glucose 74 – 106 132 mg/dL Hyperglycemia

Uric Acid 2.5 – 6.2 8.4 mg/dL Hyperuricemia,

Cholesterol 0 – 200 187 mg/dL Hypercholesterolemia

Triglycerides 0 – 150 60 mg/dL Atherosclerosis

Direct HGL 40 – 60 38 mg/dL

LDL 60 – 180 137 mg/dL

VDRL 25 – 50 12 mg/dL

ALT 8 - 52 27 U/L

Troponin T (Quantitative)

2.0 ng/ml

02-06-08

Interpretation of Results Rationale

1. < 0.03 ng/ml Low Cardiac Risk

2. Between 0.03 ng/ml &0.1 ng/ml Medium Cardiac Risk (Possible Myocardial damage)

3. Between 0.1 ng/ml & 3.0 ng/ml High Risk (Myocardial damage detected)

4. > 2.0 ng/ml Massive Myocardial damage has been detected

32

HGT (Hemoglucotest)

02-08-08

94 mg/dL (N)

IVF Sheet

02-05-08

Bottle # Types of Solution Running hours gtts/min

Time Started Rationale

1 D5W 500cc 10 cc/hr 2:45 PM Isotonic solution

2 D5W 90cc + 1 amp Isoket

10 cc/hr + 1 amp 3:25 PM Isotonic solution

3 PNSS 500cc 10 cc/hr Isotonic solution

4 PNSS 500cc 10 cc/hr 2:45 PM Isotonic solution

5 PNSS 500cc 10 cc/hr Isotonic solution

33

Electrocardiograph tracing

ECG findings

Rhythm Sinus Axis +39

Rate: Atrial 93bpm Ventricular 93bpm Position

P.R. 0.20sec Q.R.S 0.10sec Q.T. 0.44sec Q.T. Ratio

ECG Diagnosis

- sinus rhythm

- inferolateral and anterior wall ischemia

34

ECG findings

Rhythm sinus Axis +10

Rate: Atrial 93bpm Ventricular 93bpm Position

P.R. 0.20 sec Q.R.S. 0.08 sec Q.T. 0.44 sec

ECG Diagnosis

- sinus rhythm

- anterolateral wall ischemia

- left ventricular hypertrophy by voltage criteria

35

Pathophysiology with Anatomy and Physiology

A. Review of Anatomy and Physiology of the Organs Involved

Cardiovascular System

Heart

For all its might, the cone-shaped heart is a relatively small, roughly the same

size as a closed fist—about 12 cm (5 in) long, 9 cm (3.5 in) wide at its broadest point,

and 6 cm (2.5 in) thick. Its mass averages 250 g (8 oz) in adult females and 300 g (10

oz) in adult males. The heart rests on the diaphragm, near the midline of the thoracic

cavity. It lies in the mediastinum, a mass of tissue that extends from the sternum to the

vertebral column between the lungs. About two-thirds of the mass of the heart lies to the

left of the body’s midline. Visualize the heart as a cone lying on its side. The pointed

end of the heart is the apex, which is directed anteriorly, inferiorly, and to the left. The

broad portion of the heart opposite the apex is the base, which is directed posteriorly,

superiorly, and to the right.

In addition to the apex and the base, the heart has several surfaces and borders

9margins). The anterior surface is deep to the sternum and ribs. The inferior surface is

the part of the heart between the apex and the right border and rests mostly on the

diaphragm. The right border faces the right lung and extends from the inferior surface to

the base. The left border, also called the pulmonary border, faces the left lung and

extends from the base to the apex.

36

Layers and Coverings of the Heart

The heart is located between the lungs in the thoracic cavity and is surrounded

and protected by the pericardium (peri- _ around). The pericardium consists of an outer,

tough fibrous pericardium and an inner, delicate serous pericardium. The fibrous

pericardium attaches to the diaphragm and also to the great vessels of the heart. Like

all serous membranes, the serous pericardium is a double membrane composed of an

outer parietal layer and an inner visceral layer. Between these two layers is the

pericardial cavity filled with serous fluid. The wall of the heart has three layers: the outer

epicardium (epi- _ on, upon; cardia _ heart), the middle myocardium (myo muscle), and

the inner endocardium (endo- _ within, inward). The epicardium is the visceral layer of

the pericardium. The majority of the heart is myocardium or cardiac muscle tissue. The

endocardium is a thin layer of endothelium deep to the myocardium that lines the

chambers of the heart and the valves.

Surface Structures of the Heart

The human heart has four chambers and is divided into right and left sides. Each

side has an upper chamber called an atrium and a lower chamber called a ventricle.

The two atria form the base of the heart and the tip of the left ventricle forms the apex.

Auricles (auricle _ little ear) are pouch-like extensions of the atria with wrinkled edges.

Shallow grooves called sulci (sulcus, singular) externally mark the boundaries between

37

the four heart chambers. Although a considerable amount of external adipose tissue is

present on the heart surface for cushioning, most heart models do not show this.

Cardiac muscle tissue that composes the heart walls has its own blood supply and

circulation, the coronary (corona_ crown) circulation. Coronary blood vessels

encompass the heart similar to a crown and are found in sulci. On the anterior surface

of the heart, the right and left coronary arteries branch off the base of the ascending

aorta just superior to the aortic semilunar valve, and travel in the sulcus separating the

atria and ventricles. These small arteries are supplied with blood when the ventricles

are resting. When the ventricles contract, the cusps of the aortic valve open to cover the

openings to the coronary arteries.

A clinically important branch of the left coronary artery is the anterior interventricular

branch, also known as the left anterior descending (LAD) branch that lies between the

right and left ventricles and supplies both ventricles with oxygen-rich blood. This

coronary artery is commonly occluded which can result in a myocardial infarct and, at

times, death.

Great Vessels of the Heart

The great veins of the heart return blood to the atria and the great arteries carry

blood away from the ventricles. The superior vena cava, inferior vena cava, and

coronary sinus return oxygen-poor blood to the right atrium. The superior vena cava

returns blood from the head, neck, and arms; the inferior vena cava returns blood from

the body inferior to the heart. The coronary sinus is a smaller vein that returns blood

from the coronary circulation. Blood leaves the right atrium to enter the right ventricle.

From here, oxygen-poor blood passes out the pulmonary trunk, the only vessel that

removes blood from the right ventricle. This large artery divides into the right and left

pulmonary arteries that carry blood to the lungs where it is oxygenated. Oxygen-rich

blood returns to the left atrium through two right and two left pulmonary veins. The blood

then passes into the left ventricle that pumps blood into the large aorta. The aorta

distributes blood to the systemic circulation. The aorta begins as a short ascending

aorta, curves to the left to form the aortic arch, descends posteriorly and continues as

the descending aorta.

38

Internal Structures of the Heart

The heart has four valves that control the one-way flow of blood: two

atrioventricular (AV) valves and two semilunar valves (semi- _ half; lunar _ moon).

Blood passing between the right atrium and the right ventricle goes through the right AV

valve, the tricuspid valve (tri _ three; cusp _ flap). The left AV valve, the bicuspid valve,

is between the left atrium and the left ventricle. This valve clinically is called the mitral

valve (miter _ tall, liturgical headdress) because the open valve resembles a bishop’s

headdress. String-like cords called chordae tendineae (tendinous strands) attach and

secure the cusps of the AV valves to enlarged papillary muscles that project from the

ventricular walls. Chordae tendinae allow the AV valves to close during ventricular

contraction, but prevent their cusps from getting pushed up into the atria. The two

semilunar valves allow blood to flow from the ventricles to great arteries and exit the

heart. Blood in the right ventricle goes through the pulmonary (semilunar) valve to enter

the pulmonary trunk, a large artery. The aortic (semilunar) valve is located between the

left ventricle and the aorta. These two semilunar valves are identical, with each having

three pockets that fill with blood, preventing blood from flowing back into the ventricles.

The two ventricles have a thick wall between them called the interventricular septum.

Between the two atria is a thinner interatrial septum.

Coronary Circulation

There are two major coronary arteries: the right and the left. These two arteries

branch out of the aorta immediately after the aortic valve. The right coronary artery

splits into the marginal branch, which feeds blood into the right ventricle, and the

posterior interventricular branch, which supplies the left ventricle. The left coronary

artery is notably larger than the right coronary artery because it feeds the left heart,

which, as a result of it's more powerful contractions, requires a more vigorous blood

flow. The left coronary artery splits into the anterior interventricular branch and a

circumflex branch. The anterior interventricular branch runs towards the apex of the

39

heart, providing blood for both of the ventricles and the ventricular septum. The

circumflex branch, on the other hand, follows the groove between the left atrium and the

left ventricle, providing blood supply to both of these chambers until it reaches and joins

with the right coronary artery in the posterior of the heart.

The coronary arteries are especially subject to blockage and narrowing which

can cause a depletion of blood to certain parts of the heart, possibly causing a heart

attack.

Blood Flow through the Heart

The function of the right side of the heart is to collect de-oxygenated blood, in the

right atrium, from the body and pump it, via the right ventricle, into the lungs (pulmonary

circulation) so that carbon dioxide can be dropped off and oxygen picked up (gas

exchange). This happens through the passive process of diffusion. The left side (see left

heart) collects oxygenated blood from the lungs into the left atrium. From the left atrium

the blood moves to the left ventricle which pumps it out to the body. On both sides, the

lower ventricles are thicker and stronger than the upper atria. The muscle wall

surrounding the left ventricle is thicker than the wall surrounding the right ventricle due

to the higher force needed to pump the blood through the systemic circulation.

Starting in the right atrium, the blood flows through the tricuspid valve to the right

ventricle. Here it is pumped out the pulmonary semilunar valve and travels through the

pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein

to the left atrium. It then travels through the mitral valve to the left ventricle, from where

it is pumped through the aortic semilunar valve to the aorta. The aorta forks, and the

blood is divided between major arteries which supply the upper and lower body. The

blood travels in the arteries to the smaller arterioles, then finally to the tiny capillaries

which feed each cell. The (relatively) deoxygenated blood then travels to the venules,

which coalesce into veins, then to the inferior and superior venae cavae and finally back

to the right atrium where the process began.

40

Blood Vessels

Blood circulates inside the blood vessels, which form a closed transport system,

the so-called vascular system. Like a system of roads, the vascular system has its

freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the

large arteries leaving the heart. It then moves successively smaller and smaller arteries

and then into the arterioles, which feed the capillary beds in the tissues. Capillary beds

are drained by venules, which in turn empty into the great veins (venae cavae) entering

the heart. Thus arteries, which carry blood away from the heart, and veins, which drain

the tissues and return the blood to the heart, are simply conducting vessels. Only the

tiny hair-like capillaries, which extend and branch through the tissue and connect the

smallest arteries (arterioles) to the smallest veins (venules), directly serve the needs of

the body cells. The capillaries are the side streets or alleys that intimately intertwine

among the body cells. It is only through their walls that exchanges between the tissue

cells and the blood can occur. (Marieb, 2006)

41

Layers of Blood Vessel Walls

The walls of blood vessels have three coats, or tunics. The tunica intima which

lines the lumen or interior of the blood vessels, is a thin layer of endothelium (squamous

epithelial cells) resting on a basement membrane. Its cells fit closely together and form

a slick surface that decreases friction as blood flows through the vessel lumen. (Marieb,

2006)

The tunica media is the bulky middle coat. It is mostly smooth muscle and elastic

tissue. The smooth muscle, which is controlled by the sympathetic nervous system, is

active in changing the diameter of the vessels. As the vessel constrict or dilate, blood

pressure increases or decreases, respectively. Marieb, 2006)

The tunica externa is the outermost tunic; it is composed largely of fibrous

connective tissue. Its function is basically to support and protect the vessels. (Marieb,

2006)

42

The Microcirculation

The microcirculation is that portion of the circulatory system for exchange of

water, gases, nutrients, and waste material. As such, it is the most important part of the

cardiovascular system because it is where the exchange with tissues takes place.

Although the microcirculation is considered as a closed system, its walls are much more

permeable than any other part of the circulation.

Factors Affecting Flow of Blood

The flow of a fluid through a vessel is determined by the pressure difference

between the two ends of the vessel and also the resistance to flow.

• Pressure Difference. For any fluid to flow along a vessel there must be a

pressure difference otherwise the fluid will not move. In the cardiovascular

system, the “pressure head” or force is generated by the pumping of the heart

and there is a continuous drop in pressure from the left ventricle to the tissue and

also from the tissue back to the right atrium. (Hinchliff, 2000)

• Resistance to Flow. Resistance is a measure of the ease with which a fluid

flows through a tube: the easier it is the less resistance to flow, and vice versa. In

the circulatory system, the resistance is usually described as vascular resistance,

43

or also known as peripheral resistance. Resistance is essentially a measure of

the friction between the molecules of the fluid, and between the tube wall and the

fluid. The resistance depends on the viscosity of the fluid and the radius and

length of the tube. (Hinchliff, 2000)

• Radius of the Tube. The smaller the radius of a vessel, the greater is the

resistance to the movement of particles. Small alterations in the size of the radius

of the blood vessels, particularly of the more peripheral vessels, can greatly

influence the flow of blood. Atheromatous changes in the walls of large and

medium-sized arteries cause narrowing of the lumen of the vessels and result in

an increased vascular resistance. (Hinchliff, 2000)

• Length of the Tube. The longer the tube, the greater the resistance to the flow

of liquid through it. A longer vessel will require a greater pressure to force a given

volume of liquid through it than will a shorter vessel. (Hinchliff, 2000)

• Viscosity of the Fluid. Viscosity is a measure of the intermolecular or internal

friction within a fluid or in other words, of the tendency of the fluid to resist flows.

The greater the viscosity of the fluid, the greater is the force required to move

that liquid. (Hinchliff, 2000)

Blood

Blood is a specialized bodily fluid (technically a tissue) that is composed of a

liquid called blood plasma and blood cells suspended within the plasma. The blood cells

present in blood are red blood cells (also called RBCs or erythrocytes), white blood cells

(including both leukocytes and lymphocytes) and platelets (also called thrombocytes).

Plasma is predominantly water containing dissolved proteins, salts and many other

substances; and makes up about 55% of blood by volume. Mammals have red blood,

which is bright red when oxygenated, due to hemoglobin. Some animals, such as the

horseshoe crab use hemocyanin to carry oxygen, instead of hemoglobin.

44

By far the most abundant cells in blood are red blood cells. These contain hemoglobin,

an iron-containing protein, which facilitates transportation of oxygen by reversibly

binding to this respiratory gas and greatly increasing its solubility in blood. In contrast,

carbon dioxide is almost entirely transported extracellularly dissolved in plasma as

bicarbonate ion. White blood cells help to resist infections and parasites, and platelets

are important in the clotting of blood.

Blood is circulated around the body through blood vessels by the pumping action of the

heart. Arterial blood carries oxygen from inhaled air to the tissues of the body, and

venous blood carries carbon dioxide, a waste product of metabolism produced by cells,

from the tissues to the lungs to be exhaled.

Medical terms related to blood often begin with hemo- or hemato- (BE: haemo- and

haemato-) from the Greek word "α μαἷ " for "blood." Anatomically and histologically, blood

is considered a specialized form of connective tissue, given its origin in the bones and

the presence of potential molecular fibers in the form of fibrinogen.

Constituents of human blood

Blood accounts for 7% of the human body weight, with an average density of

approximately 1060 kg/m³, very close to pure water's density of 1000 kg/m3. The

average adult has a blood volume of roughly 5 litres, composed of plasma and several

kinds of cells (occasionally called corpuscles); these formed elements of the blood are

erythrocytes (red blood cells), leukocytes (white blood cells) and thrombocytes

(platelets). By volume the red blood cells constitute about 45% of whole blood, the

plasma constitutes about 55%, and white cells constitute a minute volume.

Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics; its flow

properties are adapted to flow effectively through tiny capillary blood vessels with less

resistance than plasma by itself. In addition, if all human haemoglobin was free in the

plasma rather than being contained in RBCs, the circulatory fluid would be too viscous

for the cardiovascular system to function effectvely.

45

Cells

4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In

mammals, mature red blood cells lack a nucleus and organelles. They contain the

blood's hemoglobin and distribute oxygen. The red blood cells (together with endothelial

vessel cells and other cells) are also marked by glycoproteins that define the different

blood types. The proportion of blood occupied by red blood cells is referred to as the

hematocrit, and is normally about 45%. The combined surface area of all the red cells in

the human body would be roughly 2,000 times as great as the body's exterior surface.

4,000-11,000 leukocytes: White blood cells are part of the immune system;

they destroy and remove old or aberrant cells and cellular debris, as well as attack

infectious agents (pathogens) and foreign substances. The cancer of leukocytes is

called leukemia.

200,000-500,000 thrombocytes: Platelets are responsible for blood clotting

(coagulation). They change fibrinogen into fibrin. This fibrin creates a mesh onto which

red blood cells collect and clot, which then stops more blood from leaving the body and

also helps to prevent bacteria from entering the body.

Plasma

About 55% of whole blood is blood plasma, a fluid that is the blood's liquid

medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.7-

3.0 litres in an average human. It is essentially an aqueous solution containing 92%

water, 8% blood plasma proteins, and trace amounts of other materials. Plasma

circulates dissolved nutrients, such as, glucose, amino acids and fatty acids (dissolved

in the blood or bound to plasma proteins), and removes waste products, such as,

carbon dioxide, urea and lactirc acid.

Other important components include:

46

• Serum albumin

• Blood clotting factors (to facilitate coagulation)

• Immunoglobulins (antibodies)

• Various other proteins

• Various electrolytes (mainly sodium and chloride)

The term serum refers to plasma from which the clotting proteins have been removed.

Most of the proteins remaining are albumin and immunoglobulins.

The normal pH of human arterial blood is approximately 7.40 (normal range is 7.35-

7.45), a weak alkaline solution. Blood that has a pH below 7.35 is too acidic, while blood

pH above 7.45 is too alkaline. Blood pH, arterial oxygen tension (PaO2), arterial carbon

dioxide tension (PaCO2) and HCO3 are carefully regulated by complex systems of

homeostasis, which influence the respiratory system and the urinary system in the

control the acid-base balance and respiration. Plasma also circulates hormones

transmitting their messages to various tissues.

Color

Hemoglobin

Hemoglobin is the principal determinant of the color of blood in vertebrates. Each

molecule has four heme groups, and their interaction with various molecules alters the

exact color. In vertebrates and other hemoglobin-using creatures, arterial blood and

capillary blood are bright red as oxygen impacts a strong red color to the heme group.

Deoxygenated blood is a darker shade of red with a bluish hue; this is present in veins,

and can be seen during blood donation and when venous blood samples are taken.

Blood in carbon monoxide poisoning is bright red, because carbon monoxide causes

the formation of carboxyhemoglobin. In cyanide poisoning, the body cannot utilize

oxygen, so the venous blood remains oxygenated, increasing the redness. While

hemoglobin containing blood is never blue, there are several conditions and diseases

where the color of the heme groups make the skin appear blue. If the heme is oxidized,

47

methemoglobin, which is more brownish and cannot transport oxygen, is formed. In the

rare condition sulfhemoglobinemia, arterial hemoglobin is partially oxygenated, and

appears dark-red with a bluish hue (cyanosis), but not quite as blueish as venous blood.

Veins in the skin appear blue for a variety of reasons only weakly dependent on the

color of the blood. Light scattering in the skin, and the visual processing of color play

roles as well.

Skinks in the genus Prasinohaema have green blood due to a buildup of the waste

product biliverdin.

Hemocyanin

The blood of most molluscs, including cephalopods and gastropods, as well as

some arthropods such as horseshoe crabs contains the copper-containing protein

hemocyanin at concentrations of about 50 grams per litre. Hemocyanin is colourless

when deoxygenated and dark blue when oxygenated. The blood in the circulation of

these creatures, which generally live in cold environments with low oxygen tensions, is

grey-white to pale yellow, and it turns dark blue when exposed to the oxygen in the air,

as seen when they bleed. This is due to change in color of hemocyanin when is it

oxidized. Hemocyanin carries oxygen in extracellular fluid, which is in contrast to the

intracellular oxygen transport in mammals by hemoglobin in RBCs.

Pancreatic Islets

The pancreas, located close to the stomach in the abdominal cavity is a mixed

gland. Probably the best-hidden endocrine glands in the body are the pancreatic islets,

formerly called the islets of Langerhans. These little masses of hormone-producing

tissue are scattered among the enzyme-producing acinar tissue of the pancreas. Two

important hormones produced by the islet cells are insulin and glucagons. (Marieb,

2006)

48

High levels of glucose in the blood stimulate the release of insulin from the beta

cells of the islets. Insulin acts on just about all body cells and increases their ability to

transport glucose across their plasma membranes. Once inside the cells, glucose is

oxidized for energy or converted to glycogen or fat for storage. These activities are also

speeded up by insulin. Since insulin sweeps the glucose out of the blood, its effect is

said to be hypoglycemic. As blood glucose levels fall, the stimulus for insulin release

ends (negative feedback control). Insulin is the only hormone that decreases blood

glucose levels. Insulin is absolutely necessary for the use of glucose by the body cells.

Without it, essentially no glucose can get into the cells to be used. (Marieb, 2006)

Glucagons act as an antagonist of insulin; that is, it helps to regulate blood

glucose levels but is a way opposite to that of insulin. Its release by the alpha cells of

the islets is stimulated by low blood levels of glucose. Its action is basically

hyperglycemic. Its primary target organ is the liver, which stimulates to break down

stored glycogen to glucose and to release glucose into the blood. (Marieb, 2006)

Insulin

The main function of the insulin is to participate in maintaining homeostasis of

blood glucose level and to promote other metabolic activities that are anabolic. When

absorbed nutrients, especially glucose, are in excess of immediate needs insulin

promotes storage. It reduces high blood nutrients by:

49

Acting on cell membranes and stimulating uptake and utilization of glucose by muscles

and connective tissue cells;

Increasing conversion of glucose to glycogen, especially in the liver and skeletal

muscles;

Accelerating uptake of amino acids by cells, and the synthesis of proteins;

Promoting synthesis of fatty acids and storage of fat in adipose tissue, and; Preventing

the breakdown of protein and fat and gluconeogenesis.

Glucagon

The effect of glucagon is increasing blood glucose levels by stimulating:

Conversion of glycogen to glucose (in the liver and skeletal muscle);

Gluconeogenesis, the manufacture of glucose by the body from noncarbohydrate

materials. (Burke, 1995)

Somatostatin

The effect of somatostatin (also produced by hypothalamus) is to inhibit the

secretion of both insulin and glucagons. It delays intestinal absorption of glucose.

(Smeltzer, 2007)

Metabolism

Metabolism is a broad term referring to all chemical reactions that are necessary

to maintain life. In involves catabolism, in which substances are broken down to simpler

substances, and anabolism, in which larger molecules or structures are built from

smaller ones. During catabolism, energy is released and captured to make ATP, the

energy-rich molecule used to energize all cellular activities, including catabolic

reactions. (Marieb, 2006)

50

Just as an oil furnace uses oil (its fuel) to produce heat, the cells of the body use

carbohydrates as their preferred fuel to produce cellular energy (ATP). Glucose, also

known as blood sugar, is the major breakdown product of carbohydrate digestion.

Glucose is also the major fuel used for making ATP in most body cells. Basically, the

carbon atoms released leave the cells as carbon dioxide, and the hydrogen atoms

removed (which contain energy-rich electrons) are eventually combined with oxygen to

form water. These oxygen-using events are referred to collectively as cellular

respiration. (Marieb, 2006) The overall reaction is summed up simply as:

C6H12O6 + 6 O2 => 6 CO2 + 6 H20 + ATP (energy).

51

Pathophysiology

52

53

54

55

56

Nursing Assessment (System Review and Nursing Assessment II)

57

Nursing Management

Ideal Nursing Management

Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular resistance, vasoconstriction

Actions/Interventions Rationale

Independent

Provide calm, restful surroundings, minimize environmental activity/noise. Limit the number of visitors and length of stay.

Help reduce sympathetic stimulation; promotes relaxation.

Maintain activity restrictions, e.g. bedrest/chair rest; schedule periods of uninterrupted rest; assist client with self-care activities as needed.

Reduces physical stress and tension that affect blood pressure and the course of hypertension.

Provide comfort measures, e.g. back and neck massage, elevation of head.

Decreases discomfort and may reduce sympathetic stimulation.

Instruct in relaxation techniques, guided imagery, distractions.

Can reduce stressful stimuli, promotes relaxation.

Maintain activity restrictions, e.g. bedrest/chair rest; schedule periods of uninterrupted rest; assist client with self-care activities as needed.

Reduces physical stress and tension that affect blood pressure and the course of hypertension

Provide comfort measures, e.g. back and neck massage, elevation of head.

Decreases discomfort and may reduce sympathetic stimulation.

Instruct in relaxation techniques, guided imagery, distractions

Can reduce stressful stimuli, produce calming effect, thereby reducing BP

Dependent

58

Administer medications as indicated;

Thiazide diuretics, e.g. chlorothiazide (Diuril); hydrochlorothiazide (Esidrix/HydroDIURIL); bendroflumethiazide (naturetin); indapamide (Lozol); metolazone (Diulol); quenthinazone (Hydromox)

Diuretics are considered first-line medications for uncomplicated stage I or II hypertension and may be used alone or in association with other drugs (such as β-blockers) to reduce BP in clients with relatively normal renal function. These diuretics potentiate the effects of other antihypertensive agents as well, by limiting fluid retention, and may reduce the incidence of strokes and heart failure

Nursing Diagnosis: Activity intolerance related to generalized weakness

Actions/Interventions Rationale

Independent

Instruct client in energy- conserving techniques e.g., suing chair when showering, sitting to brush teethe or comb hair, carrying out activates at a slower pace

Energy-saving techniques reduce the energy expenditure thereby assisting in equalization of oxygen supply and demand

Encourage progressive activity/self-0care when tolerated. Provide assistance as needed.

Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities

Nursing Diagnoses: Risk for impaired Gas Exchange related to alveolar-capillary membrane changes, e.g. fluid collection/shifts into interstitial space/alveoli

Actions/Interventions Rationale

Independent

Encourage frequent position changes Helps prevent atelectasis and pneumonia

Maintain chair/bed rest, with head of bed elevated 20-30 degrees, semi-

Reduce oxygen consumption/demands

59

fowler’s position. Support arms with pillows

and promotes maximal lung inflation.

Dependent

Administer supplemental oxygen as indicated

INcre4ases alveolar oxygen concentration, which may correct/reduce tissue hypoxemia.

Nursing Diagnosis: Knowledge deficit related to Lack of information/misunderstanding of medical condition/therapy needs.

Actions/Interventions Rationale

Independent

be alert to signs of avoidance, e.g., changing subject away from information being presented or extremes of behavior

Natural defenses mechanisms, such as anger or denial of significance of situation, can block learning, affecting patient’s responses and ability to assimilate information.

Encourage identification/reduction of individual risk factors, e.g., smoking/alcohol consumption, obesity.

these behaviors/chemicals have direct

adverse effect on cardiovascular function and may impede recovery, increase risk for complications

Educate client regarding gradual resumption of activities (walking, work, recreational activity.

Gradual increase in activity increases strength and prevents overexertion, may enhance, collateral circulation, and allows return to normal lifestyle.

Emphasizes importance of contacting physician if chest pain, change in anginal pattern or other symptoms recur.

Timely evaluation/intervention may prevent complications.

Stress importance of reporting development of fever in association w3ith diffuse/atypical chest pain and joint pain

post MI-complication of pericardial inflammation requires further medical evaluation/intervention.

60

Nursing diagnosis: Ineffective coping related to situational crisis

Actions/Intervention Rationale

Independent

Encourage patient to talk about what is happening at this time and what has occurred to precipitate feelings of helplessness and anxiety.

Provides clues to assist patient to develop coping and regain equilibrium.

Allow patient to be dependent in the beginning, with gradual resumption of independence in ADLs. Self-care and other activities. Make opportunities for patient to make simple decisions about care/other activities when possible, accepting choice not to do so.

Promotes feelings of security (patient will know nurse will provide safety). As control is regained, patient has the opportunity to develop adaptive coping/problem-solving skills.

Accept verbal expressions or anger, setting limits on maladaptive behavior

Verbalizing angry feelings in important process for resolution of grief and loss. However, preventing destructive actions (such as striking out at others) preserves patient’s self-esteem.

Discuss feelings of inability to find meaning in life/reason for living, feelings of futility or alienation from God.

Crisis situation may evoke, questioning of spiritual beliefs, affecting ability to cope with current situation and plan for the future.

Promote safe and hopeful environment, as needed. Identify positive aspects of this experience and assist patient to view it as a learning opportunity.

May be helpful while patient regains inner control. The ability to learn from the current situation can provide skills for moving forward

Provide support for patient to problem-solve solutions for current situation. Provide information and reinforce reality as patient begins to ask questions; look at what is happening.

Helping/SO to brainstorm possible solutions (giving consideration to the pros and cons of each) promotes feelings of self-control/esteem.

61

Provide for gradual implementation and continuation of necessary behavior and lifestly changes. Reinforce positive adaptation/ new coping behaviors

Reduces anxiety of sudden change and allows for developing new and creative solutions

Dependent

Refer to other resources as necessary (eg. Clergy, psychiatric clinical nurse specialist/psychiatrist, family/ marital therapist, addiction support groups).

Additional assistance may be needed to help patient resolve problems or make decisions.

Nursing Diagnosis: Family Coping, ineffective: risk for compromised related to prolonged disease/disability progression that exhausts the supportive capacity of family members.

Actions/Interventions Rationale

Independent

Evaluate pre-illness/current behaviors that may be interfering with the care/recovery of client

Information about family problems (e.g., divorce/ separation, financial limitations, substance use) will be helpful in determining options and developing an appropriate plan of care.

Discuss underlying reasons for patient behaviors with family.

When family members know why patient is behaving in different ways, it helps them understand and accept/deal with situation

Assist family/patient to understand “who owns the problem” and who is responsible for resolution. Avoid balance blame or guilt.

When these boundaries are defined, each individual can begin to take care of own self and stop taking care of others in inappropriate ways.

Involve family in information giving, problem solving and care of patient as feasible. Identify other ways of demonstrating support while maintaining patient’s independence

Information can reduce feelings of helplessness. Involvement in care enhances feelings of control and self worth

Dependent

62

Refer to appropriate resources for assistance as indicated (e.g. counseling, psychotherapy, financial, spiritual).

May need additional assistance in resolving family issues.

Nursing Diagnosis: Therapeutic Regimen: risk for ineffective management related to perceived barriers; economic difficulties, side effects of therapy, mistrust of regimen and/or healthcare personnel; complexity of healthcare system.

Action/Intervention Rationale

Independent

Review patients/SO’s knowledge and understanding of the need for treatment/medication, as well as consequences of the need for treatment/medication, as well as consequences of actions and choices. Not ability to comprehend information, including literacy, level of education, primary language.

Provides opportunities to clarify viewpoints/misconceptions. Verifies that patient/SO has accurate/ factual information with which to make informed choices.

Be aware of developmental and chronological age.

Impacts ability to understand own needs/incorporate into treatment regimen.

Determine cultural, spiritual, and health beliefs and ethical concerns

.

Provide insight into thoughts/factors related to individual situation. Beliefs will affect patient’s perception of situation and participation in treatment regimen. Treatment may be incongruent with patient’s social/cultural lifestyle and perceived role/responsibilities

63

Nursing Diagnosis: Pain related to an imbalance in oxygen supply and demand

Action/Interventions Rationale

Position patient in bed in semi-fowler’s position

>this allows for rest and adequate chest excursion, to increase available oxygen and to decrease cardiac work.

Administer oxygen by way of nasal cannula at 4L/min. maintain oxygen saturation at 92% or above.

>to increase oxygen supply. May decrease pain and PVCs

Administer nitroglycerin and morphine based on vital signs and pain relief.

> both medications will help alleviate pain by decreasing venous return to the heart, thereby decreasing cardiac work. Morphine will also help to decrease the patients sensation of pain.

Monitor BP closely by way of non-invasive BP monitor.

>both medications may decrease BP because both will decrease venous return. Intra-arterial blood pressure monitoring may be used if condition warrants.

Attach electrodes for continuous bedside cardiac monitor. Monitor heart rate and rhythm frequently.

>increased rate may indicate heart block; dysrhythmias are common initially, increased frequency suggests ischemia.

Administer and monitor thrombolytic therapy

>may help to relieve the coronary occlusion.

Monitor signs of bleeding; avoid unnecessary venous or arterial punctures.

>thrombolytics cause clot lysis may cause bleeding.

64

Nursing Diagnosis: decreased cardiac output related to decreased cardiac contractility and dysrrhythmias.

Actions/ Interventions Rationales

Administer I.V fluids as ordered >I.V fluid may be necessary to compensate for the decreased venous return caused by nitrates and morphine.

Monitor closely for signs of developing left ventricular failure (e.g auscultate lung sounds for crackles and heart sounds for s3).

>left ventricular failure may develop as a result of the decreased myocardial contractility and/ or the administration of excess fluids.

Monitor urine output hourly >Monitor urine output hourly

Monitor mental status >a change in mental status may indicate a decrease in cardiac output.

Interpret rhythm strip at least every 4 hours, more frequently as condition warrants. Administer antiarrythmics, if indicated.

>dysrythmias such as PVCs result in a decreased stroke volume and less coronary artery filling time. Frequent monitoring, especially during the first few hours of an acute MI and during thrombolytic therapy administration, is necessary to prevent and treat lethal dysrhythmias

Administer vasopressors; titrate to BP response.

>administration of vasopressors with aqcute MI is controversial in that they may cause an increase in systemic vascular resistance, which increases cardiac work.

Employ hemodynamic monitoring: central venous pressure CVP and pulmonary artery catheter and pulmonary artery pressure.

>these parameters will help to guide fluid volume administration, vasoactive drug administration and assess cardiac performance.

65

Nursing Diagnosis: Anxiety related to fear of death

Interventions/ Actions Rationales

Explain equipment, procedures, and need for frequent assessment to the patient and family. Discuss visiting hours and the need to allow for rest

>helps conserve energy.

Observe for autonomic signs and symptoms for anxiety (eg increase heart rate, BP and respiratory rate)

>anxiety is associated with an increase in sympathetic activity, which increases cardiac work.

Administer diazepam (valium) or morphine

>may aid in limiting patient’s anxiety

Offer back massage >touch and massage may promote relaxation.

Maintain continuity of care >consistency of routine and staff promotes trust and confidence.

66

Nursing Diagnosis: activity intolerance related to imbalance between myocardial oxygen

supply and demand.

Actions/Interventions Rationale

Document heart rate and rhythm and BP changes before, during, and after activity as indicated. Correlate with reports of chest pain/shortness of breath.

>trends determine patients response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/ return to bedrest, changes in medication regimen or use of supplemental oxygen.

Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities

>reduces myocardial workload/ oxygen consumption, reducing risk of complications (e.g extension of MI).

Instruct patient to avoid increasing abdominal pressure . e.g straining during defecation

>activities that require holding of breath and bearing down can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP.

Explain pattern of graded increase increases of activity level e.g, getting up to commode or sitting in a chair

>progressive activity provides controlled demand on the heart, increasing strength and preventing over exertion.

Review signs and symptoms reflecting intolerance of present activity level.

>palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate changes in exercise regimen or medication.

67

Nursing Diagnosis: Ineffective tissue perfusion related to interruption of blood flow.

ACTIONS/INTERVENTIONS RATIONALE

Investigate sudden changes or continued alterations in mentation e.g, anxiety, confusion, lethargy, stupor.

>cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte/ acid-base variations, hypoxia, and systemic emboli.

Inspect pallor, cyanosis, mottling, cool/clammy skin. Note strength of peripheral pulse.

>systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses.

Monitor respirations, note work of breathing

>cardiac pump failure and/ or ischemic pain may precipitate respiratory distress; however, sudden/ continued dyspnea may indicate thromboembolic pulmonary complications.

Monitor intake. Note changes in urine output. Record urine specific gravity as indicated.

>decreased intake/ persistent nausea may relut in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function.

Administer medications as indicated auch as clopidogrel (plavix)

>reduces mortality in MI patients, and is taken daily.

Assessing GI function, noting anorexia, decreased/absent bowel sounds, nausea/vomiting, abdominal, distention, constipation

>reduced blood flow to mesentery can produce GI dysfunction. E.g, loss of peristalsis. Problems may be potentiate/ aggravated by use by use of analgesics, decreased activity and dietary changes.

68

SOAPIE

S “Dali ra ko kapuyon kung ipabakod ug ipalakaw-lakaw” as verbalized by the client.

O

Heart rate of 52 beats per minute

Generalized weakness

Cold, clammy skin (Temp-36.8C)

A Decreased cardiac output related to underlying physiological condition

PSHORT TERM: at the end of 1 hour, the client will be able to verbalize feelings to cooperate

LONG TERM; at the end of 2 days, the client will be able to participate in daily activities

I

a. monitored pulse rate every four hours

To better detect arrhythmias which indicate cardiac arrest or other complications.

b. monitored skin temperature every four hours

Cold, clammy skin may indicate decreased cardiac output

c. instructed patient to report chest pain immediately

This may be a signal of myocardial hypoxia or injury

d. instructed patient to avoid overexertion ( e.g., straining during bowel movements

Overexertion increases myocardial oxygen demand which may cause bradycardia and decreased cardiac output

e. administered antiarrythmic drugs, such as cordarone, as prescribed by the doctor

Antiarryythmic drugs acts on peripheral smooth muscle to decrease peripheral resistancce

E At the end of 1 hour, the client verbalized cooperation

69

S No verbal cues

O

Moist, cool clammy skin (T-36.8C)

Non palpable dorsalis pedis both left and right

Poor capillary refill- 5 seconds

Pale extremities

Diaphoresis

Pulse rate of 52 beats per minute

A Ineffective peripheral tissue perfusion related to decreased cardiac output

P

SHORT TERM: at the end of 1 hour, the client will be able to have an improvement on peripheral tissue perfusion

LONG TERM; at the end of 1 week, the patient will maintain improved peripheral tissue perfusion

I

A. Assisted the client to ambulate but within her tolerance

To prevent thrombus formation, thus, improving blood circulation

B. Monitored and recorded intake and output

May be a sign of decreased renal perfusion

C. Provided a diet is low in fat and sodium

Foods high in fat and sodium contributes to the plaque formation that leads to decreased blood flow.

D. Instructed the significant others not to let the client wear tight clothing

To prevent impairment of blood flow.

E. Administered anticoagulants such as clopidogrel as prescribed by the doctor

To dilute and enhance further blood flow to periphery

E At the end of 1 hour, the client was able to have an improvement on peripheral tissue perfusion

70

S “ kinahanglan pa ko agakon para makabakod” as verbalized by the client

O

Heart rate of 52beats per minute

Generalized weakness

Unable to prompt up by herself

A Activity intolerance related to generalized body weakness.

P

SHORT TERM: at the end of 1 hour, the client will be able to participate in carrying out activities while on bed with assistance

LONG TERM: at the end of 2 days, the client will be able to continue in performing activities of daily living.

I

A. Taken and recorded vital signs before and after the activities

This is to provide baseline data

B. Performed passive range of motionTo asses the degree of motion

C. Encouraged client to have frequent rests during activities To prevent the patient from fatigue

D. Provided relief through comfort measures To enhance ability to participate in activities

E. Reminded the significant others in assisting the patient

To improve the mobility of the patient

EAt the end of 1 hour, the client was able to participate in carrying out activities while on bed with assistance.

“Dili man kayo ko gakaon ” as verbalized by the client

71

ODecreased consumption of her daily meal- ate 3 tbsp. of her share

Decreased weight (Present weight of 71 kilograms from her Past weight- 73 kilograms)

A Imbalanced nutrition: less than body requirements related to loss of appetite

P

SHORT TERM: at the end of 30 minutes, the patient will increase consumption of daily meal.

LONG TERM: at the end of 1 day, the client will be able to demonstrate behaviors and lifestyle changes to maintain appropriate weight.

I

A. Presented meal in an attractive manner

To entice the client’s appetite

B. Provided small frequent feeding To encourage the client to eat

C. Provided a well-ventilated area, conducive for eating

To improve the client’s appetite

D. reminded the client the importance of eating

To determine weight loss and weight gain

E. regulated and monitored IV fluids as ordered by the doctor

To provide nutritional supplements

EAt the end of 30 minutes, the patient was able to increase consumption of daily meal (8 tbsp per meal).

72

S‘dili ko kaklaro” as verbalized by the client

OCloudiness of the right eye

Presence of senile ring around the patient’s left eye

History of cataract surgery

A Risk for injury related to cloudiness of the eye secondary to aging

P

SHORT TERM: at the end of 1 hour, the client will be able to reduce risk factors and protect self from injury.

LONG TERM: at the end of 3 days, the client will be able to verbalized feeling of safety, comfort and security.

I

A. Instructed the significant others to never to leave the client

To prevent any accidents that may happen to the client

B. Placed pillow at the sides of the client This is to promote safety

C. Raised side rails. To prevent patient from falling off the bed

D. Anticipated with the patient’s needs. To avoid accidents that may cause injury to the client

E. Provided information regarding condition that may result increased risk of injury

To reduce the risk of possible occurrence of injuries

E At the end of 1 hour, the client was able to reduce risk factors and protect self from injury.

73

S “daku man kayo mi ug bayrunon diri, kanusa man ko makauli?” as verbalized by the client

O

Stares blankly for about a minute

Restlessness (consistent in changing side lying position from one side to the other)

Financial resources with a Family income of - 15,000 pesos/ month

Facial Grimace

A Anxiety related to present status secondary to hospital confinement

P

SHORT TERM: at the end of 45 minutes, the client will be able to adapt to the situational crisis and have a positive outlook with her condition.

LONG TERM: at the end of 2 days, the patient will be able to cope with the present situation

I

A. Encouraged client to express feelings

One way of releasing tension and assessing the level of anxiety.

B. Listened attentively concerning client’s feelings

To identify client’s problem regarding the situation

C. Diverted client’s attention through listening to a soothing music

This will help client divert her attention for the time being

D. Provided a less stressful environment

To prevent client from an environment that could trigger stress.

E. Instructed significant others to schedule visiting others

To promote restful environment.

E At the end of 45 minutes, the client was able to have a sense of control over the current crisis

74

S“di nako ganahan mubalik sa doctor, pareha raman gihapon, nana man akong karaan na record sa ECG, pwede nato” as verbalized by the client

O

• Restlessness

• Information misinterpretation

• Inadequate follow through of instructions

A Knowledge deficit related to disease condition

P

SHORT TERM: at the end of 1 hour, the client will participate in learning process regarding her current condition

LONG TERM: at the end of 2 days, the client will understand the importance of her treatment.

I

A. Encouraged client to verbalize feelings

To know client’s current problem

B. Discussed possible options to the family regarding her present treatment

Giving information to the family members and client’s knowledge regarding disease condition helps client cope with present condition

C. Provided information for client to refer to.

To facilitate learning regarding her treatment

D. Provided information about additional learning resources

To promote wellness

E. Emphasized the importance of follow up check-up

To have a better understanding of her condition.

E At the end of 1 hour, the client was able participate in the learning process.

S “di ko ganahan muinom sa akong mga tambal kay daghan kaayo.” As verbalized by the client

75

O Non compliance with medication

A Risk for ineffective therapeutic regimen

PSHORT TERM: at the end of 45 minutes, the client will be able to comply with the medications.

LONG TERM: at the end 2 days, the client will be able to properly comply with the medications

I

A. Encouraged client to verbalize feelings

To express client’s concerns

B. Listened attentively to clientBy actively listening, this helps in determining client’s problems and feel comfortable

C. Discussed to verbalize options regarding treatment of condition

To provide alternatives and choices regarding the course of treatment

D. Refrained family members from verbalizing negative expectations with the presence of the client

To not show inacceptance of the situation

E. Referred patient’s concern to the attending physician

To help patient understand the importance of proper compliance

E At the end of 1 hour, the family was able to verbalized feelings of control over their plight.

76

Progress Notes

Date: February 12, 2008

Day 1

Specific Objectives:

At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able

to:

1. Be acquainted with the management and staff of Saint Joseph’s Ward 5.

2. Ask permission from the family and from Mrs. F. to be the subject of the case

study.

3. Have the formal/ written consent signed, and receive the management’s

approval.

4. Inform the family and Mrs. F about the purposes and objectives of the visit.

5. Establish a contract that notes the Nurse – Client Responsibilities.

6. Conduct an interview about Mrs. F’s family history.

7. Conduct an assessment about Mrs. F’s past and present health conditions.

8. Identify problems related to Mrs. F’s present health condition.

9. Set goals for care.

10. Inform Mrs. F about follow – up visits of the group.

77

Problems identified:

• Blurred vision at the right eye

• Epigastric pain

• Nausea and vomiting

• Pallor

• Diaphoresis

• Weak pulses (radial, femoral, popliteal, posterior tibial)

• Absence of pulse beats at the Dorsalis Pedis site

• Weakness of lower extremities

• Restless

Evaluation:

After 2 hours, the group was able to meet the objectives for the day. The group

was able to meet Mrs. F and the family; explained the purpose of the meeting,

established individual roles, identified problems, and set – up parameters of succeeding

meetings.

78

Date: February 13, 2008

Day 2

Specific Objectives:

At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able

to:

1. Ask consent from the family and Mrs. F for further interview and assessment.

2. Conduct further interview about Mrs. F’s family history.

3. Conduct an assessment about Mrs. F’s past and present health condition.

4. Identify problems related to Mrs. F’s health condition.

5. Apply nursing interventions for the problems identified.

6. Provide health teachings for the improvement of Mrs. F’s health condition.

7. Evaluate progress after providing nursing care.

8. Remind Mrs. Fabout follow – up visits of the group.

Problems identified:

• Blurred vision at the right eye

• Pallor

• Diaphoresis

• Weak pulses (radial, femoral, popliteal, posterior tibial)

• Absence of pulse beats at the Dorsalis Pedis site

• Weakness of lower extremities

79

• Restless

Evaluation:

After 8 hours, the day’s objectives were met. The group was able to conduct

further assessment; applied nursing interventions for the problems identified, noted new

problems and complaints, and reminded Mrs. F about the next visits.

80

Date: February 14, 2008

Day 3

Specific Objectives:

At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able

to:

1. Ask consent from the family and Mrs. F for further interview and assessment.

2. Conduct further interview about Mrs. F’s family history.

3. Conduct further assessment about Mrs. F’s past and present health condition

4. Identify problems regarding Mrs. F’s health condition.

5. Render nursing interventions for the problems identified.

6. Evaluate progress after providing nursing care.

7. Provide health teachings for the improvement of Mrs. F’s health condition.

8. Copy data from Mrs. F’s chart.

9. Remind Mrs. F about follow – up visits of the group.

Problems identified:

• Blurred vision

• Abdominal fullness

• Diaphoresis

• Pallor

• Weak Pulse (femoral, popliteal, posterior tibial)

• Absence of pulse beats at the dorsalis pedis site

• Weakness of lower extremities

81

Evaluation:

After 2 hours, the objectives of the group were met. With the family and Mrs. F’s

consent, the group was able to conduct further assessment about Mrs. F’s past and

present health conditions and was able to apply nursing interventions in relation to the

problems identified by the group and copied data from Mrs. F’s chart and reminded Mrs.

F about succeeding visits of the group.

82

Date: February 15, 2008

Day 4

Specific Objectives:

At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able

to:

1. Ask consent from the family and Mrs. F for further interview and assessment.

2. Conduct further interview about Mrs. F’s family history.

3. Conduct further assessment about Mrs. F’s past and present health condition.

4. Identify problems regarding Mrs. F’s health condition.

5. Render nursing interventions for the problems identified.

6. Evaluate progress after providing nursing care.

7. Provide health teachings for the improvement of Mrs. F’s health condition.

8. Copy data from Mrs. F’s chart.

9. Remind Mrs. F about follow – up visits of the group.

Problems identified:

• Blurred vision

• Diaphoresis

• Weak pulse (popliteal, posterior tibial)

• Absence of pulse beats at the dorsalis pedis site

• Weakness of the lower extremities

Evaluation:

After 2 hours, the group was able to meet the day’s objectives. The group was

able to assess Mrs. F and identified new problems, gave health teachings and reminded

Mrs. F about the group’s following visits.

83

Date: February 18, 2008

Day 5

Specific Objectives:

At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be

able to:

1. Visit Mrs. F at Coca – Cola Compound, Aluba, Cagayan de Oro City.

2. Ask consent from the family and Mrs. F for further interview and assessment.

3. Conduct further interview about Mrs. F’s family history.

4. Conduct further assessment about Mrs. F’s condition after discharge.

5. Provide health teachings for the improvement of Mrs. F’s health condition.

6. Remind Mrs. F about the ending of the group’s correlation.

Evaluation:

After 2 hours, the group was able to meet the objectives. The group was able to visit

and examine Mrs. F after being discharged from the hospital. The group was able to

impart health teachings such as to return to Maria Reyna Hospital for follow – up check

– up, to maintain prescribed home medications until advised by physician to discontinue

and to do exercise regularly. The group also reminded Mrs. F that February 19, 2008

will be the group’s last visit.

84

Date: February 19, 2008

Day 6

Specific Objectives:

At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be

able to:

1. Visit Mrs. F at Coca – Cola Compound, Aluba, Cagayan de Oro City.

2. Ask consent from the family and Mrs. F for the completion of the interview and

assessment.

3. Provide additional health teachings for the improvement of Mrs. F’s health

condition.

4. Thank the family and Mrs. F for the approval and cooperation with the group.

5. End the group’s correlation with the family and Mrs. F.

Evaluation:

After 2 hours, the group was able to meet the objectives for the day. The group

was able to complete the interview and assessment of the needed data for the case

study and gave a token as a sign of appreciation for the family and for Mrs. F’s approval

and cooperation.

85

Discharge Plan and Referrals

Medications

Last February 16, 2008 Mrs. F was discharged and advised to have her follow-up check-up on February 20, 2008 with the following home medication by instructions:

• Telmizartan (Priton) 40 mg 1tab. O.D (Angiotensin II receptor blocker).• Clopidogrel (Plavix) 75 mg 1 tab O.D (Anti-coagulant).• Metoproplol(Neobloc) 50mg ½ tab O.D (Beta Blocker/Anti-Hypertensive).• Atorvastatin (Lipitor) 80 mg 1 tab O.D q hs. (Anti-Hyperlipidemic).• ISMN (Imdur) 60 mg 1 tab O.D (Anti-anginal/Nitrate/Vasodilator).• Trimetazidine (Vastarel) 1 tab BID (Anti-anginal drugs).• Amiodarone (Cordarone) 200 mg 1 tab BID (Class III/Anti-arrythmic).• Aspirin (Acet) 80 mg 1 tab O.D p.c lunch (Anti-coagulant).• Metformin HCL (I-max) 500 mg 1 tab BID (Anti-diabetic).

• Encouraged the patient and instructed the significant others to follow prescribed home medications and give drugs on time.

• Instructed the significant others to give drugs with food when indicated.

Activity

• Encouraged the patient and instructed the significant others to control activities of daily living.

• Encouraged the patient and instructed the significant others to participate in passive active range of motion as tolerated.

• Instructed the significant others to provide safety precautions to the patient, especially when ambulating or using the bathroom.

• Instructed the client’s significant others to minimize prolonged exposure to sunlight.

Diet

• Encouraged the patient and instructed the significant others to prepare foods that are:

86

Low calorie - Calorie restriction in individuals with hypertension is recommended. Otherwise normal individuals need the daily-recommended calorie according to the age, sex and physical activity.

Low fat - It is advisable to reduce the fat consumption since hypertension has greater risk of arteriosclerosis. It is better to avoid high intake of animal fat or hydrogenated oils, which contain saturated fatty acids. The cholesterol rich foods such as liver, meat, organ meat, egg yolk, lobster, crab and prawns should be minimized in the diet. The dietary fats should consist of vegetable oil like corn oil, olive oil and sunflower oil.

High fiber- Not only does a high fiber diet aid in healthy bowel movements but also research has shown that it also lowers cholesterol. There are even types of fiber that will help reduce the risk of colon cancer.

High protein – Most high protein foods are extremely low in carbohydrates and extremely low in saturated fat. Therefore, by eating a high protein diet loaded with high protein foods, at the same time you'd end up eating low carbohydrates foods and low saturated fat foods. And, if you didn't already know, in order to lose weight and lose fat, eating low carbohydrates and eating little or no saturated fat is a must. Chicken, lean meats, beef and fish and egg whites.

Low sodium and high potassium diet- Help to lower high blood pressure. Moderate sodium restriction 2- 3 gm per day decreases diastolic blood pressure 6- 10 mmHg and enhances the blood pressure lowering effect of diuretic therapy. Potassium intake should be increased. Food sources of potassium should be increased to patients who are on diuretics. For example apricots, tomato, watermelon, banana, leafy vegetables, and potato should be included in the daily diet since they contain low sodium and high potassium. Hypertensive patients with kidney disease should avoid a high intake of potassium as it puts an excessive load on the kidney.

87

Oatmeal Banana

Raw Carrots

Apple

Broccoli Raw Tomatoes

Cereals

• Instructed the significant others to avoid gastric irritant foods, such as spicy products this is to minimize gastrointestinal disorder, such as nausea and vomiting, abdominal pain, CNS disorder like dizziness, headache.

88

Treatment

• Encouraged patient to verbalize feelings and needs when presence of chest pain, weakness, and prolonged headache, this is to lessen the burden of the patient and for immediate action as well as to minimize entertaining negative thoughts.

• Encouraged patient and instruct the significant others to monitor weight and blood pressure daily.

89

Prognosis

Hypertension:

There is no cure for hypertension, but it can be controlled by changes in one’s lifestyle and the use of prescribed medications. The major goal of nursing care for hypertensive patients focuses on lowering and controlling the blood pressure without adverse effects and value cost. The patient needs to understand the disease process and how life’s changes and medications can control hypertension; the nurse needs to emphasize the concept of controlling HPN rather than curing it.

` Hypertension is more common in men than women and in people over the age of 65 than in younger persons. Hypertension is serious because people with the condition have a higher risk for heart disease and other medical problems than people with normal blood pressure. Getting regular blood pressure checks and treating hypertension as soon as it is diagnosed can avoid serious complications.

If left untreated, hypertension can lead to the following medical conditions:

• Arteriosclerosis, also called atherosclerosis • Heart attack

• Stroke

• Enlarged heart

• Kidney damage

Risk factors for hypertension include:

• Age over 60 • Male sex

• Weight

• 25Heredity

Diabetes Mellitus:

In most patients diabetes can be controlled by diet, exercise and insulin injections. If the condition is not treated, however, some serious complications may result.

For example, uncontrolled diabetes is the leading cause of blindness, kidney disease and amputations of arms and legs. It also doubles a person’s risk for heart

90

disease and increases the risk of stroke. Eye problems also occur more commonly among diabetes than in general population.

Diabetes Mellitus (DM) is a common metabolic disorder in aging populations with increased morbidity, disability and premature death. The prevalence of diabetes is about 20% in persons over 65 years of age and about 40% in persons over 85 years. A recent communication from Kolkata (NSR Medical college) as per patients attending OPD service, the prevalence was 11% in persons aged between 65-69 years. In another study at Bhubaneshwar (Orissa), prevalence of diabetes was found as high as 20% in the age group of 65 and above. The vast majority of patients with DM in the elderly are type 2 (NIDDM) diabetics. Very rarely autoimmune destruction of Beta cells leading to Type 1 (IDDM) DM can occur in the elderly. Some cases could be secondary to associated diseases or drugs.

Myocardial Infarction

The incidence and prevalence of acute myocardial infarction (MI), increases progressively with age. Based on the official survey of the Department of Health (DOH) Region 10, the rate of Myocardial Infarction morbidity cases was 3,356. The rate was 97.3%. In addition, mortality rates following Acute Myocardial Infarction (ACS) increases exponentially with age. In particular, elderly patients are less likely to report chest pain than younger patients. Confusion or altered mental status may be the presenting manifestation of Acute Myocardial Infarction in up to 20% of patients over 85 years of age. Older patients are more likely to have “SILENT” or unrecognized MI’s as well as MI”s without ST-segment elevation.

As compared with younger patients who experience heart failure, atrial fibrillation, and cardiac rupture and shock. All of which are associated with increase mortality. Other factors contributing to the poor prognosis following Acute Myocardial Infarction in elderly individuals include:

• Marked decline in cardiovascular reserve in elderly• Increase prevalence of morbid conditions• Underutilization of evidence – based theories• Women have high mortality rate after Acute Myocardial Infarction

compared with men. The extent to which their increased risk varies in treatment is not well understood.

From the information stated above, therefore the patient has poor prognosis attributed to age, sex, presence of other diseases as well as financial constraint may a

91

hindrance of her treatment. According to Dr. Cristina Cabral-Pauig, cardiologist from the University of the Philippines-Philippine General Hospital said that both hypertension and diabetes are "robust independent risk factors to the development and progression of cardiovascular disease and nephropathy." In addition, hypertension and diabetes together raise CVD risk, even worsen prognosis.

92

Evaluation

The mainstay of nursing and medical treatment with the patient having with these conditions is to help the patient to cope, alleviate distress, prevent further complications and help the patient to recover as well as to encourage the patient and the significant others to participate in the therapy. From the initiation of nursing and medical interventions the client showed some signs of recuperation and gradually showed signs of progress. This was evidence form the complete bed rest up to the condition she was given the chance to ambulate gradually as tolerated.

On the last day of visitation the patient has returned to her normal daily activity but with controlled environment and efforts in carrying tasks. Upon interview the client showed orientation in time, place and person and was aware of her condition and knows the prohibition in order to prevent complications and aggravations of her condition. Her significant other, were also supportive and showed concern for the patient.

From this, our goal was achieved as evidenced by the desire of the patient to go back to her normal daily routine and from the progress of the patient.

93