Acute Coronary Syndrome, STEMI, Anterior Wall, Killips - 1, DM Type II - Uncontrolled

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled I. INTRODUCTION Acute Coronary Syndrome is defined as a spectrum of conditions involving chest discomfort or other symptoms caused by lack of oxygen to the heart muscle (the myocardium). The unification of these manifestations of coronary artery disease under a single term reflects the understanding that these are caused by a similar pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary arteries and impaired blood supply to the heart muscle. It encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and non–ST-segment elevation myocardial infarction. Diagnosis requires an electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. In acute coronary syndrome, common electrocardiographic abnormalities include T-wave tenting or inversion, ST-segment elevation or depression (including J-point elevation in multiple leads), and pathologic Q waves. If prompt actions are not done complications such as Myocardial Infarction may take place. (http://www.mayoclinic.com/health/acutecoronary-syndrome/DS01061/DSECTION=symptoms) The risk factors for acute coronary syndrome are similar to those for other types of heart disease. It includes Older age (older than 45 for men and older than 55 for women), high blood pressure, high blood cholesterol, cigarette smoking, lack of physical activity, type 2 diabetes, family history of chest pain, heart disease or stroke. Signs and symptoms include Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer, Pain elsewhere in the body, such as the left upper arm or jaw (referred pain), nausea, vomiting, shortness of breath (dyspnea), and sudden, heavy

sweating

(diaphoresis)

(http://www.mayoclinic.com/health/acute-coronary

syndrome/DS01061/DSECTION=symptoms) According to the morbidity rate, taken from the records of the Department of Health for region X, the occurrence of cardiovascular diseases per 100,000 populations is 3,356. This data is taken from the 2001-2005, a 5 year-average record. While the occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373 per

100,000

populations.(http://www.dh.gov.uk/en/index.htmhttp://www.dh.gov.uk/en

/index.htm) On the other hand, Diabetes Mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. 1

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working. Diabetes is the third leading cause

of

death

in

the

United

States

after

heart

(http://www.medicinenet.com/diabetes_mellitus/page4.htm#tocf)

2

disease

and cancer.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled II. SCOPE AND LIMITATIONS OF THE STUDY This case study tackles about Acute Coronary Syndrome specifically on the case of patient JB. It includes essential concepts in relation to the said condition such as the patient’s profile and health history, nursing assessment and clinical manifestations, drug study and diagnostic exams done. The anatomy and physiology is also included as well as the pathophysiology of Acute Coronary Syndrome with its associated factors. The Medical and Nursing Management along with the discharge plans and other relevant data are also being covered. The scope of the plan encompasses during the course of duty last June 29, 30 and July 1 of year 2011 wherein the assigned students who have assessed the client with cumulative interaction and good rapport to the patient and significant others. Nursing Management covers the above mentioned dates which encompasses the client’s Recovery Phase. Data gathering about the Laboratory results covers from June 29 to 30, 2011 The areas of concerns are limited to the discussions of Acute Coronary Syndrome with uncontrolled diabetes type II and the quality of Nursing Care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and his medical records.

OBJECTIVES OF THE STUDY The study aims to explore the concepts about the condition and the quality of nursing care being rendered to our client that was diagnosed with Acute Coronary Syndrome and uncontrolled diabetes type II. In order to learn more about the health condition of the patient, the study wants to fathom about the predisposing and precipitating factors, anatomy and physiology and the pathophysiology of the condition experienced by the client. Basically, the main goal of this study in relation to knowledge is to identify the nursing interventions after the condition of patient. The study aims to critically analyze the qualitative and quantitative data gathered in order to establish connection between the different manifestations experienced by the patient with that of the disease process. To be able to improve skills, the students also endeavors to come up with nursing care plans that will alleviate patient’s condition. The presentors also intend to compare and contrast the ideal management for Acute

3

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled Coronary Syndrome with that of the actual management. In addition, the study seeks to disseminate essential information to everybody for awareness. Furthermore, by this study, the provider will be able to exercise that attitude of determination and in order to come up with a successful study

SIGNIFICANCE OF THE STUDY The study is significant to the following people: the client, the client’s family, and nursing students The study is significant to the client, because it enlightens the client’s queries and doubts regarding her condition. Allowing him to understand the situation of his present state, this would allow him to be more aware of the importance of following the treatment regimen. Client’s family must also be aware of the condition of the client. With the study, the client’s family will be able to participate in the client’s treatment, and they will be able realize the importance of the support system in participating in the client’s care. The study is also important to the nursing students, since it allows them to explore the client’s condition, giving them firsthand experience in observing the manifestations of the disease condition and allowing them to apply theoretical knowledge regarding nursing managements for the manifested signs and symptoms.

4

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled III. CLIENT’S PROFILE A. Socio-demographic Date Patient JB is a 54-year old male, Protestant, married to his 50-year old wife and is currently residing at Opol, Misamis Oriental was admitted last June 29, 2011 due to chest pain at Northern Mindanao Medical Center – Intensive Coronary Care Unit. B. Vital Signs Upon assessment, the patient’s vital signs were: BP: 110/80 mmHg, Temperature: 36.2 degree Celsius, PR: 58 beats per minute (bradycardia), and RR: 25 cycles per minute (tachypnea) and 27 cycles per minute (tachypnea) upon exertion. The patient weighs 62 kilograms and is 160 centimeters tall C. Health Pattern Assessment Aside from the current condition, patient also complained of non-productive cough and prostate enlargement. Generally, he looks normal and able to ambulate and change positions as well. There was no history of tobacco and illicit drug use as well as alcohol consumption yet he’s taking a cupful of coffee everyday for almost 30years. No allergies were reported. 

Past Medical History Client JB has been previously hospitalized twice. First was last July 2009 at Cagayan de Oro Medical Center with the diagnosis of Myocardial Infarction and the second admission was in Northern Mindanao Medical Center last November 2009 due to left cerebrovascular disease. He also has the family history of Diabetes Mellitus on both maternal and paternal side and taking metformin 500mg to control increase blood glucose level taken BID. He was also diagnosed to have Benign Prostate Hypertrophy (BPH) and was given tamsulosin hydrochloride 400mg OD taken every morning.



History of Present Illness Client JB was climbing the stairs upon reaching the second plight of it, he felt intense pain on his left chest that radiated to his left shoulder associated with shortness of breathing. He was then brought to the Emergency Room subsequently, thus caused him to be admitted last June 29, 2011. His diagnosis was Acute Coronary Syndrome, ST Elevation,

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled Myocardial Infarction (STEMI) Anterior Wall, Killips-1, Diabetes Mellitus Type II - Uncontrolled.



Physical Assessment Client JB has an oxygen inhalation @ 2 LPM via nasal cannula and an intravenous fluid of PNSS1L regulated at 10 cc per hour infusing well at the right arm. Capillary Blood Glucose Monitoring was also done to the patient: on the first day, he has blood glucose of 172mg/dl then the next day it became normal with a value of100mg/dl.

HEENT: Head, hair and scalp Eyes: sclera, pupils

Normocephalic with fine hair and clean scalp. Sclerae are anicteric, pupils are equal in size and reaction to light. Periorbital region is not sunken or edematous. Cornea and lens are not opaque

Ears and tympanic membrane

and conjunctiva is pale. Equal in size with no discharges and has equal

Nose

auditory function. Intact tympanic membrane. No nasal flaring noted. Septum is medial. Mucosa is pink in color. Gross smell is normal and

symmetrical. Mouth, lips, tongue, teeth and Lips are pink but oral mucosa is pale. No lesions oral mucosa

noted in the mouth. Tongue is midline. Teeth are

Throat and neck

complete with plaques noted. Gums are pinkish. Trachea and uvula are midline. Thyroids are non

Facial movements

palpable. Tonsils are not inflamed. Symmetrical.



Cognitive/ Neurological Assessment

Level of consciousness Orientation Emotional state

Conscious, coherent and responsive Oriented to time, place and person Calm, but upon exertion he feels dizzy and

Primary language Educational attainment

answers questions inappropriately. Visayan College graduate of Criminology at Ateneo de Davao University



Nutritional and Metabolic Pattern At home, Client JB usually eats three times a day with red meat and rice, but after he was diagnosed with stroke and myocardial infarction

6

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled he was consuming fish, vegetables, and rice with good appetite yet still cannot resist fatty foods and sweets too. He drinks water and other fluids at most 10 glasses a day. He takes no vitamins or mineral supplement at all. Upon hospital stay, his diet was on low salt low fat, full diabetic diet with no nausea and vomiting reported.



Elimination Pattern Patient JB usually follows a pattern in defecating, he used to defecate once every morning; his stool appears soft in consistency, yellow to brown in color and in minimal amount with no discomforts upon defecating. He urinates at about 6-8 times a day with amber to yellow colored urine and in moderate amount and with no difficulty. He has an enlarged prostate and had difficulty urinating before but it subsided after taking due medications.

Abdominal configuration

Symmetrical, no superficial veins, with no lesions

Bowel sounds

and scars Normoactive upon auscultation

Percussion

Tympanic and dullness noted on right upper quadrant



Activity-Exercise Pattern He used to be very active before but after the diagnosis of myocardial infarction, his activities and exercises were restricted but he could still walk for no more than one kilometer and can perform tolerable exercises. Upon overexertion, pain is felt radiating to the left shoulders with a pain scale of 6/10 sometimes felt at night which takes for a minute. His leisure activities include watching TV and socializing with his children and friends.

CARDIOVASCULAR STATUS Chest pain, radiation 7

Positive chest pain at the left side that radiates to the

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled left shoulder, palpitations noted at some times Point of maximal impulse, 5th intercostal space, midclavicular line Precordial area Heart sounds Peripheral pulses Capillary refill time

Flat Distinct and regular, no murmurs noted Regular and symmetrical 2 seconds, no clubbing noted

RESPIRATORY STATUS Breathing pattern Lung expansion Vocal/tactile fremitus Percussion Breath sounds Cough

Irregular (tachypnea) Symmetrical Symmetrical Resonant Rales crackles at inspiration Non - productive with colorless sputum, minimal in amount and viscous in consistency



Sleep and Rest Pattern Client JB usually sleeps about 6-8hours a day with naps during day time. He said this number of hours is adequate enough for his activities the following day. He does not have any history of sleep disturbances but he prays and meditates before sleeping to promote a good and sound sleep.



Role and Relationship Pattern Client JB is married to his 50- year old healthy wife and a father to two healthy kids. The eldest is 20 years old and has graduated Computer Science Studies and the second age 14 who is currently a fourth year high school student. He lives with his family. Client JB reported to have a Diabetes Mellitus in both maternal and paternal side but confused why he has developed Myocardial Infarction.



Value and Belief Pattern Client X is a Protestant; in fact he is a community facilitator of their church. He strongly believes that without God he will be nothing. He gets his strength in facing his condition from his faith that gives him hope. He believes his hospitalization interferes with his religious rites but he finds ways to communicate with God through prayers as an alternative. Moreover, he considers his church mates as his support group and they visited him quite often.

8

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled

9

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled

REVIEW OF SYSTEMS

Pale conjunctiva

Copious nonproductive cough

Pale oral mucosa

Abnormal increase of RR of 25 cpm (at rest) and 27cpm (upon exertion)

Pain radiating to shoulders

Chest pain of 6/10

Prostate Enlargement

CBG shows abnormal increase of blood glucose of 172mg/dl (first day) and normal 10glucose of blood 100mg/dl (second day)

Abnormal decrease of heart rate of 58 bpm (bradycard ia)

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled IV. ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The body’s primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells. Anatomy of the pancreas: The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). The pancreas is made up of two types of tissue: •

Exocrine tissue 11

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled o The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas. •

Endocrine tissue o The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas: The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes bicarbonate to neutralize stomach acid in the duodenum. The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones.

12

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled

CARDIOVASCULAR SYSTEM

13

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled The right and left coronary arteries most often arise independently from individual ostia in association with the right and left aortic valve cusps. The left anterior descending (LAD) and left circumflex (LCX) coronary arteries arise at the left main coronary artery bifurcation; they supply the anterior LV, the bulk of the interventricular septum (anterior two thirds), the apex, and the lateral and posterior LV walls. The right coronary artery (RCA) generally supplies the right ventricle (RV), the posterior third of the interventricular septum, the inferior wall (diaphragmatic surface) of the left ventricle (LV), and a portion of the posterior wall of the LV (by means of the posterior descending branch). When the posterior descending coronary artery (PDA), which supplies the posterior interventricular septum, arises from the LCX artery, the circulation is called left dominant. Most often, the PDA arises from the RCA; this anatomy is called rightdominant circulation. In two thirds of patients, the first branch of the RCA is the conus artery, which supplies the conus arteriosus (RV outflow tract); occasionally the conus arteriosus arises from a separate orifice. In 60% of patients, the sinus node artery arises from the proximal RCA, and in 40% of patients, it arises from the LCX artery. The anterior branches supply the free wall of the RV, and the acute marginal branches supply the RV. When the RCA extends to the crux (the origin of the PDA), it supplies the atrioventricular (AV) node (90%); otherwise, the AV node is supplied by the LCX. Therefore, obstruction of the RCA commonly affects the sinus node and the AV node, resulting in bradycardia, with or without heart block. Not surprisingly, RCA occlusion frequently manifests with sinus bradycardia, AV block, RV myocardial infarction, and/or inferoposterior myocardial infarction (of the LV).Heart is a hollow muscular organ that pumps blood through the body. The heart, blood, and blood vessels make up the circulatory system, which is responsible for distributing oxygen and nutrients to the body and carrying away carbon dioxide and other waste products. The heart is the circulatory system's power supply. It must beat ceaselessly because the body's tissues-especially the brain and the heart itself-depend on a constant supply of oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood for more than a few minutes, death will result. The human heart is shaped like an upside-down pear and is located slightly to the left of center inside the chest cavity. About the size of a closed fist, the heart is made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of 14

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled the body. This rhythmic contraction begins in the developing embryo about three weeks after conception and continues throughout an individual's life. The muscle rests only for a fraction of a second between beats. Over a typical life span of 76 years, the heart will beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of blood. STRUCTURE OF THE HEART The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The heart's lower two chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood away from the heart. A wall of tissue separates the right and left sides of the heart. Each side pumps blood through a different circuit of blood vessels: The right side of the heart pumps oxygen-poor blood to the lungs, while the left side of the heart pumps oxygen-rich blood to the body. Blood returning from a trip around the body has given up most of its oxygen and picked up carbon dioxide in the body's tissues. This oxygen-poor blood feeds into two large veins, the superior vena cava and inferior vena cava, which empty into the right atrium of the heart. The right atrium conducts blood to the right ventricle, and the right ventricle pumps blood into the pulmonary artery. The pulmonary artery carries the blood to the lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty into the left atrium. Blood passes from the left atrium into the left ventricle, from where it is pumped out of the heart into the aorta, the body's largest artery. Smaller arteries that branch off the aorta distribute blood to various parts of the body. A. THE HEART VALVES Four valves within the heart prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but when blood pushes against the valves in the opposite direction, the valves close. Two valves, known as atrioventricular valves, are located between the atria and ventricles. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve. The left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other two heart valves are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moon-shaped flaps of tissue. 15

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled The right semilunar valve, between the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. B. THE MYOCARDIUM Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding of tough connective tissue to form the walls of the heart's chambers. The atria, the receiving chambers of the heart, have relatively thin walls compared to the ventricles, the pumping chambers. The left ventricle has the thickest walls-nearly 1 cm (0.5 in) thick in an adult-because it must work the hardest to propel blood to the farthest reaches of the body. C. THE PERICARDIUM A tough, double-layered sac known as the pericardium surrounds the heart. The inner layer of the pericardium, known as the epicardium, rests directly on top of the heart muscle. The outer layer of the pericardium attaches to the breastbone and other structures in the chest cavity and helps hold the heart in place. Between the two layers of the pericardium is a thin space filled with a watery fluid that helps prevent these layers from rubbing against each other when the heart beats. D. THE ENDOCARDIUM The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white tissue known as the endocardium. The same type of tissue, more broadly referred to as endothelium, also lines the body's blood vessels, forming one continuous lining throughout the circulatory system. This lining helps blood flow smoothly and prevents blood clots from forming inside the circulatory system. E. THE CORONARY ARTERIES The heart is nourished not by the blood passing through its chambers but by a specialized network of blood vessels. Known as the coronary arteries, these blood vessels encircle the heart like a crown. About 5 percent of the blood pumped to the body enters the coronary arteries, which branch from the aorta just above where it emerges from the left ventricle. Three main coronary arteries-the right, the left circumflex, and the left anterior descending-nourish different regions of the heart muscle. From these three arteries arise smaller branches that enter the muscular walls of the heart to provide a constant supply of oxygen and nutrients. Veins running through 16

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled the heart muscle converge to form a large channel called the coronary sinus, which returns blood to the right atrium. FUNCTION OF THE HEART The heart's duties are much broader than simply pumping blood continuously throughout life. The heart must also respond to changes in the body's demand for oxygen. The heart works very differently during sleep, for example, than in the middle of a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can respond almost instantaneously to shifting situations-when a person stands up or lies down, for example, or when a person is faced with a potentially dangerous situation.

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled Predisposing Factors: V. PATHOPHYSIOLOGY Sedentary Lifestyle Eating habits consuming organ meats and fatty foods

Precipitating Factors:

Age (54 years old)

Poor compliance to medication

LEGEND: Increased cell division causing further mutations Predisposing Factors

Gender (male)

Precipitating Factors

Family History of DM

Disease Process Activation of the k-ras oncogene Management

Administered metformin (Glucophage) 500mg 1 tab. OD BID

Abnormal increase in blood glucose level of 139mg/dl

Diagnostic Examination Increase blood glucose level within the serum

Beta cells response poorly to hyperglycemia

18

Compensatory Mechanism Prolong lifespan of affected cells

Continuous replication of affected cells Scanty amount of insulin being released

CBG shows blood glucose level of `72mg/dL

Signs symptoms P53 and mutations which prevent apoptosis

Continuous increase in serum blood glucose

Increase glucagon release Increases number of malignant cells Administered atorvastatin Increase breakdown of (Lipitor) lipids 80mg, 1 tab, PO, OD at HS

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled ===========================> Increase hydrostatic pressure on the coronary artery Increase blood concentration which leads to its viscosity

Sluggish flow going to the heart

Intravenous PNSS at 10cc/hr

Clot formation and lipid deposition on the anterior coronary artery

Lactic acid production

Anaerobic metabolism is initiated

Ischemia on the myocardium Plaque formation in the intimal lining of the anterior coronary artery Still insufficient to supply blood to the heart The fibrous cap (plaque) protrude in the intimal lining Collateral circulation is stimulated to help perfuse the myocardium Partial blockage of the anterior coronary artery Patient JB climbed two flights of stairs 19

Chest pain radiating to the shoulders Pain scale of 6/10

Abnormal Presence of decrease NPO state surgical Possible in wound. increase in lymphocyt acid es 7.1 and production 7.9 within the GI lining

Ketoste Susceptible Activation of ril 1cap. to infection pain PO BID 1.omeprazol mediators e 20mg PO Increase respiratory rate of every 6 25cpm (at rest) and 27cpm hours (upon exertion) 1. celecoxib 2. 1.5gm IVTT ranitidine every 6 hours 500mg IVTT every 8 hrs. 2. paracetamol 60mg IVTT every 6 hours 3. ketorolac Provide oxygen 30mg IVTT every 8 hours inhalation at 2LPM via nasal cannula 4. tramadol 500mg IVTT every 6 hours

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled

Plaque ruptures

Pale mucosa Pale conjunctiva

Exposure of subendohelial matrix

Platelet adhesion to subendothelial matrix

Release of Thromboxane A2, Serotonin and other platelet aggregatory agent

Abnormal decrease of RBC (3.58), Hct (31.5) , Platelet aggregation and Hgb (11.1)

Hardening of the coronary artery

Platelet activation

Converts fibrinogen to fibrin Plasma Coagulation System activation

Change in platelet shape

20

Platelet degranulation

Enhanced affinity to fibrinogen

↑ Expression of Platelet GP IIb/IIIa

Formation of thrombin

Stabilization of fibrin clot Enhances platelet aggregation

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled Impaired repolarization of the myocardium O2 inhalation

Abnormal decrease Infarction on the myocardium takes place

of blood pressure of Decrease perfusion to the system

Abnormal ST elevation seen in the ECG

Decrease cardiac contractility

58bpm Coronary occlusion Decrease cardiac output

Further deprivation of oxygen supply to the myocardium

1. Administered enoxaparin (Clexane) 0.4cc SC every 12 hours Decrease ventricular function

2. clopidogrel (Plavix) 75 mg, 1 tab PO at HS 3. aspirin (Atria SR) 80mg, 1tab, PO, OD after PC

VI. LABORATORY RESULTS Hematology Report (06/29/11) TEST

RESULTS

REFERENCE VALUES

INTERPRETATION

Hgb

11.1

13.7-16.7 g/dL

A decrease in rbc may also decrease hemoglobin since rbc carries oxygen to the blood. A Low hemoglobin may also indicate anemia.

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A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled Hct

31.5

37.0- 47.0 gm%

A low hematocrit level indicates that a person does not have a sufficient volume of red blood cells.

WBC

12, 300

5,000-10,000 cell/mm3

A high blood count indicates is not a specific disease by itself

but

indicates

infection,

systemic

illness,

inflammation, allergy, leukemia and tissue injury. DIFFERENTIAL COUNT: Segmenters

55

45-70%

Within Normal Range

Lymphocytes

40

18-45%

Within Normal Range

Monocytes

5

4-8%

Within Normal Range

Platelet count

329, 000

144,000-372,000 cell/mm3

Within the normal range which connotes the clotting factor is good.

RBC

3.58

4.7-6.1 10^6/uL

A decrease Red blood cell production may indicate anemia and low oxygen levels due to poor heart or lung function.

MCV

81.6

80.0-96.0 fL

Within Normal Range

MCH

30

27.0-31.0 pg

Within Normal Range

MCHC

25.2

32.0-36.0%

A low MCHC number might indicate the presence of anemia, but other factors will be measured as well before making this diagnosis. The mean corpuscular

22

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled volume indicates the size of the red blood cells in a person's body.

Hematology Report (06/30/11) TEST

RESULTS

REFERENCE VALUES

INTERPRETATION

Hgb

14.0

13.7-16.7 g/dL

Within the Normal Range.

Hct

39.6

37.0- 47.0 gm%

Within Normal Range

WBC

11,000

5,000-10,000 cell/mm3

It is beyond normal range. Increase in the WBC count may indicate infection.

DIFFERENTIAL COUNT: Segmenters

23

56

45-70%

Within the Normal Range

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled Lymphocytes

20

18-45%

Within the Normal Range

Monocytes

5.0

4-8%

Within the normal range.

Platelet count

376, 000

144,000-372,000 cell/mm3

Within the normal range thus, the clotting factor is good.

RBC

4.0

4.7-6.1 10^6/uL

Within the normal Range

MCV

83.6

80.0-96.0 fL

Within the Normal Range

MCH

28.0

27.0-31.0 pg

Within the Normal Range

MCHC

36.0

32.0-36.0%

Within the Normal Range

Others Laboratory Examinations (06/29/11) Diagnostic/Laboratory Procedures/Tests

24

Purposes

Result

Analysis and Interpretation

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled 1. ECG

2. CK-MB

The electrocardiogram (ECG or ST segment elevation

Myocardial injury causes the T wave to

EKG) is a diagnostic tool that

become enlarged and symmetric. As the

measures

area of injury becomes ischemic, myocardial

and

records

the

electrical activity of the heart in

repolarization

is

altered

and

delayed,

exquisite detail. Interpretation of

causing T wave to invert. The injured

these details allows diagnosis of a

myocardial cells depolarize normally but

wide range of heart conditions.

repolarize more rapidly than normal cells,

These conditions can vary from

causing the ST segment to rise at least 1

minor to life threatening.

mm above isoelectric line.

CK-MB is a more sensitive marker 2 ng/mL (Reference Value: 0- NORMAL of myocardial injury than total CK 3 ng/mL) activity, because it has a lower basal level and a much narrower normal range.

It is the most

specific index for the diagnosis of 3. Creatinine

25

acute MI. The test is done to evaluate kidney 1.9 mg/dL (Reference Value: Any condition that impairs the function of the function. Creatinine is removed 0.59-1.21)

kidneys will probably raise the creatinine

from the body entirely by the

level in the blood. The most common

kidneys.

is

reasons for developing raised creatinine

abnormal, creatinine levels will

levels will be when the filtration mechanism

If

kidney

function

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled

4. Glucose

increase in the blood (because

becomes gradually damaged by long-term

less creatinine is released through

raised blood pressure or diabetes.

your urine). The test is done to evaluate the 139 mg/dL (Reference Value: The blood

glucose

within

the 59.9 – 110.1)

circulation.

abnormal

glucose

level

decrease

of

denotes

the

the

blood

so-called

hyperglycemia where the concentration of blood

increases

which

results

to

its

viscosity.

VII. DRUG STUDY

DRUG ORDER (Generic name, brand name, classification, dosage, route,

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS

NURSING

OF THE DRUG

RESPONSIBILITIES/ PRECAUTIONS

frequency) GENERIC NAME:

Inhibit an enzyme, 3- Secondary

atorvastatin

hydroxy-

prevention

3methylglutaryl-

cardiovascular

Patients hypersensitive of to atorvastatin and active liver disease or

BRAND NAME:

coenzyme A

Lipitor

CoA) reductase, which risk of MI, stroke, in aspartate

26

(HMG- disease (decrease unexplained persistent

CNS:

dizziness,

headache,

insomnia,

weakness EENT: rhinitis CV:

chest

1. Confirm patient through asking

his

looking

on

name his

and name

bracelet. pain, 2. Obtain a dietary history,

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled

CLASSIFICATION: Lipid-lowering agents HMG-CoA inhibitor DOSAGE: 80mg 1 tab ROUTE: PO

is

responsible

for revascularization

catalyzing an early step procedures, in

the

synthesis

cholesterol.

of angina,

or alanine and aminotransferase (ALT)

hospitalizations for CHF) with

aminotransferase (AST)

in

patients clinically

evident CHD.

peripheral edema

especially with regard to fat

Resp: bronchitis

consumption.

GI: abdominal cramps, constipation, flatulence,

diarrhea, heartburn,

elevated liver enzyme, nausea GU: erectile dysfunction

3.

Evaluate

serum

cholesterol and triglyceride levels

before

during,

and

initiating, after

the

therapy, if possible. 4. Explain to the patient

FREQUENCY: ONCE A DAY TIMING : 8pm

27

what the drug is for. 5. Administer drug before patient goes to sleep.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled

28

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification,

MECHANISM OF ACTION

dosage, route,

CONTRAINDICATIONS

INDICATIONS

ADVERSE EFFECTS

NURSING

OF THE DRUG

RESPONSIBILITIES/ PRECAUTIONS

frequency) GENERIC NAME:

Inhibits

platelet Reduction

clopidogrel bisulfate

aggregation

by atherosclerotic

irreversibly

inhibiting events in patients

BRAND NAME:

the binding of ATP to with MI.

Plavix

platelet

receptors

thereby,

decreases

CLASSIFICATION:

occurrence

Antiplatelet agent

atherosclerotic events.

Platelet

aggregation

inhibitor DOSAGE: 75mg 1 tab

of

of 1.

Hypersensitivity

to CNS:

clopidogrel bisulphate 2. Pathologic bleeding (e.g.

peptic

ulcer,

intracranial hemorrhage 3.

Severe

Patients

dizziness, fatigue

on his name bracelet.

EENT: epistaxis CV: chest pain, edema, hypertension GI:

with

headache, asking his name and looking

liver Resp: cough, dyspnea

impairment 4.

depression, 1. Confirm patient through

rare

galactose intolerance

GI

pain, dyspepsia,

gastritis, constipation Derm: rashes, purpura, pruritus, bruising

ROUTE: PO

29

3. Administer drug before

4. Monitor the vital signs prior,

during

and

after

therapy. 5. Ensure patient’s safety

Hematology: bleeding, through side rails up. neutropenia

FREQUENCY: Once a

what the drug is for.

bleeding, patient goes to sleep.

abdominal diarrhea,

2. Explain to the patient

Metabolic:

6. Keep patient’s skin intact by positioning patient every

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled Day

hypercholesterolemia Muskuloskeletal:

TIMING: HS (8PM)

arthralgia, back pain Miscellaneous:

fever,

hypersensitivity reaction

30

2 hrs.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

31

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS

NURSING

OF THE DRUG

RESPONSIBILITIES/ PRECAUTIONS

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled GENERIC NAME:

Produce analgesia and Prophylaxis

aspirin

reduce

inflammation transient

of 1.

and

MI,

BRAND NAME:

the

mild

to

Artria S.R.

prostaglandins

of fever,

moderate pain

2. Pathologic bleeding (e.g.

peptic

3.

antipyretics,

impairment

analgesics salicylates DOSAGE:80mg 1 tab

ulcer,

intracranial hemorrhage

CLASSIFICATION: nonopioid

to EENT: tinnitus,

ischemic clopidogrel bisulphate

and fever by inhibiting attacks production

Hypersensitivity

4.

Severe

Patients

GI:

GI

1. Confirm patient through

bleeding, asking his name and looking

abdominal nausea, diarrhea, epigastric

pain, on his name bracelet. vomiting, dyspepsia, distress,

liver anorexia, hepatotoxicity

what the drug is for. 3. Assess pain: location,

Hematology: increase type, and intensity before with

rare

galactose intolerance

time, and at the peak of drug

bleeding anemia,hemolysis

Miscellaneous: allergic reactions;

anaphylaxis

and laryngeal edema ROUTE: PO

2. Explain to the patient

action after administration. 4.

Administer

drug

after

lunch. 5. Monitor the vital signs, especially temperature (for

FREQUENCY: Once a

fever) prior, during and after

Day

therapy.

TIMING: after lunch

32

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled

33

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand

MECHANISM OF

name, classification,

ACTION

dosage, route,

CONTRAINDICATIONS

INDICATIONS

ADVERSE EFFECTS

NURSING

OF THE DRUG

RESPONSIBILITIES/ PRECAUTIONS

frequency) GENERIC NAME:

Potentiate the inhibitory Treatment of acute 1.

enoxaparin sodium

effect of antithrombin STon

factor

BRAND NAME:

thrombin.

Clexane

preventing formation.

CLASSIFICATION: anticoagulants

and products of

thrombus venous thromboembolism. (VTE)

dizziness, 1. Confirm patient through

segment- specific agents or pork headache, insomnia

and elevation MI Thus, prevention

to CNS:

2.

Hypersensitivity

enoxaparin sodium 3. Active bleeding

CV: edema to

GI:

on his name bracelet. vomiting,

constipation,

asking his name and looking

nausea,

reversible increase in liver enzymes

2. Explain to the patient what the drug is for. 3.

Assess

for

signs

of

GU: urinary retention

antithrombotics DOSAGE:

Xa

Hypersensitivity

4000iu

(40mg) per 0.4 ml

bleeding and hemorrhage 4. History of heparin- Derm: ecchymosis, (bleeding gums, nosebleed, induced pruritus, rash, urticaria black tarry stools, thrombocytopenia Hematology: bleeding, hematuria). Notify physician anemia,

if such manifestations occur.

thrombocytopenia ROUTE: subcutaneous FREQUENCY: 34

at 4. Administer the drug in a manner, injection site, irritation, slow subcutaneously. pain, hematoma Local:

erythema

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled Q 12H TIMING: 8am-8pm

35

5. Alternate injection site to avoid hypertrophy

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route,

MECHANISM OF

CONTRAINDICATIONS

INDICATIONS

ACTION

ADVERSE EFFECTS

NURSING

OF THE DRUG

RESPONSIBILITIES/ PRECAUTIONS

frequency) GENERIC NAME:

Binds to an enzyme on Reduction of risk of 1.

omeprazole

gastric parietal cells in GI

bleeding

Hypersensitivity

in omeprazole

the presence of acidic critically ill patients BRAND NAME:

gastric pH, preventing and

Prisolec

the final transport of where inhibition of 3. Hypocalcemia hydrogen ions in the gastric acid

CLASSIFICATION: Antiulcer agent Proton-pump inhibitor

gastric lumen.

condition

2. Metabolic alkalosis

to CNS:

dizziness, 1. Confirm patient through

headache, drowsiness, asking his name and looking fatigue, weakness

on his name bracelet.

CV: chest pain

2. Obtain a skin test prior to

GI:

abdominal

secretion may be

acid

beneficial

constipation, flatulence,

diarrhea, what the drug is for. nausea,

DOSAGE: 40mg Derm: itching, rash

TIMING: 8pm 36

4. Inform the patient that administration may cause pain on IV site.

Miscellaneous: allergic 5. Administer the drug in a reaction

FREQUENCY: Q 24H

initial administration.

regurgitation, 3. Explain to the patient

vomiting

ROUTE: IVTT

pain,

slow manner, intravenously.

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

37

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS

NURSING

OF THE DRUG

RESPONSIBILITIES/ PRECAUTIONS

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II Uncontrolled GENERIC NAME:

Unknown. A Selective

Early intervention in 1.

metoprolol

beta

acute MI

blocker

that

selectively blocks betaBRAND NAME:

adrenergic

receptors;

Lopresor

decreases

cardiac

output,

peripheral

CLASSIFICATION:

resistance, and cardiac

Antianginals,

oxygen

antihypertensive agent

and depresses rennin

Beta blockers

secretion.

DOSAGE: 50mg 1 tab ROUTE: PO FREQUENCY: BID

consumption;

Hypersensitivity

to

metoprolol 2. Uncompensated CHF 3. Pulmonary edema 4. Cardiogenic shock 5. Bradycardia or heart block

CNS: fatigue, dizziness, 1. Confirm patient through drowsiness,

anxiety, asking his name and looking

weakness nervousness, on his name bracelet. nightmares, insomnia EENT: blurred vision, stuffy nose Resp:

2. Explain to the patient what the drug is for.

bronchospasm, 3. Monitor vital signs before, during,

wheezing CV:

and

after

hypotension, administration. Take apical

peripheral

pulse before administering.

vasoconstriction,

If HR is