Myocardial Ischemia Disease

70

description

My individual case study for the 2nd semester

Transcript of Myocardial Ischemia Disease

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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

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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

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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

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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

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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.

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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

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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.

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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)

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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.

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HPNDM-type II FAMILY

HPN

HPN, PTB, Myocardial Ischemia

BA

HPN HPN

Legend:

Deceased male

Deceased female

Indicates patient

Living male

Living female

BA

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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.

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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.

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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

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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

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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

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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

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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

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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

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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

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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

Page 23: Myocardial Ischemia Disease

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

Page 24: Myocardial Ischemia 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

Page 25: Myocardial Ischemia Disease

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

Page 26: Myocardial Ischemia Disease

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

Page 27: Myocardial Ischemia Disease

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.

Page 28: Myocardial Ischemia Disease

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

Page 29: Myocardial Ischemia Disease

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.

Page 30: Myocardial Ischemia Disease

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.

Page 31: Myocardial Ischemia Disease

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

Page 32: Myocardial Ischemia Disease

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.

Page 33: Myocardial Ischemia Disease

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

Page 34: Myocardial Ischemia Disease

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

Page 35: Myocardial Ischemia Disease

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

Page 36: Myocardial Ischemia Disease

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

Page 37: Myocardial Ischemia Disease

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:

Page 38: Myocardial Ischemia Disease

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.

Page 39: Myocardial Ischemia Disease
Page 40: Myocardial Ischemia Disease

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,

Page 41: Myocardial Ischemia Disease

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.

Page 42: Myocardial Ischemia Disease

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.)

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Page 44: Myocardial Ischemia Disease

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.

Page 45: Myocardial Ischemia Disease

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)

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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.

Page 47: Myocardial Ischemia Disease

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

Page 48: Myocardial Ischemia Disease

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.)

Page 49: Myocardial Ischemia Disease

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.

Page 50: Myocardial Ischemia Disease

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.

Page 51: Myocardial Ischemia Disease

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.