Myocardial Ischemia Disease
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Transcript of Myocardial Ischemia Disease
A. Brief Description
Ischemic or ischemic heart disease (IHD), or myocardial ischemia, is a disease
characterized by reduced blood supply to the heart muscle, usually due to coronary artery
disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking,
hypercholesterolemia (high cholesterol levels), diabetes, hypertension (high blood pressure)
and is more common in men and those who have close relatives with ischemic heart disease.
Myocardial ischemia is a disorder that is usually caused by a critical coronary artery
obstruction, which is also known as atherosclerotic coronary artery disease (CAD). CAD is the
leading cause of death worldwide, and it is the second most common cause of emergency
department visits in the United States. More than $140 billion are spent each year for the
diagnosis and management of CAD.
B. Statistics
a.) International
Diagnosing myocardial ischemia prior to a heart attack is important because ischemic
heart disease is responsible for approximately 14% of all deaths worldwide. Approximately 1.5
million Americans will have a heart attack this year as a result of myocardial ischemia; about
500,000 of those will be fatal.
Angina occurs more frequently in women than in men, and in blacks and Hispanics more
than in whites. It also occurs more frequently as people age--25% of women over the age of 85
and 27% of men who are 80-84 years old have angina.
Number one killer in the United States and worldwide. Every minute, an American dies
of coronary heart disease. Coronary heart disease afflicts over 13 million Americans.
b.) Local
MORTALITY: TEN LEADING CAUSES BY SEX
Number, Rate/100,000 Population and Percent Distribution
Philippines, 2004
Source: The 2004 Philippine Health Statistics
* Percent share from total deaths, all causes, Philippines
** External Causes of Mortality
Last Update: February 11, 2008
I. OBJECTIVES
A. General Objectives
At the end of the clinical exposure, we should be able to attain and enhance our
knowledge, skills and attitude to provide nursing care to our patient with chronic kidney failure.
B. Specific Objectives
During the exposure, we should be able to:
Cognitive:
Give brief discussion or description about the case of the patient.
Understand Myocardial Ischemia, its causes and pathophysiology.
Design a plan of care for patient with Myocardial Ischemia.
Discuss the different data gathered for the patient’s health assessment.
Discuss the different nursing intervention.
To be able to set priorities and goal outcomes in collaboration with the patient.
To be able to document patient responses to care and verbal reports, if any.
Skills:
Conduct physical assessment and organize data efficiently.
Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.
Attitude:
To be able to establish rapport with the patient and folks.
To be able to develop respect and trust.
II. ANATOMY AND PHYSIOLOGY OF THE DISEASE
CARDIOVASCULAR SYSTEM
Your heart and circulatory system make up your cardiovascular system. Your heart
works as a pump that pushes blood to the organs, tissues, and cells of your body. Blood
delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products
made by those cells. Blood is carried from your heart to the rest of your body through a complex
network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules
and veins. If all the vessels of this network in your body were laid end-to-end, they would extend
for about 60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth
more than twice!
The one-way circulatory system carries blood to all parts of your body. This process of
blood flow within your body is called circulation. Arteries carry oxygen-rich blood away from your
heart, and veins carry oxygen-poor blood back to your heart.
In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings
oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to
your heart.
In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vessels
that carry oxygen-poor blood are colored blue.
Twenty major arteries make a path through your tissues, where they branch into smaller vessels
called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and
nutrients to your cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one
blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients
and pick up carbon dioxide and other waste, they move the blood back through wider vessels
called venules. Venules eventually join to form veins, which deliver the blood back to your heart
to pick up oxygen.
Coronary Arteries. Because the heart is composed primarily of cardiac muscle tissue
that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients.
The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich
blood to the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta,
the body’s main artery. Two coronary arteries, referred to as the "left" and "right" coronary
arteries, emerge from the beginning of the aorta, near the top of the heart. The initial segment of
the left coronary artery is called the left main coronary. This blood vessel is approximately the
width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries:
the left anterior descending coronary artery and the left circumflex coronary artery. The left
anterior descending coronary artery is embedded in the surface of the front side of the heart.
The left circumflex coronary artery circles around the left side of the heart and is embedded in
the surface of the back of the heart. Just like branches on a tree, the coronary arteries branch
into progressively smaller vessels. The larger vessels travel along the surface of the heart;
however, the smaller branches penetrate the heart muscle. The smallest branches, called
capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the
red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon
dioxide and other metabolic waste products, taking them away from the heart for disposal
through the lungs, kidneys and liver. When cholesterol plaque accumulates to the point of
blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the
coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area
of cardiac muscle tissue ceases to function properly. The condition when a coronary artery
becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial
infarction or heart attack.
Superior Vena Cava. The superior vena cava is one of the two main veins bringing de-
oxygenated blood from the body to the heart. Veins from the head and upper body feed into the
superior vena cava, which empties into the right atrium of the heart.
Inferior Vena Cava. The inferior vena cava is one of the two main veins bringing de-
oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the
inferior vena cava, which empties into the right atrium of the heart.
Aorta. The aorta is the largest single blood vessel in the body. It is approximately the
diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the
various parts of the body.
Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated
blood from the right ventricle to the lungs. A common misconception is that all arteries carry
oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away
from the heart.
Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood from
the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated
blood. It is more appropriate to classify veins as vessels carrying blood to the heart.
Right Atrium. The right atrium receives de-oxygenated blood from the body through the
superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The
sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract
in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from
the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow
into the right ventricle.
Right Ventricle. The right ventricle receives de-oxygenated blood as the right atrium
contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the
ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle
contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid
valve prevents blood from backing into the right atrium and the opening of the pulmonary valve
allows the blood to flow into the pulmonary artery toward the lungs.
Left Atrium. The left atrium receives oxygenated blood from the lungs through the
pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria,
the blood passes through the mitral valve into the left ventricle.
Left Ventricle. The left ventricle receives oxygenated blood as the left atrium contracts.
The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the
aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract.
As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of
the mitral valve prevents blood from backing into the left atrium and the opening of the aortic
valve allows the blood to flow into the aorta and flow throughout the body.
Papillary Muscles. The papillary muscles attach to the lower portion of the interior wall
of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in
the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary
muscles opens these valves. When the papillary muscles relax, the valves close.
Chordae Tendineae. The chordae tendineae are tendons linking the papillary muscles
to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the
papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and
decrease in tension to the respective valves, causing them to open and close. The chordae
tendineae are string-like in appearance and are sometimes referred to as "heart strings."
Tricuspid Valve. The tricuspid valve separates the right atrium from the right ventricle. It
opens to allow the de-oxygenated blood collected in the right atrium to flow into the right
ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right
atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.
Mitral Value. The mitral valve separates the left atrium from the left ventricle. It opens to
allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as
the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to
exit through the aortic valve into the aorta.
Pulmonary Valve. The pulmonary valve separates the right ventricle from the
pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected
in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from
returning to the heart.
Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the
ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow
throughout the body. It closes as the ventricles relax, preventing blood from returning to the
heart.
The Nervous System
The nervous system is a network of specialized cells that communicate information
about an animal’s surroundings and its self; it processes this information and causes reactions
in other parts of the body. It is composed of neurons and other specialized cells called glia, that
aid in the function of the neurons.
The nervous system is divided broadly into two categories; the peripheral nervous
system and the central nervous system. Neurons generate and conduct impulses between and
within the two systems. The peripheral nervous system is composed of sensory neurons and
the neurons that connect them to the nerve cord, spinal cord and brain, which make up the
central nervous system. In response to stimuli, sensory neurons generate and propagate
signals to the central nervous system which then process and conduct back signals to the
muscles and glands.
The neurons of the nervous systems of animals are interconnected in complex
arrangements and use electrochemical signals and neurotransmitters to transmit impulses from
one neuron to the next. The interaction of the different neurons form neural circuits that regulate
an organism’s perception of the world and what is going on with its body, thus regulating its
behavior. Nervous systems are found in many multicellular animals but differ greatly in
complexity between species
The central nervous system (CNS) is the largest part of the nervous system, and
includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while
the head contains and protects the brain. The CNS is covered by the meninges, a three layered
protective coat. The brain is also protected by the skull, and the spinal cord is also protected by
the vertebrae.
Brain is a part of the Central Nervous System, it plays a central role in the control of
most bodily functions, including awareness, movements, sensations, thoughts, speech, and
memory. Some reflex movements can occur via spinal cord pathways without the participation
of brain structures.
The cerebrum is the largest part of the brain and controls voluntary actions, speech,
senses, thought, and memory.
The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which
are termed fissures. Some fissures separate lobes.
The convolutions of the cortex give it a wormy appearance. Each convolution is
delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two
halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum
links the hemispheres. The right hemisphere controls voluntary limb movements on the left side
of the body, and the left hemisphere controls voluntary limb movements on the right side of the
body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four
lobes, or areas, which are interconnected.
The frontal lobes are located in the front of the brain and are responsible for voluntary
movement and, via their connections with other lobes, participate in the execution of sequential
tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.
The parietal lobes are located behind the frontal lobes and in front of the occipital lobes.
They process sensory information such as temperature, pain, taste, and touch. In addition, the
processing includes information about numbers, attentiveness to the position of one’s body
parts, the space around one’s body, and one's relationship to this space.
The temporal lobes are located on each side of the brain. They process memory and
auditory (hearing) information and speech and language functions.
The occipital lobes are located at the back of the brain. They receive and process
visual information (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition,
McGraw-Hill Int. NY 10020 2005)
III. VITAL INFORMATION
Name (initials): A.L
Age: 67 years old
Sex: Male
Address: Panit.an, Capiz
Civil Status: Widow
Religion: Roman Catholic
Occupation: Businessman
Date and Time admitted: November 5, 2009 at 4:00 pm
Ward: ICU- D
Chief Complaint: Difficulty of Breathing
Admitting Diagnosis: DM Type II, Pneumonia, Myocardial Wall Ischemia
Final Diagnosis: Myocardial Ischemia
Attending Physician/s: Dr. M. B.
IV. CLINICAL ASSESSMENT
A. Nursing History
Mr. AL is an excessive alcohol drinker. He stays on his shop often because of his
business. One day prior to admission, he has onset of whitish productive cough and difficulty of
breathing and chest pain. He has high blood pressure of 130/90 mmhg.
B. Past Health Problem / Status
Past Illnesses: Mr. A.L. is a 67 year old male suffering from hypertension, diabetes
mellitus type – 2. He also experienced chickenpox and measles during his childhood.
Allergies: He has no known allergies to food or drugs.
Previous Hospitalization: Previous hospitalization was May 2006 due to difficulty of
breathing with a diagnosis of Myocardial Infarction.
C. Family History of Illness
Upon interview, Mr. AL was diagnosed of Diabetes Mellitus Type II in the year 2004, and
he is taking Glibenclamide as his medication, according to his daughter he is also fond of eating
foods which are rich in fat and cholesterol. She has also that Mr. AL cannot eat without putting
extra salt on her food.
Both of his parents have hypertension, diabetes mellitus type -2 and a history of
bronchial asthma, eventually, he may acquire these diseases. Some of his siblings have it too,
and also to his children especially bronchial asthma.
HPNDM-type II FAMILY
HPN
HPN, PTB, Myocardial Ischemia
BA
HPN HPN
Legend:
Deceased male
Deceased female
Indicates patient
Living male
Living female
BA
V. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND
A. Educational Background
Mr. AL is a college graduate.
B. Occupational Background
He is working as a business man.
C. Religious Background
He is a Roman Catholic and attends mass on Sundays and prays the rosary at night
together with his children.
D. Economic Status
They belong to a middle class type of family and most of his children are
professionals and have a job of their own.
VI. CLINICAL INSPECTION
A. Vital Signs
Upon Admission During Care
Temperature 36.8C 36.5C
Pulse Rate 88 bpm 95 bpm
Respiration 30 bpm 36 bpm
Blood
Pressure
140/90 mmHg 130/80 mmHg
Cardiac Rate 120 bpm 130 bpm
B. Height, Weight, BMI – no data
C. Physical Assessment
General
Patient is wearing a hospital gown, with unkempt hair,
appears weak; conscious and coherent. He is lying on
bed with an ongoing IVF of #4 PLRS 1 L xKVO 5 µgtts/
min infusing well on the right metacarpal vein currently
at 770 cc level. Oxygen inhalation at 2/L min via nasal
cannula.
Skin, Hair, Nails
Dry skin, uniform in color. Hair is black with visible white
hair, no lice and dandruff and dry scalp. Fingernails are
trimmed, (+) cyanotic nailbeds, toenails are not trimmed
and unclean.
Head, Face, Lymphatics
(+) Headache. No head injuries, round in shape
and oily face.
HEENT
Upon the assessment of the client, most of the
findings are of normal findings characterized by
pupils which are equally round in shape, reactive to
light and accommodation, with her right eyebrows
evenly distributed and symmetrically aligned. With
eyelashes of normal growth, there are no purulent
or any discharges seen on the client’s eyes. No
periorbital edema noted, cornea is transparent and
shiny. Ears are of normal findings. Nose is also of
normal findings. Lips that are dark and gums
are pale
Neck and Upper extremities
No lumps or swollen glands. No reports of neck
pain and stiffness. Arms able to move freely.
Presence of palpitation in his wrist.
Chest, Breast and Axilla
Abnormal respiration upon admission with RR of
30 bpm and 36 bpm during care. Presence of chest
pain, (+) history of bronchial asthma, (+) crackles,
(+) wheezing.
Respiratory System (Chest and Lungs)
Thorax is symmetric. (+) history of bronchial
asthma, RR is above normal. (+) dyspnea, (+)
wheezing.(+) difficulty of breathing (+) productive
cough with presence of whitish phlegm.CXR
results: (+)PTB, both upper lobe with regression
and Atheromatous Aorta
Cardiovascular System
(+) history of hypertension with blood pressure of 140/90
upon admission and during care with the BP of 130/80
mmHg. (+) dyspnea, (+) tachycardia, (+) chest pain with
discomfort. Cardiac rate is above normal with AR of 130
bpm and respiration of 36 bpm.
Gastrointestinal System
During Bowel Elimination
Frequency: Once a day
Pattern: Every morning
Consistency: Normal Stool
Color: Light Brown
Odor: Normally foul stool odor
Genito – Urinary System
Quantity: 1000cc to 1200cc per shift
Color: Lt. Yellow
Musculoskeletal System (+) weakness, (+) limitation of motion or activity,
D. General Appraisal
Speech: He speaks clearly, attentive and conversive.
Language: The patient knows how to speak English, Tagalog, Bisaya.
Hearing: The patient’s hearing is good.
Mental Status: The patient is alert and attentive when asked but sometimes he is
grumpy, depending on his mood.
Emotional status: He is worried about his condition and thinks that he brings problem
to his family due to his situation.
VII. LABORATORY AND DIAGNOSTIC DATA
A. Hematology
Hematology is the branch of biology (physiology), pathology, clinical laboratory, internal
medicine, and pediatrics that is concerned with the study of blood, the blood of forming organs,
and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis,
and prevention of blood diseases.
Test Result Normal
Values
Significance
Date: 11/05/09
WBC count 18.3x10^9/L 4.5-11.0 Susceptible to infection
RBC count 4.78x10^12/L 4.2-5.4 The result is Within Normal Range.
Hemoglobin 140g/L 120-160 The result is Within Normal Range.
Hematocrit 0.42vol.fr 0.37-0.47 The result is Within Normal Range.
Mean Corpuscular
Volume (MCV)
86.0cu.u 80-96 The result is Within Normal Range.
Mean Corpuscular
Hemoglobin (MCH)
28.5uug 27-31 The result is Within Normal Range.
Mean Corpuscular
Hemoglobin the
Concentration (MCHC)
33.0g/dL 32-36 The result is Within Normal Range.
RDW 12.8% 11-16 The result is Within Normal Range.
Neutrophils 65.0% 50-70 The result is Within Normal Range.
Eosinophils 4.0% 0-3 Allergic reactions
Basophils 0.0% 0-1 The result is Within Normal Range.
Lymphocytes 11.0% 20-45 It signifies severe
debilitating illnesses.
Monocytes 0.0% 0-8 The result is Within Normal Limits.
Platelet 118000 15000-35000 The result is Within Normal Limits.
Protrombin Time 14.6sec 10-15 sec The result is within Normal Limits.
B. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly
performed on sick or aging patient. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a machine
called centrifuge. The serum layer is drawn off and a variety of compounds are then measured.
These measurements aid the veterinarian in assessing the function of various organs and body
systems.
Test Result Normal Values Significance
Date: 11/07/09
Glucose 678 mmol/L 4.10 – 5.90 Hyperglycemia
Sodium 140.0 mmol/L 137.0 – 145.0 The result is Within Normal
Limits.
Magnesium 1.10 mmol/L .70 – 1.00 The result is Within Normal
Limits.
Creatinine 129.3 mmol/L 71.0 – 133.0 Impaired renal
function, shock
Cholesterol 9.34 mmol/L 0.00 – 5.20 Elevation indicates
increase risk in
CAD
Direct HDLC .45 mmol/L 1.00 – 1.60 Indicates risks in
CAD
LDL 7.40 1.71 – 4.60 Elevation indicates
risk in CAD
VLDL 1.52 0.00 – 1.03 Elevation indicates
increase risk in
CAD
Potassium 3.8 3.5 – 5.10 The result is Within Normal
Limits.
C. Radiology
It provides a radiographic image of the organs or tissues, to detect abnormality such as
tumor, perforation, abscess, infection, foreign body or fracture.
Test X – ray Findings Impression
Date: 11/05/09
Chest PA
(mobile)
Shows regression of TB infiltrates in both upper
lobes.
PTB, both upper lobe
with regression
Atheromatous aorta.
D. Serology and Immunology
It is the science that deals with the properties and reactions of serums, especially blood
serum. It analyzes the contents and properties of blood serum.
Serum Specimen Result/s Normal Value Significance
Date: 11/07/09
Troponin – 1
Determination
(+) Positive 3.13 ug/L <0.01ug/L Indicates
Myocardial
Infarction.
HbA1c is a test that measures the amount of glycated hemoglobin in your blood.
Glycated hemoglobin is a substance in red blood cells that is formed when blood sugar
(glucose) attaches to hemoglobin
Serum Specimen Result/s Normal Value Significance
Date: 11/07/09
Hba1C (+) Positive 12.0% 4.2-6.2% It means that
your diabetes
control may not
be as good as it
should be.
High values
mean you are at
greater risk of
diabetes
complications.
VIII. PATHOPHYSIOLOGY
Non modifiable Factors:
Age
Sex
Family History
Modifiable Factors:
Abnormal lipids
Smoking
Hypertension
Diabetes mellitus
Abdominal obesity
Too much alcohol
Lack of regular exercise
continuation
Atherosclerosis
Formation of plaque deposits
Thrombosis
Occlusion by Major blood vessel
If not managed:Lyses a moved thrombus from the vessel.
Vascular wall becomes weakened and fragile
Cerebral Hamorrhage
Mass of blood from and grows
Leaking of blood from the vessel wall
IX. MEDICAL MANAGEMENT
A. Drug Study
Name of the Drug
with DosageGeneric Name Action Mechanism of
Action
Indications Side Effects Contraindications Nursing Responsibilities
Vastarel Mr
35mg/tab 1 tab
BID
Trimetazidine Antianginal
Drugs
Acts by directly
counteracting all the
major metabolic
disorders occurring
within the ischemic
cell. The actions of
trimetazidine include
limitation of
intracellular
acidosis, correction
of disturbances of
transmembrane ion
exchanges, and
prevention of
excessive
production of free
radicals.decrease
myocardial oxygen
requirement by
Long treatment
of coronary
insufficiency,
angina pectoris.
Nausea and
vomiting slight
weakness and
head ache.
Hypersensitivity to
Trimetazidine
Use cautiously with
renal dysfunction.
Assess patient for chest pain or
what its type of severity.
Instruct the client to take drugs
only for 3 times and refer
physician if frequent angina attack
will occur.
Monitor VS and refer if there is an
abnormality
Take the medicine with a full glass
of water.
Administer before meals. Caution
patient to swallow capsules whole
—not to open, chew, or crush
them. If using oral suspension,
empty packet into a small cup
containing 2 tbsp of water. Stir and
have patient drink immediately; fill
decreasing the heart
rate, ventricular
volume, blood
pressure and
contractility. In some
cases, myocardial
oxygen delivery is
increased thru
reversing coronary
arterial spasm.
cup with water and have patient
drink this water. Do not use any
other diluents.
Provide safety and security must
be provided if weakness will be
manifested.
Aldactone 25 mg Spironolactone Anti-
hypertensive
agent, diuretic,
potassium
sparing
Competes with
aldosterone for
receptor sites in the
distal renal tubules,
increasing sodium
chloride and water
excretion while
conserving
potassium and
hydrogen ions, may
block the effect of
aldosterone on
arteriolar smooth
muscle as well
Management of
edema
associated with
excessive
aldosterone
excretion,
hypertension,
primary
hyperaldosteroni
sm,
hypokalemia,
treatment of
hirsutism,
cirrhosis of liver
accompanied by
edema or
Gynecomastia; GI
symptoms;
drowsiness;
lethargy;
headache; mental
condusion; ataxia;
impotence;
menstrual
irregularities;
rarely
agranulocytosis;
usticaria; fever;
Acute renal
insufficiency, anuria,
hyperkalemia.
Educate patient to avoid
hazardous activity such as
driving until response to drug is
known. Take with meals or
milk; avoid excessive ingestion
of food high in potassium or
use of salt substitutes.
Diuretic effect may be delayed
2-3 days and maximum
hypertensive may be delayed
2-3weeks; monitor I and O
ratios and daily weight, BP,
serum electrolytes (K, Na) and
renal function
ascites
Arixtra 2.5 mg SQ
ALAW
Fondaparinux Antithrombotic
s
Decreases platelet
aggregation and
inhibits thrombus
formation. They are
effective in the
arterial circulation
Reducing the
risk of ischemic
events, but it
substantially
reduces major
bleeding and
improves long
term mortality
and morbidity
Pain, bruising,
redness, and
swelling at the
injection site may
occur. Headache,
nausea, vomiting,
swelling of the
hands/feet, or
fever may also
occur.
Contraindicated to
patients less than 50
kilograms
Have kidney disease
Active bleeding
Low level of platelets in
the blood
Before injecting each dose, clean
the injection site with rubbing
alcohol. It is important to change
the location of the injection site
daily to avoid problem areas under
the skin.
Before using, check this product
visually for particles or
discoloration. If either is present,
do not use the liquid. Do not mix
any other medication in the same
injection.
Inject this medication under the
skin of the stomach/abdomen,
usually once daily or as directed
by your doctor. Do not inject into a
muscle. To lower the risk of
bruising, do not rub the injection
site after a shot.
When treating a blood clot,
another "blood thinner" (warfarin)
is usually started within 3 days
after you start using fondaparinux.
Your doctor will direct you to use
both of these medications until the
warfarin is working well. Do not
stop either of these medications
until your doctor directs you to
stop.
Simvastatin 80 mg
OD
Lipitor Anti
hyperlipidemic
s
Inhibits HMG-CoA
reductase, the
enzyme that
catalyzes the first
step in the
cholesterol
synthesis pathway,
resulting in a
decrease in serum
cholesterol, serum
LDLs, and either an
increase or no
change in serum
HDLs.
Adjunct to diet in
the treatment of
elevated total
cholestrol and
LDL cholesterol
with primary
hypercholesterol
emia (types IIa
and IIb) in those
unresponsive to
dietary
restriction of
saturated fat
and cholesterol
and other
nonpharmacolog
ic measures
To reduce the
risk of coronary
Headache,
asthenia,
sleep
disturbances
Flatulence,
diarrhea,
abdominal
pain,
cramps,
constipation,
nausea,
dyspepsia,
heartburn,
liver failure
Sinusitis,
pharyngitis
Rhabdomyolysis
, acute renal
Contraindicated with
allergy to simvastatin,
fungal byproducts,
Assess nutrition: fat, protein,
carbohydrates
Monitor bowel pattern daily
Monitor triglycerides, cholesterol
baseline throughout treatment
Precautions:
Past liver disease, alcoholism,
severe acute infections, trauma,
severe metabolic disorders,
electrolyte imbalances, elderly,
renal disease
disease,
mortality, and
CV events,
including stroke,
TIA, MI and
reduction in
need for bypass
surgery and
angioplasty in
patients with
coronary heart
disease and
hypercholesterol
emia
Treatment of
patients with
isolated
hypertriglyceride
mia
Treatment of
type III
hyperlipoprotein
emia
Treatment of
adolescents 10-
failure,
arthralgia,
myalgia
17 yr with
heterozygous
familial
hypercholesterol
emia
Digoxin
0.25 mg ½ tab OD
Lanoxin Anti-
arrhythmics,
inotropics
Increases the force
of myocardial
contraction.
Prolongs refractory
period of the AV
node. Decreases
conduction through
the SA and AV
nodes. Digoxin
inhibits the Na-K-
ATPase membrane
pump, resulting in
an increase in
intracellular sodium
and calcium
concentrations.
Increased
intracellular
concentrations of
calcium may
promote activation
V-fib, V-flutter,
CHF, pulmonary
edema, atrial
fibrillation and or
flutter, and
paroxysmal
atrial
contractions
CNS: fatigue,
headache,
weakness
EENT: blurred
vision, yellow
vision
CV:
ECG changes
GI: anorexia,
nausea, vomiting,
diarrhea
Endocrine:
gynecomastia
Hematology:
thrombo-cytopenia
Hypersensitivity,
uncontrolled ventricular
arrhythmias, AV block,
Idiopathic hypertophic
subaortic stenosis,
constrictive pericarditis.
Use cautiously in:
electrolyte
abnormalities
(hypokalemia,
hypercalcemia, and
hypomagnesemia may
predispose toxicity),
hypothyroidism,
geriatric patients (very
sensitive to toxic
effects, dose
adjustments required
for age-related
decrease in renal
function and body
Monitor K+, Mg++, ECG,
liver/renal function tests, drug level
(therapeutic level 0.5-2.0 mg/ml,
toxicity is >2.0 mg/ml).
Before each dose assess apical
pulse for full minute, record and
report changes in rate or rhythm.
Withhold drug and contact
provider if pulse is < 60/min. or
>100 (adults) or < 110/minute
(children)
Weigh daily
Monitor I&O and signs of CHF
Instruct patient to take medication
as directed, at the same time each
day. Missed doses should be
taken within 12 hr of scheduled
dose or not taken at all. Do not
of contractile
proteins (e.g., actin,
myosin). Digoxin
also acts on the
electrical activity of
the heart, increasing
the slope of phase 4
depolarization,
shortening the
action potential
duration, and
decreasing the
maximal diastolic
potential.
weight), MI, renal
impairment, obesity
(dose should be based
on ideal body weight).
double doses.
Teach patient to take pulse and to
contact health care professional
before taking medication if pulse
rate is <60 or >100.
Inform patient that these
symptoms may be mistaken for
those of colds or flu.
Instruct patient to keep digoxin tablets in their original container and not to mix in pill boxes with other medications; they may look similar to and may be mistaken for other medications
Accupril 5 mg ¼
tab with BP
precaution
Quinapril
Hydrochloride
ACE
Inhibitors,
Antihypertensi
ve
Suppresses rennin-
angiostensin-
aldosterone system
Blocks conversion of
angiostensin I to
angiostensin II
Hypertension
Adjunctive
Therapy for CHF
Reduces
development of
severe heart
failure following
MI in clients with
impaired
left ventricular
function
Prevents kidney
failure in Type II
diabetes
Cough
Rash
Pruritus
Diaphoresis
Orthostatic
hypotension
Contraindicated with
allergy to quinapril or
other ACE inhibitors,
angioedema
Use cautiously with
impaired renal function,
unilateral, bilateral renal
artery stenosis, salt or
volume depletion.
Obtain baseline and monitor
serum/urine protein, BUN,
Creatinine,
Glucose, CBC with differential,
potassium and sodium levels
First
dose syncope may occur in those
with CHF.
Provide mouth care; alteration in
taste can occur.
Rivotril 2mg ¼ tab
OD at HS
Clonazepam Benzodiazepin
es.
Benzodiazepines
are used as a
sedative or to
decrease seizures
or anxiety.
Probably facilitates
the effects of the
inhibitory
Anxious
Panic disorder
Acute manic
episodes of
bipolar disorder
Periodic leg
Drowsiness
Abnormal eye
movements
Anorexia
Dysuria
An allergy to
clonazepam, any other
benzodiazepine, or any
ingredient of this
medication
severe breathing
problems
Don’t stop drug abruptly because
this may worsen seizures. Call
prescriber at once if adverse
reactions develop.
Assess elderly patient’s response
closely.
neurotransmitter
GABA.
movements
during sleep
Leukopenia
Shortness of
breath
Skin rashes
myasthenia gravis
significant liver disease
acute narrow or closed
angle glaucoma
Monitor patient for over sedation.
Monitor CBC and liver function
tests.
Withdrawal symptoms are similar
to those of barbiturates
Plavix
75 mg
OD
Clopivaz Anti-
thrombotic
Adenosine
diphosphate
(ADP)
receptor
antagonist
Antiplatelet
Inhibits platelet
aggregation by
blocking ADP
receptors on
platelets, preventing
clumping of
platelets.
Indicated for the
prevention of:
Myocardial
infarction
Acute coronary
syndrome
Diarrhea
Abdominal pain
Dyspepsia
Headache
Dizziness
Vertigo
Rash
Hypersensitivity to the
active substance or to
any of the excipients of
the medicinal product.
Severe liver impairment
Active pathological
bleeding such as peptic
ulcer or intracranial
hemorrhage.
Provide frequent small meals if GI
upset occurs.
Provide comfort measures and
arrange for analgesics if headache
occurs.
Take daily as prescribed. May be
taken with meals.
Monitor if GI bleeding occurs.
Monitor carefully if bleeding occurs
if you administered it with warfarin.
Drug interactions: Increased risk
of GI bleeding with NSAIDS.
Increased risk of bleeding with
warfarin.
Transderm-Nitro
(transdermal) 5
Nitroglycerin Anti-anginal
Nitrate
Relaxes vascular
smooth muscle with
Angina pectoris
Congestive
Headache,
reddening of the
Contraindicated with
allergy to nitrates,
Record characteristics and
precipitating factors of anginal
mg to anterior
chest wall, rub for
systolic blood
pressure <90
mmHg
OD
a resultant decrease
in venous return and
decrease in arterial
BP, which reduces
left ventricular
workload and
decreases
myocardial oxygen
consumption.
heart failure
Prevention of
phlebitis and
extravasations
skin, itching or
burning sensation,
facial flushing,
faintness or light-
headedness,
dizziness, postural
hypotension,
nausea, vomiting
severe anemia, early
MI, head trauma,
cerebral hemorrhage,
and hypertrophic
cardiomyopathy.
pain.
Monitor BP and apical pulse
before administration and
periodically after dose.
Have client sit or lie down if taking
drug for the first time.
Client must have continuing EKG
monitoring for IV administration
Cardioverter/ defibrillator must not
be discharged through paddle
electrode overlying
Nitro-Bid ointment or the
Transderm-Nitro Patch. Assist with
ambulating if dizzy.
Kalium Durule 1
tab OD
Potassium
Chloride
Mineral,
Electrolyte
Necessary for many
cellular metabolic
processes
Primary action
intracellular.
Conduct nerve
impulses
Contracts cardiac,
Correct
Potassium
deficiency
Strengthen
cardiac and
muscular
activities
Abdominal pain,
diarrhea,
flatulence,
nausea, vomiting,
restlessness,
weakness,
arrhythmias, GI
ulceration, stenotic
Severe renal
impairment, oliguria
Hypersensitivity to
potassium chloride
Use cautiously with
cardiac disorders,
especially if treated with
Monitor serum potassium levels
(therapeutic 3.5-5.0 mEq/L), V/S,
ECG and signs of hyper and
hypokalemia.
Assess signs of digitalis toxicity.
Give IV infusions as dilute solution
infuses slowly.
skeletal and smooth
muscle.
Maintains normal
renal function.
lesions digitalis. Observe IV sites for infiltration so
tissue necrosis will not occur.
Potassium should never be given
as an IV bolus or push.
Potassium cannot be given IM.
Monitor urine output.
80-90% K+ is excreted in a urine.
Human isophane
insulin
15 units-pre-
breakfast
12 units-pre-
supper
Insulatard Antidiabetic Insulin is a hormone
secreted by the beta
cells of pancreas
that, by receptor
mediated effects,
promotes the
storage of the
body’s fuels,
facilitating the
transport of
metabolites and ions
(potassium)
Treatment of
type 2 DMthat
cannot be
contolled by diet
or oral drugs.
Treatment of
adults with
diabetes who
require basal
insulin for the
control, of
hyperglycemia.
Chills, cold sweat,
blurred vision,
dizziness,
drowsiness,
shaking, fast
heartbeat,
weakness,
headache,
fainting, tingling of
the hands/feet,
and hunger.
Hypoglycemia,
lipodystrophy,
pruritus, rash
allergic reactions.
Contraindicated with
allergy to pork
products.
Insulin is usually stored in the
refrigerator.
Administer 15-30 min before
meals
proper technique for
administration rotation of sites;
rolling vial rather than shaking;
proper testing of glucose levels;
Encouraged to have regular
exercise
Proper diet;
Limit alcohol use;
Clarithromycin
500 mg
Biaxin Anti-biotic,
Macrolide
Macrolide antibiotic
that acts by binding
to the 50S ribosomal
subunit of
susceptible
organisms, thus
interfering with or
inhibiting microbial
Treatment of the
lower respiratory
tract infections
diarrhea, nausea,
vomiting,
abdominal pain
headache,
dizziness,
hallucination,
insomnia,
urticaria, mild skin
Hypersen-sitivity to
clarithro-mycin, other
macrolide antibiotics, or
erythro-mycin. Clients
taking pimozide. Use
with ranitidine bismuth
citrate in those with
history of acute
Before:
Note sensitivity to erythromycin or
any macrolide antibiotics.
List drugs currently prescribed to
prevent any interactions.
Document onset, severity and
protein synthesis. eruption,
anaphylactic
hearing loss, rash,
alteration in sense
of smell, hepatic
failure
porphyria. characteristics of S&S.
During:
May administer with or without
food.
-Explain effects of the drug and its
side effects.
-Administer as prescribed.
After:
Report adverse effects or lack of
improvement after 48-72 hr.
Report any persistent diarrhea.
Document administration of
medication.
B. Other Treatments
ECG
Electrocardiography (ECG or EKG) is a transthoracic interpretation of the electrical
activity of the heart over time captured and externally recorded by skin electrodes. It is a
noninvasive recording produced by an electrocardiographic device. The etymology of the word
is derived from electro, because it is related to electrical activity, cardio, Greek for heart, and
graph, a Greek root meaning "to write".
Electrical impulses in the heart originate in the sinoatrial node and travel through the
intimate conducting system to the heart muscle. The impulses stimulate the myocardial muscle
fibres to contract and thus induce systole. The electrical waves can be measured at electrodes
placed at specific points on the skin. Electrodes on different sides of the heart measure the
activity of different parts of the heart muscle. An ECG displays the voltage between pairs of
these electrodes, and the muscle activity that they measure, from different directions, also
understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in
different parts of the heart muscle. It is the best way to measure and diagnose abnormal
rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue
that carries electrical signals, or abnormal rhythms caused by electrolyte imbalances. In a
myocardial infarction (MI), the ECG can identify if the heart muscle has been damaged in
specific areas, though not all areas of the heart are covered. The ECG cannot reliably measure
the pumping ability of the heart, for which ultrasound-based (echocardiography) or nuclear
medicine tests are used.
Placement of electrodes
Ten electrodes are used for a 12-lead ECG. They are labeled and placed on the patient's body as follows
ELECTRODE
LABEL (in the
USA)
ELECTRODE PLACEMENT
V1 In the fourth intercostal space (between ribs 4 & 5) to the right of the sternum
(breastbone).
V2 In the fourth intercostal space (between ribs 4 & 5) to the left of the sternum.
V3 Between leads V2 and V4.
V4 In the fifth intercostal space (between ribs 5 & 6) in the midclavicular line (the
imaginary line that extends down from the midpoint of the clavicle (collarbone).
V5 Horizontally even with V4, but in the anterior axillary line. (The anterior axillary line
is the imaginary line that runs down from the point midway between the middle of
the clavicle and the lateral end of the clavicle; the lateral end of the collarbone is
the end closer to the arm.)
V6 Horizontally even with V4 and V5 in the mid-axillary line. (The mid-axillary line is
the imaginary line that extends down from the middle of the patient's armpit.)
Limb leads
In both the 5- and 12-lead configuration, leads I, II and III are called limb leads. The
electrodes that form these signals are located on the limbs—one on each arm and one on the
left leg. The limb leads form the points of what is known as Einthoven's triangle.
Lead I is the signal between the (negative) RA electrode (on the right arm) and the
(positive) LA electrode (on the left arm).
Lead II is the signal between the (negative) RA electrode (on the right arm) and the
(positive) LL electrode (on the left leg).
Lead III is the signal between the (negative) LA electrode (on the left arm) and the
(positive) LL electrode (on the left leg).
Precordial leads
The electrodes for the precordial leads (V1, V2, V3, V4, V5, and V6) are placed directly
on the chest. Because of their close proximity to the heart, they do not require augmentation.
Wilson's central terminal is used for the negative electrode, and these leads are considered to
be unipolar (recall that Wilson's central terminal is the average of the three limb leads. This will
approximate ground). The precordial leads view the heart's electrical activity in the so-called
horizontal plane. The heart's electrical axis in the horizontal plane is referred to as the Z axis.
Waves and intervals
A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P wave, a
QRS complex and a T wave.[23] A small U wave is normally visible in 50 to 75% of ECGs. The
baseline voltage of the electrocardiogram is known as the isoelectric line. Typically the
isoelectric line is measured as the portion of the tracing following the T wave and preceding the
next P wave.
P wave During normal atrial depolarization, the main electrical vector is
directed from the SA node towards the AV node, and spreads from
the right atrium to the left atrium. This turns into the P wave on the
ECG.
QRS
complex
The QRS complex is a recording of a single heartbeat on the ECG
that corresponds to the depolarization of the right and left
ventricles.
PR
interval
The PR interval is measured from the beginning of the P wave to
the beginning of the QRS complex.
It is usually 120 to 200 ms long.
ST
segment
The ST segment connects the QRS complex and the T wave. It has a duration of 0.08 to 0.12
sec (80 to 120 ms).
T wave The T wave represents the repolarization (or recovery) of the
ventricles. The interval from the beginning of the QRS complex to
the apex of the T wave is referred to as the absolute refractory
period. The last half of the T wave is referred to as the relative
refractory period (or vulnerable period).
QT
interval
The QT interval is measured from the beginning of the QRS
complex to the end of the T wave.
Normal values for the QT
interval are between 0.30 and
0.44 seconds.[citation needed]
U wave The U wave is not always seen. It is typically small, and, by
definition, follows the T wave.
Echocardiogram
An echocardiogram uses sound waves to produce images of your heart. This common
test allows your doctor to see how your heart is beating and pumping blood. Your doctor can
use the images from an echocardiogram to identify various abnormalities in the heart muscle
and valves.
Depending on what information your doctor needs, you may have one of several types of
echocardiograms. Each type of echocardiogram has very few risks involved.
Your doctor may suggest an echocardiogram if he or she suspects problems with the
valves or chambers of your heart or your heart's ability to pump. An echocardiogram can also
be used to detect congenital heart defects in unborn babies.
Depending on what information your doctor needs, you may have one of the following
kinds of echocardiograms:
Types
Transthoracic echocardiogram. This is a standard, noninvasive echocardiogram. A
technician (sonographer) spreads gel on your chest and then presses a device known as a
transducer firmly against your skin, aiming an ultrasound beam through your chest to your heart.
The transducer records the sound wave echoes your heart produces. A computer converts the
echoes into moving images on a monitor. If your lungs or ribs obscure the view, a small amount
of intravenous dye may be used to improve the images.
Transesophageal echocardiogram. If it's difficult to get a clear picture of your heart
with a standard echocardiogram, your doctor may recommend a transesophageal
echocardiogram. In this procedure, a flexible tube containing a transducer is guided down your
throat and into your esophagus, which connects your mouth to your stomach. From there, the
transducer can obtain more detailed images of your heart.
Doppler echocardiogram. When sound waves bounce off blood cells moving through
your heart and blood vessels, they change pitch. These changes (Doppler signals) can help
your doctor measure the speed and direction of the blood flow in your heart. Doppler techniques
are used in most transthoracic and transesophageal echocardiograms.
Stress echocardiogram. Some heart problems — particularly those involving the
coronary arteries that feed your heart muscle — occur only during physical activity. For a stress
echocardiogram, ultrasound images of your heart are taken before and immediately after
walking on a treadmill or riding a stationary bike. If you're unable to exercise, you may get an
injection of a medication to make your heart work as hard as if you were exercising.
Risks
There are minimal risks associated with a standard transthoracic echocardiogram. You
may feel some discomfort similar to pulling off an adhesive bandage when the technician
removes the electrodes placed on your chest during the procedure.
If you have a transesophageal echocardiogram, your throat may be sore for a few hours
afterward. Rarely, the tube may scrape the inside of your throat. Your oxygen level will be
monitored during the exam to check for any breathing problems caused by the sedation
medication.
During a stress echocardiogram, exercise or medication — not the echocardiogram itself
— may temporarily cause an irregular heartbeat. Serious complications, such as a heart attack,
are rare.
During the procedure
An echocardiogram can be done in the doctor's office or a hospital. After undressing
from the waist up, you'll lie on an examining table or bed. The technician will attach sticky
patches (electrodes) to your body to help detect and conduct the electrical currents of your
heart.
If you'll have a transesophageal echocardiogram, your throat will be numbed with a
numbing spray or gel. You'll likely be given a sedative to help you relax.
During the echocardiogram, the technician will dim the lights to better view the image on
the monitor. You may hear a pulsing "whoosh" sound, which is the machine recording the blood
flowing through your heart.
Most echocardiograms take less than an hour, but the timing may vary depending on
your condition. During a transthoracic echocardiogram, you may be asked to breathe in a
certain way or to roll onto your left side. Sometimes the transducer must be held very firmly
against your chest. This can be uncomfortable - but it helps the technician produce the best
images of your heart.
After the procedure
If your echocardiogram is normal, no further testing may be needed. If the results are
concerning, you may be referred to a heart specialist (cardiologist) for further assessment.
Treatment depends on what's found during the exam and your specific signs and symptoms.
You may need a repeat echocardiogram in several months or other diagnostic tests, such as a
cardiac computerized tomography (CT) scan or coronary angiogram.
Results
Information from the echocardiogram can reveal many aspects of your heart health,
including:
Heart size. Weakened or damaged heart valves, high blood pressure or other diseases
can cause the chambers of your heart to enlarge. Your doctor can use an echocardiogram to
evaluate the need for treatment or monitor treatment effectiveness.
Pumping strength. An echocardiogram can help your doctor determine your heart's
pumping strength. Specific measurements may include the percentage of blood that's pumped
out of a filled ventricle with each heartbeat (ejection fraction) or the volume of blood pumped by
the heart in one minute (cardiac output). If your heart isn't pumping enough blood to meet your
body's needs, heart failure may be a concern.
Damage to the heart muscle. During an echocardiogram, your doctor can determine
whether all parts of the heart wall are contributing equally to your heart's pumping activity. Parts
that move weakly may have been damaged during a heart attack or be receiving too little
oxygen. This may indicate coronary artery disease or various other conditions.
Valve problems. An echocardiogram shows how your heart valves move as your heart
beats. Your doctor can determine if the valves open wide enough for adequate blood flow or
close fully to prevent blood leakage. Abnormal blood flow patterns and conditions such as aortic
valve stenosis — when the heart's aortic valve is narrowed — can be detected as well.
Heart defects. Many heart defects can be detected with an echocardiogram, including
problems with the heart chambers, abnormal connections between the heart and major blood
vessels, and complex heart defects that are present at birth. Echocardiograms can even be
used to monitor a baby's heart development before birth.
X. NURSING MANAGEMENT
A. Concept Map of Nursing Problems
`
2. Acute (Chest) Pain r/t myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of the myocardium and
necrosis of the myocardium.
Objectives:(+)Restlessness, (+) Facial grimacing, (+) Fatigue, (+) Peripheral cyanosis, (+) Cold and clammy skin, (+) Palpitations (+) Shortness of breath, (+) Pain scale of 8/10
5. Low self-esteemr/t chronic illness specifically myocardial
ischemia.Objective/s:(+) indecisive nonassertive behavior, (+) Weakness, Lack of eye contact, Refusal to participate in hospital procedures, increasingly dependent on her wife
1. Ineffective airway clearance related to presence of secretions in the
tracheobronchial tree.
Objective/s: (+) Crackles, (+) Whitish productive cough, (+) Chest Pain, (+) DOB, (+) Tachycardia, (+) Weakness, (+) Confusion, RR= 36 bpm, CXR- PTB, both lobe with regression Atheromatous aorta
CC: Difficulty of BreathingMedical
Diagnosis:
6. Deficient Knowledge r/t new diagnosis and lack of understanding of medical condition.
Objectives:(+)Lack of improvement of previous regimen(+)Inadequate follow-up on instructions given.(+)Anxiety(+)Lack of understanding
3. Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and consumption as evidenced by shortness of breath.
Objectives:(+)Increased heart rate 130 bpm.(+)Increased blood pressure130/80(+)Difficulty of breathing(+)Pallor(+)Fatigue and weakness(+)Ischemic ECG changes
4. Infection r/t invasion of bacterial microorganism in the lungs
Objective/s:Based on the Laboratory results:Eosinophils = 4.0% (0-3%), WBC = 18.3X10^9/L (4.5 – 11.0 X 10 ^ 9/L), CXR results: PTB, both upper lobe with regressionAtheromatous aorta (+) whitish productive cough,
B. Nursing Care Plan
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION/S RATIONALE NURSING THEORIST/S EVALUATION
Subjective:
“Nabudlayan ako mag
ginhawa” as verbalized.
Objective/s:
(+) Crackles
(+) Whitish
productive cough
(+) Chest Pain
(+) DOB
(+)Tachycardia
(+) Weakness
(+) Confusion
RR= 36 bpm
CXR- PTB, both
lobe with regression
Atheromatous aorta
Ineffective
airway
clearance r/t
presence of
secretions in the
tracheobronchial
tree.
After 8 hours of
nursing
intervention, Mr.
AL will be able to
expectorate
secretions and
have normal
respiratory rate.
Independent:
1. Assist the Mr. AL
in performing
coughing and
breathing maneuvers.
2. Instruct the Mr. AL
in the following:
Optimal
positioning (semi
fowlers)
Use of pillow or
Hand splints when
coughing.
Use of
abdominal muscle
for more forceful
cough
Temperance of
ambulation and
1. This improves
the productivity of
cough
2. Controlled
coughing
techniques help
mobilize
secretions from
smaller airways to
larger airways
because coughing
is done at varying
times.
Faye Abdellah’s theory
of 21 Nursing Problems
(Problem Solving to
move the patients
towards health.)
Faye Abdellah’s theory
of 21 Nursing Problems
(Doing the for the
patient what they cannot
do for themselves.)
Virginia Henderson’s
theory of 14
Components of Nursing
Care (Process or
movements from
dependence to
independence.)
Goal partially
met.
After 8 hours of
nursing
interventions,
Mr. AL
secretions are
mobilized and
cough out but
the airway is
not totally free
from excessive
secretions AEB
abnormal lung
sounds or
crackles.
frequent position
change.
3. Provide back
Tapping to patient.
Dependent:
1. Administer 02
therapy as ordered
2L/minute via nasal
cannula
2. Nebulization of
salbutamol 1neb x
3doses/15min
3. To loosen
Secretions
1. For effective
oxygenation
2. To promote
softening of
secretions for
better
expectoration of
secretions
Florence Nightingale’s
theory of Environment
(Alleviate unnecessary
source of pain and
suffering)
Dorothy Johnson’s
theory of Human
Behavioral System
(Medicine focus: Cure)
Lydia Hall’s theory of
Components of Nursing
Caring (Core and Cure -
shared with other health
care providers.)
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION/S RATIONALE NURSING
THEORIST/S
EVALUATION
Objective/s:
Based on the
Laboratory results:
o Eosinophils
4.0% (0-3%)
o WBC
18.3X10^9/L (4.5 –
11.0 X 10 ^ 9/L)
o Chest X-ray
reveals:
PTB , both upper lobe
with regression
Atheromatous Aorta
(+) whitish
productive cough
Infection r/t
invasion of bacterial
microorganism in
the lungs
Mr. AL is free of
infection as
evidenced by
laboratory results
are within normal
limits throughout
hospital stay.
Independent:
1. Note for
physical evidence
of infection
2. Implement
appropriate
measures to protect
the patient from
potential infection
sources.
3. Obtain a recent
history for signs
and symptoms of
infection or
exposure to
infected individual.
1. Infections
must be treated to
stop the immune
response and
glomerular
inflammation.
2. Hand washing
by all people in
contact with the
patient is the primary
method to reduce the
risk of infection.
3. Symptoms of
Acute
glomerulonephritis
appear 10 to 14 days
after initial
streptococcal illness.
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Dorothea Orem’s
theory of Nursing
Concepts
(Identifies what
Nursing Care is
needed)
Dorothea Orem’s
theory of Nursing
Concepts
(Identifies what
Nursing Care is
needed.)
Goal Partially met.
After nursing
intervention Mr. AL
is still having
abnormal laboratory
results AEB Chest
X-ray reveals:
PTB , both upper
lobe with regression
Atheromatous Aorta
but Eosinophils and
WBC are within
normal limits.
Dependent:
1. Review results
of specimen cultures
1. Administer
Clarithromycin 500
mg.
1. Identification of
specific
microorganism will
guide selection of
appropriate
antimicrobial drugs.
2. Viral infection
does not respond to
antibiotic therapy. To
decrease the risk of
development of
bacterial strains
resistant to
antibiotics, drug
therapy should be
based on specific
culture and sensitivity
results.
Dorothea Orem’s
theory of Nursing
Concept (Self care
– ability of the
person to take care
of himself)
Dorothy
Johnson’s theory
of Human
Behavioral System
(Medicine focus:
Cure)
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION/S RATIONALE NURSING
THEORIST/S
EVALUATION
Objective/s:
(+)indecisive
nonassertive
behavior
(+)
Weakness
Lack of eye
contact
Refusal to
participate in
hospital
procedures
Increasingly
dependent on
his grandson.
Low self-esteem
r/t chronic illness
specifically
myocardial
ischemia.
After 8 hours of
nursing
intervention, Mr.
AL will manifests
more positive
self-esteem and
positively respond
to medical and
nursing
interventions
without any
refusal.
Independent:
1. Actively listen to
and respect Mr. AL
2. Assist Mr. AL in
Identifying the major
areas of concern r/t
altered self-esteem.
1. Listening and respect
increase the
development of
therapeutic relationship
with the client.
2. The nurse patient
relationship can provide
a strong basis for
implementing other
strategies to assist the
patient and family with
adaptation.
Imogene King’s
theory of Nurse –
Patient interactions
(Integrating personal
system; interpersonal
system; social
system)
Hildegard Peplau’s
theory of
Interpersonal /
Interactive
(therapeutic
interaction between
Nurse and Patient)
Goal met.
After 8 hours of
nursing intervention
Mr. REB was able to
participate in all the
nursing procedure
without any refusal
as evidence by
presence of smile on
his face and
conversant attitude
towards the health
care provider.
3. Assist Mr. AL in
Incorporating changes
in health status into
activities of daily living,
social life, interpersonal
relationships, and
occupational activities.
4. Allow Mr. REB’s
time to voice concerns
and express anger
related to having a
chronic condition.
Collaborative:
1. Use case managers
and social workers as
necessary.
3. As Mr. REB’s
condition worsen with
Myocardial Ischemia, it
is more difficult to
engage in even routing
activities.
4. Denial and anger
are anticipated
responses to the
diagnosis of a chronic
illness.
1. They can provide
psychological support
and assist in financial
arrangement.
Hildegard Peplau’s
theory of
Interpersonal /
Interactive
(Orientation,
Identification)
Jean Watson’s
theory of
Interpersonal nature
of caring (Help
persons / patients
achieve a degree of
harmony within
themselves.)
Lydia Hall’s theory
of Components of
Nursing Caring (Core
and Cure -shared
with other health
2. Refer to psychiatric
consultant as
necessary
3. Encourage use of
support groups.
2. Most patient
experiences some
degree of emotional
imbalance. With
professional psychiatric
consultation, most
patients can gradually
accept changed self-
esteem
3. Groups that come
together for mutual
goals can be most
helpful.
care providers.)
Dorothy Johnson’s
theory of Human
Behavioral System
(Nursing focus: The
behavior of the
person threatened
with illness or is ill.)
Lydia Hall’s theory
of Components of
Nursing Caring (Core
and Cure -shared
with other health
care providers.)
XI. DISCHARGE PLANNING
M – edications
Medications prescribed by the physician should be taken properly, to help the patient lessen
unusual condition.
The following are take home medications prescribed by the physician:
Vastarel mr 35mg/tab
Clovipaz 75mg/tab
Aldactone 25 mg subcutaneous
Transderm patch 5 mg
Lipitor 80 mg/tab
Lanoxin 0.25 mg/tab
Accupril 5.0 mg/tab
Rivotril 2 mg/tab
Insulatard 15 units prebreakfast
12 units presupper
Clarithomycin 500 mg.tab
E – xercise and Activity
Encourage Mr. AL to have an active range of motion exercises thrice daily to maintain his
muscle strength.
T – reatment
Continue monitoring blood pressure and ECG results and comply with the medications given
prescribed by the attending physician to prevent further complications that may occur and to
have a faster recovery.
H – ome Teaching/s
1. Instruct the client/folks on how to monitor fluid status, as well as, the signs and
symptoms in order to determine existing problems and to prevent further complications.
2. Teach/ educate the client and folks on infection prevention.
3. Instruct the client on how to delay weights and how to interpret the relationship of weight
loss/gain to need for sodium and water.
4. Instruct the client and folks about the medication metabolism.
5. Teach the client and folks about the dietary regimens such as low salt, low fat and high
fiber.
6. Importance of follow-up and physician appointment.
O – ut patient follow up
After discharge, Mr. R.E.B will have a regular follow-up check up with the physician to check
and monitor the patient’s medical condition and have a dialysis thrice a week to remove waste
products from the body and to prevent future complications.
D – iet
Maintain a low salt, low fat, and high fiber diet as prescribed by the attending physician. Advice
the patient not to eat foods that is high in cholesterol such as the fatty portion of the pork that
may increase the level of his blood pressure but to eat more green and leafy vegetables.
S – pirituality and Sexuality
In order to improve his spiritual aspects, he may attend holy masses or listen to gospel readings
and pray the holy rosary or he may seek for divine providence to the Lord. Assist the patient that
may include spiritual resources to help him deal with it.
XII. My Journey
Anticipating the unknown is something that is scary. This is one of my usual thoughts
when we will be assigned to another ward. There will be different patient, different attitude and
behavior, and lastly with different personality. I haven’t even experience some of the procedures
that might be performed. I fear o doing wrong things or mistakes that might disappoint everyone
especially to my patient. I was expecting that the staffs would be mean to us and the doctors
might be a bit of intimidated. I was expecting to be very busy and that came true.
I was wrong. The staff nurses were glad and welcomed us with a smile. It was a
satisfaction working with them when they teach us and correct the things that we’ve been doing.
They seem to be our CI because they ask questions about the drugs, procedures and IV which I
find it more interesting. These enhanced my knowledge, skills and attitude toward my patient.
I am enjoying every step of this journey, both the challenges and the success,
because I know that I control of my future. Failures are merely learning experiences that lead to
the next success. There would come times that they would be stricter to us but it is for our own
good. There would be learning if you would learn from your mistakes.
I am thankful to my CI, Mrs. Edrelyn Venturanza and Ms. Jimmelle Ellen Olilang, for
being so patient and kind to us. I like the manner she tries to emphasize our responsibilities and
obligations to our patients. She always carries a smile on her face which tells me deep inside
that I must enjoy the field of profession that I choose in every chooser carrier, there is always
hardship, sacrifices and trials that will come across the way. These 3 elements made me
stronger enough the challenge to be a successful nurse someday. I also learned that you must
grab every opportunity when you are still a student nurse, in this way we would be able to
develop skills in performing different procedure. This includes skin test, IV follow-up, OTF
feeding and subcutaneous injections.
The days of duty has seems to end so fast. I didn’t notice and feel that I will soon leave
the ICU. In our duty, I am always reminded that the life of your patient depends on my hands. I
have given the responsibility to take good care of my patients.
This month stay here in ICU would be cherished and reminisced in my life. I learned
many values, learning and procedure that would help me in rendering care to my patient.
Doing the case of my patient seems so hard yet full of learning. Even though it’s hard, I
just think that it would contribute to gain further knowledge.
Doing what you love is success. Success is not defined by fortune alone. It doesn't come
while you're looking for it. It comes unexpectedly while you're filling the needs of your clients. It
arrives in the moment you discover the key to your case and put the last piece of the puzzle in
place.