A Case Study of Chronic Calculous Cholecystitis

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

 A CASE STUDY OF MYOCARDIAL INFARCTION INFARCTION -------------------------------Submitted to The Faculty of Nursing Central Luzon College of Science and Technology Olongapo City -------------------------------In Partial Fulfillment Of the Requirements for the Course Nursing Care Management 106 BY: PUGA, EDELBERTO JR. SALAS, EMILINE R.  ARIZALA, MARIA CLOUDYN D. PEJI, AIZA SORIAO, KAREN RASHELL

BSN III- GROUP 1

DATE PRESENTED: December 15, 2012

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

Objectives: Our main reason and purpose in study and exposure in the clinical area is for us to identify problems encountered by the clients; this is one of our tools of learning knowledgeably and skillfully. We, as health care providers, it is indeed our  vocation to adjoined hands with the health team for the promotion of wellness of  our client. Our main objectives for this study are the following: 1.) To identify the chief complaints and admitting diagnosis of our patient so that we can give specific nursing interventions. 2.) To determine the family and personal health history of our p atient that may affect present health condition 3.) To identify the cause and effect of the main problem through a correct analysis of the pathophysiology of the case 4.) To make a nursing care plan for the different health pr oblems encountered by the client. In general, this study aims to enhance the skills and knowledge us the students in providing holistic care to the patient. We logically search further knowledge in order to attain the desired goal and intervention for  the wellness of the patient.

Scope and Limitations Prior to the day of duty, the group has already chosen a patient for care study. We performed a physical assessment to the patient to properly identify the nursing problems, which require necessary and direct interventions and medical regimen. The study on medications and doctor’s order were limited to our chosen patient. Thus, this care study focuses on the particular case of the patient. Since the patient’s diagnosis is more on cardiovascular disease, the group has focused on acute myocardial infarction as one of his admitting diagnosis.

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

I.

Introduction:

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium. Myocardial infarction is considered part of a spectrum referred to as acute coronary syndrome (ACS). The ACS continuum representing ongoing myocardial ischemia or injury consists of unstable angina, non –ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Patients with ischemic discomfort may or may not have ST-segment or  T-wave changes denoted on the electrocardiogram (ECG). ST elevations seen on the ECG reflect active and ongoing transmural myocardial injury. Without immediate reperfusion therapy, most persons with STEMI develop Q waves, reflecting a dead zone of myocardium that has undergone irreversible damage and death. Those without ST elevations are diagnosed either with unstable angina or NSTEMI―differentiated by the presence of cardiac enzymes. Both these conditions may or may not have changes on the surface ECG, including ST-segment depression or T-wave morphological changes. Myocardial infarction may lead to impairment of systolic or diastolic function and to increased predisposition to arrhythmias and other long-term complications. Coronary thrombolysis and mechanical revascularization have revolutionized the primary treatment of acute myocardial infarction, largely because they allow salvage of the myocardium when implemented early after the onset of ischemia. (See Treatment Strategies and Management.) The modest prognostic benefit of an opened infarct-related artery may be realized even when recanalization is induced only 6 hours or more after the onset of symptoms, that is, when the salvaging of substantial amounts of jeopardized ischemic myocardium is no longer likely. The opening of an infarct-related artery may improve ventricular function, collateral blood flow, and ventricular remodeling, and it may decrease infarct expansion, ventricular aneurysm formation, left ventricular dilatation, late arrhythmia associated with ventricular aneurysms, and mortality.

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

RISK FACTORS : These risk factors  – heredity, age and sex  – cannot be changed but if the patient changes his lifestyle and reduces risk factors, chances of living a longer  and healthier life will improve. Prevention of acute myocardial infarction is the best thing and it is never too late to change habits that can harm your heart. This means to do regular health checks and reduce coronary risk factors. Sometime s the presence of only one risk factor from the set is enough to increase the risk of  coronary heart disease. Thus, unfortunately, we see increasingly and frequently young patients (between 30-40 years) hospitalized for acute myocardial infarction, where the only measurable coronary risk factor is smoking. Stress also called the illness of the century, which like smoking is often seen in young people must also be kept under control before irreversible harmful effects on health manifest. Regular checks and blood tests, especially under the supervision of the family doctor are very important to know your level of blood lipids (cholesterol and triglycerides) and blood sugar.

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Nonmodifiable risk factors for atherosclerosis include the following:  Age Sex Family history of premature coronary heart disease Male-pattern baldness Modifiable risk factors for atherosclerosis include the following: Smoking or other tobacco use Diabetes mellitus Hypertension Hypercholesterolemia and hypertriglyceridemia, including lipoprotein disorders Dyslipidemia Obesity Sedentary lifestyle and/or lack of exercise Psychosocial stress Poor oral hygiene

inherited

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

SINGS AND SYMPTOMS:

Sometimes a heart attack starts suddenly and intensely. But often, the onset is slow, with mild pain and discomfort. Patients do not understand what is happening and wait too long before getting help. If you notice any of the myocardial infarction symptoms, do not miss a minute! Seek help immediately! When you suffer a heart attack every minute counts! Be sure to recognize clinical signs, as this can save your life.

Symptoms and signs of acute myocardial infarction need to recognize are:   

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Previous intense chest pain with pressure, burning, weight, grip sensation Pain may radiate to the shoulder, arms, neck, back and upper abdomen Pain duration is more than 20 minutes (up to several hours), does not respond to sublingual nitroglycerin tablets (3 tablets taken every 5 minutes) Pain may be accompanied by other signs: dizziness, fainting, nausea, vomiting, sweating, choking, anxiety, nervousness, palpitations (not all of  these clinical signs occur in every acute myocardial infarction). Pain usually begins with a low intensity and increase in intensity over  several minutes to a maximum. Discomfort may be intermittent. Chest pain that reaches maximum intensity within seconds can be a sign of another  disease, aneurysm of aorta.

If you have one or more of these signs, do not wait any delay could be fatal! Call the ambulance! What happens if a patient with acute myocardial infarction not present at the hospital? Risks of ignoring the warning symptoms for acute myocardial infarction are multiple: Sudden death Severe arrhythmias Development of new angina pain that further increases patient risk for  sudden death  Appearance of heart failure (fatigue, suffocation, and possibly edema in the legs being the most common symptoms)   

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CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

PATIENTS PROFILE: Name: AOF Date of Birth: March 5, 1930 Age: 82 Civil status: Married Birthplace: San Marcelino Zambales Nationality: Filipino Religion: Devine Church Chief complaints: Chest Pain Admission: Date: 12/04/12 Time: 10:20 am Attending physician: Dr. Bayot Admission Dx: Myocardial Infarction Principal Dx: Acute coronary

BASELINE VITAL SIGNS Temperature: 36.6 C Pulse Rate: 94 bpm Respiratory rate: 23 cpm Blood Pressure: 140/100 mmHg Height: 5’5’’ Weight: 77.5 kgs

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

II.

Nursing Assessment:

 A. Personal History Patient Mr. AOF is 81 years old male, a Filipino Citizen who resides at San Marcelino Zambales. He was born on was born on March 5, 1930 his religious affliation Devine Church and he is married. He is a farmer  on their own farmland. alcohol drinker during his adolescence and late adulthood He usually eats pork, vegetables, fish and love eating foods which has condiments like soy sauce and patis. He seldom drinks alcohol and smoke. B. Family Health and Illness History  According to the patient that the familial disease he knows that they have in their family was the hypertension and cardiovascular disease that is on his father’s side. According to the patient’s wife, there is no history of health problems from their family. Nobody aside from Mr. AOF has been admitted for illness. His children were neither non-smoker nor alcoholic but they do drink alcohol occasionally Although there were presence of minor illnesses before like cough, colds, LBM but they were able to catch on the treatment regimen as a home care management.

C. History of Past and Present Illness: This is the second time Mr. AOF been admitted into hospital the last time was years ago year 1980`s and diagnosed for hypertension. He had not experience any accident and injuries, prone to accident. 4 days prior to consult (+) chest pain that is tolerated, no radiating and no other signs and symptoms which recurrent. Until 1 hour prior to admission he experienced dizziness, muscle weakness, and chest pain his admission diagnosis was Myocardial infarction with principal diagnosis of Acute Coronary

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

IX. Discharged Planning:

Medicines: Teach the ff: to the client with regards to proper administration of the prescribed medication.

Environment and Exercise Encourage to establish a clean and well ventilated environment Daily activities should be spaced to provide rest periods between times of  exercise

Treatment  Advise to continue to take the prescribed home medication until end of  the regimen or unless specified by the physician Give relevant information about the drugs, their side effects & their adverse effects. Health Teaching: Instruct patient to comply with the home medications that would be given by his physician. Encourage the patient to do the recommended light exercises such as walking. Avoid doing strenuous activities. Encourage him to comply with the dietary modifications Explain to patient to refer for unusualities immediately. Out Patient Care: support and guidance related to the treatment of the disease and education and counseling related to lifestyle modification. Diet: Client is advised to follow the prescribed recommended diet; a) Diabetic diet: eat complex CHO foods with high fiber content avoid added sugar and concentrated sweets and all other CHO foods and eat regularly.b)Eat foods low in calorie, saturated fats andcholesterol; restriction of s odium; avoidance of spicy foods soft fiber food and take small frequent feedings Spiritual/Safety: Encourage going to church and asking for guidance, encourage praying.

CENTRAL LUZON COLLEGE OF SCIENCE AND TECHNOLOGY #1 CBMU, Upper Kalaklan, Olongapo City

RECOMMENDATIONS  Advised the patient for followed up check up from his assigned physician.  Advised patient peer for frequent monitoring of his vital sign to avoid any risk and possible complication. Explain the purpose and preparation for diagnostic test to have clear understanding of procedures. Provide positive reinforcement for gains/ improvement and participation inself care/treatment program. This encourages continuation of healthybehavior.  Advice patient to take his medication at home as prescribed by thephysician for  continues medication treatment. Suggest engaging in relaxing, non strenuous activity to avoid any risk recurring pain and other clinical manifestations. Encourage patient to eat nutritious food like vegetable fruits, foods the high fiber  contain like cereal and foods rich in protein.

CONCLUSIONS This case study was done successfully although we experienced some difficulties analyzing the health status of the client and understanding the medical orders given. Using our critical thinking, we were able to carefully identify the problem of our patient who needs direct interventions for the wellness of his health. Moreover, the group was able to discuss some health teachings as stated above for the improvement of the client’s health and fast re covery. The patient was able to understand the imparted health teachings and verbalized to consistently follow his treatment regimen in home caremanagement . This study also tests our abilities and skills on how to find answers to the patient’s problem, what action to be done in order to solve it and how to properly and correctly use our initiative for the success and for the good outcome of  our care study. This is one of our tasks as a student or future nurses and it serves as our training ground backed up with strict training in order for us to become equipped, productive, efficient, and world-class nurses in the future.