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Case Presentation

on
Coronary Artery Disease, Acute Myocardial Infarction

In Partial Fulfillment of the Course Requirements in


Nursing Care Management

Presented to the Clinical Instructors of


Ateneo de Davao University
Nursing Division

Submitted to:

Anselmo Lafuente, R.N.


Clinical Instructor

Submitted by:

Yap, Novelynne Joy A.


4H

Submitted on:
February 22, 2007
Table of Contents

I. Introduction....................................................................................................................3
II. Objectives......................................................................................................................5
III. Patient’s Data.................................................................................................................6
IV. Genogram.......................................................................................................................7
V. Health Status..................................................................................................................9
VI. Complete Diagnosis.....................................................................................................12
VII. Developmental Data.....................................................................................................16
VIII. Physical Assessment....................................................................................................20
IX. Anatomy and Physiology.............................................................................................23
X. Pathophysiology...........................................................................................................34
XI. Doctor’s Order….........................................................................................................40
XII. Diagnostic Examination..............................................................................................50
XIII. Drug Study..................................................................................................................64
XIV. Nursing Care Plan.......................................................................................................93
XV. Prognosis....................................................................................................................108
XVI. Bibliography..............................................................................................................110

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INTRODUCTION

Coronary Artery Disease (CAD) is characterized by the presence of atherosclerosis in the


epicardial coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis,
progressively narrow the coronary artery lumen and impair myocardial blood flow. The
reduction in coronary artery flow may be symptomatic or asymptomatic, may occur with
exertion or at rest, and may culminate in a myocardial infarction, depending on obstruction
severity and the rapidity of development.

The term myocardial infarction is derived from myocardium (the heart muscle) and
infarction (tissue death due to oxygen starvation). Myocardial infarction (MI) is the rapid
development of myocardial necrosis caused by a critical imbalance between the oxygen supply
and demand of the myocardium. This usually results from plaque rupture with thrombus
formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the
myocardium.

Cardiovascular disease is the leading cause of mortality in the United States among both
men and women in every major ethnic group. It accounts for nearly 1 million deaths per year and
was responsible for one in five deaths in the United States in 2001. Approximately 6 million men
have a history of a myocardial infarction, angina pectoris, or both. Coronary artery disease is the
most common form of cardiovascular disease. In 2001, the death rate from coronary artery
disease was 228 per 100,000 white men, 262 per 100,000 black men, 137 per 100,000 white
women, and 177 per 100,000 black women. The estimated prevalence of coronary artery disease
in men is 6.9%; among women the prevalence is 6.0%.

Internationally, diseases of the heart are the leading cause of death, causing a higher
mortality than cancer (malignant neoplasms). Some 7,200,000 men and 6,000,000 women are
living with some form of coronary heart disease. 1,200,000 people suffer a (new or recurrent)
coronary attack every year, and about 40% of them die as a result of the attack. This roughly
means that every 65 seconds, an individual dies of a coronary event.

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In the Philippines, 92 percent of Filipinos 20 years and above have at least one of the risk
factors that may soon lead to coronary artery disease and cardiovascular disease if not addressed
immediately. These risk factors include diabetes, hypercholesterolemia (high cholesterol levels
in the bloodstream), obesity, high blood pressure and smoking. In addition the National Nutrition
and Health Survey (NNHeS) report also showed that 22 out of 100 Filipino adults are
hypertensive (with blood pressure of 140/90 or higher), and 40 percent of those between 20 and
29 already have prehypertensive findings.

During my clinical exposure in the Coronary Care Unit at the Davao Medical Center last
November 27-29, 2006, I had a patient with a diagnosis of CAD, AMIK II, (+) LVH, (+) LVD,
FC III. This patient is Mr. Perfecto Pandacan Balili, a 60 years old male and will be the focus of
my case study.

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OBJECTIVES
General Objective:
Through this paper, I will be able to present details about Coronary Artery Disease,
Myocardial Infarction. The proponent gathered data through interviewing the patient and his
watchers, making use of the patient’s records from the hospital, and other researches to provide
the readers information about the said condition.
This case study would preserve and improve the quality of nursing responsibilities by
rendering care, holistically, spiritually, and whole heartedly in a manner that the client, the
student nurses and others would benefit.
This case study would be able to:
• COGNITIVE: Discuss in details of the chosen illness for the case study so as to gain
insight and knowledge about CAD, AMI
• AFFECTIVE: Have a purposeful interaction with the client’s significant others
• PSYCHOMOTOR: Enhance the ability to identify and apply nursing interventions to
provide a better care for the client’s suffering from the mentioned illness.

Specifically, this paper would be able to:


• Present the patient’s personal data with accuracy
• Present the genogram that includes the disease of the family members
• Discuss the health status of the patient that includes the past and present condition
• Present and discuss the complete diagnosis of the patient
• Interpret and discuss the developmental data of the patient
• Obtain the physical assessment of the patient
• Discuss the anatomy and physiology of the affected system
• Trace the pathophysiology of the disease and its underlying causes in relation to the
patient’s predisposing and precipitating factors
• Interpret and present the Physician’s orders

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• Discuss the different laboratory and diagnostic examinations done top the patient
• Make a drug study on the drugs prescribed to the patient
• Formulate nursing care plans for the patient
• State the prognosis and relate it with the patient’s condition
PATIENT’S DATA

Patient’s Name: Perfecto Pandacan Balili Hospital Number: 919684


Age: 60 years old
Sex: Male
Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City
Civil Status: married
Religion: Roman Catholic
Citizenship: Filipino
Birthday: July 9, 1946
Birthplace: Tagum City

Name of Spouse: Lydia Balili


Age: 57 years old
Name of Father: Julio Balili (Deceased)
Name of Mother: Vicenta Pandacan (Deceased)

Area: Coronary Care Unit


Bed: 1
Attending Physician: Dr. Voltaire Egnora
Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left
Ventricular Hypertrophy, Left Ventricular Dilatation, FC III
Chief Complaint: Dyspnea
Date and Time Admitted: November 12, 2006, 12:01 P.M.

6
7
8
LEGEND:

Couple Hypertension Rheumatic Heart Disease

Deceased Heart Problem Renal Failure

Asthma Pulmonary Tuberculosis Arthritis

Cancer CAD, AMI Pneumonia

Twin

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HEALTH STATUS

A. Personal Data
Patient’s Name: Perfecto Pandacan Balili
Age: 60 years old
Sex: Male
Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City
Chief Complaint: Dyspnea
Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II,
Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III

B. Family Background
The family has been living in Ecoland ever since Perfecto and Lydia got married, except
for some years in between when the family went to Manila but apparently they also came back
here in Davao. The couple has eleven children with 6 girls and 5 boys. Aside from that within the
6 girls there is a twin and the same applies with the 5 boys, apparently their third set of twins
died due to miscarriage.
Among the eleven children only two of them were able to finish college and the rest were
only able to study until their high school years for varied reasons. In addition, currently the
couples children are in Manila, one is in Japan and three stayed here in Davao. All of their
children are currently married except for the youngest three.
Mr. Perfecto Balili has an educational attainment of until second year high school and his
wife Lydia got until second year College with a course of Accountancy. According to Mrs. Balili
they got married when she was in third year high school because she already got pregnant with
their first child. But even though this is the case she still continued her schooling until second
year college with the financial support of her husband. In addition, she got pregnant with only a
years difference on all of her children.
Perfecto has always been a taxi driver. He supported his family’s daily needs, educational
needs and others with only this kind of job. He worked as a taxi driver both here in Davao and
even when they came to Manila he also worked as an FX driver. Back then when their children
was young Mr. Perfecto is the only one that works because Lydia is the one that takes care of the
children and until today she is still a plain house wife. But when Mr. Balili experienced his first

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heart attack in Manila, he temporarily stopped driving and took a rest. After a few months he
then continued his work and did not totally stop driving until after his third attack and so their
children are the ones that supported the family. Currently, they get their financial support in their
daughter who is in Japan.
Some of his vices include drinking and smoking. He is a hard drinker and started drinking
when he was only a teenager. He can consume half a box of cigarette in a day and this started
during his twenties. He is also fond of eating meat compared to fish and vegetables.
Furthermore, Perfecto’s father died due to cancer and his mother died due to asthma.
Among his siblings, 3 of his siblings had pulmonary tuberculosis namely Emilio, Carlos and
Lucia. One of his sisters had a renal failure and hypertension. Other than that they have no trace
of any hereditary diseases. Perfecto’s son, Adrian, had PTB and 3 of his children had pneumonia.
His daughter, Jackilyn, had Rheumatic Heart Disease and his son, Jeffrey, had asthma.

C. History of Past Illness


Back in 1986, Perfecto was diagnosed of pulmonary tuberculosis and he sought medical
help from the Barangay Health Center. He was then given the 6 months treatment for PTB, after
the completion of the medication the patient failed to have a follow-up check-up after the
treatment.
Perfecto had his first attack 7 years ago; he had his first and second heart attack in
Manila. During his first attack he was admitted in Manila Hospital then was transferred to San
Juan Hospital for five days and was then brought back to Manila Hospital. His third and fourth
heart attack happened in Davao. He was admitted in Med-Main in DMC on his third attack and
his fourth attack was in Med CP for he had COPD and was then transferred to CCU for he was
diagnosed with Coronary Artery Disease basing on his result of Echocardiogram. His fourth
attack happened only last July 2006.

D. History of Present Illness


One month PTA, the patient had his available oxygen via oxygen tank in his house as aid
for his breathing, which they bought for P4,500. He also had an air conditioned room at his home
just to aid his condition. Two weeks PTA, patient had bipedal edema, loss weight; decrease
appetite and experienced paroxysmal nocturnal dyspnea. He had difficulty sleeping during the
night. Three days PTA, patient has been having episodes of chest pain at the left anterior chest

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radiating to the arm, lasting for a minute. Five hours PTA, he had recurrence of chest pain of the
same character. He then took isosorbide mononitrate SL but without relief. Persistence of
symptoms prompted this admission, with a previously diagnosed coronary artery disease by 2D
Echo result.

E. Effects and Expectation of Illness to Family


Mr. Perfecto already had five heart attacks and his condition got worse every time this
happens. Although the family is very well aware of his degenerating condition they are still
hoping that he will get better and that will live much longer. As observed the family is not really
affluent and that they are having financial problems due to the recurrent attacks of the patient.
Luckily, they are being assisted by his daughter, Jackilyn, who had a Japanese husband and
currently resides in Japan. In addition, he also had a senior citizen’s identification card that
becomes a big aid in their financial needs. Aside from the financial help the family is greatly
affected by the patient’s condition and thus still tries their best to live a normal life.

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COMPLETE DIAGNOSIS

Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular
Hypertrophy, Left Ventricular Dilatation, FC III

Coronary
• Term applied to vessels
(Stedman’s Medical Dictionary, 25th Edition)
• Used to describe the arteries that supply blood to the muscle tissue of the heart, or the
veins that take blood away from it
(Microsoft® Encarta® Premium Suite 2005)
• Relating to or being the coronary arteries or coronary veins, or relating to the heart
(http://education.yahoo.com/reference/dictionary/entry/coronary)

Artery
• A vessel through which the blood passes away from the heart to the various parts of the
body
(Stedman’s Medical Dictionary, 25th Edition)
• Blood vessel that carries blood away from the heart
(Medical Dictionary by Gupta and Gupta)
• Are muscular blood vessels that carry away blood from the heart
(http://en.wikipedia.org/wiki/Artery)

Disease
• A definite morbid process having a characteristic train of symptoms
(Stedman’s Medical Dictionary, 25th Edition)
• Any departure from health of a structure, organ, or system
(Medical Dictionary by Gupta and Gupta)
• Disorder with a specific cause and recognizable signs and symptoms, any bodily
abnormality or failure to function properly
(Webster Dictionary)

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Coronary Artery Disease
• A disease in which there is a narrowing or blockage of the coronary arteries (blood
vessels that carry blood and oxygen to the heart
(Medical-Surgical Nursing, 9th Edition)
• Characterized by the presence of atherosclerosis in the epicardial coronary arteries.
(The Bantam Medical Dictionary)
• Occurs when the arteries that supply blood to the heart muscle (the coronary arteries)
become hardened and narrowed
(http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html)

Acute
• Having rapid onset, short or relatively severe course
(Stedman’s Medical Dictionary, 25th Edition)

Myocardial
• Pertaining to the muscular tissue of the heart
(Stedman’s Medical Dictionary, 25th Edition)
• Relating to or affecting the thick muscular wall of the heart.
(Microsoft® Encarta® Premium Suite 2005)
• The middle of 3 layers forming the wall of the heart. It is composed of cardiac muscles
and forms the greater part of the heart wall, being thicker in the ventricles than in atria.
(http://education.yahoo.com/reference/dictionary/entry/myocardial)

Infarction
• Formation of an infarct (coronary thrombosis)
(Stedman’s Medical Dictionary, 25th Edition)
• Cessation of blood flow by thrombus formation and causing issue death
(Medical Dictionary by Gupta and Gupta)
• The death of part of the whole of an organ that occurs when the artery carrying its blood
supply is obstructed by a blood clot
(www.ask.com/infarction)

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Killip’s II
• A classification of Acute Myocardial Infarction that is defined as having moderate heart
failure with basiliar rales -50% of lung field or S3 gallops, tachycardia or signs and
symptoms or right heart failure like venous or hepatic congestion
(Harrison’s Internal Medicine)

Myocardial Infarction
• A disease that occurs when the blood supply to a part of the heart is interrupted. The
resulting oxygen shortage causes damage and potential death of heart tissue
(http://en.wikipedia.org/wiki/Myocardial_infarction)
• Is the rapid development of myocardial necrosis caused by a critical imbalance between
the oxygen supply and demand of the myocardium
(http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/complications/compl
ications.htm)
• It is a disease that occurs when the blood supply to a part of the heart is interrupted
(http://www.yahoo.com/reference/dictionary/acutemyocardial infarction)

Ventricular
• Pertaining to ventricles
(Stedman’s Medical Dictionary, 25th Edition)
• Involving, affecting or relating to a ventricle
(Microsoft® Encarta® Premium Suite 2005)
• One of the chambers of the heart, the largest and the most important chamber
(www.ask.com/dictionary/left ventricle)

Hypertrophy
• Morbid enlargement or overgrowth of an organ or part due to an increase in size of its
constituent cells
(Stedman’s Medical Dictionary, 25th Edition)
• An increase in cell size
(Medical Dictionary by Gupta and Gupta)

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• Increase the size of a tissue or organ brought about by the enlargement of its cells rather
than by cell multiplication, muscles undergo these changes in response to increased work
(http://education.yahoo.com/reference/dictionary/hypertrophy)

Dilatation
• The act or process of widening or being widened, stretching or being stretched, or
enlarging or being enlarged
• something, especially a part of something else, that has become enlarged, expanded, or
stretched
(Microsoft® Encarta® Premium Suite 2005)
• The enlargement or expansion of a hollow organ or cavity
(The Bantam Medical Dictionary)

Left Ventricle Hypertrophy & Dilatation


• There were increase in the size of the left ventricle or enlargement of the left ventricle
due to increase blood volume and pressure
(http://education.yahoo.com/reference/dictionary/hypertrophy/dilatation)

FC III
• A classification of chronic heart failure that is defined as having dyspnea that occurs with
less than ordinary physical activity, can climb one or less than one flight of stairs

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DEVELOPMENTAL DATA

The middle years from 40-65, have been called the years of stability and consolidation.
For most people it is the time when children have grown and moved away or are moving away
from home. Thus, partners generally have more time for and with each other and time to pursue
interests they may have deferred for years.

Physical Development
A number of changes take place during the middle years. Both men and women
experience decreasing hormonal production during the years. The climacteric (andropause) refers
to the changes of life in men, when sexual activity decreases. In men, there is no change
comparable to menopause in women. Androgen levels decreases very slowly; however men can
still have children even in late life. The psychological problems that men experience is generally
relate to fear of getting old and to retirement, boredom and finances.
Physical changes that occurred to Perfecto were his decreasing ability to perform
activities. He easily gets tired and constantly needs assistance upon doing things or moving
about. Due to his condition he only has limited capabilities and can no longer do what he usually
does unlike the previous years before his first attack occurred.

Robert Havighurst’s Developmental task theory


Since Perfecto belonged to the middle-aged group, he had seven tasks to accomplish
according to Havighurst’s theory. These tasks are:
1. Achieving adult, civic and social responsibility. The family agreed that Perfecto has
achieved this because he was able to perform his role well. He is able to support his
eleven children and send them to school although unfortunate personal circumstances
hindered eight of them from finishing school. Although this is the case Perfecto is a
responsible citizen and is concerned for the betterment of his family and community.
2. Establishing and maintaining an economic standard of living. Perfecto works really
hard for his family. Ever since he got married he did his best to support his family. He did
a very good job since he was also able to support the schooling of his wife. He worked as
a taxi driver both here in Manila and Davao.

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3. Assisting teenage children to become responsible and happy adults. He is the
authority of the house and he makes sure that he is able to guide his children to the right
path. Many of his children did not finish their schooling because many are just not
interested to do so and there may be lack of guidance since they were a big family and
their behavior was affected by the changing environment. Although this is the case his
children as adults are responsible enough to work hard to support each other and help the
family especially when the family is on financial crisis.
4. Developing adult leisure time activities. They spend they leisure time talking at each
other, watching television or talking to neighbors and establish good relationships. Back
then he would smoke and drink with his male friends but ever since he ha his first attack
he stopped his vices.
5. Relating oneself to one’s spouse as a person. Usual petty fights happen between the
couple but they are able to patch things up and still work as a couple. They value each
others opinion and respect each others decisions.
6. Accepting and adjusting to the physiologic changes of middle age. Perfecto had
accepted the fact that he is not getting any younger anymore and it is evident on his
condition. That is why he already anticipated any changes that would happen to him
especially with his current illness. He is very well aware that his body is no longer like
before and that each attacks that occurs is worse than the previous.
7. Adjusting to aging parents. Perfecto’s parents died many years ago and so he is very
well adjusted now and accepted the fact that everyone dies eventually.

Psychosocial Development
According to Erik Erikson, a person develops throughout his lifetime. He noted that there
are levels of achievement that a person must achieve or experience. These can be achieved and
be ranked as partial, complete or unsuccessful. The greater the achievement of a person, the more
he is better and healthier in development of hid personality. Failure to achieve the task may
affect the person’s ability to achieve the next task.
According to Erik Erikson the middle adulthood belongs to the generativity versus
stagnation. In this stage work is most crucial. He observed that middle age is when they tend to
be occupied with creative and memorable work and with issues surrounding their family. It is
when they expect to “be in charge”, and the significant task is to perpetuate culture and transmit

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values of the cultures through the family and working to establish a stable environment. Strength
comes through the care of others and production of something that contributes to the betterment
of society, which Erikson calls generativity, and when they are in this stage they often fear
inactivity and meaninglessness.
As their children leave home, their goals change and they may be faced with major life
changes-midlife crisis- and the struggle with finding new meanings and purposes. If they do not
get through this stage successfully, they can become self-absorbed and stagnate.
In the case of my patient, he is on the middle adulthood stage. As of now, he has on the
stage wherein he is still guiding some of his children. He is now concerned more on his
children’s future. He is aware of social responsibility and develops leisure activities and hobbies
appropriate for his age. He previously does his best to become productive and contribute to the
society but due to his current condition he is no longer able to do that. But being the head of the
family continues to be his role only with restrictions on some actions.

Cognitive Development
Cognitive and intellectual abilities of the middle adult change very little from the young
adults. There is motivation to learn, especially if the knowledge gained can be immediately
applied and had personal relevance. Problem solving abilities remain throughout adulthood,
although the time response may be slightly longer. This is not due to a decrease in ability, but
rather due to longer memory research of increased amounts of material.
According to my patient, every problem has a solution. This shows that he is very
positive when it comes to problem solving. My patient is able to find solutions to his problems
and he does not lose hope that he could not overcome any problem he is experiencing. One
example was his admission due to his debilitating illness. He was able to surpass this problem
because of his positive attitude towards problem solving. He had undergone 4 attacks before and
he was still very positive & opens to any modification regarding his health just to live longer.

Moral Development
The middle adulthood remain at the conventional level or may move to post conventional
level, especially if the person had sustained responsibility for the welfare of others and has
consistently applied ethical principles developed in adolescence. At this level, the adult believes
that the rights of others take precedence and takes steps to support those rights.

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My patient belongs to post conventional level or self accepted moral principles. He is
able to distinguish right from wrong. He respected and takes priority the rights of others and also
maintains self respect. He believes that relationships are based on mutual trust. He has his
personal values as to the standards of our society. He views each of then as right and proper
because that is what the society wants. But the decision is still coming from him. He decides on
his own if he should follow the things that the society dictates him or simply follow what is right
for him.

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PHYSICAL ASSESSMENT

I. General appearance & mental status


Mr. Perfecto Balili, a 60 year old male client, was admitted on November 12, 2006 in
Davao Medical Center. Upon assessment the patient was lying on bed in moderate high back rest
and is awake, conscious, coherent & responsive. He has an IVF of D5W 500cc @ 300cc level
running at KVO infusing well @ right cephalic vein, with O2 inhalation @ 5Liters per minute
via nasal cannula, is wearing a hospital gown and has diaper.
The client has a generalize weakness and needs assistance upon moving or position
changes. He has difficulty of breathing and is constantly expectorating whitish phlegm into his
bedside receptacle. He is 5’6” in height and weighs 59 kg.

II. Vital Signs:


BP- 110/80mmHg
CR- 43 bpm; irregular rate and rhythm
RR- 25 cpm; regular rhythm
Temp- 36.5’ C

III. Skin
The color of the skin is brown with rough and dry texture. The patient has poor skin
turgor and clammy to touch. Scars in lower extremities are observed; no wounds or lesions are
noted.

IV. Head
He has a normocephalic configuration with head circumference of 22 cm. His facial
movements are symmetric and he has a thin, evenly distributed, white in color hair. Scalp is dry
but there is no presence of dandruff or lice upon inspection

V. Eyes
Eyes have symmetrical lids and normal periorbital area. Conjunctiva is pale and sclera is
observed to be anicteric. Both left and right pupils are black in color with pupillary size of 3mm,

21
briskly reactive to light. He has a slightly sunken periorbital region, eye bugs present with
eyebrows and eyelashes evenly distributed. Client wears eyeglasses only upon reading.

VI. Ears
Client’s ears are symmetrical and are in line with the outer canthus of the eyes. His
pinnae are normal, normoset and symmetric. No tenderness and lesions noted. Absence of
discharges on the external canal is noted. No hearing problem noted.

VII. Nose
The client’s nasolabial fold is normal, septum is medially located and no discharges are
noted. There are no deformities or inflammation on the nose noted. No nasal flaring is noted and
both nostrils are patent. He has an O2 inhalation via nasal cannula.

VIII. Mouth
The mucosa and gums of the client are pinkish and lips are dry. His tongue is medially
located. Teeth were yellowish in color with loose teeth, he do not use dentures. He has no
difficulty of swallowing and no halitosis and bleeding noted upon observation.

IX. Neck
There are no signs of abnormal growth or enlargement of the nodes of the neck of the
client. There are no lesions noted.

X. Chest and Lungs


The client has rapid, regular breathing at the rate of 25 cpm. Wheezing is noted upon
auscultation with symmetrical chest expansion. He has productive cough with whitish phlegm..

XI. Heart and Breast


The client has symmetrical, rounded shape breast with smooth surface. The areolas are
bilaterally the same and are dark brown in color. There are no masses, lesions or tenderness
noted on these areas. He has a capillary refill time of 4 seconds. His pericardial area is flat and
heart sound is weak and irregular in rate and rhythm with a rate of 43 bpm. He is hooked to a

22
cardiac monitor with Atrial Fibrillation in slow to moderate response with ST elevation pattern.
An IVF of D5W 500cc @ KVO rate infusing well @ right cephalic vein @ 300cc level

XII. Abdomen
The skin in this area has uniform color and no lesions; with flat abdominal contour thus
there is no evidence of an enlarged spleen or lived noted. He has normal bowel sound of one
every 15 seconds.

XIII. Genito-Urinary
The client wears diaper but voids freely. There are no lesions or discharges noted. He can
defecate without difficulty at least once a day.

XIV. Back and Extremities


Client needs assistance upon moving around and in doing activities of daily living. He
can extend and flex both his upper and lower extremities with (-) bipedal edema or anasarca.
Weakness upon movement is noted. He has dirty and untrimmed nails on all extremities.

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ANATOMY and PHYSIOLOGY

The cardiovascular system is sometimes called the


blood-vascular or simply the circulatory system. It consists of
the heart, which is a muscular pumping device, and a closed
system of vessels called arteries, veins, and capillaries. As the
name implies, blood contained in the circulatory system is
pumped by the heart around a closed circle or circuit of vessels
as it passes again and again through the various "circulations"
of the body. It transports food, hormones, metabolic wastes,
and gases (oxygen, carbon dioxide) to and from cells.
Components of the circulatory system include:
• blood: consisting of liquid plasma and cells
• Blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry
blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to
the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange
occurs.)
• heart: a muscular pump to move the blood

The Cardiovascular System


In order to pump blood through the body, the heart is connected to the vascular system of
the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of
the body and remove carbon dioxide and metabolic waste products from the body. The
cardiovascular system is actually made up of two major circulatory systems, acting together. The
right side of the heart pumps blood to the lungs through the pulmonary artery (PA), pulmonary
capillaries, and then returns blood to the left atrium through the pulmonary veins (PV). The left
side of the heart pumps blood to the rest of the body through the aorta, arteries, arterioles,
systemic capillaries, and then returns blood to the right atrium through the venules and great
veins.
There are two circulatory "circuits": Pulmonary circulation, involving the "right heart,"
delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the

24
"right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary
veins carry oxygen-rich blood from the lungs back to the "left heart." Systemic circulation,
driven by the "left heart," carries blood to the rest of the body. Food products enter the system
from the digestive organs into the portal vein. Waste products are removed by the liver and
kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cava.
A specialized component of the circulatory system is the lymphatic system, consisting of
a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone
marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the
veins, and through the lymph nodes and into the lymph, the body is able to eliminate the
products of cellular breakdown and bacterial invasion.

Blood Components
• Forty-five percent (45%) consists of cells - platelets, red blood cells, and white blood
cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood
cells, neutrophils and lymphocytes are the most important.
• Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Major Blood Components


Component Type Source Function
Platelets, cell fragments Bone marrow Blood clotting
life-span: 10
days
Lymphocytes (leukocytes) Bone marrow, Immunity
spleen, lymph T-cells attack cells containing
nodes viruses. B-cells produce
antibodies.
Red blood cells (erythrocytes), Filled with Bone marrow Oxygen transport
hemoglobin, a compound of iron and protein
Neutrophil (leukocyte) Bone marrow Phagocytosis
Plasma, consisting of 90% water and 10% 1. Maintenance of pH level
dissolved materials -- nutrients (proteins, salts, near 7.4
glucose), wastes (urea, creatinine), hormones, 2. Transport of large
enzymes molecules
(e.g. cholesterol)
3. Immunity (globulin)

4. Blood clotting

25
(fibrinogen)
Vascular System - the Blood Vessels
Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run
parallel throughout the body with a web-like network of capillaries connecting them. Arteries use
vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use
one-way valves controlled by muscle contractions.

Arteries
Arteries are strong, elastic vessels adapted for carrying blood away from the heart at
relatively high pumping pressure. Arteries divide into progressively thinner tubes and eventually
become fine branches called arterioles. Blood in arteries is oxygen-rich, with the exception of the
pulmonary artery, which carries blood to the lungs to be oxygenated.
The aorta is the largest artery in the body, the main artery for systemic circulation. The
major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood to the
head, abdomen, and extremities. Of special importance are the right and left coronary arteries
that supply blood to the heart itself.

Capillaries
The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed
in interstitial fluid, or lymph, produced by the lymphatic system. Capillaries are the points of
exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries
by passing through or between the cells that line the capillary. The extensive network of
capillaries is estimated at between 50,000 and 60,000 miles long.

Veins
Blood leaving the capillary beds flows into a series of progressively larger vessels, called
venules, which in turn unite to form veins. Veins are responsible for returning blood to the heart
after the blood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low,
so veins depend on nearby muscular contractions to move blood along. Veins have valves that
prevent back-flow of blood.

26
Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry
oxygenated blood from the lungs back to the heart. The major veins, like their companion
arteries, often take the name of the organ served. The exceptions are the superior vena cava and
the inferior vena cava, which collect body from all parts of the body (except from the lungs) and
channel it back to the heart.

Artery/Vein Tissues
Arteries and veins have the same three tissue layers, but the proportions of these layers
differ. The innermost is the intima; next comes the media; and the outermost is the adventitia.
Arteries have thick media to absorb the pressure waves created by the heart's pumping. The
smooth-muscle media walls expand when pressure surges, then snap back to push the blood
forward when the heart rests. Valves in the arteries prevent back-flow. As blood enters the
capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure.
Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along
veins. As with arteries, valves are again used to ensure flow in the right direction.

Anatomy of the Heart


The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies
left of the chest midline. The heart, along with the pulmonary (to and from the lungs) and
systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated
blood.
Internally, the
heart is designed as a pump with
four chambers - right atrium
(RA), right ventricle (RV),
left atrium (LA), and left ventricle
(LV). The two atria are the
smaller, upper chambers of the
heart and the two ventricles
are the larger, lower chambers
of the heart. The heart is oriented
in the chest rotated about 30

27
degrees to the left lateral side such the right ventricle is the most anterior structure of the heart.
The left ventricle is generally about twice as thick as the right ventricle because it needs to
generate enough force to push blood through the entire body while the right ventricle only needs
to generate enough force to push blood through the lungs. Ventricular contraction forces blood
into the arteries.
The heart also has four valves. The tricuspid valve is between the right atrium and right
ventricles. The pulmonary valve is between the right ventricle and the pulmonary artery. The
mitral valve is between the left atrium and the left ventricle and the aortic valve is between the
left ventricle and the aorta. The valves, under normal conditions, insure that blood only flows in
one direction in the heart.

Cardiac Muscle
Cardiac muscle is a type of involuntary mononucleated, or uninucleated, striated muscle
found exclusively within the heart. Its function is to "pump" blood through the circulatory
system by contracting.

Inside each cardiomyocyte are hundreds of myofibrils which are thin, elongated

structures. Each myofibril, in turn, consists of thin filaments and thick filaments. Each of the thin

filaments is composed of a protein called actin. Each of the thick filaments is composed of a

protein called myosin. Each myosin filament is composed of about 200 myosin molecules. Each

myosin molecule contains what is called a myosin head. Inside each cardiomyocyte there are

compartments filled with calcium. The action potential causes these compartments to release the

calcium into the cell. This calcium allows myosin heads to bind to actin filaments and pull them

by a process called a power stroke. That is how action potential causes the individual muscle

cells to contract.

28
Basic Cardiac Physiology
A basic understanding of cardiac physiology is also essential to interpreting the physical
finding during a cardiac exam. Each pump or beat of the heart consists of two parts or phases -
diastole and systole. During diastole the ventricles are filling and the atria contract. Then during
systole, the ventricles contract while the atria are relaxed and filling.
For the purposes for this discussion of cardiac physiology, we will focus on the
physiology associated with the heart sounds S1, S2, S3, and S4. S1 occurs near the beginning of
(ventricular) systole with the closing of the tricuspid and mitral valves. The closing of these two
valves with increasing pressure in the ventricles as they begin to contract should be
simultaneous. Any splitting in which the closing of the two valves are heard separately should be
considered pathological. S2 occurs near the end of (ventricular) systole with the closing of the
pulmonary and aortic valves. The closing of these two valves occurs with beginning of backward
flow in the pulmonary artery and aorta respectively as the ventricles relax. The two valves can
occur simultaneously or with slight gap between them under normal physiologic circumstances.
S3 occurs at the end of the rapid filling period of the ventricle during the beginning of
(ventricular) diastole. An S3, if heard should occur 120-170 msec after S2. S4 occurs, if heard
coincides with atrial contraction at the end of (ventricular) diastole.

The Circulation
Poorly oxygenated blood collects in two major veins: the superior vena cava and the
inferior vena cava. The superior and inferior vena cava empty into the right atrium. The coronary
sinus which brings blood back from the heart itself also empties into the right atrium. The right
atrium is the larger of the two atria although it receives the same amount of blood. The blood is
then pumped through the tricuspid valve, or
right atrioventricular valve, into the right
ventricle. From the right ventricle, blood is
pumped through the pulmonary semi-lunar
valve into the pulmonary artery. This blood
leaves the heart by the pulmonary arteries
and travels through the lungs (where it is
oxygenated) and into the pulmonary veins.
The oxygenated blood then enters the left

29
atrium. From the left atrium, the blood then travels through the bicuspid valve, also called mitral
or left atrioventricular valve, into the left ventricle. The left ventricle is thicker and more
muscular than the right ventricle because it pumps blood at a higher pressure. Also, the right
ventricle cannot be too powerful or it would cause pulmonary hypertension in the lungs. From
the left ventricle, blood is pumped through the aortic semi-lunar valve into the aorta. Once the
blood goes through systemic circulation, peripheral tissues will extract oxygen from the blood,
which will again be collected inside the vena cava and the process will continue. Peripheral
tissues do not fully deoxygenate the blood, thus venous blood does have oxygen, only in a lower
concentration in comparison to arterial blood.

The Heart's Conduction System


There are four basic components to the heart's conduction system
1. sinoatrial node (SA node)
2. inter-nodal fibre bundles
3. atrioventricular node (AV node)
4. atrioventricular bundle
The sinoatrial (SA) node is a
small mass of specialised cardiac muscle
situated in the superior aspect of the
right atrium. It lies along the
anterolateral margin of this chamber
between the orifice of the superior vena
cava and the auricle. The specialized
cardiac muscle of the SA node is
characterized by the property of
automatic self-excitation and it initiates
each beat of the heart. Therefore, the SA
node is often referred to as the
pacemaker of the heart.
Since the fibers of the SA node fuse with the surrounding atrial muscle fibers, the action
potential generated in the nodal tissue spreads throughout both atria at a rate of approximately
0.3 meter per second and produces atrial contraction. Interspersed among the atrial muscle fibers

30
are several inter nodal fiber bundles which conduct the action potential to the atrioventricular
(AV) node with a greater velocity (approximately 1.0 meter per second) than ordinary atrial
muscle. The AV node is located in the right atrium near the lower part of the interatrial septurn.
Here there is a short delay (approximately 0.1 second) in transmission of the impulse to the
ventricles.
This is important because it permits the atria to complete their contraction and empty
their blood into the ventricles before the ventricles contract. The delay occurs within the fibers of
the AV node itself as well as in special junctional fibers that connect the node with ordinary
atrial fibers.
Once the action potential leaves the AV node, it enters specialized muscle fibers called
Purkinje fibers. These are grouped into a mass termed the atrioventricular (AV) bundle, or the
bundle of His. The Purkinje fibers are very large and conduct the action potential at about six
times the velocity of ordinary cardiac muscle (i.e., 1.5 to 4.0 meters per second). Thus the
Purkinje fibers permit a very rapid and simultaneous distribution of the impulse throughout the
muscular walls of both ventricles.
As the AV bundle leaves the AV node, it descends in the interventricular septurn for a
short distance and then divides into two large branches, the right and left bundle branches. Each
of these descends along its respective side of the interventricular septum immediately beneath
the endocardium and divides into smaller and smaller branches. Terminal Purkinje fibers extend
beneath the endocardium and penetrate approximately one-third of the distance into the
myocardium. Their endings terminate upon ordinary cardiac muscle within the ventricles, and
the impulse proceeds through the ventricular muscle at about 0.3 to 0.5 meters per second. This
results in a contraction of the ventricles that proceeds upward from the apex of the heart toward
its base.
The spontaneous generation of an action potential within the SA node initiates a sequence
of events known as the cardiac cycle. Each cardiac cycle lasts approximately 0.8 second and
spans the interval from the end of one heart contraction to the end of the subsequent heart
contraction. Ordinarily this occurs about 72 times each minute.

Blood Pressure and Heart Rate


The heart beats or contracts around 72 times per minute. The human heart will undergo
over 3 billion contraction/cardiac cycles during a normal lifetime.

31
One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular
contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice
versa. Heart valves open and close to limit flow to a single direction. The sound of the heart
contracting and the valves opening and closing produces a characteristic "lub-dub" sound.

The cardiac cycle has two basic


components:
(1) contraction phase (systole) during which
blood is ejected from the heart
(2) relaxation phase (diastole) during which
the chambers of the heart are filled with
blood.
The spontaneous generation of an action
potential within the SA nodal tissue represents the start of the cardiac cycle. This electrical
impulse spreads throughout the atrial muscle and leads to contraction of the two atria.
As the atria contract, the AV valves remain open and additional blood is forced into the
ventricles from the veins. A large amount of blood has already passed from the atria to the
ventricles prior to atrial contraction.
The aortic and pulmonary (pulmonic) semilunar valves remain closed.
After the ventricles have filled (mostly by blood returning from the large veins) and the
atria have contracted, the AV valves close as the ventricles begin their contraction.
Ventricular contraction forces blood through the semilunar valves into the aorta and
pulmonary trunk.
Next, as the ventricles begin to relax, the aortic and pulmonic semilunar valves close, the
AV valves open, and blood flows into the ventricles to begin another cycle.
While the atria are in systole, the ventricles are relaxed (in diastole). The atria relax
during ventricular systole and remain in this phase even during a portion of ventricular diastole.
Blood (like any other fluid) tends to flow from a region of high pressure to one of lower
pressure.
As each chamber of the heart fills with blood, the pressure increases within it. The blood
moves out of the chamber, when the various one-way valves guarding those chambers permit it
to do so.

32
As the ventricles contract, the blood is forced in a retrograde fashion against the AV
valves, which causes them to bulge inward slightly toward the atria and which also elevates atrial
pressure.
In doing so, the AV valves are effectively closed and blood is prevented from
regurgitating back into the atria. Near the end of ventricular systole the AV valves are still closed
and since the atria are in the process of filling, this too contributes to a rise in intra-atrial
pressure.
Even before the atria enter systole, the ventricles are filled with blood to approximately
70% of their capacity. When the atria do finally contract, additional blood enters the ventricles
and elevates the intraventricular pressure. As the ventricles contract, blood is forced backward,
closing the AV valves, and a sharp rise in ventricular pressure occurs.
Although the ventricles exist as closed chambers for a brief moment, the pressure within
them soon exceeds that in the aorta and pulmonary trunk. When this happens the aortic and
pulmonic semilunar valves are forced open under pressure and blood rushes out of the ventricles
and is driven into these large vessels. Accompanying the opening of the semilunar valves is a
rapid decline in intraventricular pressure that continues until the pressure within the ventricles
becomes less than that of the atria. When this pressure differential is reached, blood within the
atria pushes the AV valves open and begins to fill the ventricles once again.
Receptors in the arteries and atria sense systemic pressure. Nerve messages from these
sensors communicate conditions to the medulla in the brain. Signals from the medulla regulate
blood pressure.

Electrocardiography (ECG, EKG)

An electrocardiogram measures changes in


electrical potential across the heart and detects
contraction pulses that pass over the surface of the heart.
There are three slow, negative changes, known as P, R,
and T. Positive deflections are the Q and S waves. The P
wave represents atrial contraction ("the lub"), the T wave
the ventricular contraction ("the dub").

33
The Lymphatic System
The lymphatic system functions 1) to absorb
excess fluid, thus preventing tissues from swelling; 2)
to defend the body against microorganisms and
harmful foreign particles; and 3) to facilitate the
absorption of fat (in the villi of the small intestine).
Capillaries release excess water and plasma
into intracellular spaces, where they mix with lymph,
or interstitial fluid. "Lymph" is a milky body fluid that
also contains proteins, fats, and a type of white blood
cells, called "lymphocytes," which are the body's first-
line defense in the immune system.
Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in
having valves that prevent backflow. Contraction of skeletal muscle causes movement of the
lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone
marrow, liver, spleen, thymus), or to the cardiovascular system.
• Lymph nodes are small irregularly shaped masses through which lymph vessels flow.
Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the
primary function (along with bone marrow) of producing lymphocytes.
• The spleen filters, or purifies, the blood and lymph flowing through it.
• The thymus secretes a hormone, thymosin, which produces T-cells, a form of
lymphocyte.

34
PATHOPHYSIOLOGY

Predisposing Factors Present (√) / Absent (x) Rationale


Individuals with history of heart diseases
within their family or first degree relatives are
Family History X
more prone in developing one himself. The
presence of coronary atherosclerosis in a parent
or sibling under 50 years old is associated with
the same finding in another family member.
Age √ More common in male aged (45 -70 y.o.)
Men are at a greater risk for the development
of CAD. Women are usually not affected by
Gender √
this disease until after menopause.
Postmenopausal increase has been attributed to
decrease levels of estrogens and rising blood
lipids.
Race X Black Americans have a higher risk than
whites. This is because they have increased
incidence of hypertension (33%)

Precipitating Factors Present (√) / Absent (x) Rationale


Past Present
Inhalation of smoke increases the blood carbon
monoxide level causing hemoglobin, the
oxygen carrying component of blood to
combine more readily with carbon monoxide
than with oxygen resulting to decrease amount
of available oxygen which may decrease the
heart’s ability to pump.
Nicotinic acid in tobacco triggers the release
Cigarette smoking √ X
of catecholamines which raises both heart rate
and blood pressure. It can also cause the
coronary arteries to constrict and increase
catecholamines may be a factor in the
increased incidence of sudden heart death.
It could also cause detrimental vascular
response and increase platelet adhesion
leading to high probability of thrombus
formation.
This refers to the elevation of cholesterol and
triglyceride levels within the blood.
Cholesterol can be obtained directly from
Hyperlipidemia X X animal dietary source or manufactured by the
liver and intestine. Triglycerides are derived
from fatty acids found in adipose tissue or the
diet. Cholesterol and triglycerides are involved

35
in the transportation, digestion and absorption
of fats.
High levels of low-density lipoproteins are
attributed to the development atherosclerosis
that would latter on cause obstruction in the
artery. LDL unlike HDL could not be
metabolized by the body. The HDL cannot
carry the bad cholesterol to the liver for
metabolism. The macrophages will then need
to modify it before HDL could interact with it.
During modification the macrophages cause
injury to the endothelial wall resulting to
fibrous formation and later on to formation of
emboli that would lead to obstruction of blood
flow to the myocardial artery.
Increase stiffness of the vessel walls leading to
vessel injury and a resulting inflammatory
response within the intima. It can also increase
the work of the left ventricle which must pump
harder to eject blood into the arteries. Increase
workload causes the heart to enlarge and
Hypertension √ X thicken (hypertrophy) a condition that may
eventually lead to cardiac failure.
In addition, increased peripheral vascular
resistance associated with hypertension
increases afterload and the demand on the left
ventricle. The result is an increased demand
for myocardial oxygen in the face of a
diminished supply.
It is noted that increase in activity can improve
the efficacy of the heart by the reduction of
heart rate and blood pressure. It also decreases
Sedentary lifestyle X √ the level of low-density lipoproteins, lowered
blood glucose levels, and improved cardiac
output has been associated with lesser chance
of CAD.
Hyperglycemia fosters increase platelet
aggregation and altered RBC function, which
Diabetes Mellitus X X
can lead to thrombus formation. Also, insulin
injures the vessel wall leading to inflammatory
response.
Obesity or excess body weight in relation to
height increases the workload and hence the
Obesity X X
oxygen demands of the heart. Obesity highly
correlates with hypertension, hyperlipidemia,
and diabetes. It is also associated with
increased caloric intake and elevated levels of

36
low-density lipoproteins.

Stress stimulates the cardiovascular system by


the release of cathecolamines, which in turn
Stress √ X
increase the heart rate and produce
vasoconstriction.
Individuals with history of CAD are more
predisposed to reoccurrence or development of
heart diseases. Since there is already previous
History of CAD √ √ formation of atherosclerosis and obstruction
within the myocardial artery the person may
then easily develop the same problem. It is
also noted that these individuals may have had
a portion of their heart than no longer
functions properly due to ischemia or necrosis.

Symptomatology Present (√) / Absent (x) Rationale


Collection of fats, cells and debris result to
development of fatty streaks. Narrowing of
epicardial blood vessel due to atheromatous
plaque would then result to coronary artery
disease. Progressive narrowing of the arterial
Dyspnea √
lumen, body will compensate through
vasodialation. But increase in occlusion will
result to gradual weakening of the
myocardium. Damage to the heart limits the
output of the left ventricle. Poor ventricular
compliance would result to dyspnea.
Development of fatty streaks between the
endothelium and internal elastic lamina.
Narrowing of epicardial blood vessel due to
Bradycardia √ atheromatous plaque would then result to
coronary artery disease. Progressive narrowing
of the arterial lumen would result to gradual
weakening of the myocardium. This would
then result to decrease in the cardiac output.
Formation of fatty streaks within the
endothelium and lamina. Narrowing of
epicardial blood vessel due to atheromatous
plaque would then result to coronary artery
disease. Progressive narrowing of the arterial
Pulmonary Edema X
lumen, body will compensate through
vasodialation. But increase in occlusion will
result to gradual weakening of the
myocardium. Damage to the heart limits the

37
output of the left ventricle. Poor ventricular
compliance would result to Pulmonary edema.
When mural thrombus forms at site of rupture,
initial platelet monolayer forms at the site.
Various agonists (collagen, ADP, epinephrine,
serotonin) promote platelet activation.
Production and release of thromboxane A2
result to further platelet activation, and
potential resistance to thrombolysis. Von
Willebrand factor (vWF) and fibrinogen are
multivalent molecules which bind to two
different platelets simultaneously, resulting in
platelet cross-linking and aggregation.
Chest pain √
Coagulation cascade is activated on exposure
of tissue factor in damaged endothelial cells at
the site of the ruptured plaque.
Conversion of prothrombin to thrombin, which
then converts fibrinogen to fibrin would result
to fluid-phase and clot-bound thrombin
participate in an autoamplification reaction that
leads to further activation of the coagulation
cascade. Coronary artery eventually becomes
occluded by a thrombus containing platelet
aggregates and fibrin strands. Imbalance
between oxygen supply and demand of the
myocardium would then lead to compromised
myocardial blood flow which does not meet the
metabolic demands of myocardial tissue.
Disruption of mid-sized atheromatous plaque
due to injury or rupture would result to an
injured but still living heart muscle which
could still conduct electrical impulses slowly.
Speed can become so slow that the spreading
impulse is preserved long enough for the
S3 heart sound X uninjured muscle to complete its contraction.
Slowed electrical signal still traveling within
the injured area can re-enter and trigger the
healthy muscle to beat again too soon. Rapid
rhythm abnormalities can occur and negatively
influence the function of the heart. This result
to increase rate or volume of ventricular filling
enabling us to hear a third heart sound.
Disruption of mid-sized atheromatous plaque
due to injury or rupture would result to an
injured but still living heart muscle which
could still conduct electrical impulses slowly.
Speed can become so slow that the spreading

38
S4 heart sound √ impulse is preserved long enough for the
uninjured muscle to complete its contraction.
Slowed electrical signal still traveling within
the injured area can re-enter and trigger the
healthy muscle to beat again too soon. Rapid
rhythm abnormalities can occur and diminished
ventricular compliance. This may reduce the
filling of the heart thus the fourth heart sound
becomes audible.
Upon the presence of abnormal heart sounds
the myocardial cells are noted to be active but
Arrhythmia √
produce quivering instead of forceful rhythmic
contractions. This prevents the heart from
pumping blood effectively thus resulting to an
abnormal intraventricular conduction leading
to abnormal heart rate and rhythm.
Obstruction of blood flow to certain parts of
the heart allows the pyruvic acid to produce
Fever X
lactic acid that injures the myocardial tissue. It
then releases cardiac enzymes that trigger the
pyrogens which increases the temperature of
the body.

39
40
DOCTOR’S ORDERS

Date/Time Doctor’s Order Rationale Remark


• Admit under white • Patient is admitted • Done
November service under the white
12,2006 service for close
monitoring

• LSLF is ordered • Done


• Low salt low fat diet for patients with
cardiac conditions to
decrease the salt and
fats that further
aggravates the pt’s
current condition
• Done
• Temperature, pulse, • Monitoring of
respiratory every TPR is done to detect
hour and record any variation or
changes from the
normal range that
would determine an
abnormality in the
patient’s condition • Done
• Venoclysis
D5W 500cc x KVO rate • It is an isotonic
solution that is needed
by our body to help
regulate the body’s
nutrients; it doesn’t
swell or shrink the
cell. Regulated only at
the rate to maintain
vein open for
emergency and IVTT
meds • Done
12:10 pm • Diagnostics:
Complete Blood Count • Complete Blood
Count offers
necessary information
about the kinds and
numbers of cells in
the blood. This
analyzes the 3 major
types of cells in the
body which are the

41
Red Blood Cell,
White Blood Cell and
Platelet • Done
Platelet
• Blood test
evaluates platelet • Done
Random Blood Sugar production

• Detects alterations • Done


Creatinine in glucose metabolism

• For evaluation of • Done


Sodium, Potassium renal function

• Evaluates fluid
and electrolyte
balance as well as • Not
renal or adrenal Done
Chest x-ray disorders

• This identifies
various abnormalities
of the lungs and
structures in the
thorax Also used to
Electrocardiogram identify localize fluid • Done
and air in the pleural
cavity

• Used to screen for


and diagnose a variety
of cardiac conditions
as well as abnormal
heart rhythms,
conduction
Troponin T qualitative
disturbance, • Done
hypertrophy and other
disorders

• Primarily ordered
to determine if heart
• Therapeutics
Isosorbide Mononitrate
attack or other • Done
changes in the heart
(ISMN) 60mg/tab
occurred
½ tab OD

Isosorbide Dinirate (ISDN) • ISMN is the • Done


treatment for anginal

42
5mg/tab attacks
1 tab now

Metoprolol 50mg/tab ½ tab • ISDN is the • Done


BID treatment for anginal
attacks

Captopril 25mg/tab ½ tab • Done


OD • Treat
hypertension,
management of
angina pectoris and
prevention of MI
Atorvastatin 80mg/tab 1 tab • Done
OD • Treat hypertension
and reduce risk of
developing congestive
heart failure following
Lactulose 30cc at HS MI • Done

• Reduction of
• Moderate High Back elevated total and • Done
Rest LDL cholesterol and
triglycerides

• For chronic • Done


• Monitor intake and constipation
output
• Lowers
diaphragm, promoting
chest expansion • Done
• O2 at 4Lpm via nasal • Determine fluid
cannula and electrolyte
balance and
effectiveness of
replacement

• Help restore or • Done


improve breathing
• Hook to cardiac monitor function and prevent
damage to vital
organs resulting from • Done
inadequate oxygen
• Refer accordingly supply

43
12:30 pm • Monitor the
patients BP, CR and • Done
ECG reading
• Retrieve previous
2Decho result c/o • It is necessary to
watcher and attach to chart refer any unusualities
to the physician
prevent further • Done
complications
• Repeat ECG after 6
hours • Have a basis of the • Done
patient’s current
situation base on the
• Additional meds result of the previous
ASA 80mg/tab OD laboratory exam • Done

• For monitoring of
Clopidogrel 25mg/tab OD any changes in the
result

• Treatment of mild
to moderate pain and • Done
prophylaxis of MI

Enoxaparin 6000 IV every • Reduction of


12 hours atherosclerotic events • Done
in patients with
atherosclerosis
Furosemide 40mg 1 tab OD resulted from recent
MI
• Done
• Prevention of deep
vein thrombosis and
Digoxin 0.25 mg/tab OD pulmonary embolism

• Management of
edema secondary to
CHF and treatment of
hypertension

• Used to slow the


ventricular rate in
tachyarrhythmias such
as AF and atrial
flutter
November • To CCU • Place in a special • Done
12, 2006 area for close

44
monitoring
8:30 pm • Start O2 5Lpm per • Done
nasal cannula
• Furosemide 40 mg • Done
IVTT now
• Spironolactone 100 mg • Done
1 tab now • Counteracts
then OD potassium loss
induced by other
diuretics, for edema
• Refer and hypertension • Done

November • Continue meds • Medication needs • Done


13, 2006 to be continued for
continuity of
treatment
(+) chest pain
• Complete bed rest • Minimize the • Done
without bathroom privilege workload of the heart
and promote rest
• Refer • Done
• Give Isordil 5mg SL • Done
• If not relieved by Isordil • Treatment of • Done
may give Tramadol 1 amp moderate to
IVTT moderately severe
pain
10:35 am
• Give Isordil 5g SL now • Done
(+) Chest • Treatment and
tightness • Start Isoket drip D5W • Done
500cc + 1 amp Isoket to run prevention of angina
O2 = 96 pectoris attacks
BP = 140/120 out at 10cc/hr

• Avoid valsalva • Activities that • Done


maneuver require holding of
breath and bearing
down can result in
bradycardia,
temporarily reduced
cardiac output and
rebound tachycardia
with elevated BP.
• Done
• For Pro-time • Screens for lack of
coagulation factors
necessary for blood
clotting. Measures
time required for a
fibrin clot to form

45
• Done
• Activated Partial • Assess bleeding
Thromboplastin Time disorders or the
effectiveness of • Done
• Refer heparin therapy by
evaluating intrinsic
coagulation factors
necessary for blood
clotting
• Done
6:30 pm • Isordil 5mg SL now • Done
7:30 pm • Increase Isoket drip to
8:45 pm 15cc/hr • Done
(+) chest pain • Morphine 2mg IVTT • Management of
now severe pain,
pulmonary edema and
pain associated with
MI
November • Repeat ECG 12 leads • Done
14, 2006 with long lead II
• Review of medicines • Done
100/64 1. Spironolactone 25mg 1
tab OD
2. Digoxin 0.25 mg/tab OD
3. Carvedilol 6.25mg ½ tab • Treatment for
OD essential hypertension
4. Captopril 25mg/tab OD and CHF
5. Atorvastatin 80 mg tab
OD
6. ASA 80 mg 1 tab OD
7. Clopidogrel 75mg/tab
OD
8. Enoxaparin 0.6ml SQ • Done
every 12
• Discontinue meds not in
review of • Done
medicines
• Refer
November • Continue meds • Done
15, 2006 • Refer • Done
10:20 am

98/61
I = 1085
O = 800
(-) chest pain
(+) bowel

46
movement
November • Give Isordil 5mg 1 tab • Done
16, 2006 SL now then PRN for chest
2:50 am pain

(+) chest pain

7:15 am • Continue meds • Done


still with • ISDN 5mg/tab SL PRN • Done
occasional for chest pain
chest pain • Senna concentrate 2 tabs • Treatment for • Done
at HS constipation
• Refer • Done
November • Diagnostics: repeat ECG • Done
17, 2006 12 leads now
9:30 am • Repeat Creatinine, • Done
Sodium, Potassium
• Continue all meds • Done
• Refer accordingly • Done
November • Diagnostics: repeat • Not
18, 2006 serum electrolyte Done
• ISMN 60 mg ½ tab
(+) chest pain OD • Done
125/98 • Continue all other meds
• Done
November • Resume Isoket drip • Done
19, 2006 (D5W 90cc + 1 amp Isoket)
8:30 am to run at 10cc/hr
• Continue other meds • Done
• Refer • Done
November • Continue all meds • Done
20, 2006 • Refer accordingly • Done
7:20 am • Continue Isoket drip • Done

102/68

9:00 am • Start Warfarin 5mg ½ • Prophylaxis and • Done


tab OD treatment of venous
(+) chills • For stat Complete blood thrombosis, • Done
(+) dyspnea count, Platelet count and pulmonary embolism,
130/100 Creatinine AF with embolization
O2 sat 97 and management MI
Hgt 72
130/90
• Referred due to dyspnea • Done
• Diagnostics:
• Determine blood

47
Hemogluco test now glucose level • Done

Electrocardigram now • Determine the • Done


Arterial Blood Gas now acid-base balance • Done
and/or the respiratory
Creatinine, Sodium, or metabolic status • Done
Potassium
• A hypertonic • Done
• Give D5W 50cc 1 vial solution used for the
slow IVTT now treatment of
• Refer once with result hypoglycemic shock • Done
November • Review of medicines • Done
21, 2006 Spironolactone 20 mg 1 tab
7:22 am OD
(-) chest pain Digoxin 0.25 mg ½ tab OD
Captopril 25 mg 1 tab OD
Atorvastatin 40 mg 1 tab
OD
ASA 80 mg 1 tab OD
Clopidogrel 75 mg/tab OD
Senna concentrate 2 tabs
OD
ISMN 60mg ½ tab OD
Warfarin 5mg ½ tab OD
Enoxaparin 0.6 ml SQ every
12 hours
• Refer • Done
November 22, • Diagnostics: • Done
2006 Repeat Protime
• Continue all meds • Done
• Refer • Done

• Ceftazidime 1gram • Third generation • Done


IVTT q8 ANST (-) cephalosporins used
as treatment for
infection
• Clindamycin 300mg • Anti-infective for • Done
1cap q6 PO infection
November 23, • For repeat chest x-ray • Done
2006 today • Done
7:05am • Continue antibiotics • For mild to • Done
• Paracetamol 500mg 1tab moderate pain and
q4 fever
• Refer

48
CXR was read
• Bibasal pneumonia
• Left sided cardiomegaly
• Underlying minimal
pleural effusion
• Pericardial effusion not
entirely ruled out
• Not congested
Dr. Daguman
November 24, • Omeprazole 40mg IVTT • Management for • Done
2006 every 12 hours GERD and duodenal
8:00am • please retrieve chest x- ulcer • Done
ray place on bedside
(+) epigastric • hold aspirin, warfarin, • Done
pain enoxaparine temporarily
(+) increase • Refer • Done
salivation
(-) chest pain

8:15 am • for STAT 12 lead ECG • Done


• Omeprazole 80mg IVTT • Done
now then 40mg IVTT q12
• Rebamipide 100mg 1 • Treatment of • Done
tab 3x a day gastric mucosal
lesions, acute gastritis
and gastric ulcer
10:30am
• Continue Omeprazole • Done
and Rebamipide
• retrieve chest x-ray • Done
ASAP • Done
• Refer
1:00pm • Short-term
treatment for • Done
• Ranitidine 1 ampule duodenal and gastric
IVTT OD ulcer and GERD

• Prevention and
treatment of • Done
• Vitamin K 1 ampule hypothrombinemia
IVTT OD associated with • Done
• Refer excessive doses of
anticoagulants
4:15 pm • Treatment and
prevention of nausea • Done
• Metoclopramide 1 and vomiting

49
ampule IVTT now
November 25, • Hold clindamycin • Done
2006 • House Omeprazole IV to • Done
Pantoprazole 40mg 1 tab • Treatment of mild
OD reflux
• Rebamipide 100mg 1 • Done
tab TID
• Repeat CBC, platelet • Done
count • Done
• Continue meds • Done
• Refer
November 26, • Diagnostics: • Done
2006 Follow up repeat CBC,
5:45 am platelet
Repeat protime, Sodium, • Done,
Potassium protime
Not Done
• Continue meds • Done
November 27, • Continue all meds • Done
2006 • Consume and • Done
10:15am discontinue ceftazidime, • Treatment of mild,
start levofloxacin moderate or severe
500mg/cap OD infection • Not
• Still for repeat protime Done
• Refer • Done
November 28, • Resume Coumadin • Done
2006 (Warfarin) 2.5mg ½ tab OD
9:35 am • Resume Aspirin 80mg 1 • Done
tab OD
• Continue Pantoprazole • Done
PO • Done
• Repeat chest x-ray today
November 29, • Please retrieve chest x- • Not
2006 ray due 11/28/06 Done
10:30am • Continue meds
• refer • Done
• Done

50
DIAGNOSTIC EXAMINATIONS

Date Diagnostic Procedure Rationale Normal values Result Impression


November Arterial Blood Blood gases are pH pH
12, Gas(ABG)- Arterial used to determine 7.35-7.45 mmHg 7.568mmHg Increased pH
2006 blood gas analysis is the acid-base
a test in which blood balance and/or the pCO2 pCO2
is taken from an respiratory or 35-45 mmmHg 16mmHg Decreased pCO2;
artery in your wrist metabolic status of
to evaluate how the client. pO2 pO2
effective your lungs 80-100mmHg 137.3mmHg Increased pO2
in bringing oxygen to The pH is the
the blood and measurement of HCO3 HCO3
removing carbon the free hydrogen 22.0-27.0 mmol/L 14.2mmol/L Decreased HCO3
dioxide from it ion concentration
in the blood.
BE(ecf) BE(ecf)
pCO2 represents (-2)-(+2) mmol/L -7.8 Decreased base excess;
the partial pressure indicates non respi/meta
carbon dioxide disturbance or true base
exerts in the deficit
arterial blood.
O2sat O2sat Normal
pO2 represents the 80-100% 99.1%
partial pressure of
oxygen in the
blood, identifies
how well the lungs
are oxygenating
the blood. Partially Compensated
Respiratory Alkalosis
HCO3 is an
alkaline substance

51
that functions as an
important buffer in
November the blood stream. pH pH Normal
21, 7.35-7.45 mmHg 7.439 mmHg
2006 O2 sat is the
amount of oxygen pCO2 pCO2 Decreased pCO2
actually bound to 35-45 mmmHg 22.9 mmmHg
the hemoglobin
and available for pO2 pO2 Increased pO2
transport 80-100mmHg 124.2 mmHg
throughout the
body. HCO3 HCO3 Decreased HCO3
22.0-27.0 mmol/L 15.2 mmol/L

BE(ecf) BE(ecf) Decreased base excess


(-2)-(+2) mmol/L -9.0 mmol/L

O2sat O2sat Normal


80-100% 98.6%

Fully Compensated
Respiratory Alkalosis

52
Date Diagnostic Procedure Rationale Normal values Result Impression
November Blood Chemistry Analysis of the Glucose RBS
12, 2006 physical, chemical, 3.90-6.10 6.52 Increased; may indicate
and DM or stress
microbiological Creatinine
properties of 53.0-115.0 mmol/L 146.53 Increased; may indicate
blood, carried out impaired renal function,
to diagnose essential hypertension,
disease, monitor acute MI, severe CHF or
treatment, or detect urinary obstruction
the presence of Sodium
specific substance. 136.0-145.0 mmol/L 140 Normal

RBS is used as a Potassium


random screen for 3.5-5.5 mmol/L 5.1 Normal
glucose level.
Chloride
Creatinine is 098.0-106.0 mmol/L 107.0 Increased; may indicate
essential in the dehydration, cardiac
evaluation of renal decompensation, or
function. metabolic acidosis

Sodium and
November Potassium
17, 2006 evaluates fluid and Creatinine
electrolyte balance 53.0-115.0 mmol/L 123.61 Increased
as well as renal or
adrenal disorders Sodium
136.0-145.0 mmol/L 144 Normal
Chloride helps
diagnose disorders Potassium
of acid-base and 3.5-5.5 mmol/L 4.0 Normal
water balance.

53
Responsible for
November maintaining water Creatinine
21, 2006 balance and 53.0-115.0 mmol/L 127.80 Increased
cellular integrity
through its Sodium
influence on 136.0-145.0 mmol/L 140 Normal
osmotic pressure.
Potassium
3.5-5.5 mmol/L 4.4 Normal

November Sodium
26, 2006 136.0-145.0 mmol/L 141 Normal

Potassium
3.5-5.5 mmol/L 4.0 Normal

54
Date Diagnostic Procedure Rationale Normal values Result Impression
November Blood Hematology Hgb
12, 135-175g/L 157 Normal
2006 Hemoglobin Evaluates blood
loss, erythropoietic Hct
ability, anemia and 0.40-0.52 0.47 Normal
response to
therapy. It is an RBC
important 4.20-6.10x10’6/uL 5.08 Normal
component of red
blood cell that WBC
carries oxygen and 5.0-10.0x10’3/uL 5.40 Normal
carbon dioxide to
and from the Neutrophil
tissues. 55-75% 67 Normal

Hematocrit Evaluates blood Lympocytes


loss, anemia, blood 20-35 21 Normal
replacement
therapy and fluid Monocytes
balance and 2-10 10 Normal
screens red blood
cell status. It is the Eosinophil
measure of red 1-5 2 Normal
blood cells within
the volume and Basophil
also evaluates 0-1 0 Normal
dehydration and
hypervolemia. Platelet
150-400x10’3/uL 132 Decreased; may be due to
medication, blood clotting
Erythrocyte Evaluates anemia, factor is decreased and so
polycythemia and at high risk for

55
calculates red spontaneous bleeding
blood cell indices.
Oxygen transport
to the cells
throughout the
November body depends upon Hgb
21, sufficient numbers 135-175g/L 161 Normal
2006 of red blood cells
with adequate Hct
amount of 0.40-0.52 0.49 Normal
hemoglobin.
RBC
Leukocytes Evaluates a 4.20-6.10x10’6/uL 5.14 Normal
number of
conditions and WBC
differentiates 5.0-10.0x10’3/uL 11.26 Increased; may indicate
causes of infection, inflammation,
alterations in the tissue necrosis or stress
total WBC count Neutrophil
including 55-75% 91 Increased; may indicate
inflammation, bacterial infection, tissue
infection, tissue necrosis or MI
necrosis and/or Lympocytes
leukemic 20-35 6 Decreased; may indicate
neoplasm. defective lymphatic
circulation, renal failure
Neutrophils Increase neutrophil or advanced tuberculosis
count may indicate Monocytes
parasitic or 2-10 2 Normal
bacterial infection,
metabolic disorder Eosinophil
including diabetic 1-5 1 Normal
acidosis. Decrease

56
in level may Basophil
indicate infection 0-1 0 Normal
and anemia.
Platelet
Lymphocyte Evaluate bacterial 150-400x10’3/uL 133 Decreased; may be due to
and viral infection, medication, blood clotting
immune disease, factor is decreased and so
leukemia and at high risk for
ulcerative colitis. spontaneous bleeding
Elevated levels
may indicate active
November viral infection and
25, depressed level Hgb
2006 may indicate 135-175g/L 165 Normal
exhausted immune
system. Hct
0.40-0.52 0.46 Normal
Monocyte Evaluates function
of phagocytic RBC
scavenger to 4.20-6.10x10’6/uL 5.31 Normal
remove foreigh
materials. WBC
5.0-10.0x10’3/uL 4.83 Decreased; may indicate
Eosinophils Primary influenced bone marrow failure,
by antigen-body overwhelming infection,
responses. dietary deficiency or drug
toxicity
Basophils Basophil function Neutrophil
not understood as 55-75% 74 Normal
well as other white
cell types; it is Lympocytes
believed to be 20-35 14 Decreased; may indicate
related to allergic defective lymphatic

57
and anaphylactic circulation, renal failure
responses. or advanced tuberculosis
Monocytes
Platelet Evaluates platelet 2-10 12 Increased; may indicate
production. It notes infection such as
the platelet size tuberculosis and subacute
and shape. Low bacterial endocarditis
levels predispose Eosinophil
bleeding while 1-5 0 Decreased; may indicate
high levels may stress response associated
increase the risk of with trauma, shock or
thrombocytosis. CHF
Basophil
0-1 0 Normal

Platelet Decreased; may be due to


150-400x10’3/uL 141 medication, blood clotting
factor is decreased and so
at high risk for
spontaneous bleeding

58
Date Diagnostic Rationale Normal Values Result Impression
Procedure
November Urinalysis- is the Screens for Color- Pale-star Color- yellow Normal
12, 2006 testing of the abnormalities colored to amber color
physical within the urinary
characteristics and system as well as Appearance- clear to Appearance- Hazy or cloudy urine may
compositions of for systemic slightly hazy slightly cloudy indicate the presence of
freshly voided urine problems that may RBC, WBC, bacteria, pus,
manifest symptoms phosphate, uric acid or
through the urinary spermatozoa
tract.
Reaction- 4.8-7.8 Reaction- 6.0 Normal

Specific gravity- 1.003- Specific gravity- Normal


1.035 1.025

Albumin- Negative Albumin- (+++) Positive albumin may


indicate nephritic
syndrome, UTI, fever,
trauma, CHF, acute
infection, or kidney
disease

Sugar- Negative Sugar-(-) Normal

Normal RBC- 0- 2 hpf Result RBC - 25- Increased; may indicate


30hpf renal problem

Normal Pus cells- 0-2 Result pus cells 3- Increased; may indicate
hpf 4hpf presence of infection or
tuberculosis

59
Date: May 15, 2006

Diagnostic procedure:
Echocardiogram (2D Echo report) test evaluates the size, shape & motion of various
structures within the heart, it is a noninvasive test.

Rationale:
This ultrasonic test diagnoses abnormalities in anatomy and valvular function within the
heart. Sound waves are bounced off the heart using a transducer to image the heart in motion as
well as its valves and vessels.

Normal findings:
Normal anatomical structure and position, normal and patent arteries and/or veins of the
heart, normal valve structure, normal valve structure, normal blood flow within the heart, normal
ventricular function, absence of thrombi or bacterial vegetations, absence of pericardial effusions

Result: Echo-Doppler findings


• Eccentric left ventricular hypertrophy with multisegmental wall
motion abnormal with depressed systolic function
• Left ventricular ejection fraction of 23%
• Dilated left atrium
• Normal right atrium, main pulmonary artery & aortic root
dimension
• Aortic sclerosis with aortic regurgitation of 2+
• Mitral sclerosis with mild mitral regurgitation
• Mild tricuspid regurgitation
• Structurally normal tricuspid valve & pulmonic valve
• No intra-cardiac thrombus or pericardial effusion noted
• Normal pulmonary artery pressure by tricuspid regurgitation jet

60
Date: November 23, 2006

Diagnostic procedure:
Chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray
makes images of the lungs, airway, blood vessels and the bones of the spine and chest

Rationale:
Identify various abnormalities of the lungs and structures in the thorax, including the
heart, great vessels, ribs or diaphragm. It may also be used as a general screening tool or for a
specific diagnostic purpose, including identification of pulmonary diseases or orthopedic
abnormalities. It is also used to evaluate the status of respiratory abnormalities or cardiac
conditions.

Normal Findings:
Normal chest and surrounding structures, including bony thorax, soft tissues,
mediastinum, lungs, pleura, heart, and great vessels

Result:
Study done in AP supine view. Haziness is noted in both lower lung fields. A thin band
of opacity is noted in the right apex. The rest of the lungs are clear. Tracheal air column is at
midline. The heart is enlarged with inferolateral displacement of the cardiac apex, fullness of the
retro cardiac space and splaying of the carina. Both costophrenic sulci are blunted. The
hemidiaphragms are obscured. The rest of the included structures are unremarkable.

Impression:
• Left sided cardiomegaly. Please correlate with ECG findings
• Bibasal pneumonia with underlying minimal pleural effusion
• Apico-pleural thickening, right

61
Diagnostic procedure:
Electrocardiogram (ECG) most common test of heart’s condition and is used to
graphically record the electrical current generated by the beating heart

Rationale:
This electrophysiologic test is used primarily to screen for and diagnose a variety of
cardiac conditions as well as to monitor the heart’s response to therapy. It is used to diagnose
abnormal heart rhythms, conduction disturbances, hypertrophy of cardiac chambers, myocardial
infarction and ischemia and pericarditis.

Normal findings:
Normal sinus rhythm, normal conduction patterns, absence of areas of infarct or ischemia

First result: Second result:


AF in MVR Course AF in slow VR
Old inferior wall infarct Infarction anterolateral wall
Incomplete RBBB, LAD, PVW R wave program
Anterolateral wall infarct Incomplete RBBB

62
Date: November 12, 2006

Immunology:
Troponin – T qualitative is reliable markers of myocardial injury and is found in human
serum within 4-6 hours following MI

Rationale:
Primarily ordered for people who have chest pain to see if they have had a heart attack or
other damage to the heart. It is done 2-3 times in 12-16 hours period.

Result: POSITIVE

Implication:
• It indicates pulmonary embolism because of right ventricular dilatation and myocardial
injury

63
Hematology:
PROTIME and APTT

Rationale (ProTime):
Screens for lack of coagulation factors necessary for blood clotting. Prothrombin time
measures the time required for a fibrin clot to form in a citrated plasma sample after addition of
calcium ions and tissue thromboplastin and compares this with fibrin clotting time in a control
sample plasma.
Rationale (APTT):
Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic
coagulation factors necessary for blood clotting. The basis of the test is fibrin clot formation and
it evaluates all the clotting factors of the intrinsic pathway except factors VII and VIII.

Normal Findings (ProTime): 11-14 seconds


Normal Findings (APTT): 27-34 seconds

November 16, 2006 November 16, 2006 November 22, 2006


Result: 19.5 seconds Result: 40 seconds Result: 16.3 seconds

Increased protime may Increased Activated Partial Increased protime may indicate
indicate deficiency of Thromboplastin Time deficiency of clotting factors or
clotting factors or circulating (APTT), may indicate circulating anticoagulant
anticoagulant products vitamin k deficiency or products
presence of circulating
anticoagulants

64
DRUG STUDY

Generic Name: Isosorbide Mononitrate


Brand Name: Monoket
Classification: Anti-angina
Frequency/Route/Dose: 60 mg/tab ½ tab OD
Action: Produces vasodilation; decreases left ventricular end-diastolic pressure and left
ventricular end-diastolic volume. Net effect is reduced myocardial oxygen consumption;
increase coronary blood flow by dilating coronary arteries and improving collateral flow
of ischemic regions.
Indication: Acute treatment of anginal attacks; long term prophylactic management of angina
pectoris
Contraindication: Hypersensitivity to nitrates, severe anemia, head trauma, cerebral hemorrhage
Adverse Effects:
CNS: headache, apprehension, weakness, dizziness
CV: tachycardia, hypotension, syncope, paradoxical bradycardia
GI: nausea, vomiting, abdominal pain
Misc: Flushing, tolerance, pruritus, rash
Drug Interaction: Additive hypotension with anti-hypertesiv, acute ingestion of alcohol, beta-
adrenergic blocking agents, calcium channel blockers and phenothiazines.
Nursing Responsibilities:
• Assess location, duration, intensity, and precipitating factors of anginal pain
• Monitor BP and pulse routinely
• Taken on an empty stomach with a full glass of water
• Instruct to take medication as directed
• Caution to make position changes slowly to minimize orthostatic hypotension
• Advise to avoid activities that requires alertness
• Advise to notify physician or other health care provider if dry mouth or blurred vision
occurs

65
Generic Name: Isosorbide Dinitrate
Brand Name: Isordil
Classification: Anti-angina
Frequency/Route/Dose: 5 mg/tab 1 tab now
Action: Produces vasodilation; decreases left ventricular end-diastolic pressure and left
ventricular end-diastolic volume. Net effect is reduced myocardial oxygen consumption;
increase coronary blood flow by dilating coronary arteries and improving collateral flow
of ischemic regions.
Indication: Acute treatment of anginal attacks; long term prophylactic management of angina
Pectoris; treatment of chronic congestive heart failure
Contraindication: Hypersensitivity to nitrates, severe anemia, head trauma, cerebral hemorrhage
Adverse Effects:
CNS: headache, apprehension, weakness, dizziness
CV: tachycardia, hypotension, syncope, paradoxical bradycardia
GI: nausea, vomiting, abdominal pain
Misc: Flushing, tolerance, pruritus, rash
Drug Interaction: Additive hypotension with anti-hypertesiv, acute ingestion of alcohol, beta-
adrenergic blocking agents, calcium channel blockers and phenothiazines.
Nursing Responsibilities:
• Assess location, duration, intensity, and precipitating factors of anginal pain
• Monitor BP and pulse routinely
• Taken 1 hour before or 2 hours after with full glass of water for better absorption
• Instruct to take medication as directed
• Caution to make position changes slowly to minimize orthostatic hypotension
• Advise to avoid activities that requires alertness
• Advise to notify physician or other health care provider if dry mouth or blurred vision
occurs

66
Generic Name: Metoprolol
Brand Name: Lopressor
Classification: Beta-Adrenergic blocking agents (Anti-hypertensive)
Frequency/Route/Dose: 50 mg/tab ½ tab BID
Action: Block stimulation of beta1 adrenergic receptors, do not usually affect beta2 receptor sites
Indication: Management of hypertension, angina pectoris; prevention of myocardial infarction
Contraindication: Uncompensated congestive heart failure, pulmonary edema, cardiogenic
shock, bradycardia or heart block, known alcohol intolerance
Adverse Effects:
CNS: fatigue, weakness, dizziness, depression, insomia, memory loss, mental status
changes, anxiety, nervousness, drowsiness
CV: bradycardia, hypotension, congestive heart failure, pulmonary edema, peripheral
vasoconstriction
Resp: bronchospasm, wheezing
EENT: blurred vision, stuffy nose
GI: constipation, nausea, diarrhea, vomiting, liver function abnormalities
GU: impotence, decreased libidourinary frequency, urinary retention
Derma: rashes
Endo: hyperglycemia, hypoglycemia
MS: joint pain, back pain
Drug Interaction: Barbiturates, rifampicin: increase metabolism of metorpolol effect Cardiac
glycosides, diltiazem, verapamil: cause excessive bradycardia and increase depressant
effect on myocardium. Catecholamine-depleting drugs such as H2 antagonist, MAO
inhibitors, reserpine: have additive effect when given with beta-blockers.
Chlorpromazine, cimetidine, verapamil: decrease hepatic clearance. Indomethacin:
decrease anti-hypertensive effect
Nursing Responsibilities:
• Always check apical pulse rate before giving drug

67
• Monitor BP, ECG and pulse frequently
• Monitor Intake and Output ratios and daily weight
• Assess frequency and characteristics of anginal attacks periodically throughout therapy
• Instruct patient to take drug exactly as prescribed and to take it with meals.
• Advise to avoid activities that require alertness
• Advise to make position changes slowly to prevent orthostatic hypotension

68
Generic Name: Captopril
Brand Name: Capoten
Classification: ACE Inhibitors (Anti-hypertensive)
Frequency/Route/Dose: 25 mg/tab ½ tab OD
Action: Prevents production of angiotensin II, a potent vasoconstrictor that stimulates the
production of aldosterone by blocking its conversion to the active form-result is systemic
vasodilation
Indication: Management of hypertension, management of congestive heart failure, reduction of
risk of death or development of congestive heart failure following myocardial infarction
Contraindication: Hypersensitivity to ACE inhibitors, hypotension, oliguria, renal impairment,
hepatic impairment, elderly patients
Adverse Effects:
CNS: dizziness, headache, fatigue, insomia, weakness
CV: hypotension, tachycardia, angina pectoris
Resp: cough
GI: anorexia, loss of taste perception, nausea, diarrhea
GU: proteinuria, renal failure, impotence
Derma: rashes
Hemat: neutropenia, agranulocytosis
Misc: angioedema, fever
Drug Interaction: Excessive hypotension may occur with concurrent use of diuretics. Additive
hypotension with other anti-hypertensive, nitrates, phenothiazines, and acute ingestion of
alcohol. Anti-hypertensive response may be blunted by NSAIDs. Absorption may
decrease with antacids, increases levels and may increase risk of lithium or digoxin
toxicity.
Nursing Responsibilities:
• Monitor BP and pulse frequently
• Administer 1 hour before or 2 hours after meals for better absorption

69
• Instruct patient to take drug exactly as prescribed
• Instruct to notify physician or other health care provider is mouth sores, sore throat,
fever, swelling of hands and feet, irregular heart beat, chest pain, difficulty swallowing or
skin rash occurs
• Advise to avoid foods containing high levels of potassium or sodium unless directed
• Advise to avoid activities that require alertness
• Advise to make position changes slowly to prevent orthostatic hypotension

70
Generic Name: Lactulose
Brand Name: Lactulose PSE
Classification: Laxative (hyperosmotic)
Frequency/Route/Dose: 30 cc at HS
Action: Increases water content and softens stool; lowers the pH of the colon, which inhibits the
diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia
levels
Indication: Treatment of chronic constipation
Contraindication: Patients with low-galactose diets, diabetes mellitus, excessive or prolonged use
Adverse Effects:
GI: cramps, distention, flatulence, belching, diarrhea
Endo: hyperglycemia
Drug Interaction: Should not be used with other laxatives. Anti-infectives may diminish
effectiveness and antacids may decrease the effect of lactulose on colonic pH
Nursing Responsibilities:
• Assess for abdominal distention, presence of bowel sounds, and normal pattern of bowel
function
• Assess color, consistency, and amount of stool produced
• Instruct patient to take drug exactly as prescribed
• Mix with fruit juice, water, milk or carbonated citrus beverages to improve flavor; may
be administered on an empty stomach for more rapid results
• Encourage to use other forms of bowel regulation, such as increasing bulk in the diet,
increasing fluid intake, increasing mobility
• Caution patient that medication may cause belching, flatulence, or abdominal cramping

71
Generic Name: Aspirin
Brand Name: ASA
Classification: Salicylates, NSAID, Antiplatelet, Antipyretic
Frequency/Route/Dose: 80 mg/tab 1 tab OD
Action: Produce analgesia and reduce inflammation and fever by inhibiting the production of
prostaglandins, decreases platelet aggregation
Indication: Management of inflammatory disorders including: rheumatoid arthritis; treatment of
mild to moderate pain; treatment of fever; prophylaxis of transient ischemic attacks and
myocardial infarction
Contraindication: Hypersensitivity to aspirin, salicylates, NSAIDs; bleeding disorders; history of
GI bleeding; severe renal disease; severe hepatic disease
Adverse Effects:
EENT: tinnitus, hearing loss
GI: dyspepsia, heartburn, epigastric distress, nausea, vomiting, anorexia, abdominal pain,
GI bleeding, hepatotoxicity
Hemat: anemia, hemolysis, increased bleeding time
Misc: noncardiogenic pulmonary edema, allergic reactions
Drug Interaction: May potentiate warfarin, heparin or thrombolytic agents. May increase the
bleeding with valproic acid, cefoperazone, cefamandole. May enhance the activity of
penicillins, phenytoin, valproic acid, oral hypoglycemic agents and sulfonamides. May
antagonize the beneficial effects of probenecid
Nursing Responsibilities:
• Assess pain and limitation of movement
• Assess fever and note associated signs
• Advise patient to take drug with food, milk, antacid, or large glass of water to reduce
adverse GI reactions.
• Tell patient that sustained-release or enteric-coated forms shouldn’t be crushed or chewed
but swallowed.
• Advise to report signs of tinnitus, bleeding of gums, bruising, fever, black tarry stools

72
• Teach patient on sodium restricted diet to avoid buffered-aspirin preparations
• Advise patient to take only prescribed dosage
Generic Name: Clopidogrel
Brand Name: Plavix
Classification: Anticoagulant, Antithrombotics
Frequency/Route/Dose: 25 mg/tab OD
Action: Obtained by depolymerization of unfractioned porcine heparin. An antithombolytic drug.
They enhance the inhibition of factor Xa and thrombin by binding to and accelerating
anti-thrombin II activity
Indication: Reduction of atherosclerotic events in patients wit hatherosclerosis documented by
recent ischemic stroke or Myocardial infarction
Contraindication: Severe liver impairment, peptic ulcer and intracranial hemorrhage
Adverse Effects:
GI: bleeding, abdominal pain, dyspepsia, gastritis, constipation
EENT: ocular hemorrhage
Derm: purpura, bruising, rash pruritus
Drug Interaction: Warfarin, aspirin, heparin, thrombolytic or NSAIDS, increase risk of bleeding
Nursing Responsibilities:
• Tell patient to refrain from activities in which trauma and bleeding may occur
• Advise patient that drug may be taken without regards to meals
• Instruct patient to inform physician or other health care provider if unusual bleeding or
bruising occur

73
Generic Name: Enoxaparin
Brand Name: Lovenox
Classification: Heparin, anticoagulant (antithrombotic)
Frequency/Route/Dose: 6000 IU q 12
Action: Potentiate the inhibitory effect of antithrombin on factor Xa and thrombin. In low doses
it prevents conversion of prothrombin to thrombin by its effects on factor Xa. In high
doses it neutralize thrombin, preventing the conversion of fibrinogen to fibrin.
Indication: Prevention of deep vein thrombosis and pulmonary embolism, atrial fibrillation with
embolization
Contraindication: Hypersensitivity to the drug, open wounds, severe liver or kidney disease,
untreated hypertension, spinal cord or brain injury, history of bleeding disorders
Adverse Effects:
CV: edema
GI: hepatitis
Derm: rashes
Hemat: bleeding, anemia
Local: irritation, pain, hematoma
Misc: fever
Drug Interaction: Risk of bleeding may be increased by concurrent use of drugs that affect
platelet function, including aspirin, NSAIDs, some penicillins, valproic acid,
cefmetazole, quinidine, dextran and thrombolytic agents
Nursing Responsibilities:
• Assess for signs of bleeding and hemorrhage
• Assess for evidence of additional or increased thrombosis.
• Monitor patient for hypersensitivity reactions
• Advise to report any symptoms of unusual bleeding or bruising
• Instruct not to take medications containing aspirin, ibuprofen, naproxen or ketoprofen

74
Generic Name: Furosemide
Brand Name: Lasix
Classification: Loop diuretics
Frequency/Route/Dose: 40 mg 1 tab OD
Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal
tubule. Increases renal excretion of water, sodium, chloride, magnesium, hydrogen and
calcium.
Indication: Management of edema secondary to congestive heart failure, hepatic or renal disease,
treatment of hypertension
Contraindication: Hypersensitivity to the drug, hepatic coma, severe liver disease, electrolyte
depletion, geriatric patients, diabetes mellitus
Adverse Effects:
CNS: dizziness, headache, nervousness, insomia
CV: hypotension
GI: nausea, vomiting, diarrhea, constipation, dry mouth, dyspepsia
EENT: hearing loss, tinnitus
Derm: rashes, photosensitivity
F and E: hyperglycemia
Hemat: blood dyscrasias
MS: muscle cramps
Misc: increased BUN
Drug Interaction: Additive hypotension with antihypertensives or nitrates. Decreases lithium
excretion, may cause toxicity. May increase the effectiveness of warfarin, thrombolytics
and anticoagulants
Nursing Responsibilities:
• Assess fluid status throughout therapy
• Monitor BP and pulse before and during administration
• Assess patient for tinnitus and hearing loss
• Administer medication in the morning to prevent disruption of sleep cycle

75
• Administer orally with food or milk to minimize gastric irritation
• Caution to make position changes slowly to prevent orthostatic hypotension
Generic Name: Digoxin
Brand Name: Lanoxin
Classification: Antiarrhythmics, digitalis glycosides
Frequency/Route/Dose: 0.25 mg/tab OD
Action: Inhibits sodium potassium-activated adenosine triphosphate, thereby promoting
movement of calcium from extracellular to intracellular cytoplasm and strengthening
myocardial contraction.
Indication: Heart failure, paroxysmal supra-ventricular tachycardia, atrial fibrillation and flutter
Contraindication: Hypersensitive to drug and in those with digitalis-induced toxicity, ventricular
fibrillation, or ventricular tachycardia unless caused by heart failure.
Adverse Effects:
CNS: fatigue, weakness, headache, blured vision, yellow vision
CV: arrhythmias, bradycardia, ECG changes
GI: nausea, vomiting, diarrhea, anorexia
Endo: gynecomastia
Hemat: thrombocytopenia
Drug Interaction: Antacids, decreased absorption of oral digoxin. Antibiotics: increased risk for
toxicity because of altered intestinal flora. Anticho-linergics: may increase digoxin
absorption of oral digoxin tablets
Nursing Responsibilities:
• Monitor apical pulse and BP periodically
• Monitor ECG throughout therapy
• Monitor intake and output and daily weights
• Monitor potassium levels. Take corrective measures before hypokalemia occurs
• Can be administered without regard to meals
• Tell patient to report pulse below 60 bpm or above 110 bpm, or skipped beats or other
rhythm changes
• Instruct to take medication as directed

76
Generic Name: Spironolactone
Brand Name: Aldactone
Classification: Potassium-sparing diuretics
Frequency/Route/Dose: 100 mg 1 tab now then OD
Action: Causes excretion of sodium bicarbonate and calcium while conserving potassium and
hydrogen ions
Indication: Counteracts potassium loss induced by other diuretics, treat edema or hypertension
Contraindication: Hypersensitivity to drug, hyperkalemia, hepatic dysfunction, renal
insufficiency, history of gout or kidney stone
Adverse Effects:
CNS: headache, clumsiness, dizziness
CV: arrhythmias
GI: gastrointestinal irritation
GU: impotence
Endo: gynecomastia
F and E: hyperkalemia, hyponatremia
Hemat: dyscrasias
MS: muscle cramps
Misc: allergic reactions
Drug Interaction: ACE inhibitors: increased risk of hyperkalemia; Aspirin: possible blocked
diuretic effect
Nursing Responsibilities:
• Monitor intake and output
• Monitor signs and symptoms of hypokalemia
• Give the drug with meals, to enhance absorption
• Administer in the morning to avoid interrupting sleep pattern
• Warn patient to avoid excessive ingestion of potassium-rich foods
• Caution patient not to perform hazardous activities if adverse CNS reactions occur

77
• Advise patient to notify physician or other health care provider if muscle cramps or
weakness occurs

Generic Name: Tramadol


Brand Name: Ultram
Classification: Analgesic
Frequency/Route/Dose: 1 amp IVTT
Action: A centrally acting synthetic analgesic compound not chemically related to opiates. Drug
is thought to bind to opioid receptors and inhibit reuptake of nor-epinephrine and
serotonin
Indication: Treatment of moderate to moderately severe pain
Contraindication: Hypersensitivity to drug and those with acute intoxication from alcohol,
hypnotics, centrally acting analgesics, opioids
Adverse Effects:
CNS: headache, drowsiness, sleep disorder, nervousness, seizures
CV: vasodilation
GI: nausea, constipation, vomiting, dyspepsia, dry mouth, diarrhea, abdominal pain
GU: urinary retention, urinary frequency
EENT: visual disturbances
Derm: pruritus, sweating
Drug Interaction: Carbamazepine: increased tramadol metabolism
Nursing Responsibilities:
• Assess type, location, and intensity of pain
• Assess BP and respiratory rate before and periodically during administration
• Assess bowel function routinely
• May be administered without regards to meal
• Instruct patient to avoid activities that require alertness
• Advise to make position changes slowly to prevent orthostatic hypotension

78
Generic Name: Morphine
Brand Name: Astramorph
Classification: Opioid Analgesic
Frequency/Route/Dose: 2 mg IVTT now
Action: Binds with opiate receptors in the CNS, altering both perception and emotional response
to pain.
Indication: Management of severe pain, pulmonary edema, pain associated with MI
Contraindication: Hypersensitivity to drug and in those with conditions that would prelude
administration of opioids by IV route (acute bronchial asthma or upper airway
obstruction)
Adverse Effects:
CNS: sedation, somnolence, clouded sensorium, euphoria, seizures, dizziness,
nightmares, hallucinations
CV: hypotension, bradycardia, shock, cardiac arrest
Resp: respiratory depression
EENT: diplopia, blurred vision
GI: nausea, vomiting, constipation, ileus
GU: urinary retention
Derm: sweating, flushing, itching
Misc: tolerance, physical dependence
Drug Interaction: CNS depressants, general anesthetics, hypnotics, sedatives: may cause
respiratory depression, hypotension, profound sedation, or coma
Nursing Responsibilities:
• Assess type, location, and intensity of pain
• Assess BP, pulse and respiration before and periodically during administration
• Assess bowel function routinely
• May be administered with food or milk to minimize GI irritation
• Don’t crush, break or chew extended-release tablets

79
• Watch for pruritus and skin flushing with epidural administration
• Caution ambulatory patients about going out of bed or walking
• Advise patient to change position slowly to prevent orthostatic hypotension
Generic Name: Senna Concentrate
Brand Name: Senokot
Classification: Laxative (stimulant)
Frequency/Route/Dose: 2 tabs HS
Action: Active components of senna alter water and electrolyte transport in the large intestine,
resulting in accumulation of water and increased peristalsis
Indication: Treatment of constipation, particularly when associated with slow transit time,
constipating drugs, irritable or spastic bowel syndrome
Contraindication: Hypersensitivity to any ingredient, nausea or vomiting or other symptoms of
appendicitis, acute surgical abdomen, fecal impaction, abdominal pain
Adverse Effects:
GI: nausea, diarrhea, cramping
GU: pink-red or brown-black discoloration of urine
F and E: electrolyte abnormalities
Misc: laxative dependence
Drug Interaction: Laxatives containing aluminum, calcium or magnesium impair absorption of
tetracycline due to release of free calcium
Nursing Responsibilities:
• Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of
bowel function
• Assess color, consistency and amount of stool produced
• Take with a full glass of water. Administer at bedtime for evacuation 6-12 hours later
• Advise patient that laxative should be used only for short-term therapy
• Encourage to use other forms of bowel regulation such as increasing bulk in diet,
increasing fluid intake, increasing mobility
• Inform patient that this medication may cause changes in urine color
• Advise not to use laxatives when abdominal pain, nausea, vomiting or fever are present

80
Generic Name: Warfarin
Brand Name: Coumadin
Classification: Anticoagulant
Frequency/Route/Dose: 5 mg ½ tab OD
Action: Inhibits vitamin K-dependent activation of clotting factors II, VII, IX, and X, formed in
the liver
Indication: Prophylaxis and treatment of venous thrombosis, atrial fibrillation with embolization,
pulmonary embolism, adjunct in prohylaxis of systemic embolism after MI
Contraindication: Hemorrhage tendency, blood dyscrasias, recent or contemplated surgery of
CNS bleeding tendencies associated with active ulceration or overt bleeding
Adverse Effects:
GI: nausea, cramping
Derm: dermal necrosis
Hemat: bleeding
Misc: fever
Drug Interaction: Effects diminished by barbiturates, cholestyramine, gluthetimide, rifampicin,
vitamin K
Nursing Responsibilities:
• Assess patient for signs of bleeding and hemorrhage
• Administer medication same time each day
• Medication requires 3-5 days to reach effective levels
• Instruct to take medication as directed
• Review foods high in vitamin K
• Advise to report signs of unusual bleeding or bruising
• Instruct not to drink alcohol or OTC medications such as those containing aspirin,
ibuprofen, or naproxen

81
Generic Name: Ceftazidime
Brand Name: Ceptaz
Classification: Anti-infective (third generation cephalosporins)
Frequency/Route/Dose: 1 gm IVTT q 8 hours
Action: Binds to bacterial cell wall membrane, causing cell death. Bactericidal action against
susceptible bacteria
Indication: Treatment of skin an skin structure infections, bone and joint infections, urinary
infections, respiratory infections, intra-abdominal infections, septicemia
Contraindication: Hypersensitivity to cephalosporins, serious hypersensitivity to penicillins,
renal impairment, hepatic or renal impairment
Adverse Effects:
CNS: seizures
GI: nausea, vomiting, diarrhea, cramping, colitis
Derm: rashes, urticaria
Hemat: blood dyscrasias, hemolytic anemia, bleeding
Misc: superinfection, allergic reactions
Drug Interaction: Probenecid decreases excretion and increases serum levels. Ingestion of
alcohol within 48-72 hours of cefoperazone may result in a disulfiram-like reaction.
Nursing Responsibilities:
• Assess patient for infection
• Obtain history to determine previous use of and reactions to penicillins or cephalosporins
• Observe for signs and symptoms of anaphylaxis
• May be administered on full or empty stomach. Administer with food may minimize GI
irritation
• Tell patient to take exact amount as prescribed
• Inform patient not to crush, break or chew extended-release tablets
• Advise to report signs of superinfection

82
• Instruct patient to finish the medication completely
• Instruct patient to notify physician and other health care provider if fever and diarrhea
develops

Generic Name: Clindamycin


Brand Name: Dalacin
Classification: Anti-infective
Frequency/Route/Dose: 300 mg 1 tab q 6 hours
Action: Inhibits protein synthesis in susceptible bacteria. Bactericidal or bacteriostatic
Indication: Treatment of skin an skin structure infections, bone and joint infections, urinary
infections, respiratory infections, intra-abdominal infections, septicemia
Contraindication: Hypersensitivity to drug, severe liver impairment, diarrhea, alcohol intolerance
Adverse Effects:
CNS: dizziness, vertigo, headache
CV: hypotension, arrhythmias
GI: nausea, vomiting, diarrhea, colitis
Derm: rashes
Drug Interaction: Erythromycin: may block access of clindamycin to its site of action.
Neuromuscular blockers: increase neuromuscular blockade possible
Nursing Responsibilities:
• Assess patient for infection
• Observe for signs and symptoms of anaphylaxis
• Administered with a full glass of water. May be given with meals
• Tell patient to take exact amount as prescribed
• Inform patient not to crush, break or chew extended-release tablets
• Instruct patient to finish the medication completely
• Instruct patient to notify physician and other health care provider if fever and diarrhea
develops
• Observe patient for signs and symptoms of superinfection

83
Generic Name: Acetaminophen
Brand Name: Paracetamol
Classification: Nonopioid analgesic, antipyretic
Frequency/Route/Dose: 500 mg 1 tab q 4 hours
Action: Thought to produce analgesia by blocking generation of pain impulses, probably by
inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substance
that synthesize pain receptors to mechanical or chemical stimulation
Indication: Mild to moderate pain, fever
Contraindication: Hypersensitivity to drug, products containing alcohol, severe hepatic disease,
renal disease, malnutrition
Adverse Effects:
GI: hepatic necrosis
Derm: rash, urticaria
Drug Interaction: Chronic concurrent use with NSAIDs including aspirin may increase the risk
of adverse reactions. Barbiturates, carbamazepine, rifampicins: may reduce therapeutic
effects and cause hepatotoxicity
Nursing Responsibilities:
• Assess type, location, and intensity prior to and 30-60 minutes following administration
• Assess fever and associated signs
• Administer with full glass of water
• May be taken with food or on an empty stomach
• Advise patient to take medication exactly as directed
• Advise patient to notify physician or other health care provider if discomfort or fever is
not relieved

84
Generic Name: Omeprazole
Brand Name: Losec
Classification: Anti-ulcer, Gastric acid pump inhibitor
Frequency/Route/Dose: 80 mg IVTT now then 40 mg IVTT q 12 hours
Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH,
preventing the final transport of hydrogen ions into the gastric lumen
Indication: Management of GERD, management of gastric ulcer, treatment of gastric
hypersecretory conditions
Contraindication: Hypersensitivity to drug
Adverse Effects:
CNS: weakness, dizziness, headache, fatigue
CV: chest pain
GI: abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea,
vomiting
Derm: rash, itching
Drug Interaction: Decreases metabolism and may increase effects of phenytoin,
diazepam, and warfarin. May interfere with absorption of drugs requiring acid gastric pH
including ketoconazole, ampicillin and iron salts
Nursing Responsibilities:
• Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool
• Administer doses before meals, preferably in the morning
• May be administered concurrently with antacids
• Instruct to take medication as directed
• May cause occasional drowsiness, or dizziness. Caution patient to avoid activities that
require alertness

85
• Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent
headache to the physician promptly

Generic Name: Metoclopramide


Brand Name: Clopra
Classification: Antiemetic, GI stimulant
Frequency/Route/Dose: 10 mg 1 tab 3 times a day
Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates the
motility of the upper GI tract and accelerates gastric emptying
Indication: Nausea and vomiting with GI disorder, disorders in reduced GI motility
Contraindication: Hypersensitivity, GI hemorrhage or obstruction, perforation, epilepsy
Adverse Effects:
CNS: restlessness, drowsiness, fatigue, extrapyramidal effect, depression, irritability,
anxiety
CV: arrhythmias
GI: constipation, diarrhea, nausea, dry mouth
Endo: gynecomastia
Drug Interaction: Phenothiazines, lithium, centrally-active agents including anti-depressants,
anti-epileptics and sympathemimetics
Nursing Responsibilities:
• Assess patient for nausea, vomiting, abdominal distention and bowel sounds prior to or
following administration
• Assess patient for extrapyramidal effects
• Assess for signs of depression
• Administer 30 minutes before meals and at bedtime
• Instruct to take medication as directed
• Caution to avoid activities that requires alertness
• Advise to notify physician or other health care provider if involuntary movements occurs

86
Generic Name: Levofloxacin
Brand Name: Levox
Classification: Quinolones
Frequency/Route/Dose: 500 mg 1 cap OD
Action: Synthetic, broad spectrum antibacterial agents, the fluorine molecule confers increased
activity against gram positive organism as well as broadens the spectrum against gram
positive organism
Indication: Acute bacterial exacerbation of chronic bronchitis, community acquired pneumonia
Contraindication: Hypersensitivity to quinolones, epilepsy, history of tendon disorders related to
fluoroquinolones therapy
Adverse Effects:
CNS: headache, insomnia, dizziness
GI: Nausea and vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence,
Derm: rash, pruritus
Drug Interaction: Absorption impaired by antacids, sucralfate, mental cautions, and Zinc-
containing multi-vitamin preparation, probeneclol and cimetidine may affect the rate and
extent of levofloxacin absorption
Nursing Responsibilities:
• Obtain specimen for culture and sensitivity test
• Tell patient to take exact amount as prescribed
• Tell patient that drug may be taken with meals
• Inform patient not to crush, break or chew extended-release tablets

87
Generic Name: Ranitidine
Brand Name: Zantac
Classification: Antiemetic, antacids
Frequency/Route/Dose: 1 amp IVTT OD
Action: Potent anti-ulcer drug that competetively and reversibly inhibits histamine action at H2
receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces
pepsin secretion.
Indication: Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal
ulcer patient after healing of acute ulcer
Contraindication: Acute poyphyria; hyper-sensitivity to ranitidine
Adverse Effects:
CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo, mental confusion,
agitation
Resp: bradycardia
GI: constipation, nausea, abdominal pain
Drug Interaction: Antacids: interfere with ranitidine absorption. Diazepam: decrease absorption
of diazepam
Nursing Responsibilities:
• Assess patient for nausea, vomiting, abdominal distention and bowel sounds prior to or
following administration
• Administer 30 minutes before meals
• Instruct to take medication as directed
• Caution to avoid activities that requires alertness
• Advise to notify physician or other health care provider if involuntary movements occurs
• Be alert for signs of hepatotoxicity
• Long-term therapy may lead to vitamin B12 deficiency

88
• Monitor creatinine clearance

Generic Name: Phytonadione


Brand Name: Vitamin K
Classification: Vitamin
Frequency/Route/Dose: 1 amp IVTT
Action: Required for hepatic synthesis of blood coagulation factors II, VII, IX and X.
Indication: Prevention and treatment of hypoprothrombinemia, which may be associated with
excessive doses of oral anticoagulants, salicylates. Nutritional deficiencies, prevention of
hemorrhagic disease
Contraindication: Hypersensitivity and intolerance, impaired liver function
Adverse Effects:
GI: gastric upset, unusual taste
Derm: rash, urticaria, flushing
Local: swelling, pain at IV site
Misc: hemolytic anemia, hyperbilirubinemia, allergic reactions
Drug Interaction: Large doses will counteract the effect of warfarin. Large doses of salicylates or
broad-spectrum anti-infectives may increase vitamin K requirements.
Nursing Responsibilities:
• Monitor for frank and occult bleeding
• Monitor BP and pulse frequently
• Instruct to take medication as ordered
• Advise patient to report any symptoms of unusual bleeding or bruising

89
Generic Name: Pantoprazole
Brand Name: Pantoloc
Classification: Antacids, antiulcerants
Frequency/Route/Dose: 40mg/tab OD
Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH,
preventing the final transport of hydrogen ions into the gastric lumen
Indication: Treatment of mild reflux, duodenal or gastric ulcer, reflux esophagitis
Contraindication: Hypersensitivity, impaired liver function
Adverse Effects:
CNS: headache, dizziness
GI: diarrhea, nausea, upper abdominal pain, flatulence
Derm: rash, pruritus
Drug Interaction: Ketoconazole may affect absorption of drugs whose absorption is pH-
dependent
Nursing Responsibilities:
• Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool
• Administer doses before meals, preferably in the morning
• May be administered concurrently with antacids
• Instruct to take medication as directed
• May cause occasional drowsiness, or dizziness. Caution patient to avoid activities that
require alertness
• Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent
headache to the physician promptly

90
Generic Name: Rebamipide
Brand Name: Mucosta
Classification: Gastrointestinal/ hepatobiliary drugs
Frequency/Route/Dose: 100 mg/tab TID
Action: Reacts with gastric acid to form thick paste which selectively adheres to ulcer surface
Indication: Treatment of gastric mucosal lesions, acute gastritis, gastric ulcer
Contraindication: Hypersensitivity to the drug
Adverse Effects:
GI: diarrhea, nausea, vomiting, constipation
Derm: pruritus
Drug Interaction: Antacids interfere with absorption. Diazepam decrease absorption
Nursing Responsibilities:
• Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool
• Assess for abdominal pain
• Administer on empty stomach, 1 hour before meals
• Increase fluid intake
• Instruct to take medication as directed
• Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent
headache to the physician promptly

91
Generic Name: Atorvastatin
Brand Name: Lipitor
Classification: Antihyperlipidemic agent
Frequency/Route/Dose: 80 mg/tab 1 tab OD HS
Action: Inhibits an enzyme, 3 hydroxy-3-methylglutaryl-coenzyme A reductase, which is
responsible for catalyzing an early step in the synthesis of cholesterol. Slowing the
progression of CAD with resultant decrease in MI and need for myocardial
revascularization
Indication: Reduction of elevated total and LDL cholesterol and triglycerides in patients with
primary hypercholesterolemia, mixed hyperlipidemia
Contraindication: Hypersensitivity to the drug, active liver disease
Adverse Effects:
CNS: dizziness, headache, insomia
GI: GI disturbance
MS: muscle cramps
Derm: pruritus
Drug Interaction: Risk of myopathy increased with concurrent administration of cyclosporine,
fibric acid derivatives, erythromycin, niacin.
Nursing Responsibilities:
• Obtain diet history, especially on fatty foods
• Administer with food
• Instruct patient to have diet restrictions on fats, cholesterol, carbohydrates and alcohol
• Advise to take medication as directed
• Caution patient to avoid activities that require alertness
• Advise patient to notify physician or other health care provider if any unusualities occurs

92
Generic Name: Carvedilol
Brand Name: Dilatrend
Classification: Beta Adrenergic Blocking agent
Frequency/Route/Dose: 6.25 mg ½ tab OD
Action: Block stimulation of beta1 adrenergic receptors, do not usually affect beta2 receptor sites
Indication: CHF, hypertension
Contraindication: Hypersensitivity to the drug, disease of the respiratory tract, , asthma, chronic
bronchitis, SA block, 2nd and 3rd degree AV block, MI with complications, severe liver
dysfunction, metabolic acidosis
Adverse Effects:
CNS: dizziness, headache, tiredness, nausea
GI: andominal pain, diarrhea, constipation, vomiting
Resp: bronchospastic reactions
Drug Interaction: BP lowering drugs, reserpine, methyldopa, clonidine, rifampicin
Nursing Responsibilities:
• Always check apical pulse rate before giving drug
• Monitor BP, ECG and pulse frequently
• Monitor Intake and Output ratios and daily weight
• Assess frequency and characteristics of anginal attacks periodically throughout therapy
• Instruct patient to take drug exactly as prescribed and to take it with meals
• Advise to avoid activities that require alertness
• Advise to make position changes slowly to prevent orthostatic hypotension

93
NURSING CARE PLAN

Name: Perfecto Pandacan Balili Room and Bed #: CCU bed 1


Age: 60 y.o. Attending Physician: Dr. Voltaire Egnora
Sex: Male Institution: Davao Medical Center
Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III

Date and Cues Need Nursing Diagnosis Objective Nursing Intervention Evaluation
Time

Novembe S: C Acute pain related to Within my 1 1. Administer medication Goal Met


r 28, 2006 “Sakit akong O decreased myocardial hour span of as indicated (antianginal,
dughan” as G blood flow as care my beta-blocker, analgesics) November 28,
3-11 shift verbalized by the N evidenced by reports patient will R: Immediate response in relief 2006
patient. I of chest pain be able to of pain.
5:00 T secondary to CAD, report relief 6:00 p.m.
p.m. O: I AMI or control of 2. Administer
- Pupillary V chest pain as supplemental oxygen as
size 3mm E Rationale: evidenced by indicated Within my 1
isocoric, brisk patients R: Increases amount of oxygen hour span of care
and reactive to - Pain is an unpleasant verbalization, available for myocardial my patient was
light sensory and absence of uptake and thereby may relieve be able to
- Pale P emotional experience restlessness, discomfort associated with report relief or
conjunctiva E arising from actual or diaphoresis, tissue ischemia. control of chest
noted R potential tissue facial pain as
- Pink C damage. grimace and 3. Monitor characteristics evidenced by:
mucous E vital signs of pain, noting verbal
membrane and P Acute Myocardial within reports, nonverbal cues, “ Dili na sakit
lips noted T Infarction (AMI) normal range and hemodynamic akong dughan.”
- Grimaced U occurs when coronary response. as verbalized by
face noted A blood flow decreases R: Variation of appearance and the patient
- Crackles L abruptly after a behavior may occur.
noted upon thrombotic occlusion Respirations may be increased - absence
auscultation P of a coronary artery as a result of pain and of
- Productive A previously narrowed associated anxiety, while restlessness
cough noted T by atherosclerosis. release of stress induced noted
- Whitish T Infarction occurs catecholamines will increase - absence
phlegm noted E when an heart rate and BP. of
- Irregular R atherosclerotic plaque diaphoresis
cardiac rate N fissures, ruptures, or 4. Review history of noted
and rhythm ulcerates and when previous angina or MI pain - Absence
noted conditions (local or R: May differentiate current of facial
- Clutching systemic) favor pain from preexisting patterns, grimace
chest noted thrombogenesis, so as well as identify noted
- diaphoresi that a mural thrombus complications such as - vital
s noted forms at the site of extension of infarction, signs within
- cold, rupture and leads to pulmonary embolus, or normal range
clammy skin coronary artery pericarditis. (Temp=36,
noted occlusion. After an RR=22 cpm,
- Pale nail initial platelet 5. Instruct patient to report CR= 60 bpm,
beds noted monolayer forms at pain immediately BP= 90/60
- Capillary the site of the R: Delay in reporting pain mmHg)
refill of 1 ruptured plaque, hinders pain relief or may
second various agonists require increased dosage of
- Weakness (collagen, ADP, medication to achieve relief.
noted epinephrine, Severe pain may induce shock
- restlessnes serotonin) promote by stimulating the sympathetic
s noted platelet activation. nervous system, thereby
- irritability There is production creating further damage and
noted and release of interfering with diagnostics
- narrowed thromboxane A2 (a and relief of pain.
focus (reduced potent local Evaluated by:
interaction vasoconstrictor), 6. Provide quiet
with people) further platelet environment, calm

95
noted activation, and activities and comfort Yap, Novelynne
- Pain scale potential resistance to measures. Joy
of 6 out of 10 thrombolysis. R: Decreases external stimuli,
(0 being no which may aggravate anxiety
pain and 10 as The coagulation and cardiac strain and limit
very severe cascade is activated coping abilities and adjustment
pain) on exposure of tissue to current situation.
- Temp=35, factor in damaged
RR=25 cpm, endothelial cells at the 7. Assist in relaxation
CR= 47 bpm, site of the ruptured techniques such as deep
BP= 80/60 plaque. Factors VII breathing, visualization and
mmHg and X are activated, guided imagery
ultimately leading to R: Helpful in decreasing
the conversion of perception of pain. Provides a
prothrombin to sense of having some control
thrombin, which then over the situation, increase in
converts fibrinogen to positive attitude.
fibrin. The culprit
coronary artery 8. Check vital signs before
eventually becomes and after narcotic
occluded by a medication
thrombus containing R: Hypotension or respiratory
platelet aggregates depression can occur as a result
and fibrin strands. of narcotic administration.
These may increase myocardial
This occlusion will damage in presence of
impede the flow of ventricular insufficiency.
blood to the cardiac
muscles. Decrease 9. Place patient at
cardiac functioning complete rest during
will lead to imbalance anginal episodes
between myocardial R: Reduces myocardial oxygen
oxygen supply and demand to minimize risk of

96
demand wherein the tissue injury or necrosis.
heart is unable to meet
the metabolic 10. Elevate head of bed if
demands of the body. patient is short of breath
Lack of blood and R: Facilitates gas exchange to
oxygen supply in the decrease hypoxia and resultant
cardiac muscle will shortness of breath.
lead to ischemia and
thus to experience of 11. Monitor heart rate and
pain. rhythm
R: Patient may have acute life-
threatening dysrhythmias,
which occur in response to
ischemic changes or stress.

12. Stay with the patient


who is experiencing pain or
appears anxious
Source: R: Anxiety releases
catecholamines, which increase
Pathophysiology: myocardial workload and can
Concepts and prolong ischemic pain.
Applications for Presence of nurse can reduce
Health Care feelings of fear and
Professionals, 3rd helplessness.
Edition by Nowak
13. Provide light meals.
Harrison’s Internal Have patient rest for 1 hour
Medicine, 5th Edition after meals
R: Decreases myocardial
workload associated with work
of digestion, reducing risk of
anginal attack.

97
14. Monitor serial ECG
changes
R: Ischemia during anginal
attack may cause transient ST
segment depression or
elevation and T wave
inversion. Serial tracing verify
ischemic changes, which may
disappear when patient is pain-
free. They also provide a
baseline with which to
compare later pattern changes.

Source:
- Nursing Care Plan, 4th
Edition by Doenges
- Nurse’s Pocket Guide,
8th Edition by Doenges

98
Name: Perfecto Pandacan Balili Room and Bed #: CCU bed 1
Age: 60 y.o. Attending Physician: Dr. Voltaire Egnora
Sex: Male Institution: Davao Medical Center
Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III

Date and Cues Need Nursing Diagnosis Objective Nursing Intervention Evaluation
Time
1. Determine baseline
S/O: Decrease Cardiac Within my 8 vital signs Goal Partially
November - Pupillary A Output related to hours span of R: Provide opportunities to Met
27, 2006 size 3mm C altered heart rate and care my track changes.
isocoric, brisk T rhythm as evidenced patient will November 27,
3-11 shift and reactive to I by atrial fibrillation in be able to 2. Auscultate BP, 2006
light V slow to moderate maintain compare both arms and
4:30 - Pale I ventricular response hemodynamic obtain lying, sitting and 10:00 p.m.
p.m. conjunctiva T with ST elevation stability as standing pressures when
noted Y pattern secondary to evidenced by: able Within my 8
- O2 CAD, AMIK II R: Hypotension may occur hours span of
inhalation at 5 - - BP related to ventricular care my patient
lpm via nasal within dysfunction, hypoperfusion of was able to
cannula noted E Rationale: normal the myocardium, and vagal maintain
- Pink X range stimulation. However, hemodynamic
mucous E Acute Myocardial (90/60- hypertension is also a common stability as
membrane and R Infarction (AMI) 120/90 phenomenon, possibly related evidenced by:
lips noted C generally occurs mmHg) to pain, anxiety, catecholamine
- Symmetri I when coronary blood - CR release, and/or preexisting - BP
cal chest S flow decreases within vascular problems. Orthostatic within normal
expansion E abruptly after a normal hypotension may be associated range
noted thrombotic occlusion range (60- with complications of infarct. (110/80mmHg)
- Crackles of a coronary artery 100 bpm) - Adequate
noted upon previously narrowed - Adequ 3. Evaluate quality and urinary output
auscultation by atherosclerosis. ate urinary equality of pulse as (I-370 cc, O-
- Productive When a coronary output indicated 300 cc)

99
cough noted artery thrombus - Decre R: Decreased cardiac output - Absence
- Whitish P develops rapidly at a ase results in diminished of dyspnea
phlegm noted A site of vascular injury, dysrhythmia weak/thready pulses. (RR-20 cpm)
- Irregular T this injury is - Absen Irregularities suggest
cardiac rate T produced or ce of dysrhythmias, which may But was not able
and rhythm E facilitated by factors dyspnea require further evaluation or to maintain
noted R such as cigarette monitoring. hemodynamic
- Showing N smoking, stability on:
atrial hypertension, and 4. Auscultate heart sound;
fibrillation in lipid accumulation. note development of S3 - CR (52
slow to Infarction occurs and S4 bpm)
moderate when an R: S3 is usually associated - Cardiac
ventricular atherosclerotic plaque with HF, but it may also be rhythm remains
response with fissures, ruptures, or noted with mitral insufficiency the same
ST elevation ulcerates and when and left ventricular overload
pattern conditions (local or that can accompany severe
- Non- systemic) favor infarction. S4 may be
distended thrombogenesis, so associated with myocardial
abdomen that a mural thrombus ischemia, ventricular
noted forms at the site of stiffening, and pulmonary or
- Grossly rupture and leads to systemic hypertension.
normal coronary artery
extremities occlusion. After an 5. Presence or
noted initial platelet murmurs/rubs
- Cool skin monolayer forms at R: Indicates disturbance of Evaluated by:
noted the site of the normal blood flow within the
- Pale nail ruptured plaque, heart. Presence of rub with an
beds noted various agonists infarction is all associated with Yap, Novelynne
- Capillary (collagen, ADP, inflammation. Joy
refill of 1 epinephrine,
second serotonin) promote 6. Auscultate breath
- Weakness platelet activation. sounds
noted After agonist R: Crackles reflecting

100
- Temp=35. stimulation of pulmonary congestion may
6, RR=23 platelets, there is develop because of depressed
cpm, CR= 43 production and myocardial function.
bpm, BP= release of
80/60 mmHg thromboxane A2 (a 7. Monitor heart rate and
potent local rhythm
vasoconstrictor), R: Heart rate and rhythm
further platelet respond to medication and
activation, and activity, as well as developing
potential resistance to complications/dysrhythmias,
thrombolysis. which could compromise
cardiac function or increase
The coagulation ischemic damage. Acute or
cascade is activated chronic atrial flutter/fibrillation
on exposure of tissue may be seen with coronary
factor in damaged artery or valvular involvement
endothelial cells at and may or may not be
the site of the pathogenic.
ruptured plaque.
Factors VII and X are 8. Place on moderate high
activated, ultimately back rest
leading to the R: Lowers diaphragm,
conversion of promoting chest expansion.
prothrombin to
thrombin, which then 9. Note response to
converts fibrinogen to activity and promote rest
fibrin. Fluid-phase appropriately
and clot-bound R: Overexertion increases
thrombin participate oxygen consumption/demand
in an and can compromise
autoamplification myocardial function.
reaction that leads to
further activation of 10. Provide bedside

101
the coagulation commode if unable to use
cascade. The culprit bathroom
coronary artery R: Attempts at using bedpan
eventually becomes can be exhausting and
occluded by a psychologically stressful,
thrombus containing thereby increasing oxygen
platelet aggregates demand and cardiac workload.
and fibrin strands.
11. Provide small or easily
This occlusion will digested meals. Restrict
impede the flow of caffeine intake
blood to the cardiac R: Large meals may increase
muscle and other parts myocardial workload and
of the body. Therefore cause vagal stimulation
there is inadequate resulting in bradycardia or
blood pumped by the ectopic beats. Caffeine is a
heart to meet the direct cardiac stimulant that
metabolic demands of can increase heart rate.
the body. This cardiac
problem also alters 12. Avoid activities such as
the cardiac rate and isometric exercises, rectal
rhythm as the body stimulation, vomiting,
reacts to the lack of spasmodic coughing.
blood carrying oxygen Administer stool softeners
in which the occlusion as ordered.
results to tissue R: These may stimulate
ischemia and valsalva response.
eventually to necrosis.
13. Administer
The infracted area in supplemental oxygen, as
AMI will eventually indicated
heal and the necrotic R: Increases amount of
myocardial cells will .oxygen available for

102
be replaced by dense myocardial uptake, reducing
fibrous connective ischemia and resultant
tissue (scarring). This dysrhythmias.
area cannot contribute
to pumping except to 14. Maintain IV access as
maintain the integrity indicated
of the ventricular R: Patent line is important for
wall. administration of emergency
drugs in presence of persistent
dysrhythmias or chest pain.

15. Administer
antidysrhythmic drugs and
ACE inhibitors as ordered.
R: Dysrhythmias are usually
treated symptomatically,
Source: except for PVCs, which are
often treated prophylactically.
Pathophysiology: Early inclusion of ACE
Concepts and inhibitor therapy enhances
Applications for ventricular output, increases
Health Care survival and may slow
Professionals, 3rd progression of heart failure.
Edition by Nowak

Harrison’s Internal
Medicine, 5th Edition

Source:
- Nursing Care Plan, 4th
Edition by Doenges
- Nurse’s Pocket Guide,

103
8th Edition by Doenges

104
Name: Perfecto Pandacan Balili Room and Bed #: CCU bed 1
Age: 60 y.o. Attending Physician: Dr. Voltaire Egnora
Sex: Male Institution: Davao Medical Center
Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III

Date and Cues Need Nursing Diagnosis Objective Nursing Intervention Evaluation
Time
1. Determine baseline
S: Activity Intolerance Within my 8 vital signs Goal Partially
Novembe “Dali ko makapoy A related to decrease hours span of R: Provide opportunities to Met
r 29, 2006 ug lisod mulihok” C cardiac functioning as care my track changes.
as verbalized by T evidenced by irregular patient will November 29,
3-11 shift the patient I cardiac rate and be able to 2. Record or document 2006
V rhythm secondary to demonstrate heart rate, rhythm, and BP
4:30 O: I CAD, AMIK II progressive changes before, during, and 10:00 p.m.
p.m. - Pupillary T increase in after activity as indicated.
size 3mm Y tolerance for Correlate with reports of Within my 8
isocoric, brisk Rationale: activity with chest pain or shortness of hours span of
and reactive to - heart breath. care my patient
light There is insufficient rate/rhythm R: Trends determine patient’s was able to
- Pale E physiological or and BP response to activity and may demonstrate
conjunctiva X psychological energy within indicate myocardial oxygen progressive
noted E to endure or complete patient’s deprivation that may require increase in
- O2 R required or desired normal limits decrease in activity level or tolerance for
inhalation at 5 C daily activities. and skin return to bed rest, changes in activity as
lpm via nasal I warm, pink medication regimen or use of evidenced by:
cannula noted S Acute Myocardial and dry. supplemental oxygen.
- Pink E Infarction (AMI) - BP
mucous occurs when coronary 3. Promote rest initially. within normal
membrane and blood flow decreases Limit activities on basis of range
lips noted abruptly after a pain or hemodynamic (100/80mmHg)
- Symmetri thrombotic occlusion response. Provide nonstress - Skin
cal chest of a coronary artery diversional activities warm to touch

105
expansion previously narrowed R: Reduce myocardial - Dry skin
noted P by atherosclerosis. workload or oxygen noted
- Crackles A Infarction occurs consumption, reducing risk of - Pinkish
noted upon T when an complications conjunctiva,
auscultation T atherosclerotic plaque mucous
- Productive E fissures, ruptures, or 4. Limit visitors and/or membrane and
cough noted R ulcerates and when visiting by patient, initially nail beds noted
- Whitish N conditions (local or R: Lengthy or involved
phlegm noted systemic) favor conversations can be very But was not able
- Irregular thrombogenesis, so taxing for the patient; however, to demonstrate
cardiac rate that a mural thrombus periods of quiet visitation can progressive
and rhythm forms at the site of be therapeutic. increase in
noted rupture and leads to tolerance for
- Showing coronary artery 5. Instruct patient to avoid activity as
atrial occlusion. After an increasing abdominal evidenced by:
fibrillation in initial platelet pressure like straining
slow to monolayer forms at during defecation - CR (57
moderate the site of the R: Activities that require bpm)
ventricular ruptured plaque, holding of breath and bearing - Cardiac
response with various agonists down can result in bradycardia, rhythm remains
ST elevation (collagen, ADP, temporarily reduced cardiac the same
pattern epinephrine, output and rebound tachycardia
- Non- serotonin) promote with elevated BP.
distended platelet activation.
abdomen After agonist 6. Explain pattern of
noted stimulation of graded increase of activity
- Grossly platelets, there is level like getting up in
normal production and chair when there is no pain,
extremities release of progressive ambulation,
noted thromboxane A2 (a and resting for 1 hour after
- Cool skin potent local meals. Evaluated by:
noted vasoconstrictor), R: Progressive activity
- Dry, further platelet provides a controlled demand

106
rough skin activation, and on the heart, increasing Yap, Novelynne
noted potential resistance to strength and preventing Joy
- Pale nail thrombolysis. overexertion
beds noted
- Capillary The coagulation 7. Review signs and
refill of 1 cascade is activated symptoms reflecting
second on exposure of tissue intolerance of present
- Weakness factor in damaged activity level or requiring
noted endothelial cells at the notification of nurse or
- Needing site of the ruptured physician
assistance plaque. Factors VII R: Palpitations, pulse
upon changing and X are activated, irregularities, development of
positions ultimately leading to chest pain, or dyspnea may
noted the conversion of indicate need for changes in
- Temp=35. prothrombin to exercise regimen or medication
5, RR=23 thrombin, which then
cpm, CR= 57 converts fibrinogen to 8. Place on moderate high
bpm, BP= fibrin. The culprit back rest
90/70 mmHg coronary artery R: Lowers diaphragm,
eventually becomes promoting chest expansion.
occluded by a
thrombus containing 9. Note response to
platelet aggregates activity
and fibrin strands. R: Overexertion increases
oxygen consumption/demand
This occlusion will and can compromise
impede the flow of myocardial function.
blood to the cardiac
muscles. Decrease 10. Provide bedside
cardiac functioning commode if unable to use
will lead to imbalance bathroom
between myocardial R: Attempts at using bedpan
oxygen supply and can be exhausting and

107
demand wherein the psychologically stressful,
heart is unable to meet thereby increasing oxygen
the metabolic demand and cardiac workload.
demands of the body.
Performing activities 11. Provide small or easily
increases oxygen digested meals. Restrict
consumption from the caffeine intake
body in which an R: Large meals may increase
individual with such myocardial workload and
imbalance will have cause vagal stimulation
difficulty performing resulting in bradycardia or
the task. ectopic beats. Caffeine is a
direct cardiac stimulant that
can increase heart rate.

12. Plan care with rest


periods in between
R: reduce fatigue

13. Encourage patient to


Source: maintain positive attitude;
suggest use of relaxation
Pathophysiology: techniques such as
Concepts and visualization or guided
Applications for imagery as appropriate
Health Care R: Enhance sense of well-
Professionals, 3rd being
Edition by Nowak
14. Administer
Harrison’s Internal supplemental oxygen, as
th
Medicine, 5 Edition indicated
R: Increases amount of
.oxygen available for

108
myocardial uptake, reducing
ischemia and resultant
dysrhythmias.

15. Maintain IV access as


indicated
R: Patent line is important for
administration of emergency
drugs in presence of persistent
dysrhythmias or chest pain.

Source:
- Nursing Care Plan, 4th
Edition by Doenges
- Nurse’s Pocket Guide,
8th Edition by Doenges

109
PROGNOSIS

MI may be associated with a mortality rate as high as 30%, with more than half of deaths
occurring in the prehospital setting. Prognosis is highly variable and depends on a number of
factors related largely on infarct size, left ventricular function and the presence or absence of
ventricular arrhythmias. Prognosis is significantly worsened if a mechanical complication
(papillary muscle rupture, myocardial free wall rupture, and so on) were to occur.

Overall, the prognosis is poor. This is for the reason that the patient’s condition has been
transpiring for years. He had attacks in the past and his condition has complications already.
Regardless of the patient’s willingness to comply with all the medical regimens that would
possibly help his condition there is only small hope that normal cardiac rate and rhythm would
be achieved basing on the amount of myocardial tissue that has already been damaged. The
family also lacks the financial support that they would need for medical intervention and this is
also with respect to the patient’s age.

CRITERIA ACTUAL JUSTIFICATION


Poor Fair Good
The patient already had four attacks prior to the
present hospitalization. This implies that the
condition of the patient continuously deteriorates
Duration of illness √ every after the attack. In addition, it only
indicates that the patient is unable to meet the
necessary interventions to prevent having another
attack.
The patient is very willing to take all the available
Willingness to √ prescribed medications. In fact, he always asks
take medication questions regarding it. He would ask for the
purpose of his medicines before taking it.
The patient is not getting any younger and at his
current age (60 y.o.) there is a higher risk for
acquiring such illness. Since the patient’s immune
Age √ system and other bodily functions deteriorates as
he continuously age he will no longer be able to
fight against infection or inflammation that could
also trigger the aforementioned illness.
The patient wanted to go home with ordered
Expectations to √ medications however, he is also aware of the
illness reality that his condition is worsening. He and his
family still hopes that Mr. Perfecto would fully
recover from his illness.
The patient lives in an air conditioned room and
is provided with his oxygen tank. There is no air
Environment √ pollutant present that could worsen his respiratory
problems and the patient already stopped all his
vices ever since he had his attack.
The family is always there to provide assistance
and support the patient. Although this is the case
Family support √ the family still lacks assistance on other matter
such as financial aid. The help the patient gets
from his daughter is not enough to sustain all that
should necessarily be done to achieve optimal
health.

111
BIBLIOGRAPHY

Harrison’s Internal Medicine


Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Geissler-Murr, Nurses’ Pocket
Guide, Diagnoses, Interventions and Rationales. 9th Edition
Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Geissler-Murr, Nursing Care Plan
Guidelines for Individualizing Nursing Care 6th Edition
Nowak, Thomas. Pathophysiology: Concepts and Application for Health Care Professionals, 3rd
Edition
Rod Seeleys, Trent D. Stephens, Philip Tate, Essentials of Anatomy and Physiology 4th Edition
Suzanne C. Smeltzer, Brenda G. Bare, Brunner and Suddhart’s Textbook on Medical-Surgical
10th Edition
Sylvia A. Price, Lorraine M. Wilson, Pathophysiology Clinical Concepts of Disease Process 4th
Edition
Wilson, et al. Harrison’s Principles of Internal Medicine, 12th Edition

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