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I. INTRODUCTION

The patient is a 73 years old female, admitted at 10:00 pm of June 21, 2019 at
Quirino Memorial Medical Center (QMMC) Female Philhealth Ward. The patient’s complain is
difficulty of breathing. After series of assessment and procedures, the patient admitting
diagnosed NSTEMI Hypertension: Diabetes Mellitus type 2
Hypertension is another name for high blood pressure. It can lead to severe
complications and increases the risk of heart disease, stroke, and death.
Diabetes Mellitus type 2 most prevalent form of diabetes is characterized by a
combination of insulin resistance and insulin deficiency.
Myocardial Infarction also known as a heart attack occurs when blood flow
decreases or stops to a part of the heart, causing damage to the heart muscle. The most common
symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw.
NSTEMI is a type of heart attack. NSTEMI stands for Non-Segment elevation of
myocardial infarction. Sometimes an NSTEMI is known as a non-STEMI. A myocardial
infarction is the medical term for a heart attack. ST refers to the ST segment, which is part of the
EKG heart tracing used to diagnose a heart attack.
This study aims for understanding the cause,manifestation,treatment,and prevention
of the disease. Increase awareness of every individual who may have this kind of this disease.this
case presentation of disease is interesting to study because most of the people right now diabetes
and hypertension most common illness, so it can be help of us to understand the needs and
prevention of disease.
On june 27, 2019, I was care and handled the patient for 2 days.

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NURSING THEORIES

Dorothea Orem Self Care Deficit

In the Dorothea Orem Self Care Deficit Nursing Theory, the role of a nurse is to fill-in the gaps
of care that an individual cannot provide for themselves. Orem theorizes that individuals will
initiate and perform their own self-care activities on a regular basis so that their overall health
and well-being can be maximized.
It is only when an individual can no longer care for themselves that they will seek out
professional care from a provider, such as a nurse. This means nursing is more of a reactive than
proactive action in the eyes of Orem. Only when a person cannot care continuously for
themselves is it appropriate for a nurse to provide assistance.
According to Orem, nurses have the ability to provide five different methods of help in order to
restore an individual’s ability to care for themselves.

 By acting on a health issue immediately while providing services for others.

 Guiding others in the actions necessary to provide care.
 Supporting other nurses and supporting patients in providing and maintain care needs.
 Continuously providing an environment which promotes personal development instead of
nursing reliance.
 Teaching one another to enhance skill-building at all levels of the nursing spectrum.

There are 6 primary assumptions that Orem makes within the Self Care Deficit Nursing
Theory.

1. People are supposed to be self-reliant, responsible for their personal care and anyone else
in their family who may be in need of care.
2. Each person is a distinct individual.

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3. Nursing should be considered a form of action because it is an interaction which occurs

between 2+ people.
4. One of the most important components of prevention and the removal of ill health at the
primary care level is to successfully meet developmental and universal self-care
requisites.
5. The knowledge an individual has about their potential health issues is a necessary
component of any self-care behaviors they may be able to implement.
6. Self-care and dependent care are both learned behaviors within the context of a socio-
cultural element.
These assumptions are based on the idea that everyone at their core level has a desire to perform
the basics of universal self-care. Sometimes referred to as the activities of daily living, or ADLs,
these are the life processes of self-care that everyone can perform at some level.
This includes being able to access air, food, and water resources when necessary. It also includes
a provision of care when elimination processes need to be implemented.
The 3 Steps of Orem’s Nursing Process
Based on the need to help others and the assumptions about nursing, Orem developed a 3-step
process that helps to determine when there is a self-care deficit that would need to be addressed.
These steps are similar to the standard nursing processes of assessment, diagnosis, and
implementation/evaluation, but with greater detail.
Step #1: Data Collection. The first step in the Self Care Deficit Nursing Theory is to determine
why nursing is required. By evaluating the health status of an individual, what the doctor’s
perspective of that health status happens to be, and then the individual’s perception, it becomes
possible to analyze and interpret the data collected to make a judgment regarding care.
Additional data to be collected includes the health goals of the individual, how those goals are
reflected within the context of that person’s life, and what their requirements for future self-care
happen to be.
Step #2: Organization. The second step in this theory has the nurse designing a system that will
be at least partially compensatory or supportive in the education of the patient. This is done
through an organization of the components an individual would need to perform effective future
self-care and then selecting the correct combination of methods to create a treatment plan. The
overall goal is for an individual to overcome any current self-care deficits.
Step #3: Assistance. Once the methods for overcoming a self-care deficit are identified, the
nurse will then assist the individual or the family/caregivers of the individual in self-care matters.
A plan will be implemented so that all goals can be achieved so that the desired health results can
happen. Assistance is provided in evaluating results so that actions can be directed or modified
based on the events which occur.
Each step is then implemented with current technologies, polices, and skills that are available to
the nurse. The goal is always the same: to promote human growth and development within a
healthcare perspective.
The Strengths and Weaknesses of the Self Care Deficit Nursing Theory
As with any theory, there are strengths and weaknesses which should be examined when looking
at this idea. Orem’s Self Care Deficit Nursing Theory does provide a number of unique strengths
to the health care industry. This theory does have some limitations which must be considered as
well.

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It provides nurses with a comprehensive basis for their practice. It also provides a foundation for
research, education, and administration within the nursing industry so that skill-building can
occur. It species when nursing is required and promotes ongoing health maintenance through the
concept of promoting ongoing good health.
On the other hand, this idea is a general system theory which does not take into account
individualized variables. Orem treats the nursing system as a single entity instead. This causes
some individuals who may have physical, mental, or emotional deficits that prevent effective
self-care from possibly receiving the primary care they need.
Health is also a dynamic entity, always changing under the guise of this theory. This is not
always the case. The theory is also orientated to illnesses, so trauma and other health concerns
are not addressed whatsoever. If someone is consistently in good health, the assumption is that
they are maintaining their own self-care appropriately.
The goal of Dorothea Orem’s Self Care Deficit Nursing Theory is to help nurses understand their
patients on a better level. By teaching people and other nurses how self-care can be
implemented, it becomes possible to treat illness or disease more effectively. In return, better
overall health can be achieved.
It refers to my patient will seek out a balance between rest, activity and social interaction, or
work. They will avoid any hazards that may put their life at risk while promoting the
mechanisms of human functioning. That able to fill-in the deficit that has occurred so an
individual can restore their own self-care. This may mean must provide the ADLs an individual
requires until they are able to restore their own self-care. It also means that for some individuals,
long-term total care may also be required because there is a chronic deficit that has been
identified.

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Patient’s Data

Name: Patient B
Address: 80 Kalayaan Diliman Central, Quezon City
Age: 73 y/o
Gender: Female WEIGHT: 48 kg
Birthdate: 5/17/1946
Birthplace: Pangasinan
WARD: Female Philhealth Ward 5
OCCUPATION: Housewife
Marital status: Married
Religion: Catholic
Date of Admission: June 21, 2019
Admission Diagnosis: NSTEMI secondary Hypertension, Diabetes mellitus type 2

CHIEF COMPLAINT:
DOB upon admission
Weakness
Shortness of breath
Dizziness

HISTORY OF PRESENT ILLNESS:

One year prior to admission, patient remembered that she would always experience shortness
of breath Everytime she walked, washed clothes and performed chores. Everytime she
experience this, she would stop for a while to rest but denied using any medication.
Five months prior to admission, patient stated that she was getting their clothes, she felt chest
pain and it radiated up to her left arm and experienced shortness of breath while walking to the
sofa and feel unconscious thereafter. She didn't have any clue what happened to her. Her
husband brought her to QMMC ER. She stated that she was unconscious when she was taken in
the ER. Narrative that ER episode, she was intubated.
Diagnostic test were ordered; 2- D Echo result showed dilated left ventricular dimension with
concentric left ventricular hypertrophy with normal contractility and systolic function with
dropler evidence of Grade I diastolic dysfunction (impaired relaxation). Mitral Valve sclerosis
with mild regurgitation.Mitral annular calcifications. Mild Tricuspid regurgitation.Normal
Pulmonary artery pressure.
ECG result Sinus rhythm. Left Ventricular hypertrophy by voltage criteria with strain and/or
ischemia pattern.

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Blood Test: Red blood cells low range 2.99, Hemoglobin low 94.00, Hematocrit low 0.28, MCH
high 31.60.LDL low 2.00.Potassium high 5.42. Then after 6 days may go home and give
medication to be taken ff.: Clopidogrel, Omeprazole, ketoanalogue, atorvastatin.
Four months prior to admission, patient stated no signs and symptoms experienced.
Three months prior to admission, patient didn't have any experience of sickness.
Two months prior to admission, patient stated that sometimes she would feel shortness of
breath while walking and doing household chores.
Five hours prior to admission, patient was preparing their food when she felt shortness of
breath so she went to sofa and took a rest.
One hour prior to admission, patient felt pain in chest and shortness of breath and decided to
go to the QMMC and was admitted, she had difficulty of breathing and sudden onset of chest
pain with heaviness without fever,cough and colds.
Laboratory test given and result; CBC RBC low range 2.89 Hemoglobin low range 92.0
hematocrit low range 0.27 MCH high range 31.70 , Na 1443.26, K 3.58, BUN 5.2, CREA, 86,PT
12.1, APTT low range 24.8,ABG pH 7.45 PCo2 23.3 HCo3 14.4. Troponin I high 0.968 Ng/mL.

PAST MEDICAL HISTORY:

Hypertension 2016 taking medication Losartan and Amlodipine

Diabetes mellitus 2007 Metformin
Jan.26, 2019 diagnosed Myocardial Infarction secondary to Hypertension; diabetes mellitus type
2

FAMILY HISTORY:

Father Mother

Diabetes Mellitus type2 Heart attack

Sister

Heart attack

PSYCHOSOCIAL HISTORY:

The patient stated that she does household chores: cooking, laundry washes and washing dishes
and after she watch t.v or sometimes she can nap. She stated that has an average of 8 hours sleep
per day, usually from 9:00 pm to 5:00 Am.
She lives in a small house with her daughter and husband.

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REVIEW OF SYSTEM

GENERAL DATA:
(+) weight loss (+) weakness
(+) conscious
" Namayat ako at nanghihina ako"

INTEGUMENTARY SYSTEM:
(-) scars (-) change in color
(-) skin rashes

HEAD, EARS, NOSE, THROAT:

(-) hair loss (-) dandruff
(+) dizziness (-) hearing loss
(+) dental problems (-) tenderness
(+) change in vision (-) eye color change
(+) pale conjunctiva (-) difficulty swallowing
"Nahihilo ako kapag tumatayo ako"
MOUTH:
(-) dry lips (-) mouth sores

NECK:
(-) Lumps\swelling (-) Enlarged or tender nodes
(-) goiter

BREAST:
(-) Nipple discharge (-) Lump/tenrderness/swelling

RESPIRATORY:
(-) chest pain (-) cough and colds
(+) Shortness of breathing
" Nahihirapan ako huminga kapag naglalakad ako"
NEURO:
(+) blurring of vision
(+) dizziness

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"Nanlabo ung paningin dahil naoperahan ako noon sa cataract ko at nahihilo ako kapag
tumatayo"
CHEST AND LUNGS:
(+) symmetrical (+) clear sounds (+) resonance

HEART:
Precordium Heart rate rhythm
(+) dynamic (+) fast beat (+) regular

" Mabilis Ang tibok Ng puso ko"

ABDOMEN:
(+) soft to touch (+) normoactive
(-) abdominal pain (+) resonance

EXTREMITIES:
Capillary refill: (+) <3 secs (-) no edema

GENITOURINARY:
(-) dysuria

FEMALE GENITAL:
(+) Menopause
"Menopause na ako"

MUSCULOSKELETAL:
(-) muscle pain (-) joint pain
(-) back pain (+) muscle weakness
" Nanghihina ako"

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PHYSICAL ASSESSMENT
General Physical Survey
Patient was received conscious, coherent and cooperative. The patient wearing t-shirt and black
shorts lying on bed.

The patient’s Vital sign are as follows:

Temp. 36.7
RR: 25cpm
PR: 110bpm
BP: 180/70
O2: 97

Head: generally round normo-cephalic and symmetrical,with frontal, parietal, and occipital
prominences. Has a smooth skull contour. No tenderness about palpitation.The facial features are
symmetric and no nodules and masses. Has symmetric facial movement. Black hair and short
hair cut. No infections noted.
Skin: smooth skin and warm to touch. Skin color is fair, no pallor and jaundice.
Nails: have an intact epidermis and a capillary refill of less than 3 seconds
Eyes: symmetrically aligned with equal movement. Eyelashes equal distributed. An eyelid
closed symmetrically has complete closure of the eyes. Both eyes are coordinated, with parallel
alignment, pupils equally reactive to light and accommodation. The patient have pale in
conjunctiva. Sclera is white
Ears: Ear color is same as facial skin, they are symmetrical and normal aligned, not painful to
touch, firm and not tender. No visible discharge.
Mouth: lips are not dry. Teeth are complete missing. No signs of tenderness. The lips color is
black. Patient can purse his lips and puff out her cheek. Patient can easily open and close her
mouth. The tongue moves easily and without tremor. Tonsils are lesion free and right in size for
the patient’s age. Voice is clear yet minimal.
Nose: nose is symmetric. No discharge, no tenderness, no lesions noted. Nasal airway is patent.
Neck: symmetrical with intact skin and no masses, swelling and no lymph node enlargement.
Breast: Skin is smooth. Nipples are round and inverted. No signs mass and tenderness
Lungs and Thoracic: Symmetric chest expansion, resonance upon percussion. No masses or
nodules were inflamed during palpitation. Breath sounds are normal upon auscultation.
Abdomen: Have a flabby round abdomen with resonance sounds upon auscultation. Resonance
sounds upon percussion. During palpitation no tenderness and pain .
Urinary: The patient not experiencing dysuria.
Musculoskeletal: All muscle of upper and lower extremities have a weakness with a grade of 3.
They have no pain. Body parts are symmetrical. Body is in alignment.

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COURSE IN THE WARD

DOCOTORS ORDER

6/21/2019
10:10 pm
 Please admit patient under the service of Dr.Lobator to MICU
 Secure patient for admission and management
 IVF:ISDN drip: 10mg = 90cc PNSSx 15 ggts/min
 2-3ggts/min until chest pain free
 NGT feeding : 1200 kcal divided into 6 feedings

 Laboratory test: CBC ,Na,K,U, BUN,Crea, SGPT,SGOT,PT,PTT,Chest X-ray,

ABG

Meds: Aspirin 80mg/tab OD, clopidogrel 75mg/tab OD, Lactulose 70cc OD,Enoxaparin 0.4 c
SQ OD,captopril 25g/tab BID,furosemide 40mg TIV evry12 hrs.,Ampicillin,omeprazole 40mg
TIV OD,

 insulin sliding scale:

180-200 -2 units
201-250 -4 units
251-300 – 6 units
301-300 – 8 units
350-400 – 10 units
>400 refer to mrod
> menoclopromide 10mg TIV every 8 hrs, as necessary, atorvastatin 40 mg/tab OD.
Give clonidine 75mcg

Nurse,s notes

6/21/2019
11:37 pm

FOCUS: Ineffective Airway

DATA: > Admitted for inhalation occupied by due to dyspnea asses with cough and cold.
 Seen and examine of DOB with advice made and carried into
 Conscious and coherent
ACTION: > Consent for advice and management done and signed.
 ISDM drop @ 15mgtts/min.

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 PNSS 90 cc
 v/s BP 160/80
 PR 110 RR 3298% o2 sat
 Temp. 36.7C CBG 306 then refered with sliding order
 Close watcher and monitoring.
RESPONSE: >

6/22/2019

6am FOCUS: Health Instructiolns

DATA: Awake and coherent. Companion on bedside

ACTION: provided health instructions on treatment required.

Instructed client mofifications: low salt low fat and exercises, limit activities.

RESPONSE: knowledge of condition.

6/22/2019

2pm FOCUS: risk for chest pain

DATA: with ongoing ISDN drip as order

ACTION: Maintained on high

RESPONSE: no chest

6/22/2019

10 pm FOCUS: elevate bed.

DATA: bp 170/80 mmhg

ACTION: safety precaution

Clonidine 75mcg

Refer to Dr.

RESPONSE:

Doctors order:

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6/23/2019
2:00 pm

 Remove IFC,NGT
 Start LSLF diet with SAP
 CBC monitoring to TID premeals
 Start amlodipine, clonidine, PRN
 Mgt. sit on bed . sign and symptom of headache
 Vs evry 2

6/23/2019

6am FOCUS: Risk for aspiration

DATA: on bed, awake with NGT intact

ACTION: Monitored for intoward signs and symptoms

provided adequate rest and comfort. Encourage do deep breathing exercises.

With strict aspiration precaution via NGT

IFC and NGT removal aseptically. Istructed to eat per orem but with aspirate precaution.

RESPONSE: safe, feedy and tablets tolerated.

6/23/2019

2pm FOCUS: Health instructions

DATA: awake

ACTION:side rails up

inform medication

RESPONSE: safe

6/24/2019
2:00pm

 To consume ISDN shift to heplock

 Hold Amlodipine

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 Stop captopril
 Start metropolol
 Repeat CBC Na K Cl BUN Crea tom AM

4:05 pm

 Maintain full bladder and/or clamp IFC 4hrs prior procedure

 Transport patient to DRS 15 min prior Dr.

6/24/2019

6 am FOCUS: Risk for Aspiration

DATA: on bed, awake, with NGT removal

With ISDN drip @ 15ugtts/min

ACTION: encourage to deep breathing

Monitored for aspiration. Provide adequate rest and comfort.

RESPONSE: feedy per orem tolerated, safe

6/24/2019

2pm FOCUS: risk for chest pain

DATA: ISDN drip

ACTION: kept safe, side rails up. Monitoring

RESPONSE: no chest pain

6/24/2019

10 pm FOCUS: provision of care

DATA: awake, conscious. Maintain side rails up. Encourage verbalize feeling.

Monitored and referred for any signs and symptoms

Clonidine75 mcg BP 160/80

Kept safe

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6/25/2019
5 pm
 Mgt transfer .patient to female ward
 Secure transfer lu ppmc divided into 2 aliqouts
 IVF to 40 cc/hr day transfusion
 WOF : congestion

6/25/2019

6am FOCUS: health teaching

DATA: on bed,awake. With heplockintact

ACTION: deep breathing exercise. P;rovide adequate rest and comfort.

2pm FOCUS: provision of care

DATA: on bed

ACTION: safety measure on bed

RESPONSE:

10 pm FOCUS: provision of care

ACTION: maintained side rails up

Encourage to verbalize feelings. Monitored and refered for any signs and symptoms

Verified doctors order for blood teransfusion. Baseline vital signs taken prior to BT. BP 140/80,

t: 36.6 PR 82 RR 20 o2 Sat 92 %

4 pm FOCUS: risk for blood transfusion reaction

BT of 1st drip PRBC at with NUBSP 20190374655, properly typed and crossmatched

Obstruct per any BT reactions. Kept safe. Endorsed with ongoing BT.

6/26/2019

6am FOCUS: Risk for BT reaction

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DATA: received with B T of PRCB Type A t approximately 50cc NVBSP

20190379655

ACTION: observed for any signs and symptoms of BT reaction

BT consumed @ am. Transfused and align @ 1pm. NVBSP 20190379655. Blood extracted on

5/28/19. Expiration 7/9/19.

RESPONSE: Endorsed with ongoing BT.

6/26/2017
7:45pm

 Remove and replace present IV site (r-hand) (phlebitis)

 Maintain heplock
 Hold captopirl
 Complete 5 days enoxaparin and discontinue
 Atorvastatin to 40mg 1tab OD
 Omeprazolen IV to Omeprazole 40mg 1cup po OD
 Secure 1 units PRBC and crossmatched in 2 aliqouts
 May walk around
 Hold Lantus for now
 Continue CBG monitoring

6:00 pm

 Repeat CBCPC + BUN Crea 6hrs BT

 Still for FOMT bottle at bedside

6/26/2019

6am FOCUS: Risk for BT reaction

DATA: received with B T of PRCB Type A t approximately 50cc NVBSP

20190379655

ACTION: observed for any signs and symptoms of BT reaction

BT consumed @ am. Transfused and align @ 1pm. NVBSP 20190379655. Blood extracted on

5/28/19. Expiration 7/9/19.

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RESPONSE: Endorsed with ongoing BT.

6/26.2019

2pm FOCUS: risk for BT reaction

DATA: Advised with ongoing BT of alignments infusinf well

ACTION: observed for any BT reaction. Kept siderails up. BT ended

Observe for any past BT reaction

RESPONSE: no noted BT reaction

10 pm FOCUS: provision of care

DATA: awake and conscious

ACTION: maintained siderails up. Encourage to verbalize feeling. Monitored and refered

signs ans symptoms. Kept safe

6/27/2019
2:00 pm

 NonST
 For repeat HBGs today

 Repeat to SVC consultant

4:00 pm

 Follow up repeat ABG

 For partial MGH once ok

 Refer

 Start linagliptin 5mg tab po OD

 To discharge once okay

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6/27.2019

 6am FOCUS: Health promotion

 DATA: awake, conscious

 ACTION: safety measured provided, monitored for recurrence of chest

pain. Advised to avoid stream activities.

 RESPONSE: not in distress

6/27.2019

 2pm FOCUS: fall precaution

DATA: awake, conscious

ACTION: kept siderails up. Observed for any outward signs and symptoms

RESPONSE: safe and stable.

 10pm FOCUS: provision care

DATA: awake, conscious and coherent

ACTION: kept siderails up for safety. Encouraged adequate rest and sleep.

Position comfort

RESPONSE: keptsafe and rested.

6/28/2019

6 am FOCUS: provision of care

DATA: on bed, conscious and coherent

ACTION: safety measures provided. Provided adequate rest and sleep.Monitored for any

signs and symptoms.

Keep monitored.

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REVIEW OF RELATED LITERATURE

Hypertension- Sytolic when the ventricle of the heart is contract.

Diastolic when the ventricle is relax.
Is the force that a person's blood exerts against the walls of their blood vessels. This pressure
depends on the resistance of the blood vessels and how hard the heart has to work.
Etiology: the measure of the force of blood pushing against blood vessel walls. The heartpumps
blood into blood vessels, which carry the blood throughout the body. High blood pressure, also
called hypertension, is dangerous because it makes the heart work harder to pump blood out to the
body and contributes to hardening of the arteries, or atherosclerosis, to stroke, kidney disease, and
to heart failure.
The effects of hypertension may take years develop, but ultimately. If untreated—high
blood pressure overworks the heart, because the left ventricle works harder to pump blood,it is
the area most often affected, leading to left ventricle hypertrophy or muscle enlargement. As a
result, this extra tissue does not have adequate blood supply,often leading to chestpain due to
ischemia or myocardial infarction. Over a period of years the vessel will become hardened and
lose elasticity.

 Stage 1 high blood pressure: 130-139/80-89

 Stage 2 high blood pressure: 140 and above/90 and above
Treatment:
Diet Low salt Low fat, Exercise
Medication: Anti-Hypertensive: Ace inhibitors, Calcium channel blockers, Thiazide diuretics,
Beta blocker, Angiotensin.

Diabetes Mellitus type 2

Diabetes is becoming more common in the United States. From 1980 through 2002, the number
of Americans with diabetes more than doubled and increased in all age groups. Currently, it is
estimated that more than 23 million people in the United States have diabetes, although almost
one third of these cases are undiagnosed. The number of people newly diagnosed with diabetes
increases by about 1 million people per year (Centers for Disease Control and Prevention [CDC],
2008). By 2030, the number of cases is expected to exceed 30 million. In 2000, the worldwide
estimate of the prevalence of diabetes was 171 million people, and by 2030, this is expected to
increase to more than 360 million (World Health Organization, 2008). Diabetes is especially
prevalent in the elderly; as many as 50% of people older than 65 years of age have some degree
of glucose intolerance. People 65 years and older account for almost 40% of people with
diabetes. Minority populations are disproportionately affected by diabetes. From 1980 through
2002, the age-adjusted prevalence of diabetes increased among all gender and race groups, but
compared to Caucasians, African Americans and members of other racial and ethnic groups
(Native Americans and persons of Hispanic origin) are more likely to develop diabetes, are at

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greater risk for many of the complications, and have higher death rates due to diabetes (CDC,
2008)
Diabetes has far-reaching and devastating physical, social, and economic consequences,
including the following: • In the United States, diabetes is the leading cause of nontraumatic
amputations, blindness in working-age adults, and end-stage renal disease (CDC, 2008). •
Diabetes is the third leading cause of death from disease, primarily because of the high rate of
cardiovascular disease (myocardial infarction, stroke, and peripheral vascular disease) among
people with diabetes. • Hospitalization rates for people with diabetes are 2.4 times greater for
adults and 5.3 times greater for children than for the general population. The economic cost of
diabetes continues to increase because of increasing health care costs and an aging population.
Half of all people who have diabetes and are older than 65 years of age are hospitalized each
year, and severe and life-threatening complications often contribute to the increased rates of
hospitalization. Costs related to diabetes are estimated to be almost $174 billion annually,
including direct medical care expenses and indirect costs attributable to disability and premature
death (ADA, 2008a).
Pathophysiology
Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans
in the pancreas. Insulin is an anabolic, or storage, hormone. When a person eats a meal, insulin
secretion increases and moves glucose from the blood into muscle, liver, and fat cells. In those
cells, insulin • Transports and metabolizes glucose for energy • Stimulates storage of glucose in
the liver and muscle (in the form of glycogen) • Signals the liver to stop the release of glucose •
Enhances storage of dietary fat in adipose tissue • Accelerates transport of amino acids (derived
from dietary protein) into cells Insulin also inhibits the breakdown of stored glucose, protein, and
fat. During fasting periods (between meals and overnight), the pancreas continuously releases a
small amount of insulin (basal insulin); another pancreatic hormone called glucagon (secreted by
the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and
stimulates the liver to release stored glucose. The insulin and the glucagon together maintain a
constant level of glucose in the blood by stimulating the release of glucose from the liver.
Initially, the liver produces glucose through the breakdown of glycogen (glycogenolysis). After 8
to 12 hours without food, the liver forms glucose from the breakdown of noncarbohydrate
substances, including amino acids (gluconeogenesis).
Type 2 Diabetes
Type 2 diabetes affects approximately 90% to 95% of people with the disease (CDC, 2008). It
occurs more commonly among people who are older than 30 years of age and obese (National
Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2005), although its incidence
is rapidly increasing in younger people because of the growing epidemic of obesity in children,
adolescents, and young adults (CDC, 2008). The two main problems related to insulin in type 2
diabetes are insulin resistance and impaired insulin secretion. Insulin resistance refers to a
decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell
surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes,

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these intracellular reactions are diminished, making insulin less effective at stimulating glucose
uptake by the tissues and at regulating glucose release by the liver (Fig. 41-1). The exact
mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 diabetes are
unknown, although genetic factors are thought to play a role. To overcome insulin resistance and
to prevent the buildup of glucose in the blood, increased amounts of insulin must be secreted to
maintain the glucose level at a normal or slightly elevated level. This is called metabolic
syndrome, which includes hypertension, hypercholesterolemia, and abdominal obesity. However,
if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and
type 2 diabetes develops. Despite the impaired insulin secretion that is characteristic of type 2
diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying
production of ketone bodies. Therefore, DKA does not typically occur in type 2 diabetes.
However, uncontrolled type 2 diabetes may lead to another acute problem—hyperglycemic
hyperosmolar nonketotic syndrome (see later discussion). Because type 2 diabetes is associated
with a slow, progressive glucose intolerance, its onset may go undetected for many years. If the
patient experiences symptoms, they are frequently mild and may include fatigue, irritability,
polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision (if glucose
levels are very high). For most patients (approximately 75%), type 2 diabetes is detected
incidentally (eg, when routine laboratory tests or ophthalmoscopic examinations are performed).
One consequence of undetected diabetes is that long-term diabetes complications (eg, eye
disease, peripheral neuropathy, peripheral vascular disease) may have developed before the
actual diagnosis of diabetes is made (ADA, 2009a), signifying that the blood glucose has been
elevated for a time before diagnosis.
Etiology: Insulin resistance with relative of insulin deficiency. Most of these clients is obese,
when weight is lose the insulin resistance will diminishes but reappears if the clients regain
weight. Age, lack of exercise, hypertension amd dyslipidemia are all risk factors.
Hyperglycemia results when the pancreas cannot match the body’s need for insulin and/or when
the number of insulin receptor sites are decreased or altered.
Treatment: There is no cure for diabetes but we aim is to control the blood sugar and prevention
of early detection of complication.
Exercises, diet
Medication: metformin tablet and Insulin injection.
Myocardial Infarction NSTEMI
The most common cause of cardiovascular disease in the United States is atherosclerosis, an
abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial
blood vessel walls. These substances block and narrow the coronary vessels in a way that
reduces blood flow to the myocardium. Atherosclerosis involves a repetitious inflammatory
response to injury of the artery wall and subsequent alteration in the structural and biochemical
properties of the arterial walls. New information that relates to the development of
atherosclerosis has increased the understanding of treatment and prevention of this progressive
and potentially life-threatening process. Pathophysiology Atherosclerosis is thought to begin as

20
 21

fatty streaks of lipids that are deposited in the intima of the arterial wall. These lesions
commonly begin early in life, perhaps even in childhood. Not all fatty streaks later develop into
advanced lesions. Genetics and environmental factors are involved in the progression of these
lesions. The development of atherosclerosis over many years involves an inflammatory response,
which begins with injury to the vascular endothelium (Futterman & Lemberg, 2006). The injury
may be initiated by smoking, hypertension, and other factors. The presence of inflammation has
multiple effects on the arterial wall, including the attraction of inflammatory cells, such as
monocytes (macrophages). The macrophages ingest lipids, becoming “foam cells” that transport
the lipids into the arterial wall. Activated macrophages also release biochemical substances that
can further damage the endothelium, attracting platelets and initiating clotting (Carreiro-
Lewandowski, 2006). Smooth muscle cells within the vessel wall subsequently proliferate and
form a fibrous cap over a core filled with lipid and inflammatory infiltrate. These deposits, called
atheromas or plaques, protrude into the lumen of the vessel, narrowing it and obstructing blood
flow. Plaque may be stable or unstable, depending on the degree of inflammation and thickness
of the fibrous cap. If the fibrous cap over the plaque is thick and the lipid pool remains relatively
stable, it can resist the stress of blood flow and vessel movement. If the cap is thin and
inflammation is ongoing, the lesion becomes what is called vulnerable plaque. At this point, the
lipid core may grow, causing it to rupture and hemorrhage into the plaque. A ruptured plaque is a
focus for thrombus formation. The thrombus may then obstruct blood flow, leading to acute
coronary syndrome (ACS), which may result in an acute myocardial infarction (MI) if quick,
decisive action is not taken. When an MI occurs, a portion of the heart muscle becomes necrotic.
The anatomic structure of the coronary arteries makes them particularly susceptible to the
mechanisms of atherosclerosis. As Figure 28-2 shows, the three major coronary arteries have
multiple branches. Atherosclerotic lesions most often form where the vessels branch, suggesting
a hemodynamic component that favors their formation (Porth & Matfin, 2009). Although heart
disease is most often caused by atherosclerosis of the coronary arteries, other phenomena may
also decrease blood flow to the heart. Examples include vasospasm (sudden constriction or
narrowing) of a coronary artery, myocardial trauma from internal or external forces, structural
disease, congenital anomalies, decreased oxygen supply (eg, from acute blood loss, anemia, or
low blood pressure), and increased oxygen demand (eg, from rapid heart rate, thyrotoxicosis, or
use of cocaine).
Etiology: When the heart muscle does not get adequate oxygen due to decrease in blood supply,
an increase oxygen need or a combination of both. The decrease in blood supply in most
commonly caused by atherosclerotic plaque of coronary artery disease. Any that increase oxygen
need of the heart beyond the supply level may lead to myocardial infarct. Activities may include
shock, hemorrhage, stress or excessive physical exertion.
Symptoms: svere chest pain, diaphoresis(sweating), nausea, is not obvious pain left arm,shoulder
and jaw pain.
Treatment: Involves immediate attention to prevent shock, relieve respiratory distress and
decrease workload on the heart.

21
 22

In individual lying in position and tight or restrictive clothing to improve respiratory function.
If cardiac arrest occur CPR can do that. Administer oxygen and pain medication. Medication to
treat arrhythmias.
IV thrombolytic or clot busting therapy using tissue plasminogen activator or streptokinase to
utilize open occlusion and restore blood flow.
Prognosis: Improves if vigorous treatment begins immediately.
Blood Test: Troponin I levels: point of care testing
CK-MB or creatinine kinase and myoglobin.
ECG, to the ECHO.

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Anatomy and Physiology

Cardiovascular system

Anatomy of the Heart

The heart, arteries, and veins, along with the blodd., make up the cardiovascular system.
The heart is a four chambered muscular structure. It is about the size of a man’s fist and weighta
about 300 grams. The heart is situated approximately in the middle of the chest, slightly to the
left behind the sternum (breastbone).
The heart is composed of the pericardium, the chambers, and the valves. The pericardium
is a two-layer sac with fluid between the layers. The wall of the heart is divided into three
layers. Epicardium is the outermost layer , the myocardium is the middle layer, and the
endocardium is the innermost layer.
There are fourchambers in the heart, the right atrium, right ventricle,left atrium, and the
left ventricle. The tricuspid valve is between the right atrium and ventricle, the pulmonary valve
is between the right ventricles and pulmonary artery, and the aortic valve is between the left
ventricle and the aorta.
Blood enters the heart from the superior vena cava, then passes through the right atrium
and the tricuspid valve into the right ventricle. It then passes through the pulmonary valve into
the pulmonary artery, and travels to the lungs where carbon dioxide is exchange for oxygen.
The oxygenated blood returns to the heart through the pulmonary vein, and is pumped into the
left atrium through the mitral valve and into the left ventricle. It passes through the aortic valve
into the aorta and to the body. The heart itself is supplied with blood by the coronary arteries.

Cardiac muscle normally contracts continually throughout one’s lifetime. Designated areas of
the heart produce electrical stimulation, causing the heart muscle to contract and pump the blood
into the body. This sequence of events is termed the cardiac cycle. It begins in th sinoatrial (SA)
node, then passes to the atrioventricular (AV) node to the bundle og HIS and the Purkinje fibers.

23
 24

One sequence of the conduction pathway is one cardiac cycle. This is represented on the
electrocardiogram as the PQRST segment. The P wave represents the electrical stimulation
beginning and passing over the atria (depolarization). The QRS wave is caused be stimulation
passing over the ventricles. The T wave represents the recovery of the ventricles (repolarization).
The cardiac cycle repeats itself approximately 60-100 times per min. in the average adult. One
cycle is one heart beat. The pulsation (heart beat) felt with hand over the chest or the finger tips
placed over an artery (such as at the wrist and neck) is called the pulse. The pulse rate is the
number of pulsation felt in a minute. The closing of the heart valves produces the sounds heard
when listeniong with a stethoscope over the heart.
The circulatory component of the cardiovascular systems includes the arteries and veins. The
three major subsystems include the portal unit, pulmonary unit, and the systemic unit. Each of
these circulatory subsystems have special functions in addition to delivering blood to the body.
The portal unit or subsystem includes the circulation to the stomach, spleen, intestine and
pancreas. Blood from these organs goes through the liver before returning to the heart. The
pulmonary susbsystem includes the pulmonary artery and its divisions. Leading from the heart to
lungs, the circulation through the lungs, the pulmonary vein leading from the lungs back to the
heart. In this suvbsystem, nonoxygenated blood from the systemic circulation passes through the
lungs where an exchange of carbon dioxide for oxygen occurs. The oxygenated blood returns to
the heart to the pumped through the body. The systemic subsystem includes all the arteries and
veins, and their capillaries not already included in the previous subsystem. This subsysrtem
carries the oxygenand nutrients to the body cells and removes waste products.
The level of pressure of the blood pushing against the walls of the vessels as it is delivered
throughout the body referred to as blood pressure. Most individuals are familiar with the arterial
blood pressure taken by the arm over the brachial artery. The pressure measured with
sphygmomanometer is divided into two parts. The systolic pressuire, caused by contraction of
the ventricles, is the first number to record. The second number is diastolic pressure, reflectiong
the relaxation of the ventricles. The average adult pressure is 120/80 mm Hg (millimeters of
mercury).

ENDOCRINE SYSTEM

The Pancreas

The pancreas, located in the upper abdomen, has endocrine

as well as exocrine functions (see Fig. 40-1). The exocrine

functions include secretion of pancreatic enzymes into the

gastrointestinal (GI) tract through the pancreatic duct. The

endocrine functions include secretion of insulin, glucagon,

and somatostatin directly into the bloodstream.

24
 25

The Exocrine Pancreas

The secretions of the exocrine portion of the pancreas are

collected in the pancreatic duct, which joins the common

bile duct and enters the duodenum at the ampulla of Vater.

Surrounding the ampulla is the sphincter of Oddi, which

partially controls the rate at which secretions from the pancreas and the gallbladder enter the
duodenum.

The secretions of the exocrine pancreas are digestive enzymes high in protein content and an
electrolyte-rich fluid.

The secretions, which are very alkaline because of their

high concentration of sodium bicarbonate, are capable of

neutralizing the highly acid gastric juice that enters the

duodenum. The enzyme secretions include amylase, which

aids in the digestion of carbohydrates; trypsin, which aids

in the digestion of proteins; and lipase, which aids in the

digestion of fats. Other enzymes that promote the breakdown of more complex foodstuffs are
also secreted.

Hormones originating in the GI tract stimulate the secretion of these exocrine pancreatic juices.
The hormone

secretin is the major stimulus for increased bicarbonate secretion from the pancreas, and the
major stimulus for digestive enzyme secretion is the hormone CCK-PZ. The vagus

nerve also influences exocrine pancreatic secretion.

The Endocrine Pancreas

The islets of Langerhans, the endocrine part of the pancreas, are collections of cells embedded in
the pancreatic

tissue. They are composed of alpha, beta, and delta cells.

25
 26

The hormone produced by the beta cells is called insulin;

the alpha cells secrete glucagon, and the delta cells secrete

somatostatin.

Insulin

A major action of insulin is to lower blood glucose by permitting entry of glucose into the cells
of the liver, muscle,

and other tissues, where it is either stored as glycogen or

used for energy. Insulin also promotes the storage of fat in

adipose tissue and the synthesis of proteins in various body

tissues. In the absence of insulin, glucose cannot enter the

cells and is excreted in the urine. This condition, called diabetes mellitus, can be diagnosed by
high levels of glucose

in the blood. In diabetes mellitus, stored fats and protein are

used for energy instead of glucose, causing loss of body mass.

(Diabetes mellitus is discussed in detail in Chapter 41.) The

level of glucose in the blood normally regulates the rate of

insulin secretion from the pancreas.

Glucagon

The effect of glucagon (opposite to that of insulin) is chiefly

to raise the blood glucose by converting glycogen to glucose

in the liver. Glucagon is secreted by the pancreas in response to a decrease in the level of blood
glucose.

Somatostatin

Somatostatin exerts a hypoglycemic effect by interfering

with release of growth hormone from the pituitary and

26
 27

glucagon from the pancreas, both of which tend to raise

blood glucose levels.

Endocrine Control of Carbohydrate Metabolism

Glucose required for energy is derived by metabolism of ingested carbohydrates and also from
proteins by the process

of gluconeogenesis. Glucose can be stored temporarily in

the form of glycogen in the liver, muscles, and other tissues.

The endocrine system controls the level of blood glucose by

regulating the rate at which glucose is synthesized, stored,

and moved to and from the bloodstream. Through the action of hormones, blood glucose is
normally maintained at

less than 100 mg/dL (5.5 mmol/L). Insulin is the primary

hormone that lowers the blood glucose level. Hormones

that raise the blood glucose level are glucagon, epinephrine,

adrenocorticosteroids, growth hormone, and thyroid hormone.

The endocrine and exocrine functions of the pancreas

are interrelated. The major exocrine function is to facilitate

digestion through secretion of enzymes into the proximal

duodenum. Secretin and CCK-PZ are hormones from the

GI tract that aid in the digestion of food substances by controlling the secretions of the pancreas.
Neural factors also

influence pancreatic enzyme secretion. Considerable dysfunction of the pancreas must occur
before enzyme secretion decreases and protein and fat digestion becomes impaired. Pancreatic
enzyme secretion is normally 1500 to2500 mL/day.

Gerontologic Considerations

27
 28

There is little change in the size of the pancreas with age.

However, there is an increase in fibrous material and some

fatty deposition in the normal pancreas in people older than70 years of age. Some localized
arteriosclerotic changes occur with age. There is also a decreased rate of pancreatic secretion
(decreased lipase, amylase, and trypsin) and decreased bicarbonate output in older people. Some

impairment of normal fat absorption occurs with increasing

age, possibly because of delayed gastric emptying and pancreatic insufficiency. Decreased
calcium absorption may also

occur. These changes require care in interpreting diagnostic

test results in the normal elderly patient and in providing

dietary counseling.

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 29

PATHOPHYSIOLOGY

Precipitating Predisposing

Diet: carbohydrates Age: 73 yrs olg

Genetics: family history of
diabetes mellitus type and
heart attack

On set of cell Insulin resistance

degradation of insulin
receptor site

Glucose cannot enter into

Dysfunction of pancreas
the bloodstream

Impaired insulin secretion Decrease blood platelet

levels

Increase insulin demand

Weakness

Compensation of pancreas

Exhaustion of pancreas

Insulin insufficiency

Glucose builds up in the

bloodstream
Increase blood viscosity
(hyperglycemia)

29
 30

Increase blood pressure in

the arterioles

Increased Peripheral
Insulin resistance
resistance

Arteriolar narrowing
Vasoconstriction

Damage of coronary
arteries

Plaque of the vessel

Vascular endothelium
injury

Thrombus formation

Blockage of the heart

muscle

Low RBC Dizziness

Low level of oxygen
in the blood

Difficulty of breathing
Decreased oxygen rich
supply
30
 31

Interpretation

On set of cells degrataion of insulin receptor site the pancreas will dysfunction and impaired
insulin secretion and insuliun demand in compensation of pancreas.Exhaustion of pancreas
insulin insufficiency that glucose builds up in the blood stream (hyperglycemia) that glucose
cannot enter into the bloodstream and decrease production of blood and experience of weakness
of the body. And it will increase blood viscosity to increase blood pressure in the arterioles that
increased pheripheral resistance that may cause vasoconstriction and it can narrowing of the
arteriolar and the coronary may damage and it can be cause of atherosclerosis and the vascular
endothelium can injured so it can be transform in thrombus transformation. This can be blockage
of the heart muscle. If they have a plaque the oxygen rich supply you need can be decreases. Due
to the flow of the blood carries oxygen into the body can be difficult to flow. And make you a
low level of blood can’t carry enough oxygen into the body. And shortness of breath appears.
Due to lack of oxygen they need. Experience low RBC is a condition in which you don't have
enough healthy red blood cells to carry adequate oxygen to the body's tissues and you can sign of
dizziness.

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 32

LABORATORY RESULTS

Name: Patient B Age: 73 Date: 6/21/2019 Time: 9:39pm

Room/Bed: ER FIO2: 21%

ARTERIAL BLOOD GAS

Results:
Ph 7.45 (7.35-7.45) HCO3 14.4 (22-26 mEq/L)
pCO2 23.3 (35-45) B.E -8.8 ( +/-2 mEq/L)
po2 67.8 (80-100) O2 sat 93.5
Interpretation:
Respiratory alkalosis: the ph is normal range and the PCO2 and HCO3 is decreased in normal
range.
This is the range of oxygen and carbon dioxide into the body.

Name: Patient B Age: 73 Date: 6/21/2019 Time: 5:15 am

Room/Bed: ER FIO2 : 44%

ARTERIAL BLOOD GAS

Results:
Ph 7.45 (7.35-7.45) HCO3 22.5 (22-26 mEq/L)
pCO2 26.8 (35-45) B.E -3.6 ( +/-2 mEq/L)
po2 70.5 (80-100) O2 sat 97.1%
Interpretation:
Respiratory alkalosis: the ph is normal range and the PCO2 and HCO3 is decreased in normal
range.
This is the range of oxygen and carbon dioxide into the body.

32
 33

Name: Patient B
Received Lab Checked-in Released
21-june-2019 6:07 pm 21-june-2019 6:19 pm 21-june-2019 6:21 pm

Test Name Result Unit Reference Range

Hematology
Complete Blood Count
RBC count L 2.89 4.7-6.1
Hemoglobin L 92.0 140-180
Hematocrit L 0.27 0.40-0.54
MCV 94.80 80.0-96.0
MCH H 31.70 27.0-31.0
MCHC 33.50 32.0-36.0
RDW 12.4 11.6-14.6
Platelet count 246 150-450
MPV 9.10 6.5-12.0
PDW 15.90 15.0-17.0
WBC 9.7 5.0-10.0
Different count
Nuetrophil H 0.75 0.50-0.70
Lymphocytes L 0.17 0.2-0.5
Eosinophil 0.03 0.0-0.06
Monocytes 0.04 0.02-0.09
Basophil 0.01 0.0-0.02

Interpretation:
The first hematology report, which was taken last june 21, 2019, shows normal result aside from
the RBC,Hemoglobin, hemnatocrit, MCH, neutrophil and lymphocytes.
The decreased level of hemoglobin will result to decrease oxygen supply to the body and
decreased hematocrit indicates that the mass of RBC is decreased due to the plaque of the
vessels.
The increased neutrophils and decresed lymphocytes due to infection be blocking the vessel.
The high MCH decreased due to the thickening or large blood cells.

33
 34

Name: Biaco, Erlinda Zamora

Received Lab Checked-in Released
21-june-2019 6:07 pm 21-june-2019 6:32 pm 21-june-2019 6:41 pm

Test Name Result Unit Reference Range

COAGULATION
Prothrombin Time 12.1 secs 11.7-14.8
protime 115
PT Percent Activity 0.91 INR
PT INR 13.2 secs 11.7-14.8
PT Normal control
APTT
APTT L 24.8 secs 27.2-32
APTT Normal 31.1 secs 26.00-34.00
Activity

Interpretation:
Decreased APTT the range secs to form a clot.

Name: Patient B
Received Lab Checked-in Released
21-june-2019 6:07 pm 21-june-2019 6:50 pm 21-june-2019 6:59 pm

Test Name Unit Reference Range

Immunology
Troponin 0.968 high ng/mL 0.034

Interpretation:
Elevated Troponin I is the range of damage of the heart muscle.

34
 35

Name: Patient B
Received Lab Checked-in Released
25-june-2019 5:49 am 29-june-2019 5:55 am 25-june-2019 5:56 am

Test Name Result Unit Reference Range

Hematology
Complete Blood
Count
RBC count L 2.93 4.7-6.1
Hemoglobin L 83.0 140-180
Hematocrit L 0.25 0.40-0.54
MCV 86.50 80.0-96.0
MCH 28.40 27.0-31.0
MCHC 32.90 32.0-36.0
RDW 13.0 11.6-14.6
Platelet count 451 150-450
MPV 8.50 6.5-12.0
PDW 15.90 15.0-17.0
WBC 52 5.0-10.0
Different count
Nuetrophil 0.63 0.50-0.70
Lymphocytes 0.24 0.2-0.5
Eosinophil 0.06 0.0-0.06
Monocytes 0.06 0.02-0.09
Basophil 0.01 0.0-0.02

Interpretation:
The second hematology report, which was taken last june 21, 2019, shows normal result aside
from the RBC,Hemoglobin, hemnatocrit, MCH, neutrophil and lymphocytes.
The decreased level of hemoglobin will result to decrease oxygen supply to the body and
decreased hematocrit indicates that the mass of RBC is decreased due to the plaque of the
vessels.

35
 36

Name: Patient B
Received Lab Checked-in Released
25-june-2019 5:49 am 29-june-2019 6:14 am 25-june-2019 6:22 am
Test Name Result Unit
Clinical chemistry
Sodium 143.26 137-145 Mmol/L
Potassium 3.58 3.5-5.1Mmol/L
Chloride 106.00 98-107 Mmol/L
Blood urea nitrogen 5.2 2.5-6.1 Mmol/L
Creatinine 86 46-92 Mmol/L

Interpretation:
The CBC count taken june 29,2019 .The sodium, Potasium,chloride, BUN,CREA is in normal
range.

NAME: Patient B Date: 6/25/2019

AGE: 73 y/0 Gender: female Lab.no.: 6.24 Hosp.no: 1246980
BLOOD TYPING AND CROSSMATCHING RESULT
Patient’s blood type: A Rh Group: POSITIVE Done by:
Source Serial compone ABO Rh phase Salin Protei Coomb interpretatio
of numb nt typing typing s e n 37 ’s n
blood er (RT) C (AHG) C I
Hemolyzed
QMM NVB PRBC A positive MAJ reg reg reg inpatens
C SP OR
2019 (PSR
0379 D)
655
AUT
O
CON
TRO
L
(PSP
R)

EXTRACTION: 5/28/2019 EXPIRATION: 7/9/2019

Interpretation:
The type of blood is type A+.

36
 37

DRUG STUDY

Name of Classification Mechanism of Contraindication Indications, Side and Adverse Nursing Responsibilities
Drug Action Route and Effects
Dosage
Metoprolol Antianginal Inhibits Acute heart I: CNS: Anxiety, -Advise patient to notify prescriber
Tartate Antihypertensi stimulation of failure, Hypertensio Confusion, if pulse rate falls below 60 bpm or
(Lopressor) ve beta1 – receptor Bradycardia < 45 n Dizziness, is significantly lower than usual.
MI sites in bpm, D:50 mg/tab Drowsiness, -be aware that patients who take
Prophylaxis decreased Hypersensitivity to Fatigue, metoprolol may be at risk for AV
and treatment cardiac metoprolol or its Headache block.
excitability, components CV: Angina, -If AV block results from depressed
cardiac output arrhythmias, AV node conduction, prepare to
and myocardial Orthostatic administer appropriate drug, as
oxygen demand. hypotension prescribed, or assist with insertion
These effects EENT: Nasal of temporary pacemaker.
help relieve congestion, Taste -Be aware that abrupt withdrawal of
angina and disturbance drug can precipitate thyroid storm
reduce blood GI: Constipation, in patient with hyperthyroidism or
pressure. Diarrhea, Nausea, thyrotoxicosis.
Vomiting -Abrupt discontinuation of drug can
MS: Backpain, cause myocardial ischemia, Mi or
Myalgia severe hypertension especially in
RESP: Dyspnea patient with cardiac diseases.
SKIN: -Check blood pressure an hour or
Diaphoresis, two after administering the drug.
Rash, Urticaria

37
 38
Name of Contraindications Indications
Drug Dosage
Brand Name: 40 mg > Contraindicated >Short-term treatment of
Prilosec /cup with hypersensitivity active duodenal ulcer;
OD AC to omeprazole its First-line therapy in treatment
Generic name:
of heartburn or symptoms of
Omeprazole components;use
gastroesophageal reflux
cautiously with
disease(GERD); >Short-term
pregnancy,lactation. treatment of active benign
gastric ulcer; GERD,severe
erosive esophagitis,poorly
responsive
symptomaticGERD;
>Long-term
therapy:Treatment of
pathologic hyper secretory
conditions (Zollinger-
Ellisonsyndrome,multipleade
nomas,systemicmastocytosis);
Eradication of H. pylori With
amoxicillin or metronidazole.
38
Adverse Effect
>diarrhea,nausea,fatigue,const
ipation,
vomiting,flatulence,acid
regurgitation,taste
prevention.arthralgia,myalgia.
urticaria,dry mouth,
dizziness,headache,paraesthes
ia,abdominal pain,skin rashes,
weakness,back pain,upper
respiratory infection,cough.
Potentially fatal:
Anaphyolaxis
Nursing Responsibilities
>caution patient to swallow
capsules whole-not to
open,chew,or crush them.
>Arrange for further
evaluation of patient after 8
weeks of theraphy for
gastroreflux disorders;not
intended for maintenance
theraphy.
>Administer antacids with
omeprazole,it needed.
Teaching points:
Take the drug before meds.
Swallow the capsules
whole;do not chew,open,
or crush them.This drug
will need to be taken for
upto 8 week (short-term
therapy)or far a prolonged
period >5yrs in some
classes.have regular
medical follow- up visits.
 Name of Contraindications Indications39 Adverse Nursing Responsibilities
Drug Dosage Effect
Brand Name: >hypersensitivity,acti >reduction of risk of stroke and >Headache,platul >Stress that atorvastatin
Atorvastatin ve liver disease or heart attack in type @ diabetes ence,diarrhea,vo is anadjunct to not a substitute
unexplained patients without evidence of miting,anorexiaan for low-cholesterol diet
Generic name:
heart disease but with other CV gioedema,myalgi >Tell patient to take drug
Lipitor persistent elevation of
risk factors and a,alopecia,allergy, at thesame time each day
serum revascularization procedures in infection,chest tomaintain its effects
transaminase,porphyr patient without evidence if pain
ia,pregnancy,lactation coronary heart disease(CHD)but Potentially fatal: >Instruct patient to take a
. multiple risk factors other than Thrombocytopeni missed dose as soon as
diabetes(eg.smoking,HTN,low a,rhabdomyolysis possible. If it’s almost time
HDL, family history of CHD,to with acute renal
reduce risk of for his next dose, he should
failure.
MI,revascularization skip the missed dose.
procedures,hospitalization for
CHF and angina. >Advise patient to
. notify prescriber immediately
if he develops unexplained
muscle pain, tenderness, or
weakness,especially if
accompanied by fatigue or
fever

39
 40

Name of Contraindications Indications Adverse Nursing Responsibilities

Drug Dosage Effect
Brand Name: ORAL > Hypersensitivity.Disorders of > It is indicated >.Side Effects: > Monitor BP carefully when
Catapres 0.1mg cardiac pacemaker is the treatment >Dry mouth discontinuing clonidine;hypertension
0.2mg activityand conduction.Pregnancy for >Drowsiness usually returns within 48 hr2.
Generic name :
hypertension. >Dizziness
Clonidine o.3mg andlactation.
>Constipation Advise patient to take
75mg / drug exactly as prescribed and not to
tablet PRN >Sedation
stop abruptly because withdrawal
Adverse Effects:
symptoms andsevere hypertension
>Vomiting
may occur..
>Loss of appetite
>Malaise (a
Instruct patient to
generalill
consult prescriberif dry mouth or
feeling)
drowsiness becomesa problem.
>Elevated
liverenzymes
During oral clonidine therapy.
(foundusing a
Tominimize these effects,
blood test)
prescriber may suggest taking most of
>Weight gain
dosage at bedtime.5.
>Rash.
Instruct patient to report
chest pain,dizziness with position
changes,excessive drowsiness,
rash, urineretention, and vision
changes. Asneeded, tell patient to
rise slowly toavoid hypotensive
effects..

40
 41

Name of Indications Adverse Effect Nursing Responsibilities

Drug Dosage Contraindications
Brand Name: >Contraindicated i > Reduction > CNS: > Assessment
Clopidogrel 75mg 1 n: of atherosclerotic Depression,Dizziness, Assess patient for symptoms of
Tab PO Hypersensitivity events(MI, Fatigue,HeadacheEENT: stroke,peripheral vascular disease, or
Pathologic stroke, Epistaxis. MI periodically during therapy.Monitor
OD
bleeding(peptic vascular death) in Resp: patient for signs of thrombotic thrombocytic
ulcer, intracranial patients at riskfor purpura
Cough, Dyspnea.
hemorrhage)Lactati such events (thrombocytopenia,microangiopathic
CV:
on. including recent hemolytic anemia,neurologic findings, renal
MI,acute Chest Pain,
Use Cautiously in: dysfunction, fever).May rarely occur, even
coronary Edema,Hypertension.
Patients at risk after short exposure(<2 wk). Requires
syndrome GI: prompt treatment.
for bleeding GI Bleeding, Abdominal
(unstable Implementation
(trauma,surgery, or angina/non-Q- Pain, Diarrhea,Dyspepsia,
Discontinue clopidogrel 5-7 days
other pathologic waveMI), stroke, Gastritis.
beforeplanned surgical procedures.
conditions)History or peripheral Derm:
PO:
of GIbleeding/ulcer vascular disease. Pruritus, Purpura,Rash.
Administer once daily without regardto
disease Severe Hemat: food.
hepatic impairment. Bleeding,Neutropenia, Patient/Family Teaching
Thrombotic
Instruct patient to take medication exactly
ThrombocytopenicPurpura.
as directed. Take missed doses as soon as
Metab: possible unless almost time for next dose;
Hypercholesterolemia. do not double doses. Advise patient to
MS: notify health care professional promptly if
Arthralgia, Back Pain. fever, chills, sore throat, or unusual
Misc: bleeding or bruising occurs. Advise
Fever,Hypersensitivity patient to notify health care professional of
Reactions. medication regimen prior to treatment or
surgery.

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Name of Nursing
Contraindications Indications Adverse Effect
Drug Dosage Responsibilities

> Monitor CBC and

> Patients at risk for platelet counts.watch
Brand Name: thromboembolic for signs and
Lenovox complications due to >CNS: dizziness, symptoms of bleeding
severely restricted headache,insomnia,confusi > Teach patient safety
>hypersensitivity to mobility during acute on, cerebrovascular measures to avoid
Generic name illness. accident. bruising or bleeding.
drug
: >prevention of ischemic CV: edema, chest pain, >As appropriate,
heparin,sulfites,benzyl
Enoxaparin 0.4 cc complications of unstable atrial fibrillation, heart review all other
alcoholor pork products
SQ OD angina or non Q wave failure. significant and life-
>thrombocytopenia myocardial infarction. GU: Urinary retention threatening adverse
>active major bleeding. >Hospitalized patients Skin: btuising.pruritis, reactions and
Therapeutic with acute DVT with or rash. Urticaria. interactions, especially
class: without pulmonary those related to drugs,
anticoagulant embolism.(given with tests.
warfarin sodium)

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Name of Drug Contraindications Indications Adverse Effect Nursing Responsibilities

Dosage
Brand Name: >hypersensitivity to >Mild pain. >EENT: hearing loss, >watch for signs and symptoms
Bayer aspirin > 80mg salicylates, other >acute tinnitus of hypersensitivity and other
1 TAB NSAIDS rheumatic fever >GI: nausea, adverse reactions, especially
>to reduce risk vomiting, abdom inal bleeding tendency
Generic name : OD >renal impairment
of transient pain, heart burn, >stay alert for signs and
Aspirin >blood coagulation ischemic attacks anorexia symptoms of acute toxicity
defects >to reduce risk Respiratory: wheezes >monitor elderly partients
Therapeutic class: Concurrent of myocardial SKIN: rash.urticaria, carefully because they’re at
anticoagulant use infarction bruising angioedema greater risk for salicylate
Anti-piuretic, toxicity.
antiplatelet drug >pregnancy
> check salicylate blood levels
Pharmacological: . frequently.
NSAIDS >evaluate patient for signs and
Nonsteroidal anti- symptoms of hearing loss
inflamatory drug tinnitus, vertigo

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Name of Drug Contraindications Indications Adverse Effect Nursing

Dosage Responsibilities
Brand Name: >hypersensitivity to >Essential >CNS: headachedizziness, > monitor patient for
Norvasc 75mg 1 drug hypertension, chronic drowsiness, fatigue,weakness worsening angina.
tab PRN . stable angina pectoris CV: peripheral edema, >monitor heart rate,
Generic name :
and vasospastic angina,bradycardia,hypotension blood pressure
Amlodipine angina. GI: nausea, abdominal discomfort >assess for heart
besylate Musculoskeletal:muscle cramps, failure,report signs
muscle pain and symptoms.
Therapeutic SKIN: rash,pruritis,
class: urticaria,flushing
Antihypertensive

Name of Drug Contraindications Indications Adverse Effect Nursing Responsibilities

Dosage

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Brand Name: >Hypersensitivity >to fascilitate small >CNS:drowsiness,restlessness > Monitor blood
Metoclopramide 10 mg >pheochromocytoma bowel intubation; , anxiety,depression, pressure during iv
radiologic irritability, fatgigue, administration.
hydrochloride IV >parkinson’s disease
examination when insomnia. >stay alert for
Generic name : PRN Q8 >suspected GI delayed >CV: hypertension, depression and other
obstruction, gastricemptying hypotension edverse effect.
Therapeutic class: perforation or interferes. >GI: nausea, constipation, Tell patient to take 30
antiemetic , GI stimulant hemorrhage >gastroesophageal diarrhea, dry mouth minutes before meals.
>history of seizure reflux >instruct patient to
disorder. >prevention of report involuntary
postoperative nausea movements of face and
and vomiting altered consciousness or
blood pressure

Name of Nursing
Dosage Contraindications Indications Adverse Effect
Drug Responsibilities

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>Monitor for sudden

blood pressure drop
Brand Name:
within 3 hours of
Capoten initial dose if patient
>CNS:
>hypersensitivity to is receiving
>hypertension dizziness,headache,drowsiness,
Generic name drug or other ACE fatigue, weakness concurrentdiuretics.
>heart failure
: inhibitors CV: angina: pectoris, >tell patient to take
25 mg >left ventricular drug 1 hour before
Captopril > Angioedema dysfunction after tachycardia
1TAB BID meals on empty
> pregnancy myocardial EENT:sinusitis
stomach.
infarction GI:nausea, diarrhea,anorexia
Therapeutic >advice patient to
. SKIN: angioedema report fever, rash,
class:
Anti- aore throat, mouth
sores, irregular heart
hypertensive
beat, chest pain.

Nursing Care Plan

Assessment Planning Interventions Rationale Evaluation

Diagnosis

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Subjective:
“nanghihina Activity Short-term goal: 1. Establish rapport. 1. To gain trust. Short-term goal:
ako.” intolerance 2. Monitored and 2. To obtain baseline
As verbalized related to assessed vital sign. data.
After 2-3 hrs of After 2 hrs of
3. Assessed patient’s 3. To note for any
by the patient. plaque nursing intervention nursing intervention
general physical abnormality.
Objective: manifested the patient will condition. 4. To determine muscle patient will
PR: 110 by participate of range 4. Performed muscle functioning on the participated in range
weakness. motion exercise on strength test. extremities. of motion exercise.
RR:25
extremities. 5. Promoted 5. To boost strength.
BP: 180/70 adequate rest. 6. Knowledge promotes
Muscle strength 6. Range of motion awareness to prevent Long-term goal:
test: Long-Term Goal: by closed and the complication of
Right arm: 4/5 open arms and overexertion. After 2 days of
After 2 days of stretching. nursing intervention
Left arm: 4/5
Right Leg: 4/5 nursing Intervention patient can walk and
Left leg: 4/5 patient will do daily do activities with
activity with assist of assist of family
family members. members.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:
“nahihirapan ako Ineffective airway Short-term goal: 1. Monitor vital 1. Provides Short-term goal:
huminga kapag clearance related to signs PR,RR baseline data
naglalakad ako “ as plaque as and blood information for
After 3-5 hrs of After 5 hrs of nursing
pressure. formulating
verbalized by the manifested by nursing intervention patient can
2. Observe and goals.

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patient shortness of breath. intervention monitor the 2. Sleep walk slowly to comfort
patient will do patients sleep deprivation and room with support.
daily living pattern. difficulties
Objective:
3. Observe and during sleep can
PR: 110 activities. Long-term goal:
document affect the
RR: 25 response to activity level of
BP: 160/80 Long-term goal: activity. patient. After 2 days of nursing
4. Teaching 3. Close intervention patient can
patient activity monitoring will
After 2 days of go to toilet room
of deep serve as a cause
nursing breathing for optimal slowly without any
intervention exercises 3x a progression of signs of difficulty
patient can do day or more activity. breathing.
daily activities daily. 4. Knowledge
with support 5. Sitting up in 30 promotes
without any signs mins. 3x daily. awareness to
prevent the
of difficulty
complication of
breathing. overexertion.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:
“Nahihilo ako Risk for injury Short-term goal:  Monitor vital  For provides Short-term goal:
kapag tumatayo” as related to high After 5 hrs of signs data
PR,RR,BP,and information.

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verbalized by the pressure as nursing intervention TEMP,  For the safety of After 5hrs. of nursing
patient. manifested by patient can  Keep the side the patient. intervention patient can
Objective: dizziness. cooperate. rails up.  For the cooperate of my nursing
 Teach the knowledge
PR: 110 care to her.
patient to awareness and
RR: 25 Long-term goal: sitting 30 mins. to circulate the
BP: 160/80  Keep the linen blood flow. Long-term goal:
After 2 days of stretch.  For the physical
 Instruct the mobility.
nursing intervention After 2 days of nursing
patient for  For the safety of
patient can be safety assistance if the patient. intervention patient is are
and free from when she’s free from injury and goal
injury. doing. has been met.

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XIV. DISCHARGE PLAANING

Name: Patient B Age: 73 yrs old Religion: Catholic

Diagnosis: nstemi secondary to hypertension, Diabetes mellitus type 2

Hospital: Quirini Memorial Medical Center Ward: Female Philhealth Ward

Physician:

A. Objectives

Ensuring that the patients' need to know their health and will do after they return home.

B. Medications
 Atorvastatin 40 mg/ tablet once a day
 Clopidegrel 75 mg/ tablet once a day
 Omeprazole 40mg 1 cup once a day
 Amlodipine 10 mg/tablet once a day

C. Health Teaching

1. Seek care immediately if:

* You are tired and your heart is beating faster than usual.

* You are bleeding gums or nose.

* You urinate less than usual or not.

* You have swelling in your feet and ankle

2. Taking medications:

* do not start or stop any medicines unless your doctor provide tells you to.

*use washcloth on your skin and soft toothbrush to your teeth for prebvent bleeding.

*do not take ibuprofen instead.

*if you have a side effect to your medicine or allergic reaction tell your doctor asap.

* check your blood pressure and Glucose level in your home.

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3. Lifestyle teaching

* Low salt and low fat diet to increase blood pressure and risk for heart attack and sugar.

4. Exercise

* makes your heart stronger, lower your blood pressure and helps prevent heart attack.

30-60mins.a day, 5-7 days a week by walking.

 Maintain a healthy weight.

 Manage stress cause increase your blood pressure
 Go for follow-up check up to your doctor if they tell you.

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