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Coronary Artery Disease, Acute Myocardial Infarction
In Partial Fulfillment of the Course Requirements in Nursing Care Management
Presented to the Clinical Instructors of Ateneo de Davao University Nursing Division
Submitted to:
Anselmo Lafuente, R.N. Clinical Instructor Submitted by:
Yap, Novelynne Joy A. 4H Submitted on:
February 22, 2007 Table of Contents
I.
Introduction....................................................................................................................3
II.
Objectives......................................................................................................................5
III.
Patient’s Data.................................................................................................................6
IV.
Genogram.......................................................................................................................7
V.
Health Status..................................................................................................................9
VI.
Complete Diagnosis.....................................................................................................12
VII.
Developmental Data.....................................................................................................16
VIII.
Physical Assessment....................................................................................................20
IX.
Anatomy and Physiology.............................................................................................23
X.
Pathophysiology...........................................................................................................34
XI.
Doctor’s Order….........................................................................................................40
XII.
Diagnostic Examination..............................................................................................50
XIII.
Drug Study..................................................................................................................64
XIV.
Nursing Care Plan.......................................................................................................93
XV.
Prognosis....................................................................................................................108
XVI. Bibliography..............................................................................................................110
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INTRODUCTION Coronary Artery Disease (CAD) is characterized by the presence of atherosclerosis in the epicardial coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis, progressively narrow the coronary artery lumen and impair myocardial blood flow. The reduction in coronary artery flow may be symptomatic or asymptomatic, may occur with exertion or at rest, and may culminate in a myocardial infarction, depending on obstruction severity and the rapidity of development. The term myocardial infarction is derived from myocardium (the heart muscle) and infarction (tissue death due to oxygen starvation). Myocardial infarction (MI) is the rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium. This usually results from plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium. Cardiovascular disease is the leading cause of mortality in the United States among both men and women in every major ethnic group. It accounts for nearly 1 million deaths per year and was responsible for one in five deaths in the United States in 2001. Approximately 6 million men have a history of a myocardial infarction, angina pectoris, or both. Coronary artery disease is the most common form of cardiovascular disease. In 2001, the death rate from coronary artery disease was 228 per 100,000 white men, 262 per 100,000 black men, 137 per 100,000 white women, and 177 per 100,000 black women. The estimated prevalence of coronary artery disease in men is 6.9%; among women the prevalence is 6.0%. Internationally, diseases of the heart are the leading cause of death, causing a higher mortality than cancer (malignant neoplasms). Some 7,200,000 men and 6,000,000 women are living with some form of coronary heart disease. 1,200,000 people suffer a (new or recurrent) coronary attack every year, and about 40% of them die as a result of the attack. This roughly means that every 65 seconds, an individual dies of a coronary event.
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In the Philippines, 92 percent of Filipinos 20 years and above have at least one of the risk factors that may soon lead to coronary artery disease and cardiovascular disease if not addressed immediately. These risk factors include diabetes, hypercholesterolemia (high cholesterol levels in the bloodstream), obesity, high blood pressure and smoking. In addition the National Nutrition and Health Survey (NNHeS) report also showed that 22 out of 100 Filipino adults are hypertensive (with blood pressure of 140/90 or higher), and 40 percent of those between 20 and 29 already have prehypertensive findings. During my clinical exposure in the Coronary Care Unit at the Davao Medical Center last November 27-29, 2006, I had a patient with a diagnosis of CAD, AMIK II, (+) LVH, (+) LVD, FC III. This patient is Mr. Perfecto Pandacan Balili, a 60 years old male and will be the focus of my case study.
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OBJECTIVES General Objective: Through this paper, I will be able to present details about Coronary Artery Disease, Myocardial Infarction. The proponent gathered data through interviewing the patient and his watchers, making use of the patient’s records from the hospital, and other researches to provide the readers information about the said condition. This case study would preserve and improve the quality of nursing responsibilities by rendering care, holistically, spiritually, and whole heartedly in a manner that the client, the student nurses and others would benefit. This case study would be able to: •
COGNITIVE: Discuss in details of the chosen illness for the case study so as to gain insight and knowledge about CAD, AMI
•
AFFECTIVE: Have a purposeful interaction with the client’s significant others
•
PSYCHOMOTOR: Enhance the ability to identify and apply nursing interventions to provide a better care for the client’s suffering from the mentioned illness.
Specifically, this paper would be able to: •
Present the patient’s personal data with accuracy
•
Present the genogram that includes the disease of the family members
•
Discuss the health status of the patient that includes the past and present condition
•
Present and discuss the complete diagnosis of the patient
•
Interpret and discuss the developmental data of the patient
•
Obtain the physical assessment of the patient
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Discuss the anatomy and physiology of the affected system
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Trace the pathophysiology of the disease and its underlying causes in relation to the patient’s predisposing and precipitating factors
•
Interpret and present the Physician’s orders
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•
Discuss the different laboratory and diagnostic examinations done top the patient
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Make a drug study on the drugs prescribed to the patient
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Formulate nursing care plans for the patient
•
State the prognosis and relate it with the patient’s condition
PATIENT’S DATA Patient’s Name: Perfecto Pandacan Balili
Hospital Number: 919684
Age: 60 years old Sex: Male Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City Civil Status: married Religion: Roman Catholic Citizenship: Filipino Birthday: July 9, 1946 Birthplace: Tagum City Name of Spouse: Lydia Balili Age: 57 years old Name of Father: Julio Balili (Deceased) Name of Mother: Vicenta Pandacan (Deceased) Area: Coronary Care Unit Bed: 1 Attending Physician: Dr. Voltaire Egnora Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III Chief Complaint: Dyspnea Date and Time Admitted: November 12, 2006, 12:01 P.M.
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LEGEND: Couple
Hypertension
Rheumatic Heart Disease
Deceased
Heart Problem
Renal Failure
Asthma
Pulmonary Tuberculosis
Arthritis
Cancer
CAD, AMI
Pneumonia
Twin
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HEALTH STATUS A. Personal Data Patient’s Name: Perfecto Pandacan Balili Age: 60 years old Sex: Male Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City Chief Complaint: Dyspnea Medical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III B. Family Background The family has been living in Ecoland ever since Perfecto and Lydia got married, except for some years in between when the family went to Manila but apparently they also came back here in Davao. The couple has eleven children with 6 girls and 5 boys. Aside from that within the 6 girls there is a twin and the same applies with the 5 boys, apparently their third set of twins died due to miscarriage. Among the eleven children only two of them were able to finish college and the rest were only able to study until their high school years for varied reasons. In addition, currently the couples children are in Manila, one is in Japan and three stayed here in Davao. All of their children are currently married except for the youngest three. Mr. Perfecto Balili has an educational attainment of until second year high school and his wife Lydia got until second year College with a course of Accountancy. According to Mrs. Balili they got married when she was in third year high school because she already got pregnant with their first child. But even though this is the case she still continued her schooling until second year college with the financial support of her husband. In addition, she got pregnant with only a years difference on all of her children. Perfecto has always been a taxi driver. He supported his family’s daily needs, educational needs and others with only this kind of job. He worked as a taxi driver both here in Davao and even when they came to Manila he also worked as an FX driver. Back then when their children was young Mr. Perfecto is the only one that works because Lydia is the one that takes care of the children and until today she is still a plain house wife. But when Mr. Balili experienced his first 10
heart attack in Manila, he temporarily stopped driving and took a rest. After a few months he then continued his work and did not totally stop driving until after his third attack and so their children are the ones that supported the family. Currently, they get their financial support in their daughter who is in Japan. Some of his vices include drinking and smoking. He is a hard drinker and started drinking when he was only a teenager. He can consume half a box of cigarette in a day and this started during his twenties. He is also fond of eating meat compared to fish and vegetables. Furthermore, Perfecto’s father died due to cancer and his mother died due to asthma. Among his siblings, 3 of his siblings had pulmonary tuberculosis namely Emilio, Carlos and Lucia. One of his sisters had a renal failure and hypertension. Other than that they have no trace of any hereditary diseases. Perfecto’s son, Adrian, had PTB and 3 of his children had pneumonia. His daughter, Jackilyn, had Rheumatic Heart Disease and his son, Jeffrey, had asthma. C. History of Past Illness Back in 1986, Perfecto was diagnosed of pulmonary tuberculosis and he sought medical help from the Barangay Health Center. He was then given the 6 months treatment for PTB, after the completion of the medication the patient failed to have a follow-up check-up after the treatment. Perfecto had his first attack 7 years ago; he had his first and second heart attack in Manila. During his first attack he was admitted in Manila Hospital then was transferred to San Juan Hospital for five days and was then brought back to Manila Hospital. His third and fourth heart attack happened in Davao. He was admitted in Med-Main in DMC on his third attack and his fourth attack was in Med CP for he had COPD and was then transferred to CCU for he was diagnosed with Coronary Artery Disease basing on his result of Echocardiogram. His fourth attack happened only last July 2006. D. History of Present Illness One month PTA, the patient had his available oxygen via oxygen tank in his house as aid for his breathing, which they bought for P4,500. He also had an air conditioned room at his home just to aid his condition. Two weeks PTA, patient had bipedal edema, loss weight; decrease appetite and experienced paroxysmal nocturnal dyspnea. He had difficulty sleeping during the night. Three days PTA, patient has been having episodes of chest pain at the left anterior chest 11
radiating to the arm, lasting for a minute. Five hours PTA, he had recurrence of chest pain of the same character. He then took isosorbide mononitrate SL but without relief. Persistence of symptoms prompted this admission, with a previously diagnosed coronary artery disease by 2D Echo result. E. Effects and Expectation of Illness to Family Mr. Perfecto already had five heart attacks and his condition got worse every time this happens. Although the family is very well aware of his degenerating condition they are still hoping that he will get better and that will live much longer. As observed the family is not really affluent and that they are having financial problems due to the recurrent attacks of the patient. Luckily, they are being assisted by his daughter, Jackilyn, who had a Japanese husband and currently resides in Japan. In addition, he also had a senior citizen’s identification card that becomes a big aid in their financial needs. Aside from the financial help the family is greatly affected by the patient’s condition and thus still tries their best to live a normal life.
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COMPLETE DIAGNOSIS Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killip’s II, Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC III Coronary •
Term applied to vessels (Stedman’s Medical Dictionary, 25th Edition)
•
Used to describe the arteries that supply blood to the muscle tissue of the heart, or the veins that take blood away from it (Microsoft® Encarta® Premium Suite 2005)
•
Relating to or being the coronary arteries or coronary veins, or relating to the heart (http://education.yahoo.com/reference/dictionary/entry/coronary)
Artery •
A vessel through which the blood passes away from the heart to the various parts of the body (Stedman’s Medical Dictionary, 25th Edition)
•
Blood vessel that carries blood away from the heart (Medical Dictionary by Gupta and Gupta)
•
Are muscular blood vessels that carry away blood from the heart (http://en.wikipedia.org/wiki/Artery)
Disease •
A definite morbid process having a characteristic train of symptoms (Stedman’s Medical Dictionary, 25th Edition)
•
Any departure from health of a structure, organ, or system (Medical Dictionary by Gupta and Gupta)
•
Disorder with a specific cause and recognizable signs and symptoms, any bodily abnormality or failure to function properly (Webster Dictionary) 13
Coronary Artery Disease •
A disease in which there is a narrowing or blockage of the coronary arteries (blood vessels that carry blood and oxygen to the heart (Medical-Surgical Nursing, 9th Edition)
•
Characterized by the presence of atherosclerosis in the epicardial coronary arteries. (The Bantam Medical Dictionary)
•
Occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed (http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html)
Acute •
Having rapid onset, short or relatively severe course (Stedman’s Medical Dictionary, 25th Edition)
Myocardial •
Pertaining to the muscular tissue of the heart (Stedman’s Medical Dictionary, 25th Edition)
•
Relating to or affecting the thick muscular wall of the heart. (Microsoft® Encarta® Premium Suite 2005)
•
The middle of 3 layers forming the wall of the heart. It is composed of cardiac muscles and forms the greater part of the heart wall, being thicker in the ventricles than in atria. (http://education.yahoo.com/reference/dictionary/entry/myocardial)
Infarction •
Formation of an infarct (coronary thrombosis) (Stedman’s Medical Dictionary, 25th Edition)
•
Cessation of blood flow by thrombus formation and causing issue death (Medical Dictionary by Gupta and Gupta)
•
The death of part of the whole of an organ that occurs when the artery carrying its blood supply is obstructed by a blood clot (www.ask.com/infarction) 14
Killip’s II •
A classification of Acute Myocardial Infarction that is defined as having moderate heart failure with basiliar rales -50% of lung field or S3 gallops, tachycardia or signs and symptoms or right heart failure like venous or hepatic congestion (Harrison’s Internal Medicine)
Myocardial Infarction •
A disease that occurs when the blood supply to a part of the heart is interrupted. The resulting oxygen shortage causes damage and potential death of heart tissue (http://en.wikipedia.org/wiki/Myocardial_infarction)
•
Is the rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium
(http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/complications/compl ications.htm) •
It is a disease that occurs when the blood supply to a part of the heart is interrupted (http://www.yahoo.com/reference/dictionary/acutemyocardial infarction)
Ventricular •
Pertaining to ventricles (Stedman’s Medical Dictionary, 25th Edition)
•
Involving, affecting or relating to a ventricle (Microsoft® Encarta® Premium Suite 2005)
•
One of the chambers of the heart, the largest and the most important chamber (www.ask.com/dictionary/left ventricle)
Hypertrophy •
Morbid enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells (Stedman’s Medical Dictionary, 25th Edition)
•
An increase in cell size (Medical Dictionary by Gupta and Gupta)
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•
Increase the size of a tissue or organ brought about by the enlargement of its cells rather than by cell multiplication, muscles undergo these changes in response to increased work (http://education.yahoo.com/reference/dictionary/hypertrophy)
Dilatation •
The act or process of widening or being widened, stretching or being stretched, or enlarging or being enlarged
•
something, especially a part of something else, that has become enlarged, expanded, or stretched (Microsoft® Encarta® Premium Suite 2005)
•
The enlargement or expansion of a hollow organ or cavity (The Bantam Medical Dictionary)
Left Ventricle Hypertrophy & Dilatation •
There were increase in the size of the left ventricle or enlargement of the left ventricle due to increase blood volume and pressure (http://education.yahoo.com/reference/dictionary/hypertrophy/dilatation)
FC III •
A classification of chronic heart failure that is defined as having dyspnea that occurs with less than ordinary physical activity, can climb one or less than one flight of stairs
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DEVELOPMENTAL DATA The middle years from 40-65, have been called the years of stability and consolidation. For most people it is the time when children have grown and moved away or are moving away from home. Thus, partners generally have more time for and with each other and time to pursue interests they may have deferred for years. Physical Development A number of changes take place during the middle years. Both men and women experience decreasing hormonal production during the years. The climacteric (andropause) refers to the changes of life in men, when sexual activity decreases. In men, there is no change comparable to menopause in women. Androgen levels decreases very slowly; however men can still have children even in late life. The psychological problems that men experience is generally relate to fear of getting old and to retirement, boredom and finances. Physical changes that occurred to Perfecto were his decreasing ability to perform activities. He easily gets tired and constantly needs assistance upon doing things or moving about. Due to his condition he only has limited capabilities and can no longer do what he usually does unlike the previous years before his first attack occurred. Robert Havighurst’s Developmental task theory Since Perfecto belonged to the middle-aged group, he had seven tasks to accomplish according to Havighurst’s theory. These tasks are: 1. Achieving adult, civic and social responsibility. The family agreed that Perfecto has achieved this because he was able to perform his role well. He is able to support his eleven children and send them to school although unfortunate personal circumstances hindered eight of them from finishing school. Although this is the case Perfecto is a responsible citizen and is concerned for the betterment of his family and community. 2.
Establishing and maintaining an economic standard of living. Perfecto works really
hard for his family. Ever since he got married he did his best to support his family. He did a very good job since he was also able to support the schooling of his wife. He worked as a taxi driver both here in Manila and Davao. 17
3. Assisting teenage children to become responsible and happy adults. He is the authority of the house and he makes sure that he is able to guide his children to the right path. Many of his children did not finish their schooling because many are just not interested to do so and there may be lack of guidance since they were a big family and their behavior was affected by the changing environment. Although this is the case his children as adults are responsible enough to work hard to support each other and help the family especially when the family is on financial crisis. 4. Developing adult leisure time activities. They spend they leisure time talking at each other, watching television or talking to neighbors and establish good relationships. Back then he would smoke and drink with his male friends but ever since he ha his first attack he stopped his vices. 5. Relating oneself to one’s spouse as a person. Usual petty fights happen between the couple but they are able to patch things up and still work as a couple. They value each others opinion and respect each others decisions. 6. Accepting and adjusting to the physiologic changes of middle age. Perfecto had accepted the fact that he is not getting any younger anymore and it is evident on his condition. That is why he already anticipated any changes that would happen to him especially with his current illness. He is very well aware that his body is no longer like before and that each attacks that occurs is worse than the previous. 7. Adjusting to aging parents. Perfecto’s parents died many years ago and so he is very well adjusted now and accepted the fact that everyone dies eventually. Psychosocial Development According to Erik Erikson, a person develops throughout his lifetime. He noted that there are levels of achievement that a person must achieve or experience. These can be achieved and be ranked as partial, complete or unsuccessful. The greater the achievement of a person, the more he is better and healthier in development of hid personality. Failure to achieve the task may affect the person’s ability to achieve the next task. According to Erik Erikson the middle adulthood belongs to the generativity versus stagnation. In this stage work is most crucial. He observed that middle age is when they tend to be occupied with creative and memorable work and with issues surrounding their family. It is when they expect to “be in charge”, and the significant task is to perpetuate culture and transmit 18
values of the cultures through the family and working to establish a stable environment. Strength comes through the care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, and when they are in this stage they often fear inactivity and meaninglessness. As their children leave home, their goals change and they may be faced with major life changes-midlife crisis- and the struggle with finding new meanings and purposes. If they do not get through this stage successfully, they can become self-absorbed and stagnate. In the case of my patient, he is on the middle adulthood stage. As of now, he has on the stage wherein he is still guiding some of his children. He is now concerned more on his children’s future. He is aware of social responsibility and develops leisure activities and hobbies appropriate for his age. He previously does his best to become productive and contribute to the society but due to his current condition he is no longer able to do that. But being the head of the family continues to be his role only with restrictions on some actions. Cognitive Development Cognitive and intellectual abilities of the middle adult change very little from the young adults. There is motivation to learn, especially if the knowledge gained can be immediately applied and had personal relevance. Problem solving abilities remain throughout adulthood, although the time response may be slightly longer. This is not due to a decrease in ability, but rather due to longer memory research of increased amounts of material. According to my patient, every problem has a solution. This shows that he is very positive when it comes to problem solving. My patient is able to find solutions to his problems and he does not lose hope that he could not overcome any problem he is experiencing. One example was his admission due to his debilitating illness. He was able to surpass this problem because of his positive attitude towards problem solving. He had undergone 4 attacks before and he was still very positive & opens to any modification regarding his health just to live longer. Moral Development The middle adulthood remain at the conventional level or may move to post conventional level, especially if the person had sustained responsibility for the welfare of others and has consistently applied ethical principles developed in adolescence. At this level, the adult believes that the rights of others take precedence and takes steps to support those rights. 19
My patient belongs to post conventional level or self accepted moral principles. He is able to distinguish right from wrong. He respected and takes priority the rights of others and also maintains self respect. He believes that relationships are based on mutual trust. He has his personal values as to the standards of our society. He views each of then as right and proper because that is what the society wants. But the decision is still coming from him. He decides on his own if he should follow the things that the society dictates him or simply follow what is right for him.
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PHYSICAL ASSESSMENT I. General appearance & mental status Mr. Perfecto Balili, a 60 year old male client, was admitted on November 12, 2006 in Davao Medical Center. Upon assessment the patient was lying on bed in moderate high back rest and is awake, conscious, coherent & responsive. He has an IVF of D5W 500cc @ 300cc level running at KVO infusing well @ right cephalic vein, with O2 inhalation @ 5Liters per minute via nasal cannula, is wearing a hospital gown and has diaper. The client has a generalize weakness and needs assistance upon moving or position changes. He has difficulty of breathing and is constantly expectorating whitish phlegm into his bedside receptacle. He is 5’6” in height and weighs 59 kg. II. Vital Signs: BP- 110/80mmHg CR- 43 bpm; irregular rate and rhythm RR- 25 cpm; regular rhythm Temp- 36.5’ C III. Skin The color of the skin is brown with rough and dry texture. The patient has poor skin turgor and clammy to touch. Scars in lower extremities are observed; no wounds or lesions are noted. IV. Head He has a normocephalic configuration with head circumference of 22 cm. His facial movements are symmetric and he has a thin, evenly distributed, white in color hair. Scalp is dry but there is no presence of dandruff or lice upon inspection V. Eyes Eyes have symmetrical lids and normal periorbital area. Conjunctiva is pale and sclera is observed to be anicteric. Both left and right pupils are black in color with pupillary size of 3mm,
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briskly reactive to light. He has a slightly sunken periorbital region, eye bugs present with eyebrows and eyelashes evenly distributed. Client wears eyeglasses only upon reading. VI. Ears Client’s ears are symmetrical and are in line with the outer canthus of the eyes. His pinnae are normal, normoset and symmetric. No tenderness and lesions noted. Absence of discharges on the external canal is noted. No hearing problem noted. VII. Nose The client’s nasolabial fold is normal, septum is medially located and no discharges are noted. There are no deformities or inflammation on the nose noted. No nasal flaring is noted and both nostrils are patent. He has an O2 inhalation via nasal cannula. VIII. Mouth The mucosa and gums of the client are pinkish and lips are dry. His tongue is medially located. Teeth were yellowish in color with loose teeth, he do not use dentures. He has no difficulty of swallowing and no halitosis and bleeding noted upon observation. IX. Neck There are no signs of abnormal growth or enlargement of the nodes of the neck of the client. There are no lesions noted. X. Chest and Lungs The client has rapid, regular breathing at the rate of 25 cpm. Wheezing is noted upon auscultation with symmetrical chest expansion. He has productive cough with whitish phlegm.. XI. Heart and Breast The client has symmetrical, rounded shape breast with smooth surface. The areolas are bilaterally the same and are dark brown in color. There are no masses, lesions or tenderness noted on these areas. He has a capillary refill time of 4 seconds. His pericardial area is flat and heart sound is weak and irregular in rate and rhythm with a rate of 43 bpm. He is hooked to a
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cardiac monitor with Atrial Fibrillation in slow to moderate response with ST elevation pattern. An IVF of D5W 500cc @ KVO rate infusing well @ right cephalic vein @ 300cc level XII. Abdomen The skin in this area has uniform color and no lesions; with flat abdominal contour thus there is no evidence of an enlarged spleen or lived noted. He has normal bowel sound of one every 15 seconds. XIII. Genito-Urinary The client wears diaper but voids freely. There are no lesions or discharges noted. He can defecate without difficulty at least once a day. XIV. Back and Extremities Client needs assistance upon moving around and in doing activities of daily living. He can extend and flex both his upper and lower extremities with (-) bipedal edema or anasarca. Weakness upon movement is noted. He has dirty and untrimmed nails on all extremities.
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ANATOMY and PHYSIOLOGY The cardiovascular system is sometimes called the blood-vascular or simply the circulatory system. It consists of the heart, which is a muscular pumping device, and a closed system of vessels called arteries, veins, and capillaries. As the name implies, blood contained in the circulatory system is pumped by the heart around a closed circle or circuit of vessels as it passes again and again through the various "circulations" of the body. It transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include: •
blood: consisting of liquid plasma and cells
•
Blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.)
•
heart: a muscular pump to move the blood
The Cardiovascular System In order to pump blood through the body, the heart is connected to the vascular system of the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of the body and remove carbon dioxide and metabolic waste products from the body. The cardiovascular system is actually made up of two major circulatory systems, acting together. The right side of the heart pumps blood to the lungs through the pulmonary artery (PA), pulmonary capillaries, and then returns blood to the left atrium through the pulmonary veins (PV). The left side of the heart pumps blood to the rest of the body through the aorta, arteries, arterioles, systemic capillaries, and then returns blood to the right atrium through the venules and great veins. There are two circulatory "circuits": Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the
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"right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from the lungs back to the "left heart." Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter the system from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cava. A specialized component of the circulatory system is the lymphatic system, consisting of a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion. Blood Components •
Forty-five percent (45%) consists of cells - platelets, red blood cells, and white blood cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood cells, neutrophils and lymphocytes are the most important.
•
Fifty-five percent (55%) consists of plasma, the liquid component of blood. Major Blood Components Component Type
Source
Function
Platelets, cell fragments
Bone marrow Blood clotting life-span: 10 days
Lymphocytes (leukocytes)
Bone marrow, Immunity spleen, lymph T-cells attack cells containing nodes viruses. B-cells produce antibodies.
Red blood cells (erythrocytes), Filled with Bone marrow Oxygen transport hemoglobin, a compound of iron and protein Neutrophil (leukocyte) Plasma, consisting of 90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes
Bone marrow
Phagocytosis 1. Maintenance of pH level near 7.4 2. Transport of large molecules (e.g. cholesterol) 3. Immunity (globulin) 4. Blood
clotting 25
(fibrinogen) Vascular System - the Blood Vessels Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of capillaries connecting them. Arteries use vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use one-way valves controlled by muscle contractions. Arteries Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into progressively thinner tubes and eventually become fine branches called arterioles. Blood in arteries is oxygen-rich, with the exception of the pulmonary artery, which carries blood to the lungs to be oxygenated. The aorta is the largest artery in the body, the main artery for systemic circulation. The major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood to the head, abdomen, and extremities. Of special importance are the right and left coronary arteries that supply blood to the heart itself. Capillaries The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed in interstitial fluid, or lymph, produced by the lymphatic system. Capillaries are the points of exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries by passing through or between the cells that line the capillary. The extensive network of capillaries is estimated at between 50,000 and 60,000 miles long. Veins Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules, which in turn unite to form veins. Veins are responsible for returning blood to the heart after the blood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low, so veins depend on nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood.
26
Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry oxygenated blood from the lungs back to the heart. The major veins, like their companion arteries, often take the name of the organ served. The exceptions are the superior vena cava and the inferior vena cava, which collect body from all parts of the body (except from the lungs) and channel it back to the heart. Artery/Vein Tissues Arteries and veins have the same three tissue layers, but the proportions of these layers differ. The innermost is the intima; next comes the media; and the outermost is the adventitia. Arteries have thick media to absorb the pressure waves created by the heart's pumping. The smooth-muscle media walls expand when pressure surges, then snap back to push the blood forward when the heart rests. Valves in the arteries prevent back-flow. As blood enters the capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure. Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along veins. As with arteries, valves are again used to ensure flow in the right direction. Anatomy of the Heart The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline. The heart, along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood. Internally,
the
heart is designed
as a pump with
four chambers -
right
(RA),
ventricle
right
atrium (RV),
left atrium (LA),
and left ventricle
(LV). The two
atria
smaller,
chambers of the
heart
upper
and
the
two
are
the
ventricles
are the larger,
lower chambers
of the heart. The
heart is oriented
in
rotated about 30
the
chest
27
degrees to the left lateral side such the right ventricle is the most anterior structure of the heart. The left ventricle is generally about twice as thick as the right ventricle because it needs to generate enough force to push blood through the entire body while the right ventricle only needs to generate enough force to push blood through the lungs. Ventricular contraction forces blood into the arteries. The heart also has four valves. The tricuspid valve is between the right atrium and right ventricles. The pulmonary valve is between the right ventricle and the pulmonary artery. The mitral valve is between the left atrium and the left ventricle and the aortic valve is between the left ventricle and the aorta. The valves, under normal conditions, insure that blood only flows in one direction in the heart. Cardiac Muscle Cardiac muscle is a type of involuntary mononucleated, or uninucleated, striated muscle found exclusively within the heart. Its function is to "pump" blood through the circulatory system
by
contracting.
Inside each cardiomyocyte are hundreds of myofibrils which are thin, elongated structures. Each myofibril, in turn, consists of thin filaments and thick filaments. Each of the thin filaments is composed of a protein called actin. Each of the thick filaments is composed of a protein called myosin. Each myosin filament is composed of about 200 myosin molecules. Each myosin molecule contains what is called a myosin head. Inside each cardiomyocyte there are compartments filled with calcium. The action potential causes these compartments to release the calcium into the cell. This calcium allows myosin heads to bind to actin filaments and pull them by a process called a power stroke. That is how action potential causes the individual muscle cells to contract.
28
Basic Cardiac Physiology A basic understanding of cardiac physiology is also essential to interpreting the physical finding during a cardiac exam. Each pump or beat of the heart consists of two parts or phases diastole and systole. During diastole the ventricles are filling and the atria contract. Then during systole, the ventricles contract while the atria are relaxed and filling. For the purposes for this discussion of cardiac physiology, we will focus on the physiology associated with the heart sounds S1, S2, S3, and S4. S1 occurs near the beginning of (ventricular) systole with the closing of the tricuspid and mitral valves. The closing of these two valves with increasing pressure in the ventricles as they begin to contract should be simultaneous. Any splitting in which the closing of the two valves are heard separately should be considered pathological. S2 occurs near the end of (ventricular) systole with the closing of the pulmonary and aortic valves. The closing of these two valves occurs with beginning of backward flow in the pulmonary artery and aorta respectively as the ventricles relax. The two valves can occur simultaneously or with slight gap between them under normal physiologic circumstances. S3 occurs at the end of the rapid filling period of the ventricle during the beginning of (ventricular) diastole. An S3, if heard should occur 120-170 msec after S2. S4 occurs, if heard coincides with atrial contraction at the end of (ventricular) diastole. The Circulation Poorly oxygenated blood collects in two major veins: the superior vena cava and the inferior vena cava. The superior and inferior vena cava empty into the right atrium. The coronary sinus which brings blood back from the heart itself also empties into the right atrium. The right atrium is the larger of the two atria although it receives the same amount of blood. The blood is then pumped through the tricuspid valve, or right atrioventricular valve, into the right ventricle. From the right ventricle, blood is pumped through the pulmonary semi-lunar valve into the pulmonary artery. This blood leaves the heart by the pulmonary arteries and travels through the lungs (where it is oxygenated) and into the pulmonary veins. The oxygenated blood then enters the left 29
atrium. From the left atrium, the blood then travels through the bicuspid valve, also called mitral or left atrioventricular valve, into the left ventricle. The left ventricle is thicker and more muscular than the right ventricle because it pumps blood at a higher pressure. Also, the right ventricle cannot be too powerful or it would cause pulmonary hypertension in the lungs. From the left ventricle, blood is pumped through the aortic semi-lunar valve into the aorta. Once the blood goes through systemic circulation, peripheral tissues will extract oxygen from the blood, which will again be collected inside the vena cava and the process will continue. Peripheral tissues do not fully deoxygenate the blood, thus venous blood does have oxygen, only in a lower concentration in comparison to arterial blood. The Heart's Conduction System There are four basic components to the heart's conduction system 1. sinoatrial node (SA node) 2. inter-nodal fibre bundles 3. atrioventricular node (AV node) 4. atrioventricular bundle The sinoatrial (SA) node is a small mass of specialised cardiac muscle situated in the superior aspect of the right
atrium.
It
lies
along
the
anterolateral margin of this chamber between the orifice of the superior vena cava and the auricle. The specialized cardiac muscle of the SA node is characterized
by
the
property
of
automatic self-excitation and it initiates each beat of the heart. Therefore, the SA node is often referred to as the pacemaker of the heart. Since the fibers of the SA node fuse with the surrounding atrial muscle fibers, the action potential generated in the nodal tissue spreads throughout both atria at a rate of approximately 0.3 meter per second and produces atrial contraction. Interspersed among the atrial muscle fibers 30
are several inter nodal fiber bundles which conduct the action potential to the atrioventricular (AV) node with a greater velocity (approximately 1.0 meter per second) than ordinary atrial muscle. The AV node is located in the right atrium near the lower part of the interatrial septurn. Here there is a short delay (approximately 0.1 second) in transmission of the impulse to the ventricles. This is important because it permits the atria to complete their contraction and empty their blood into the ventricles before the ventricles contract. The delay occurs within the fibers of the AV node itself as well as in special junctional fibers that connect the node with ordinary atrial fibers. Once the action potential leaves the AV node, it enters specialized muscle fibers called Purkinje fibers. These are grouped into a mass termed the atrioventricular (AV) bundle, or the bundle of His. The Purkinje fibers are very large and conduct the action potential at about six times the velocity of ordinary cardiac muscle (i.e., 1.5 to 4.0 meters per second). Thus the Purkinje fibers permit a very rapid and simultaneous distribution of the impulse throughout the muscular walls of both ventricles. As the AV bundle leaves the AV node, it descends in the interventricular septurn for a short distance and then divides into two large branches, the right and left bundle branches. Each of these descends along its respective side of the interventricular septum immediately beneath the endocardium and divides into smaller and smaller branches. Terminal Purkinje fibers extend beneath the endocardium and penetrate approximately one-third of the distance into the myocardium. Their endings terminate upon ordinary cardiac muscle within the ventricles, and the impulse proceeds through the ventricular muscle at about 0.3 to 0.5 meters per second. This results in a contraction of the ventricles that proceeds upward from the apex of the heart toward its base. The spontaneous generation of an action potential within the SA node initiates a sequence of events known as the cardiac cycle. Each cardiac cycle lasts approximately 0.8 second and spans the interval from the end of one heart contraction to the end of the subsequent heart contraction. Ordinarily this occurs about 72 times each minute. Blood Pressure and Heart Rate The heart beats or contracts around 72 times per minute. The human heart will undergo over 3 billion contraction/cardiac cycles during a normal lifetime. 31
One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice versa. Heart valves open and close to limit flow to a single direction. The sound of the heart contracting and the valves opening and closing produces a characteristic "lub-dub" sound. The
cardiac
cycle
has
two
basic
components: (1) contraction phase (systole) during which blood is ejected from the heart (2) relaxation phase (diastole) during which the chambers of the heart are filled with blood. The spontaneous generation of an action potential within the SA nodal tissue represents the start of the cardiac cycle. This electrical impulse spreads throughout the atrial muscle and leads to contraction of the two atria. As the atria contract, the AV valves remain open and additional blood is forced into the ventricles from the veins. A large amount of blood has already passed from the atria to the ventricles prior to atrial contraction. The aortic and pulmonary (pulmonic) semilunar valves remain closed. After the ventricles have filled (mostly by blood returning from the large veins) and the atria have contracted, the AV valves close as the ventricles begin their contraction. Ventricular contraction forces blood through the semilunar valves into the aorta and pulmonary trunk. Next, as the ventricles begin to relax, the aortic and pulmonic semilunar valves close, the AV valves open, and blood flows into the ventricles to begin another cycle. While the atria are in systole, the ventricles are relaxed (in diastole). The atria relax during ventricular systole and remain in this phase even during a portion of ventricular diastole. Blood (like any other fluid) tends to flow from a region of high pressure to one of lower pressure. As each chamber of the heart fills with blood, the pressure increases within it. The blood moves out of the chamber, when the various one-way valves guarding those chambers permit it to do so. 32
As the ventricles contract, the blood is forced in a retrograde fashion against the AV valves, which causes them to bulge inward slightly toward the atria and which also elevates atrial pressure. In doing so, the AV valves are effectively closed and blood is prevented from regurgitating back into the atria. Near the end of ventricular systole the AV valves are still closed and since the atria are in the process of filling, this too contributes to a rise in intra-atrial pressure. Even before the atria enter systole, the ventricles are filled with blood to approximately 70% of their capacity. When the atria do finally contract, additional blood enters the ventricles and elevates the intraventricular pressure. As the ventricles contract, blood is forced backward, closing the AV valves, and a sharp rise in ventricular pressure occurs. Although the ventricles exist as closed chambers for a brief moment, the pressure within them soon exceeds that in the aorta and pulmonary trunk. When this happens the aortic and pulmonic semilunar valves are forced open under pressure and blood rushes out of the ventricles and is driven into these large vessels. Accompanying the opening of the semilunar valves is a rapid decline in intraventricular pressure that continues until the pressure within the ventricles becomes less than that of the atria. When this pressure differential is reached, blood within the atria pushes the AV valves open and begins to fill the ventricles once again. Receptors in the arteries and atria sense systemic pressure. Nerve messages from these sensors communicate conditions to the medulla in the brain. Signals from the medulla regulate blood pressure. Electrocardiography (ECG, EKG) An electrocardiogram measures changes in electrical
potential
across
the
heart
and
detects
contraction pulses that pass over the surface of the heart. There are three slow, negative changes, known as P, R, and T. Positive deflections are the Q and S waves. The P wave represents atrial contraction ("the lub"), the T wave the ventricular contraction ("the dub").
33
The Lymphatic System The lymphatic system functions 1) to absorb excess fluid, thus preventing tissues from swelling; 2) to defend the body against microorganisms and harmful foreign particles; and 3) to facilitate the absorption of fat (in the villi of the small intestine). Capillaries release excess water and plasma into intracellular spaces, where they mix with lymph, or interstitial fluid. "Lymph" is a milky body fluid that also contains proteins, fats, and a type of white blood cells, called "lymphocytes," which are the body's firstline defense in the immune system. Lymph flows from small lymph capillaries into lymph vessels that are similar to veins in having valves that prevent backflow. Contraction of skeletal muscle causes movement of the lymph fluid through valves. Lymph vessels connect to lymph nodes, lymph organs (bone marrow, liver, spleen, thymus), or to the cardiovascular system. •
Lymph nodes are small irregularly shaped masses through which lymph vessels flow. Clusters of nodes occur in the armpits, groin, and neck. All lymph nodes have the primary function (along with bone marrow) of producing lymphocytes.
•
The spleen filters, or purifies, the blood and lymph flowing through it.
•
The thymus secretes a hormone, thymosin, which produces T-cells, a form of lymphocyte.
34
PATHOPHYSIOLOGY Predisposing Factors
Present (√) / Absent (x)
Family History
X
Age
√
Gender
√
Race
X
Precipitating Factors
Present (√) / Absent (x) Past Present
Cigarette smoking
√
X
Hyperlipidemia
X
X
Rationale Individuals with history of heart diseases within their family or first degree relatives are more prone in developing one himself. The presence of coronary atherosclerosis in a parent or sibling under 50 years old is associated with the same finding in another family member. More common in male aged (45 -70 y.o.) Men are at a greater risk for the development of CAD. Women are usually not affected by this disease until after menopause. Postmenopausal increase has been attributed to decrease levels of estrogens and rising blood lipids. Black Americans have a higher risk than whites. This is because they have increased incidence of hypertension (33%) Rationale Inhalation of smoke increases the blood carbon monoxide level causing hemoglobin, the oxygen carrying component of blood to combine more readily with carbon monoxide than with oxygen resulting to decrease amount of available oxygen which may decrease the heart’s ability to pump. Nicotinic acid in tobacco triggers the release of catecholamines which raises both heart rate and blood pressure. It can also cause the coronary arteries to constrict and increase catecholamines may be a factor in the increased incidence of sudden heart death. It could also cause detrimental vascular response and increase platelet adhesion leading to high probability of thrombus formation. This refers to the elevation of cholesterol and triglyceride levels within the blood. Cholesterol can be obtained directly from animal dietary source or manufactured by the liver and intestine. Triglycerides are derived from fatty acids found in adipose tissue or the diet. Cholesterol and triglycerides are involved 35
Hypertension
√
X
Sedentary lifestyle
X
√
Diabetes Mellitus
X
X
Obesity
X
X
in the transportation, digestion and absorption of fats. High levels of low-density lipoproteins are attributed to the development atherosclerosis that would latter on cause obstruction in the artery. LDL unlike HDL could not be metabolized by the body. The HDL cannot carry the bad cholesterol to the liver for metabolism. The macrophages will then need to modify it before HDL could interact with it. During modification the macrophages cause injury to the endothelial wall resulting to fibrous formation and later on to formation of emboli that would lead to obstruction of blood flow to the myocardial artery. Increase stiffness of the vessel walls leading to vessel injury and a resulting inflammatory response within the intima. It can also increase the work of the left ventricle which must pump harder to eject blood into the arteries. Increase workload causes the heart to enlarge and thicken (hypertrophy) a condition that may eventually lead to cardiac failure. In addition, increased peripheral vascular resistance associated with hypertension increases afterload and the demand on the left ventricle. The result is an increased demand for myocardial oxygen in the face of a diminished supply. It is noted that increase in activity can improve the efficacy of the heart by the reduction of heart rate and blood pressure. It also decreases the level of low-density lipoproteins, lowered blood glucose levels, and improved cardiac output has been associated with lesser chance of CAD. Hyperglycemia fosters increase platelet aggregation and altered RBC function, which can lead to thrombus formation. Also, insulin injures the vessel wall leading to inflammatory response. Obesity or excess body weight in relation to height increases the workload and hence the oxygen demands of the heart. Obesity highly correlates with hypertension, hyperlipidemia, and diabetes. It is also associated with increased caloric intake and elevated levels of 36
low-density lipoproteins.
Stress
√
X
History of CAD
√
√
Symptomatology
Present (√) / Absent (x)
Dyspnea
√
Bradycardia
√
Pulmonary Edema
X
Stress stimulates the cardiovascular system by the release of cathecolamines, which in turn increase the heart rate and produce vasoconstriction. Individuals with history of CAD are more predisposed to reoccurrence or development of heart diseases. Since there is already previous formation of atherosclerosis and obstruction within the myocardial artery the person may then easily develop the same problem. It is also noted that these individuals may have had a portion of their heart than no longer functions properly due to ischemia or necrosis. Rationale Collection of fats, cells and debris result to development of fatty streaks. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. Progressive narrowing of the arterial lumen, body will compensate through vasodialation. But increase in occlusion will result to gradual weakening of the myocardium. Damage to the heart limits the output of the left ventricle. Poor ventricular compliance would result to dyspnea. Development of fatty streaks between the endothelium and internal elastic lamina. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. Progressive narrowing of the arterial lumen would result to gradual weakening of the myocardium. This would then result to decrease in the cardiac output. Formation of fatty streaks within the endothelium and lamina. Narrowing of epicardial blood vessel due to atheromatous plaque would then result to coronary artery disease. Progressive narrowing of the arterial lumen, body will compensate through vasodialation. But increase in occlusion will result to gradual weakening of the myocardium. Damage to the heart limits the 37
Chest pain
√
S3 heart sound
X
output of the left ventricle. Poor ventricular compliance would result to Pulmonary edema. When mural thrombus forms at site of rupture, initial platelet monolayer forms at the site. Various agonists (collagen, ADP, epinephrine, serotonin) promote platelet activation. Production and release of thromboxane A2 result to further platelet activation, and potential resistance to thrombolysis. Von Willebrand factor (vWF) and fibrinogen are multivalent molecules which bind to two different platelets simultaneously, resulting in platelet cross-linking and aggregation. Coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. Conversion of prothrombin to thrombin, which then converts fibrinogen to fibrin would result to fluid-phase and clot-bound thrombin participate in an autoamplification reaction that leads to further activation of the coagulation cascade. Coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. Imbalance between oxygen supply and demand of the myocardium would then lead to compromised myocardial blood flow which does not meet the metabolic demands of myocardial tissue. Disruption of mid-sized atheromatous plaque due to injury or rupture would result to an injured but still living heart muscle which could still conduct electrical impulses slowly. Speed can become so slow that the spreading impulse is preserved long enough for the uninjured muscle to complete its contraction. Slowed electrical signal still traveling within the injured area can re-enter and trigger the healthy muscle to beat again too soon. Rapid rhythm abnormalities can occur and negatively influence the function of the heart. This result to increase rate or volume of ventricular filling enabling us to hear a third heart sound. Disruption of mid-sized atheromatous plaque due to injury or rupture would result to an injured but still living heart muscle which could still conduct electrical impulses slowly. Speed can become so slow that the spreading 38
S4 heart sound
√
Arrhythmia
√
Fever
X
impulse is preserved long enough for the uninjured muscle to complete its contraction. Slowed electrical signal still traveling within the injured area can re-enter and trigger the healthy muscle to beat again too soon. Rapid rhythm abnormalities can occur and diminished ventricular compliance. This may reduce the filling of the heart thus the fourth heart sound becomes audible. Upon the presence of abnormal heart sounds the myocardial cells are noted to be active but produce quivering instead of forceful rhythmic contractions. This prevents the heart from pumping blood effectively thus resulting to an abnormal intraventricular conduction leading to abnormal heart rate and rhythm. Obstruction of blood flow to certain parts of the heart allows the pyruvic acid to produce lactic acid that injures the myocardial tissue. It then releases cardiac enzymes that trigger the pyrogens which increases the temperature of the body.
39
40
DOCTOR’S ORDERS Date/Time November 12,2006
Doctor’s Order • Admit under white service
• Low salt low fat diet
• Temperature, pulse, respiratory every hour and record
• Venoclysis D5W 500cc x KVO rate
12:10 pm
• Diagnostics: Complete Blood Count
Rationale • Patient is admitted under the white service for close monitoring
Remark • Done
• LSLF is ordered for patients with cardiac conditions to decrease the salt and fats that further aggravates the pt’s current condition
•
Done
•
Done
•
Done
•
Done
• Monitoring of TPR is done to detect any variation or changes from the normal range that would determine an abnormality in the patient’s condition • It is an isotonic solution that is needed by our body to help regulate the body’s nutrients; it doesn’t swell or shrink the cell. Regulated only at the rate to maintain vein open for emergency and IVTT meds • Complete Blood Count offers necessary information about the kinds and numbers of cells in the blood. This analyzes the 3 major types of cells in the body which are the
41
Red Blood Cell, White Blood Cell and Platelet
•
Done
Random Blood Sugar
• Blood test evaluates platelet production
•
Done
Creatinine
• Detects alterations in glucose metabolism
•
Done
Sodium, Potassium
• For evaluation of renal function
•
Done
Chest x-ray
• Evaluates fluid and electrolyte balance as well as renal or adrenal disorders
Platelet
Electrocardiogram
Troponin T qualitative
• Therapeutics Isosorbide Mononitrate (ISMN) 60mg/tab ½ tab OD Isosorbide Dinirate (ISDN)
• This identifies various abnormalities of the lungs and structures in the thorax Also used to identify localize fluid and air in the pleural cavity
• Not Done
•
Done
•
Done
• Primarily ordered to determine if heart attack or other changes in the heart occurred
•
Done
• ISMN is the treatment for anginal
•
Done
• Used to screen for and diagnose a variety of cardiac conditions as well as abnormal heart rhythms, conduction disturbance, hypertrophy and other disorders
42
5mg/tab 1 tab now
attacks
Metoprolol 50mg/tab ½ tab BID
• ISDN is the treatment for anginal attacks
Captopril 25mg/tab ½ tab OD
Atorvastatin 80mg/tab 1 tab OD
Lactulose 30cc at HS • Moderate High Back Rest
• Monitor intake and output
•
Done
•
Done
•
Done
•
Done
• Reduction of elevated total and LDL cholesterol and triglycerides
•
Done
• For chronic constipation
•
Done
•
Done
•
Done
•
Done
• Treat hypertension, management of angina pectoris and prevention of MI • Treat hypertension and reduce risk of developing congestive heart failure following MI
• Lowers diaphragm, promoting chest expansion • O2 at 4Lpm via nasal cannula
• Hook to cardiac monitor
• Refer accordingly
• Determine fluid and electrolyte balance and effectiveness of replacement • Help restore or improve breathing function and prevent damage to vital organs resulting from inadequate oxygen supply
43
12:30 pm • Retrieve previous 2Decho result c/o watcher and attach to chart
• Repeat ECG after 6 hours • Additional meds ASA 80mg/tab OD Clopidogrel 25mg/tab OD
• Monitor the patients BP, CR and ECG reading • It is necessary to refer any unusualities to the physician prevent further complications • Have a basis of the patient’s current situation base on the result of the previous laboratory exam
Furosemide 40mg 1 tab OD
Digoxin 0.25 mg/tab OD
Done
•
Done
•
Done
•
Done
•
Done
•
Done
•
Done
•
Done
• For monitoring of any changes in the result • Treatment of mild to moderate pain and prophylaxis of MI
Enoxaparin 6000 IV every 12 hours
•
• Reduction of atherosclerotic events in patients with atherosclerosis resulted from recent MI • Prevention of deep vein thrombosis and pulmonary embolism • Management of edema secondary to CHF and treatment of hypertension
November 12, 2006
•
To CCU
• Used to slow the ventricular rate in tachyarrhythmias such as AF and atrial flutter • Place in a special area for close
44
monitoring 8:30 pm
• Start O2 5Lpm per nasal cannula • Furosemide 40 mg IVTT now • Spironolactone 100 mg 1 tab now then OD • Refer
November 13, 2006
Done
•
Done
•
Done
•
Done
• Continue meds
• Medication needs to be continued for continuity of treatment
•
Done
• Complete bed rest without bathroom privilege
• Minimize the workload of the heart and promote rest
•
Done
• • •
Done Done Done
• •
Done Done
•
Done
•
Done
(+) chest pain
• Refer • Give Isordil 5mg SL • If not relieved by Isordil may give Tramadol 1 amp IVTT 10:35 am (+) Chest tightness O2 = 96 BP = 140/120
• Counteracts potassium loss induced by other diuretics, for edema and hypertension
•
• Give Isordil 5g SL now • Start Isoket drip D5W 500cc + 1 amp Isoket to run out at 10cc/hr
• Treatment of moderate to moderately severe pain • Treatment and prevention of angina pectoris attacks
• Avoid valsalva maneuver
• Activities that require holding of breath and bearing down can result in bradycardia, temporarily reduced cardiac output and rebound tachycardia with elevated BP.
• For Pro-time
• Screens for lack of coagulation factors necessary for blood clotting. Measures time required for a fibrin clot to form
45
• Activated Partial Thromboplastin Time • Refer
6:30 pm 7:30 pm 8:45 pm (+) chest pain
November 14, 2006 100/64
November 15, 2006 10:20 am
• Isordil 5mg SL now • Increase Isoket drip to 15cc/hr • Morphine 2mg IVTT now
• Repeat ECG 12 leads with long lead II • Review of medicines 1. Spironolactone 25mg 1 tab OD 2. Digoxin 0.25 mg/tab OD 3. Carvedilol 6.25mg ½ tab OD 4. Captopril 25mg/tab OD 5. Atorvastatin 80 mg tab OD 6. ASA 80 mg 1 tab OD 7. Clopidogrel 75mg/tab OD 8. Enoxaparin 0.6ml SQ every 12 • Discontinue meds not in review of medicines • Refer • Continue meds • Refer
• Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting
• Management of severe pain, pulmonary edema and pain associated with MI
•
Done
•
Done
• •
Done Done
•
Done
•
Done
•
Done
•
Done
•
Done
• •
Done Done
• Treatment for essential hypertension and CHF
98/61 I = 1085 O = 800 (-) chest pain (+) bowel 46
movement November 16, 2006 2:50 am
• Give Isordil 5mg 1 tab SL now then PRN for chest pain
• Done
• Continue meds • ISDN 5mg/tab SL PRN for chest pain • Senna concentrate 2 tabs at HS • Refer • Diagnostics: repeat ECG 12 leads now • Repeat Creatinine, Sodium, Potassium • Continue all meds • Refer accordingly • Diagnostics: repeat serum electrolyte • ISMN 60 mg ½ tab OD • Continue all other meds
• Done • Done
(+) chest pain 7:15 am still with occasional chest pain
November 17, 2006 9:30 am
November 18, 2006 (+) chest pain 125/98 November 19, 2006 8:30 am
November 20, 2006 7:20 am
• Treatment for constipation
• Done • Done • Done • Done • Done • Done • Not Done • Done • Done • Done
• Resume Isoket drip (D5W 90cc + 1 amp Isoket) to run at 10cc/hr • Continue other meds • Refer • Continue all meds • Refer accordingly • Continue Isoket drip
• • • • •
Done Done Done Done Done
102/68 9:00 am (+) chills (+) dyspnea 130/100 O2 sat 97 Hgt 72 130/90
• Start Warfarin 5mg ½ tab OD • For stat Complete blood count, Platelet count and Creatinine • Referred due to dyspnea • Diagnostics:
• Prophylaxis and treatment of venous thrombosis, pulmonary embolism, AF with embolization and management MI
• Done • Done
• Done • Determine blood 47
Hemogluco test now
glucose level
• Done
Electrocardigram now Arterial Blood Gas now
• Determine the acid-base balance and/or the respiratory or metabolic status
• Done • Done
• A hypertonic solution used for the treatment of hypoglycemic shock
• Done
Creatinine, Sodium, Potassium • Give D5W 50cc 1 vial slow IVTT now • Refer once with result November 21, 2006 7:22 am (-) chest pain
November 22, 2006
• Review of medicines Spironolactone 20 mg 1 tab OD Digoxin 0.25 mg ½ tab OD Captopril 25 mg 1 tab OD Atorvastatin 40 mg 1 tab OD ASA 80 mg 1 tab OD Clopidogrel 75 mg/tab OD Senna concentrate 2 tabs OD ISMN 60mg ½ tab OD Warfarin 5mg ½ tab OD Enoxaparin 0.6 ml SQ every 12 hours • Refer • Diagnostics: Repeat Protime • Continue all meds • Refer • Ceftazidime 1gram IVTT q8 ANST (-)
November 23, 2006 7:05am
• Clindamycin 300mg 1cap q6 PO • For repeat chest x-ray today • Continue antibiotics • Paracetamol 500mg 1tab q4 • Refer
• Done
• Done • Done
• Done • Done • Done • Done • Third generation cephalosporins used as treatment for infection • Anti-infective for infection
• For mild to moderate pain and fever
• Done
• Done • Done • Done • Done
48
November 24, 2006 8:00am (+) epigastric pain (+) increase salivation (-) chest pain 8:15 am
10:30am
CXR was read • Bibasal pneumonia • Left sided cardiomegaly • Underlying minimal pleural effusion • Pericardial effusion not entirely ruled out • Not congested Dr. Daguman • Omeprazole 40mg IVTT every 12 hours • please retrieve chest xray place on bedside • hold aspirin, warfarin, enoxaparine temporarily • Refer
• for STAT 12 lead ECG • Omeprazole 80mg IVTT now then 40mg IVTT q12 • Rebamipide 100mg 1 tab 3x a day
• Management for GERD and duodenal ulcer
• Ranitidine 1 ampule IVTT OD
• Vitamin K 1 ampule IVTT OD • Refer 4:15 pm • Metoclopramide 1
• Done • Done • Done
• Done • Done • Treatment of gastric mucosal lesions, acute gastritis and gastric ulcer
• Continue Omeprazole and Rebamipide • retrieve chest x-ray ASAP • Refer
1:00pm
• Done
• Done
• Done • Done • Done • Short-term treatment for duodenal and gastric ulcer and GERD • Prevention and treatment of hypothrombinemia associated with excessive doses of anticoagulants • Treatment and prevention of nausea and vomiting
• Done
• Done • Done
• Done
49
November 25, 2006
November 26, 2006 5:45 am
November 27, 2006 10:15am
November 28, 2006 9:35 am
November 29, 2006 10:30am
ampule IVTT now • Hold clindamycin • House Omeprazole IV to Pantoprazole 40mg 1 tab OD • Rebamipide 100mg 1 tab TID • Repeat CBC, platelet count • Continue meds • Refer • Diagnostics: Follow up repeat CBC, platelet Repeat protime, Sodium, Potassium • Continue meds • Continue all meds • Consume and discontinue ceftazidime, start levofloxacin 500mg/cap OD • Still for repeat protime • Refer • Resume Coumadin (Warfarin) 2.5mg ½ tab OD • Resume Aspirin 80mg 1 tab OD • Continue Pantoprazole PO • Repeat chest x-ray today • Please retrieve chest xray due 11/28/06 • Continue meds • refer
• Treatment of mild reflux
• Done • Done • Done • Done • Done • Done • Done
• Treatment of mild, moderate or severe infection
• Done, protime Not Done • Done • Done • Done • Not Done • Done • Done • Done • Done • Done • Not Done • Done • Done
50
DIAGNOSTIC EXAMINATIONS Date November 12, 2006
Diagnostic Procedure Arterial Blood Gas(ABG)- Arterial blood gas analysis is a test in which blood is taken from an artery in your wrist to evaluate how effective your lungs in bringing oxygen to the blood and removing carbon dioxide from it
Rationale Blood gases are used to determine the acid-base balance and/or the respiratory or metabolic status of the client. The pH is the measurement of the free hydrogen ion concentration in the blood. pCO2 represents the partial pressure carbon dioxide exerts in the arterial blood. pO2 represents the partial pressure of oxygen in the blood, identifies how well the lungs are oxygenating the blood.
Normal values pH 7.35-7.45 mmHg
Result pH 7.568mmHg
Impression
pCO2 35-45 mmmHg
pCO2 16mmHg
pO2 80-100mmHg
pO2 137.3mmHg
Increased pO2
HCO3 22.0-27.0 mmol/L
HCO3 14.2mmol/L
Decreased HCO3
BE(ecf) (-2)-(+2) mmol/L
BE(ecf) -7.8
O2sat 80-100%
O2sat 99.1%
Increased pH Decreased pCO2;
Decreased base excess; indicates non respi/meta disturbance or true base deficit Normal
Partially Compensated Respiratory Alkalosis
HCO3 is an alkaline substance
51
November 21, 2006
that functions as an important buffer in the blood stream. O2 sat is the amount of oxygen actually bound to the hemoglobin and available for transport throughout the body.
pH 7.35-7.45 mmHg
pH 7.439 mmHg
Normal
pCO2 35-45 mmmHg
pCO2 22.9 mmmHg
Decreased pCO2
pO2 80-100mmHg
pO2 124.2 mmHg
Increased pO2
HCO3 22.0-27.0 mmol/L
HCO3 15.2 mmol/L
Decreased HCO3
BE(ecf) (-2)-(+2) mmol/L
BE(ecf) -9.0 mmol/L
Decreased base excess
O2sat 80-100%
O2sat 98.6%
Normal
Fully Compensated Respiratory Alkalosis
52
Date November 12, 2006
Diagnostic Procedure Rationale Blood Chemistry Analysis of the physical, chemical, and microbiological properties of blood, carried out to diagnose disease, monitor treatment, or detect the presence of specific substance. RBS is used as a random screen for glucose level. Creatinine is essential in the evaluation of renal function.
November 17, 2006
Sodium and Potassium evaluates fluid and electrolyte balance as well as renal or adrenal disorders Chloride helps diagnose disorders of acid-base and water balance.
Normal values Glucose RBS 3.90-6.10
Result
Impression
6.52
Increased; may indicate DM or stress
Creatinine 53.0-115.0 mmol/L
146.53
Increased; may indicate impaired renal function, essential hypertension, acute MI, severe CHF or urinary obstruction
Sodium 136.0-145.0 mmol/L
140
Normal
Potassium 3.5-5.5 mmol/L
5.1
Normal
Chloride 098.0-106.0 mmol/L
107.0
Increased; may indicate dehydration, cardiac decompensation, or metabolic acidosis
Creatinine 53.0-115.0 mmol/L
123.61
Increased
Sodium 136.0-145.0 mmol/L
144
Normal
Potassium 3.5-5.5 mmol/L
4.0
Normal
53
November 21, 2006
November 26, 2006
Responsible for maintaining water balance and cellular integrity through its influence on osmotic pressure.
Creatinine 53.0-115.0 mmol/L
127.80
Sodium 136.0-145.0 mmol/L
140
Normal
Potassium 3.5-5.5 mmol/L
4.4
Normal
Sodium 136.0-145.0 mmol/L
141
Normal
Potassium 3.5-5.5 mmol/L
4.0
Normal
Increased
54
Date November 12, 2006
Diagnostic Procedure Blood Hematology Hemoglobin
Hematocrit
Erythrocyte
Rationale Evaluates blood loss, erythropoietic ability, anemia and response to therapy. It is an important component of red blood cell that carries oxygen and carbon dioxide to and from the tissues. Evaluates blood loss, anemia, blood replacement therapy and fluid balance and screens red blood cell status. It is the measure of red blood cells within the volume and also evaluates dehydration and hypervolemia. Evaluates anemia, polycythemia and
Normal values Hgb 135-175g/L
Result
Impression
157
Normal
Hct 0.40-0.52
0.47
Normal
RBC 4.20-6.10x10’6/uL
5.08
Normal
WBC 5.0-10.0x10’3/uL
5.40
Normal
Neutrophil 55-75%
67
Normal
Lympocytes 20-35
21
Normal
Monocytes 2-10
10
Normal
Eosinophil 1-5
2
Normal
Basophil 0-1
0
Normal
Platelet 150-400x10’3/uL
132
Decreased; may be due to medication, blood clotting factor is decreased and so at high risk for
55
calculates red blood cell indices. Oxygen transport to the cells throughout the body depends upon sufficient numbers of red blood cells with adequate amount of hemoglobin.
November 21, 2006
Leukocytes
Neutrophils
Evaluates a number of conditions and differentiates causes of alterations in the total WBC count including inflammation, infection, tissue necrosis and/or leukemic neoplasm. Increase neutrophil count may indicate parasitic or bacterial infection, metabolic disorder including diabetic acidosis. Decrease
spontaneous bleeding
Hgb 135-175g/L
161
Normal
Hct 0.40-0.52
0.49
Normal
RBC 4.20-6.10x10’6/uL
5.14
Normal
WBC 5.0-10.0x10’3/uL
11.26
Increased; may indicate infection, inflammation, tissue necrosis or stress
Neutrophil 55-75%
91
Increased; may indicate bacterial infection, tissue necrosis or MI
Lympocytes 20-35
6
Decreased; may indicate defective lymphatic circulation, renal failure or advanced tuberculosis
Monocytes 2-10
2
Normal
Eosinophil 1-5
1
Normal
56
in level may indicate infection and anemia. Lymphocyte
November 25, 2006
Monocyte
Evaluate bacterial and viral infection, immune disease, leukemia and ulcerative colitis. Elevated levels may indicate active viral infection and depressed level may indicate exhausted immune system. Evaluates function of phagocytic scavenger to remove foreigh materials.
Eosinophils
Primary influenced by antigen-body responses.
Basophils
Basophil function not understood as well as other white cell types; it is believed to be related to allergic
Basophil 0-1
0
Platelet 150-400x10’3/uL
133
Decreased; may be due to medication, blood clotting factor is decreased and so at high risk for spontaneous bleeding
Hgb 135-175g/L
165
Normal
Hct 0.40-0.52
0.46
Normal
RBC 4.20-6.10x10’6/uL
5.31
Normal
WBC 5.0-10.0x10’3/uL
4.83
Decreased; may indicate bone marrow failure, overwhelming infection, dietary deficiency or drug toxicity
Neutrophil 55-75%
74
Normal
Lympocytes 20-35
14
Decreased; may indicate defective lymphatic
Normal
57
and anaphylactic responses. Platelet
Evaluates platelet production. It notes the platelet size and shape. Low levels predispose bleeding while high levels may increase the risk of thrombocytosis.
circulation, renal failure or advanced tuberculosis Monocytes 2-10
12
Increased; may indicate infection such as tuberculosis and subacute bacterial endocarditis
Eosinophil 1-5
0
Decreased; may indicate stress response associated with trauma, shock or CHF
Basophil 0-1
0
Normal
Platelet 150-400x10’3/uL
141
Decreased; may be due to medication, blood clotting factor is decreased and so at high risk for spontaneous bleeding
58
Date November 12, 2006
Diagnostic Procedure Urinalysis- is the testing of the physical characteristics and compositions of freshly voided urine
Rationale
Normal Values
Result
Impression
Screens for abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through the urinary tract.
Color- Pale-star colored to amber color
Color- yellow
Normal
Appearance- clear to slightly hazy
Appearanceslightly cloudy
Hazy or cloudy urine may indicate the presence of RBC, WBC, bacteria, pus, phosphate, uric acid or spermatozoa
Reaction- 4.8-7.8
Reaction- 6.0
Normal
Specific gravity- 1.003- Specific gravity1.035 1.025
Normal
Albumin- Negative
Albumin- (+++)
Positive albumin may indicate nephritic syndrome, UTI, fever, trauma, CHF, acute infection, or kidney disease
Sugar- Negative
Sugar-(-)
Normal
Normal RBC- 0- 2 hpf
Result RBC - 2530hpf
Increased; may indicate renal problem
Normal Pus cells- 0-2 hpf
Result pus cells 34hpf
Increased; may indicate presence of infection or tuberculosis
59
Date: May 15, 2006 Diagnostic procedure: Echocardiogram (2D Echo report) test evaluates the size, shape & motion of various structures within the heart, it is a noninvasive test. Rationale: This ultrasonic test diagnoses abnormalities in anatomy and valvular function within the heart. Sound waves are bounced off the heart using a transducer to image the heart in motion as well as its valves and vessels. Normal findings: Normal anatomical structure and position, normal and patent arteries and/or veins of the heart, normal valve structure, normal valve structure, normal blood flow within the heart, normal ventricular function, absence of thrombi or bacterial vegetations, absence of pericardial effusions Result: Echo-Doppler findings •
Eccentric left ventricular hypertrophy with multisegmental wall
motion abnormal with depressed systolic function •
Left ventricular ejection fraction of 23%
•
Dilated left atrium
•
Normal right atrium, main pulmonary artery & aortic root
dimension •
Aortic sclerosis with aortic regurgitation of 2+
•
Mitral sclerosis with mild mitral regurgitation
•
Mild tricuspid regurgitation
•
Structurally normal tricuspid valve & pulmonic valve
•
No intra-cardiac thrombus or pericardial effusion noted
•
Normal pulmonary artery pressure by tricuspid regurgitation jet
60
Date: November 23, 2006 Diagnostic procedure: Chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the lungs, airway, blood vessels and the bones of the spine and chest Rationale: Identify various abnormalities of the lungs and structures in the thorax, including the heart, great vessels, ribs or diaphragm. It may also be used as a general screening tool or for a specific diagnostic purpose, including identification of pulmonary diseases or orthopedic abnormalities. It is also used to evaluate the status of respiratory abnormalities or cardiac conditions. Normal Findings: Normal chest and surrounding structures, including bony thorax, soft tissues, mediastinum, lungs, pleura, heart, and great vessels Result: Study done in AP supine view. Haziness is noted in both lower lung fields. A thin band of opacity is noted in the right apex. The rest of the lungs are clear. Tracheal air column is at midline. The heart is enlarged with inferolateral displacement of the cardiac apex, fullness of the retro cardiac space and splaying of the carina. Both costophrenic sulci are blunted. The hemidiaphragms are obscured. The rest of the included structures are unremarkable. Impression: •
Left sided cardiomegaly. Please correlate with ECG findings
•
Bibasal pneumonia with underlying minimal pleural effusion
•
Apico-pleural thickening, right
61
Diagnostic procedure: Electrocardiogram (ECG) most common test of heart’s condition and is used to graphically record the electrical current generated by the beating heart Rationale: This electrophysiologic test is used primarily to screen for and diagnose a variety of cardiac conditions as well as to monitor the heart’s response to therapy. It is used to diagnose abnormal heart rhythms, conduction disturbances, hypertrophy of cardiac chambers, myocardial infarction and ischemia and pericarditis. Normal findings: Normal sinus rhythm, normal conduction patterns, absence of areas of infarct or ischemia
First result: AF in MVR Old inferior wall infarct Incomplete RBBB, Anterolateral wall infarct
Second result: Course AF in slow VR Infarction anterolateral wall LAD, PVW R wave program Incomplete RBBB
62
Date: November 12, 2006 Immunology: Troponin – T qualitative is reliable markers of myocardial injury and is found in human serum within 4-6 hours following MI Rationale: Primarily ordered for people who have chest pain to see if they have had a heart attack or other damage to the heart. It is done 2-3 times in 12-16 hours period. Result: POSITIVE Implication: •
It indicates pulmonary embolism because of right ventricular dilatation and myocardial injury
63
Hematology: PROTIME and APTT Rationale (ProTime): Screens for lack of coagulation factors necessary for blood clotting. Prothrombin time measures the time required for a fibrin clot to form in a citrated plasma sample after addition of calcium ions and tissue thromboplastin and compares this with fibrin clotting time in a control sample plasma. Rationale (APTT): Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting. The basis of the test is fibrin clot formation and it evaluates all the clotting factors of the intrinsic pathway except factors VII and VIII. Normal Findings (ProTime): 11-14 seconds Normal Findings (APTT): 27-34 seconds November 16, 2006 Result: 19.5 seconds
November 16, 2006 Result: 40 seconds
November 22, 2006 Result: 16.3 seconds
Increased protime may indicate deficiency of clotting factors or circulating anticoagulant products
Increased Activated Partial Thromboplastin Time (APTT), may indicate vitamin k deficiency or presence of circulating anticoagulants
Increased protime may indicate deficiency of clotting factors or circulating anticoagulant products
64
DRUG STUDY Generic Name: Isosorbide Mononitrate Brand Name: Monoket Classification: Anti-angina Frequency/Route/Dose: 60 mg/tab ½ tab OD Action: Produces vasodilation; decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume. Net effect is reduced myocardial oxygen consumption; increase coronary blood flow by dilating coronary arteries and improving collateral flow of ischemic regions. Indication: Acute treatment of anginal attacks; long term prophylactic management of angina pectoris Contraindication: Hypersensitivity to nitrates, severe anemia, head trauma, cerebral hemorrhage Adverse Effects: CNS: headache, apprehension, weakness, dizziness CV: tachycardia, hypotension, syncope, paradoxical bradycardia GI: nausea, vomiting, abdominal pain Misc: Flushing, tolerance, pruritus, rash Drug Interaction: Additive hypotension with anti-hypertesiv, acute ingestion of alcohol, betaadrenergic blocking agents, calcium channel blockers and phenothiazines. Nursing Responsibilities: •
Assess location, duration, intensity, and precipitating factors of anginal pain
•
Monitor BP and pulse routinely
•
Taken on an empty stomach with a full glass of water
•
Instruct to take medication as directed
•
Caution to make position changes slowly to minimize orthostatic hypotension
•
Advise to avoid activities that requires alertness
•
Advise to notify physician or other health care provider if dry mouth or blurred vision occurs 65
Generic Name: Isosorbide Dinitrate Brand Name: Isordil Classification: Anti-angina Frequency/Route/Dose: 5 mg/tab 1 tab now Action: Produces vasodilation; decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume. Net effect is reduced myocardial oxygen consumption; increase coronary blood flow by dilating coronary arteries and improving collateral flow of ischemic regions. Indication: Acute treatment of anginal attacks; long term prophylactic management of angina Pectoris; treatment of chronic congestive heart failure Contraindication: Hypersensitivity to nitrates, severe anemia, head trauma, cerebral hemorrhage Adverse Effects: CNS: headache, apprehension, weakness, dizziness CV: tachycardia, hypotension, syncope, paradoxical bradycardia GI: nausea, vomiting, abdominal pain Misc: Flushing, tolerance, pruritus, rash Drug Interaction: Additive hypotension with anti-hypertesiv, acute ingestion of alcohol, betaadrenergic blocking agents, calcium channel blockers and phenothiazines. Nursing Responsibilities: •
Assess location, duration, intensity, and precipitating factors of anginal pain
•
Monitor BP and pulse routinely
•
Taken 1 hour before or 2 hours after with full glass of water for better absorption
•
Instruct to take medication as directed
•
Caution to make position changes slowly to minimize orthostatic hypotension
•
Advise to avoid activities that requires alertness
•
Advise to notify physician or other health care provider if dry mouth or blurred vision occurs
66
Generic Name: Metoprolol Brand Name: Lopressor Classification: Beta-Adrenergic blocking agents (Anti-hypertensive) Frequency/Route/Dose: 50 mg/tab ½ tab BID Action: Block stimulation of beta1 adrenergic receptors, do not usually affect beta2 receptor sites Indication: Management of hypertension, angina pectoris; prevention of myocardial infarction Contraindication: Uncompensated congestive heart failure, pulmonary edema, cardiogenic shock, bradycardia or heart block, known alcohol intolerance Adverse Effects: CNS: fatigue, weakness, dizziness, depression, insomia, memory loss, mental status changes, anxiety, nervousness, drowsiness CV: bradycardia, hypotension, congestive heart failure, pulmonary edema, peripheral vasoconstriction Resp: bronchospasm, wheezing EENT: blurred vision, stuffy nose GI: constipation, nausea, diarrhea, vomiting, liver function abnormalities GU: impotence, decreased libidourinary frequency, urinary retention Derma: rashes Endo: hyperglycemia, hypoglycemia MS: joint pain, back pain Drug Interaction: Barbiturates, rifampicin: increase metabolism of metorpolol effect Cardiac glycosides, diltiazem, verapamil: cause excessive bradycardia and increase depressant effect on myocardium. Catecholamine-depleting drugs such as H2 antagonist, MAO inhibitors,
reserpine:
have
additive
effect
when
given
with
beta-blockers.
Chlorpromazine, cimetidine, verapamil: decrease hepatic clearance. Indomethacin: decrease anti-hypertensive effect Nursing Responsibilities: •
Always check apical pulse rate before giving drug
67
•
Monitor BP, ECG and pulse frequently
•
Monitor Intake and Output ratios and daily weight
•
Assess frequency and characteristics of anginal attacks periodically throughout therapy
•
Instruct patient to take drug exactly as prescribed and to take it with meals.
•
Advise to avoid activities that require alertness
•
Advise to make position changes slowly to prevent orthostatic hypotension
68
Generic Name: Captopril Brand Name: Capoten Classification: ACE Inhibitors (Anti-hypertensive) Frequency/Route/Dose: 25 mg/tab ½ tab OD Action: Prevents production of angiotensin II, a potent vasoconstrictor that stimulates the production of aldosterone by blocking its conversion to the active form-result is systemic vasodilation Indication: Management of hypertension, management of congestive heart failure, reduction of risk of death or development of congestive heart failure following myocardial infarction Contraindication: Hypersensitivity to ACE inhibitors, hypotension, oliguria, renal impairment, hepatic impairment, elderly patients Adverse Effects: CNS: dizziness, headache, fatigue, insomia, weakness CV: hypotension, tachycardia, angina pectoris Resp: cough GI: anorexia, loss of taste perception, nausea, diarrhea GU: proteinuria, renal failure, impotence Derma: rashes Hemat: neutropenia, agranulocytosis Misc: angioedema, fever Drug Interaction: Excessive hypotension may occur with concurrent use of diuretics. Additive hypotension with other anti-hypertensive, nitrates, phenothiazines, and acute ingestion of alcohol. Anti-hypertensive response may be blunted by NSAIDs. Absorption may decrease with antacids, increases levels and may increase risk of lithium or digoxin toxicity. Nursing Responsibilities: •
Monitor BP and pulse frequently
•
Administer 1 hour before or 2 hours after meals for better absorption 69
•
Instruct patient to take drug exactly as prescribed
•
Instruct to notify physician or other health care provider is mouth sores, sore throat, fever, swelling of hands and feet, irregular heart beat, chest pain, difficulty swallowing or skin rash occurs
•
Advise to avoid foods containing high levels of potassium or sodium unless directed
•
Advise to avoid activities that require alertness
•
Advise to make position changes slowly to prevent orthostatic hypotension
70
Generic Name: Lactulose Brand Name: Lactulose PSE Classification: Laxative (hyperosmotic) Frequency/Route/Dose: 30 cc at HS Action: Increases water content and softens stool; lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia levels Indication: Treatment of chronic constipation Contraindication: Patients with low-galactose diets, diabetes mellitus, excessive or prolonged use Adverse Effects: GI: cramps, distention, flatulence, belching, diarrhea Endo: hyperglycemia Drug Interaction: Should not be used with other laxatives. Anti-infectives may diminish effectiveness and antacids may decrease the effect of lactulose on colonic pH Nursing Responsibilities: •
Assess for abdominal distention, presence of bowel sounds, and normal pattern of bowel function
•
Assess color, consistency, and amount of stool produced
•
Instruct patient to take drug exactly as prescribed
•
Mix with fruit juice, water, milk or carbonated citrus beverages to improve flavor; may be administered on an empty stomach for more rapid results
•
Encourage to use other forms of bowel regulation, such as increasing bulk in the diet, increasing fluid intake, increasing mobility
•
Caution patient that medication may cause belching, flatulence, or abdominal cramping
71
Generic Name: Aspirin Brand Name: ASA Classification: Salicylates, NSAID, Antiplatelet, Antipyretic Frequency/Route/Dose: 80 mg/tab 1 tab OD Action: Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins, decreases platelet aggregation Indication: Management of inflammatory disorders including: rheumatoid arthritis; treatment of mild to moderate pain; treatment of fever; prophylaxis of transient ischemic attacks and myocardial infarction Contraindication: Hypersensitivity to aspirin, salicylates, NSAIDs; bleeding disorders; history of GI bleeding; severe renal disease; severe hepatic disease Adverse Effects: EENT: tinnitus, hearing loss GI: dyspepsia, heartburn, epigastric distress, nausea, vomiting, anorexia, abdominal pain, GI bleeding, hepatotoxicity Hemat: anemia, hemolysis, increased bleeding time Misc: noncardiogenic pulmonary edema, allergic reactions Drug Interaction: May potentiate warfarin, heparin or thrombolytic agents. May increase the bleeding with valproic acid, cefoperazone, cefamandole. May enhance the activity of penicillins, phenytoin, valproic acid, oral hypoglycemic agents and sulfonamides. May antagonize the beneficial effects of probenecid Nursing Responsibilities: •
Assess pain and limitation of movement
•
Assess fever and note associated signs
•
Advise patient to take drug with food, milk, antacid, or large glass of water to reduce adverse GI reactions.
•
Tell patient that sustained-release or enteric-coated forms shouldn’t be crushed or chewed but swallowed.
•
Advise to report signs of tinnitus, bleeding of gums, bruising, fever, black tarry stools
72
•
Teach patient on sodium restricted diet to avoid buffered-aspirin preparations
•
Advise patient to take only prescribed dosage
Generic Name: Clopidogrel Brand Name: Plavix Classification: Anticoagulant, Antithrombotics Frequency/Route/Dose: 25 mg/tab OD Action: Obtained by depolymerization of unfractioned porcine heparin. An antithombolytic drug. They enhance the inhibition of factor Xa and thrombin by binding to and accelerating anti-thrombin II activity Indication: Reduction of atherosclerotic events in patients wit hatherosclerosis documented by recent ischemic stroke or Myocardial infarction Contraindication: Severe liver impairment, peptic ulcer and intracranial hemorrhage Adverse Effects: GI: bleeding, abdominal pain, dyspepsia, gastritis, constipation EENT: ocular hemorrhage Derm: purpura, bruising, rash pruritus Drug Interaction: Warfarin, aspirin, heparin, thrombolytic or NSAIDS, increase risk of bleeding Nursing Responsibilities: •
Tell patient to refrain from activities in which trauma and bleeding may occur
•
Advise patient that drug may be taken without regards to meals
•
Instruct patient to inform physician or other health care provider if unusual bleeding or bruising occur
73
Generic Name: Enoxaparin Brand Name: Lovenox Classification: Heparin, anticoagulant (antithrombotic) Frequency/Route/Dose: 6000 IU q 12 Action: Potentiate the inhibitory effect of antithrombin on factor Xa and thrombin. In low doses it prevents conversion of prothrombin to thrombin by its effects on factor Xa. In high doses it neutralize thrombin, preventing the conversion of fibrinogen to fibrin. Indication: Prevention of deep vein thrombosis and pulmonary embolism, atrial fibrillation with embolization Contraindication: Hypersensitivity to the drug, open wounds, severe liver or kidney disease, untreated hypertension, spinal cord or brain injury, history of bleeding disorders Adverse Effects: CV: edema GI: hepatitis Derm: rashes Hemat: bleeding, anemia Local: irritation, pain, hematoma Misc: fever Drug Interaction: Risk of bleeding may be increased by concurrent use of drugs that affect platelet function, including aspirin, NSAIDs, some penicillins, valproic acid, cefmetazole, quinidine, dextran and thrombolytic agents Nursing Responsibilities: •
Assess for signs of bleeding and hemorrhage
•
Assess for evidence of additional or increased thrombosis.
•
Monitor patient for hypersensitivity reactions
•
Advise to report any symptoms of unusual bleeding or bruising
•
Instruct not to take medications containing aspirin, ibuprofen, naproxen or ketoprofen
74
Generic Name: Furosemide Brand Name: Lasix Classification: Loop diuretics Frequency/Route/Dose: 40 mg 1 tab OD Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, hydrogen and calcium. Indication: Management of edema secondary to congestive heart failure, hepatic or renal disease, treatment of hypertension Contraindication: Hypersensitivity to the drug, hepatic coma, severe liver disease, electrolyte depletion, geriatric patients, diabetes mellitus Adverse Effects: CNS: dizziness, headache, nervousness, insomia CV: hypotension GI: nausea, vomiting, diarrhea, constipation, dry mouth, dyspepsia EENT: hearing loss, tinnitus Derm: rashes, photosensitivity F and E: hyperglycemia Hemat: blood dyscrasias MS: muscle cramps Misc: increased BUN Drug Interaction: Additive hypotension with antihypertensives or nitrates. Decreases lithium excretion, may cause toxicity. May increase the effectiveness of warfarin, thrombolytics and anticoagulants Nursing Responsibilities: •
Assess fluid status throughout therapy
•
Monitor BP and pulse before and during administration
•
Assess patient for tinnitus and hearing loss
•
Administer medication in the morning to prevent disruption of sleep cycle 75
•
Administer orally with food or milk to minimize gastric irritation
•
Caution to make position changes slowly to prevent orthostatic hypotension
Generic Name: Digoxin Brand Name: Lanoxin Classification: Antiarrhythmics, digitalis glycosides Frequency/Route/Dose: 0.25 mg/tab OD Action: Inhibits sodium potassium-activated adenosine triphosphate, thereby promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Indication: Heart failure, paroxysmal supra-ventricular tachycardia, atrial fibrillation and flutter Contraindication: Hypersensitive to drug and in those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure. Adverse Effects: CNS: fatigue, weakness, headache, blured vision, yellow vision CV: arrhythmias, bradycardia, ECG changes GI: nausea, vomiting, diarrhea, anorexia Endo: gynecomastia Hemat: thrombocytopenia Drug Interaction: Antacids, decreased absorption of oral digoxin. Antibiotics: increased risk for toxicity because of altered intestinal flora. Anticho-linergics: may increase digoxin absorption of oral digoxin tablets Nursing Responsibilities: •
Monitor apical pulse and BP periodically
•
Monitor ECG throughout therapy
•
Monitor intake and output and daily weights
•
Monitor potassium levels. Take corrective measures before hypokalemia occurs
•
Can be administered without regard to meals
•
Tell patient to report pulse below 60 bpm or above 110 bpm, or skipped beats or other rhythm changes
•
Instruct to take medication as directed
76
Generic Name: Spironolactone Brand Name: Aldactone Classification: Potassium-sparing diuretics Frequency/Route/Dose: 100 mg 1 tab now then OD Action: Causes excretion of sodium bicarbonate and calcium while conserving potassium and hydrogen ions Indication: Counteracts potassium loss induced by other diuretics, treat edema or hypertension Contraindication: Hypersensitivity to drug, hyperkalemia, hepatic dysfunction, renal insufficiency, history of gout or kidney stone Adverse Effects: CNS: headache, clumsiness, dizziness CV: arrhythmias GI: gastrointestinal irritation GU: impotence Endo: gynecomastia F and E: hyperkalemia, hyponatremia Hemat: dyscrasias MS: muscle cramps Misc: allergic reactions Drug Interaction: ACE inhibitors: increased risk of hyperkalemia; Aspirin: possible blocked diuretic effect Nursing Responsibilities: •
Monitor intake and output
•
Monitor signs and symptoms of hypokalemia
•
Give the drug with meals, to enhance absorption
•
Administer in the morning to avoid interrupting sleep pattern
•
Warn patient to avoid excessive ingestion of potassium-rich foods
•
Caution patient not to perform hazardous activities if adverse CNS reactions occur
77
•
Advise patient to notify physician or other health care provider if muscle cramps or weakness occurs
Generic Name: Tramadol Brand Name: Ultram Classification: Analgesic Frequency/Route/Dose: 1 amp IVTT Action: A centrally acting synthetic analgesic compound not chemically related to opiates. Drug is thought to bind to opioid receptors and inhibit reuptake of nor-epinephrine and serotonin Indication: Treatment of moderate to moderately severe pain Contraindication: Hypersensitivity to drug and those with acute intoxication from alcohol, hypnotics, centrally acting analgesics, opioids Adverse Effects: CNS: headache, drowsiness, sleep disorder, nervousness, seizures CV: vasodilation GI: nausea, constipation, vomiting, dyspepsia, dry mouth, diarrhea, abdominal pain GU: urinary retention, urinary frequency EENT: visual disturbances Derm: pruritus, sweating Drug Interaction: Carbamazepine: increased tramadol metabolism Nursing Responsibilities: •
Assess type, location, and intensity of pain
•
Assess BP and respiratory rate before and periodically during administration
•
Assess bowel function routinely
•
May be administered without regards to meal
•
Instruct patient to avoid activities that require alertness
•
Advise to make position changes slowly to prevent orthostatic hypotension
78
Generic Name: Morphine Brand Name: Astramorph Classification: Opioid Analgesic Frequency/Route/Dose: 2 mg IVTT now Action: Binds with opiate receptors in the CNS, altering both perception and emotional response to pain. Indication: Management of severe pain, pulmonary edema, pain associated with MI Contraindication: Hypersensitivity to drug and in those with conditions that would prelude administration of opioids by IV route (acute bronchial asthma or upper airway obstruction) Adverse Effects: CNS: sedation, somnolence, clouded sensorium, euphoria, seizures, dizziness, nightmares, hallucinations CV: hypotension, bradycardia, shock, cardiac arrest Resp: respiratory depression EENT: diplopia, blurred vision GI: nausea, vomiting, constipation, ileus GU: urinary retention Derm: sweating, flushing, itching Misc: tolerance, physical dependence Drug Interaction: CNS depressants, general anesthetics, hypnotics, sedatives: may cause respiratory depression, hypotension, profound sedation, or coma Nursing Responsibilities: •
Assess type, location, and intensity of pain
•
Assess BP, pulse and respiration before and periodically during administration
•
Assess bowel function routinely
•
May be administered with food or milk to minimize GI irritation
•
Don’t crush, break or chew extended-release tablets 79
•
Watch for pruritus and skin flushing with epidural administration
•
Caution ambulatory patients about going out of bed or walking
•
Advise patient to change position slowly to prevent orthostatic hypotension
Generic Name: Senna Concentrate Brand Name: Senokot Classification: Laxative (stimulant) Frequency/Route/Dose: 2 tabs HS Action: Active components of senna alter water and electrolyte transport in the large intestine, resulting in accumulation of water and increased peristalsis Indication: Treatment of constipation, particularly when associated with slow transit time, constipating drugs, irritable or spastic bowel syndrome Contraindication: Hypersensitivity to any ingredient, nausea or vomiting or other symptoms of appendicitis, acute surgical abdomen, fecal impaction, abdominal pain Adverse Effects: GI: nausea, diarrhea, cramping GU: pink-red or brown-black discoloration of urine F and E: electrolyte abnormalities Misc: laxative dependence Drug Interaction: Laxatives containing aluminum, calcium or magnesium impair absorption of tetracycline due to release of free calcium Nursing Responsibilities: •
Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function
•
Assess color, consistency and amount of stool produced
•
Take with a full glass of water. Administer at bedtime for evacuation 6-12 hours later
•
Advise patient that laxative should be used only for short-term therapy
•
Encourage to use other forms of bowel regulation such as increasing bulk in diet, increasing fluid intake, increasing mobility
•
Inform patient that this medication may cause changes in urine color
•
Advise not to use laxatives when abdominal pain, nausea, vomiting or fever are present
80
Generic Name: Warfarin Brand Name: Coumadin Classification: Anticoagulant Frequency/Route/Dose: 5 mg ½ tab OD Action: Inhibits vitamin K-dependent activation of clotting factors II, VII, IX, and X, formed in the liver Indication: Prophylaxis and treatment of venous thrombosis, atrial fibrillation with embolization, pulmonary embolism, adjunct in prohylaxis of systemic embolism after MI Contraindication: Hemorrhage tendency, blood dyscrasias, recent or contemplated surgery of CNS bleeding tendencies associated with active ulceration or overt bleeding Adverse Effects: GI: nausea, cramping Derm: dermal necrosis Hemat: bleeding Misc: fever Drug Interaction: Effects diminished by barbiturates, cholestyramine, gluthetimide, rifampicin, vitamin K Nursing Responsibilities: •
Assess patient for signs of bleeding and hemorrhage
•
Administer medication same time each day
•
Medication requires 3-5 days to reach effective levels
•
Instruct to take medication as directed
•
Review foods high in vitamin K
•
Advise to report signs of unusual bleeding or bruising
•
Instruct not to drink alcohol or OTC medications such as those containing aspirin, ibuprofen, or naproxen
81
Generic Name: Ceftazidime Brand Name: Ceptaz Classification: Anti-infective (third generation cephalosporins) Frequency/Route/Dose: 1 gm IVTT q 8 hours Action: Binds to bacterial cell wall membrane, causing cell death. Bactericidal action against susceptible bacteria Indication: Treatment of skin an skin structure infections, bone and joint infections, urinary infections, respiratory infections, intra-abdominal infections, septicemia Contraindication: Hypersensitivity to cephalosporins, serious hypersensitivity to penicillins, renal impairment, hepatic or renal impairment Adverse Effects: CNS: seizures GI: nausea, vomiting, diarrhea, cramping, colitis Derm: rashes, urticaria Hemat: blood dyscrasias, hemolytic anemia, bleeding Misc: superinfection, allergic reactions Drug Interaction: Probenecid decreases excretion and increases serum levels. Ingestion of alcohol within 48-72 hours of cefoperazone may result in a disulfiram-like reaction. Nursing Responsibilities: •
Assess patient for infection
•
Obtain history to determine previous use of and reactions to penicillins or cephalosporins
•
Observe for signs and symptoms of anaphylaxis
•
May be administered on full or empty stomach. Administer with food may minimize GI irritation
•
Tell patient to take exact amount as prescribed
•
Inform patient not to crush, break or chew extended-release tablets
•
Advise to report signs of superinfection 82
•
Instruct patient to finish the medication completely
•
Instruct patient to notify physician and other health care provider if fever and diarrhea develops
Generic Name: Clindamycin Brand Name: Dalacin Classification: Anti-infective Frequency/Route/Dose: 300 mg 1 tab q 6 hours Action: Inhibits protein synthesis in susceptible bacteria. Bactericidal or bacteriostatic Indication: Treatment of skin an skin structure infections, bone and joint infections, urinary infections, respiratory infections, intra-abdominal infections, septicemia Contraindication: Hypersensitivity to drug, severe liver impairment, diarrhea, alcohol intolerance Adverse Effects: CNS: dizziness, vertigo, headache CV: hypotension, arrhythmias GI: nausea, vomiting, diarrhea, colitis Derm: rashes Drug Interaction: Erythromycin: may block access of clindamycin to its site of action. Neuromuscular blockers: increase neuromuscular blockade possible Nursing Responsibilities: •
Assess patient for infection
•
Observe for signs and symptoms of anaphylaxis
•
Administered with a full glass of water. May be given with meals
•
Tell patient to take exact amount as prescribed
•
Inform patient not to crush, break or chew extended-release tablets
•
Instruct patient to finish the medication completely
•
Instruct patient to notify physician and other health care provider if fever and diarrhea develops
•
Observe patient for signs and symptoms of superinfection
83
Generic Name: Acetaminophen Brand Name: Paracetamol Classification: Nonopioid analgesic, antipyretic Frequency/Route/Dose: 500 mg 1 tab q 4 hours Action: Thought to produce analgesia by blocking generation of pain impulses, probably by inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substance that synthesize pain receptors to mechanical or chemical stimulation Indication: Mild to moderate pain, fever Contraindication: Hypersensitivity to drug, products containing alcohol, severe hepatic disease, renal disease, malnutrition Adverse Effects: GI: hepatic necrosis Derm: rash, urticaria Drug Interaction: Chronic concurrent use with NSAIDs including aspirin may increase the risk of adverse reactions. Barbiturates, carbamazepine, rifampicins: may reduce therapeutic effects and cause hepatotoxicity Nursing Responsibilities: •
Assess type, location, and intensity prior to and 30-60 minutes following administration
•
Assess fever and associated signs
•
Administer with full glass of water
•
May be taken with food or on an empty stomach
•
Advise patient to take medication exactly as directed
•
Advise patient to notify physician or other health care provider if discomfort or fever is not relieved
84
Generic Name: Omeprazole Brand Name: Losec Classification: Anti-ulcer, Gastric acid pump inhibitor Frequency/Route/Dose: 80 mg IVTT now then 40 mg IVTT q 12 hours Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH, preventing the final transport of hydrogen ions into the gastric lumen Indication: Management of GERD, management of gastric ulcer, treatment of gastric hypersecretory conditions Contraindication: Hypersensitivity to drug Adverse Effects: CNS: weakness, dizziness, headache, fatigue CV: chest pain GI: abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting Derm: rash, itching Drug Interaction: Decreases metabolism and may increase effects of phenytoin, diazepam, and warfarin. May interfere with absorption of drugs requiring acid gastric pH including ketoconazole, ampicillin and iron salts Nursing Responsibilities: •
Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool
•
Administer doses before meals, preferably in the morning
•
May be administered concurrently with antacids
•
Instruct to take medication as directed
•
May cause occasional drowsiness, or dizziness. Caution patient to avoid activities that require alertness
85
•
Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent headache to the physician promptly
Generic Name: Metoclopramide Brand Name: Clopra Classification: Antiemetic, GI stimulant Frequency/Route/Dose: 10 mg 1 tab 3 times a day Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates the motility of the upper GI tract and accelerates gastric emptying Indication: Nausea and vomiting with GI disorder, disorders in reduced GI motility Contraindication: Hypersensitivity, GI hemorrhage or obstruction, perforation, epilepsy Adverse Effects: CNS: restlessness, drowsiness, fatigue, extrapyramidal effect, depression, irritability, anxiety CV: arrhythmias GI: constipation, diarrhea, nausea, dry mouth Endo: gynecomastia Drug Interaction: Phenothiazines, lithium, centrally-active agents including anti-depressants, anti-epileptics and sympathemimetics Nursing Responsibilities: •
Assess patient for nausea, vomiting, abdominal distention and bowel sounds prior to or following administration
•
Assess patient for extrapyramidal effects
•
Assess for signs of depression
•
Administer 30 minutes before meals and at bedtime
•
Instruct to take medication as directed
•
Caution to avoid activities that requires alertness
•
Advise to notify physician or other health care provider if involuntary movements occurs
86
Generic Name: Levofloxacin Brand Name: Levox Classification: Quinolones Frequency/Route/Dose: 500 mg 1 cap OD Action: Synthetic, broad spectrum antibacterial agents, the fluorine molecule confers increased activity against gram positive organism as well as broadens the spectrum against gram positive organism Indication: Acute bacterial exacerbation of chronic bronchitis, community acquired pneumonia Contraindication: Hypersensitivity to quinolones, epilepsy, history of tendon disorders related to fluoroquinolones therapy Adverse Effects: CNS: headache, insomnia, dizziness GI: Nausea and vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence, Derm: rash, pruritus Drug Interaction: Absorption impaired by antacids, sucralfate, mental cautions, and Zinccontaining multi-vitamin preparation, probeneclol and cimetidine may affect the rate and extent of levofloxacin absorption Nursing Responsibilities: •
Obtain specimen for culture and sensitivity test
•
Tell patient to take exact amount as prescribed
•
Tell patient that drug may be taken with meals
•
Inform patient not to crush, break or chew extended-release tablets
87
Generic Name: Ranitidine Brand Name: Zantac Classification: Antiemetic, antacids Frequency/Route/Dose: 1 amp IVTT OD Action: Potent anti-ulcer drug that competetively and reversibly inhibits histamine action at H2 receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion. Indication: Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer Contraindication: Acute poyphyria; hyper-sensitivity to ranitidine Adverse Effects: CNS: headache, malaise, dizziness, somnolence, insomnia, vertigo, mental confusion, agitation Resp: bradycardia GI: constipation, nausea, abdominal pain Drug Interaction: Antacids: interfere with ranitidine absorption. Diazepam: decrease absorption of diazepam Nursing Responsibilities: •
Assess patient for nausea, vomiting, abdominal distention and bowel sounds prior to or following administration
•
Administer 30 minutes before meals
•
Instruct to take medication as directed
•
Caution to avoid activities that requires alertness
•
Advise to notify physician or other health care provider if involuntary movements occurs
•
Be alert for signs of hepatotoxicity
•
Long-term therapy may lead to vitamin B12 deficiency 88
•
Monitor creatinine clearance
Generic Name: Phytonadione Brand Name: Vitamin K Classification: Vitamin Frequency/Route/Dose: 1 amp IVTT Action: Required for hepatic synthesis of blood coagulation factors II, VII, IX and X. Indication: Prevention and treatment of hypoprothrombinemia, which may be associated with excessive doses of oral anticoagulants, salicylates. Nutritional deficiencies, prevention of hemorrhagic disease Contraindication: Hypersensitivity and intolerance, impaired liver function Adverse Effects: GI: gastric upset, unusual taste Derm: rash, urticaria, flushing Local: swelling, pain at IV site Misc: hemolytic anemia, hyperbilirubinemia, allergic reactions Drug Interaction: Large doses will counteract the effect of warfarin. Large doses of salicylates or broad-spectrum anti-infectives may increase vitamin K requirements. Nursing Responsibilities: •
Monitor for frank and occult bleeding
•
Monitor BP and pulse frequently
•
Instruct to take medication as ordered
•
Advise patient to report any symptoms of unusual bleeding or bruising
89
Generic Name: Pantoprazole Brand Name: Pantoloc Classification: Antacids, antiulcerants Frequency/Route/Dose: 40mg/tab OD Action: Binds to an enzyme on gastric parietal cells in the presence of acid gastric pH, preventing the final transport of hydrogen ions into the gastric lumen Indication: Treatment of mild reflux, duodenal or gastric ulcer, reflux esophagitis Contraindication: Hypersensitivity, impaired liver function Adverse Effects: CNS: headache, dizziness GI: diarrhea, nausea, upper abdominal pain, flatulence Derm: rash, pruritus Drug Interaction: Ketoconazole may affect absorption of drugs whose absorption is pHdependent Nursing Responsibilities: •
Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool
•
Administer doses before meals, preferably in the morning
•
May be administered concurrently with antacids
•
Instruct to take medication as directed
•
May cause occasional drowsiness, or dizziness. Caution patient to avoid activities that require alertness
•
Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent headache to the physician promptly
90
Generic Name: Rebamipide Brand Name: Mucosta Classification: Gastrointestinal/ hepatobiliary drugs Frequency/Route/Dose: 100 mg/tab TID Action: Reacts with gastric acid to form thick paste which selectively adheres to ulcer surface Indication: Treatment of gastric mucosal lesions, acute gastritis, gastric ulcer Contraindication: Hypersensitivity to the drug Adverse Effects: GI: diarrhea, nausea, vomiting, constipation Derm: pruritus Drug Interaction: Antacids interfere with absorption. Diazepam decrease absorption Nursing Responsibilities: •
Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the stool
•
Assess for abdominal pain
•
Administer on empty stomach, 1 hour before meals
•
Increase fluid intake
•
Instruct to take medication as directed
•
Advise patient to report onset of black tarry stools, diarrhea, abdominal pain or persistent headache to the physician promptly
91
Generic Name: Atorvastatin Brand Name: Lipitor Classification: Antihyperlipidemic agent Frequency/Route/Dose: 80 mg/tab 1 tab OD HS Action: Inhibits an enzyme, 3 hydroxy-3-methylglutaryl-coenzyme A reductase, which is responsible for catalyzing an early step in the synthesis of cholesterol. Slowing the progression of CAD with resultant decrease in MI and need for myocardial revascularization Indication: Reduction of elevated total and LDL cholesterol and triglycerides in patients with primary hypercholesterolemia, mixed hyperlipidemia Contraindication: Hypersensitivity to the drug, active liver disease Adverse Effects: CNS: dizziness, headache, insomia GI: GI disturbance MS: muscle cramps Derm: pruritus Drug Interaction: Risk of myopathy increased with concurrent administration of cyclosporine, fibric acid derivatives, erythromycin, niacin. Nursing Responsibilities: •
Obtain diet history, especially on fatty foods
•
Administer with food
•
Instruct patient to have diet restrictions on fats, cholesterol, carbohydrates and alcohol
•
Advise to take medication as directed
•
Caution patient to avoid activities that require alertness
•
Advise patient to notify physician or other health care provider if any unusualities occurs
92
Generic Name: Carvedilol Brand Name: Dilatrend Classification: Beta Adrenergic Blocking agent Frequency/Route/Dose: 6.25 mg ½ tab OD Action: Block stimulation of beta1 adrenergic receptors, do not usually affect beta2 receptor sites Indication: CHF, hypertension Contraindication: Hypersensitivity to the drug, disease of the respiratory tract, , asthma, chronic bronchitis, SA block, 2nd and 3rd degree AV block, MI with complications, severe liver dysfunction, metabolic acidosis Adverse Effects: CNS: dizziness, headache, tiredness, nausea GI: andominal pain, diarrhea, constipation, vomiting Resp: bronchospastic reactions Drug Interaction: BP lowering drugs, reserpine, methyldopa, clonidine, rifampicin Nursing Responsibilities: •
Always check apical pulse rate before giving drug
•
Monitor BP, ECG and pulse frequently
•
Monitor Intake and Output ratios and daily weight
•
Assess frequency and characteristics of anginal attacks periodically throughout therapy
•
Instruct patient to take drug exactly as prescribed and to take it with meals
•
Advise to avoid activities that require alertness
•
Advise to make position changes slowly to prevent orthostatic hypotension
93
NURSING CARE PLAN Name: Perfecto Pandacan Balili Age: 60 y.o. Sex: Male Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III Date and Time
Cues
Novembe S: r 28, 2006 “Sakit akong dughan” as 3-11 shift verbalized by the patient. 5:00 p.m. O: - Pupillary size 3mm isocoric, brisk and reactive to light - Pale conjunctiva noted - Pink mucous membrane and lips noted - Grimaced face noted
Room and Bed #: CCU bed 1 Attending Physician: Dr. Voltaire Egnora Institution: Davao Medical Center
Need
Nursing Diagnosis
Objective
Nursing Intervention
Evaluation
C O G N I T I V E
Acute pain related to decreased myocardial blood flow as evidenced by reports of chest pain secondary to CAD, AMI
1. Administer medication as indicated (antianginal, beta-blocker, analgesics) R: Immediate response in relief of pain.
Goal Met
-
Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage.
Within my 1 hour span of care my patient will be able to report relief or control of chest pain as evidenced by patients verbalization, absence of restlessness, diaphoresis, facial grimace and vital signs within normal range
P E R C E P T U A
Rationale:
Acute Myocardial Infarction (AMI) occurs when coronary blood flow decreases
November 28, 2006 6:00 p.m.
2. Administer supplemental oxygen as indicated R: Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia.
Within my 1 hour span of care my patient was be able to report relief or control of chest pain as 3. Monitor characteristics evidenced by: of pain, noting verbal reports, nonverbal cues, “ Dili na sakit and hemodynamic akong dughan.” response. as verbalized by R: Variation of appearance and the patient
- Crackles noted upon auscultation - Productive cough noted - Whitish phlegm noted - Irregular cardiac rate and rhythm noted - Clutching chest noted - diaphoresi s noted - cold, clammy skin noted - Pale nail beds noted - Capillary refill of 1 second - Weakness noted - restlessnes s noted - irritability noted - narrowed focus (reduced interaction with people)
L P A T T E R N
abruptly after a thrombotic occlusion of a coronary artery previously narrowed by atherosclerosis. Infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions (local or systemic) favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion. After an initial platelet monolayer forms at the site of the ruptured plaque, various agonists (collagen, ADP, epinephrine, serotonin) promote platelet activation. There is production and release of thromboxane A2 (a potent local vasoconstrictor), further platelet
behavior may occur. Respirations may be increased as a result of pain and associated anxiety, while release of stress induced catecholamines will increase heart rate and BP. 4. Review history of previous angina or MI pain R: May differentiate current pain from preexisting patterns, as well as identify complications such as extension of infarction, pulmonary embolus, or pericarditis. 5. Instruct patient to report pain immediately R: Delay in reporting pain hinders pain relief or may require increased dosage of medication to achieve relief. Severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain.
- absence of restlessness noted absence of diaphoresis noted - Absence of facial grimace noted - vital signs within normal range (Temp=36, RR=22 cpm, CR= 60 bpm, BP= 90/60 mmHg)
Evaluated by: 6. Provide environment,
quiet calm
95
noted - Pain scale of 6 out of 10 (0 being no pain and 10 as very severe pain) - Temp=35, RR=25 cpm, CR= 47 bpm, BP= 80/60 mmHg
activation, and potential resistance to thrombolysis. The coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. Factors VII and X are activated, ultimately leading to the conversion of prothrombin to thrombin, which then converts fibrinogen to fibrin. The culprit coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. This occlusion will impede the flow of blood to the cardiac muscles. Decrease cardiac functioning will lead to imbalance between myocardial oxygen supply and
activities and comfort Yap, Novelynne measures. Joy R: Decreases external stimuli, which may aggravate anxiety and cardiac strain and limit coping abilities and adjustment to current situation. 7. Assist in relaxation techniques such as deep breathing, visualization and guided imagery R: Helpful in decreasing perception of pain. Provides a sense of having some control over the situation, increase in positive attitude. 8. Check vital signs before and after narcotic medication R: Hypotension or respiratory depression can occur as a result of narcotic administration. These may increase myocardial damage in presence of ventricular insufficiency. 9. Place patient at complete rest during anginal episodes R: Reduces myocardial oxygen demand to minimize risk of
96
demand wherein the heart is unable to meet the metabolic demands of the body. Lack of blood and oxygen supply in the cardiac muscle will lead to ischemia and thus to experience of pain.
Source: Pathophysiology: Concepts and Applications for Health Care Professionals, 3rd Edition by Nowak Harrison’s Internal Medicine, 5th Edition
tissue injury or necrosis. 10. Elevate head of bed if patient is short of breath R: Facilitates gas exchange to decrease hypoxia and resultant shortness of breath. 11. Monitor heart rate and rhythm R: Patient may have acute lifethreatening dysrhythmias, which occur in response to ischemic changes or stress. 12. Stay with the patient who is experiencing pain or appears anxious R: Anxiety releases catecholamines, which increase myocardial workload and can prolong ischemic pain. Presence of nurse can reduce feelings of fear and helplessness. 13. Provide light meals. Have patient rest for 1 hour after meals R: Decreases myocardial workload associated with work of digestion, reducing risk of anginal attack.
97
14. Monitor serial ECG changes R: Ischemia during anginal attack may cause transient ST segment depression or elevation and T wave inversion. Serial tracing verify ischemic changes, which may disappear when patient is painfree. They also provide a baseline with which to compare later pattern changes.
Source: - Nursing Care Plan, 4th Edition by Doenges - Nurse’s Pocket Guide, 8th Edition by Doenges
98
Name: Perfecto Pandacan Balili Age: 60 y.o. Sex: Male Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III Date and Time
Cues
S/O: November - Pupillary 27, 2006 size 3mm isocoric, brisk 3-11 shift and reactive to light 4:30 - Pale p.m. conjunctiva noted - O2 inhalation at 5 lpm via nasal cannula noted - Pink mucous membrane and lips noted - Symmetri cal chest expansion noted - Crackles noted upon auscultation - Productive
Need
Nursing Diagnosis
A C T I V I T Y
Decrease Cardiac Output related to altered heart rate and rhythm as evidenced by atrial fibrillation in slow to moderate ventricular response with ST elevation pattern secondary to CAD, AMIK II
E X E R C I S E
Rationale: Acute Myocardial Infarction (AMI) generally occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously narrowed by atherosclerosis. When a coronary
Room and Bed #: CCU bed 1 Attending Physician: Dr. Voltaire Egnora Institution: Davao Medical Center Objective
Nursing Intervention
1. Determine baseline Within my 8 vital signs hours span of R: Provide opportunities to care my track changes. patient will be able to 2. Auscultate BP, maintain compare both arms and hemodynamic obtain lying, sitting and stability as standing pressures when evidenced by: able R: Hypotension may occur BP related to ventricular within dysfunction, hypoperfusion of normal the myocardium, and vagal range stimulation. However, (90/60hypertension is also a common 120/90 phenomenon, possibly related mmHg) to pain, anxiety, catecholamine CR release, and/or preexisting within vascular problems. Orthostatic normal hypotension may be associated range (60- with complications of infarct. 100 bpm) Adequ 3. Evaluate quality and ate urinary equality of pulse as output indicated
Evaluation Goal Partially Met November 27, 2006 10:00 p.m. Within my 8 hours span of care my patient was able to maintain hemodynamic stability as evidenced by: -
BP within normal range (110/80mmHg) Adequate urinary output (I-370 cc, O300 cc)
99
cough noted - Whitish phlegm noted - Irregular cardiac rate and rhythm noted - Showing atrial fibrillation in slow to moderate ventricular response with ST elevation pattern - Nondistended abdomen noted - Grossly normal extremities noted - Cool skin noted - Pale nail beds noted - Capillary refill of 1 second - Weakness noted
P A T T E R N
artery thrombus develops rapidly at a site of vascular injury, this injury is produced or facilitated by factors such as cigarette smoking, hypertension, and lipid accumulation. Infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions (local or systemic) favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion. After an initial platelet monolayer forms at the site of the ruptured plaque, various agonists (collagen, ADP, epinephrine, serotonin) promote platelet activation. After agonist
-
Decre
R: Decreased cardiac output ase results in diminished dysrhythmia weak/thready pulses. Absen Irregularities suggest ce of dysrhythmias, which may dyspnea require further evaluation or monitoring.
-
Absence of dyspnea (RR-20 cpm)
But was not able to maintain hemodynamic stability on:
4. Auscultate heart sound; note development of S3 CR (52 and S4 bpm) R: S3 is usually associated Cardiac with HF, but it may also be rhythm remains noted with mitral insufficiency the same and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension. 5. Presence or murmurs/rubs R: Indicates disturbance of Evaluated by: normal blood flow within the heart. Presence of rub with an infarction is all associated with Yap, Novelynne inflammation. Joy 6. Auscultate sounds R: Crackles
breath reflecting
100
- Temp=35. 6, RR=23 cpm, CR= 43 bpm, BP= 80/60 mmHg
stimulation of platelets, there is production and release of thromboxane A2 (a potent local vasoconstrictor), further platelet activation, and potential resistance to thrombolysis. The coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. Factors VII and X are activated, ultimately leading to the conversion of prothrombin to thrombin, which then converts fibrinogen to fibrin. Fluid-phase and clot-bound thrombin participate in an autoamplification reaction that leads to further activation of
pulmonary congestion may develop because of depressed myocardial function. 7. Monitor heart rate and rhythm R: Heart rate and rhythm respond to medication and activity, as well as developing complications/dysrhythmias, which could compromise cardiac function or increase ischemic damage. Acute or chronic atrial flutter/fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathogenic. 8. Place on moderate high back rest R: Lowers diaphragm, promoting chest expansion. 9. Note response to activity and promote rest appropriately R: Overexertion increases oxygen consumption/demand and can compromise myocardial function. 10. Provide
bedside
101
the coagulation cascade. The culprit coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands. This occlusion will impede the flow of blood to the cardiac muscle and other parts of the body. Therefore there is inadequate blood pumped by the heart to meet the metabolic demands of the body. This cardiac problem also alters the cardiac rate and rhythm as the body reacts to the lack of blood carrying oxygen in which the occlusion results to tissue ischemia and eventually to necrosis. The infracted area in AMI will eventually heal and the necrotic myocardial cells will
commode if unable to use bathroom R: Attempts at using bedpan can be exhausting and psychologically stressful, thereby increasing oxygen demand and cardiac workload. 11. Provide small or easily digested meals. Restrict caffeine intake R: Large meals may increase myocardial workload and cause vagal stimulation resulting in bradycardia or ectopic beats. Caffeine is a direct cardiac stimulant that can increase heart rate. 12. Avoid activities such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing. Administer stool softeners as ordered. R: These may stimulate valsalva response. 13. Administer supplemental oxygen, as indicated R: Increases amount of .oxygen available for
102
be replaced by dense fibrous connective tissue (scarring). This area cannot contribute to pumping except to maintain the integrity of the ventricular wall.
Source: Pathophysiology: Concepts and Applications for Health Care Professionals, 3rd Edition by Nowak
myocardial uptake, reducing ischemia and resultant dysrhythmias. 14. Maintain IV access as indicated R: Patent line is important for administration of emergency drugs in presence of persistent dysrhythmias or chest pain. 15. Administer antidysrhythmic drugs and ACE inhibitors as ordered. R: Dysrhythmias are usually treated symptomatically, except for PVCs, which are often treated prophylactically. Early inclusion of ACE inhibitor therapy enhances ventricular output, increases survival and may slow progression of heart failure.
Harrison’s Internal Medicine, 5th Edition Source: - Nursing Care Plan, 4th Edition by Doenges - Nurse’s Pocket Guide,
103
8th Edition by Doenges
104
Name: Perfecto Pandacan Balili Age: 60 y.o. Sex: Male Diagnosis: CAD, AMIK II, (+) LVH, (+) LVD, FC III Date and Time
Cues
S: Novembe “Dali ko makapoy r 29, 2006 ug lisod mulihok” as verbalized by 3-11 shift the patient 4:30 p.m.
O: - Pupillary size 3mm isocoric, brisk and reactive to light - Pale conjunctiva noted - O2 inhalation at 5 lpm via nasal cannula noted - Pink mucous membrane and lips noted - Symmetri cal chest
Need
A C T I V I T Y
Nursing Diagnosis
Objective
Activity Intolerance related to decrease cardiac functioning as evidenced by irregular cardiac rate and rhythm secondary to CAD, AMIK II
Within my 8 hours span of care my patient will be able to demonstrate progressive increase in tolerance for activity with heart rate/rhythm and BP within patient’s normal limits and skin warm, pink and dry.
Rationale: E X E R C I S E
Room and Bed #: CCU bed 1 Attending Physician: Dr. Voltaire Egnora Institution: Davao Medical Center
There is insufficient physiological or psychological energy to endure or complete required or desired daily activities. Acute Myocardial Infarction (AMI) occurs when coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery
Nursing Intervention
Evaluation
1. Determine baseline vital signs R: Provide opportunities to track changes.
Goal Partially Met
2. Record or document heart rate, rhythm, and BP changes before, during, and after activity as indicated. Correlate with reports of chest pain or shortness of breath. R: Trends determine patient’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level or return to bed rest, changes in medication regimen or use of supplemental oxygen.
November 29, 2006 10:00 p.m. Within my 8 hours span of care my patient was able to demonstrate progressive increase in tolerance for activity as evidenced by:
BP 3. Promote rest initially. within normal Limit activities on basis of range pain or hemodynamic (100/80mmHg) response. Provide nonstress Skin diversional activities warm to touch
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expansion noted - Crackles noted upon auscultation - Productive cough noted - Whitish phlegm noted - Irregular cardiac rate and rhythm noted - Showing atrial fibrillation in slow to moderate ventricular response with ST elevation pattern - Nondistended abdomen noted - Grossly normal extremities noted - Cool skin noted - Dry,
P A T T E R N
previously narrowed by atherosclerosis. Infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions (local or systemic) favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion. After an initial platelet monolayer forms at the site of the ruptured plaque, various agonists (collagen, ADP, epinephrine, serotonin) promote platelet activation. After agonist stimulation of platelets, there is production and release of thromboxane A2 (a potent local vasoconstrictor), further platelet
R: Reduce myocardial Dry skin workload or oxygen noted consumption, reducing risk of Pinkish complications conjunctiva, mucous 4. Limit visitors and/or membrane and visiting by patient, initially nail beds noted R: Lengthy or involved conversations can be very But was not able taxing for the patient; however, to demonstrate periods of quiet visitation can progressive be therapeutic. increase in tolerance for 5. Instruct patient to avoid activity as increasing abdominal evidenced by: pressure like straining during defecation CR (57 R: Activities that require bpm) holding of breath and bearing Cardiac down can result in bradycardia, rhythm remains temporarily reduced cardiac the same output and rebound tachycardia with elevated BP. 6. Explain pattern of graded increase of activity level like getting up in chair when there is no pain, progressive ambulation, and resting for 1 hour after meals. Evaluated by: R: Progressive activity provides a controlled demand
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rough skin noted - Pale nail beds noted - Capillary refill of 1 second - Weakness noted - Needing assistance upon changing positions noted - Temp=35. 5, RR=23 cpm, CR= 57 bpm, BP= 90/70 mmHg
activation, and potential resistance to thrombolysis.
on the heart, strength and overexertion
The coagulation cascade is activated on exposure of tissue factor in damaged endothelial cells at the site of the ruptured plaque. Factors VII and X are activated, ultimately leading to the conversion of prothrombin to thrombin, which then converts fibrinogen to fibrin. The culprit coronary artery eventually becomes occluded by a thrombus containing platelet aggregates and fibrin strands.
7. Review signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician R: Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication
This occlusion will impede the flow of blood to the cardiac muscles. Decrease cardiac functioning will lead to imbalance between myocardial oxygen supply and
increasing Yap, Novelynne preventing Joy
8. Place on moderate high back rest R: Lowers diaphragm, promoting chest expansion. 9. Note response to activity R: Overexertion increases oxygen consumption/demand and can compromise myocardial function. 10. Provide bedside commode if unable to use bathroom R: Attempts at using bedpan can be exhausting and
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demand wherein the heart is unable to meet the metabolic demands of the body. Performing activities increases oxygen consumption from the body in which an individual with such imbalance will have difficulty performing the task.
psychologically stressful, thereby increasing oxygen demand and cardiac workload. 11. Provide small or easily digested meals. Restrict caffeine intake R: Large meals may increase myocardial workload and cause vagal stimulation resulting in bradycardia or ectopic beats. Caffeine is a direct cardiac stimulant that can increase heart rate. 12. Plan care with periods in between R: reduce fatigue
Source: Pathophysiology: Concepts and Applications for Health Care Professionals, 3rd Edition by Nowak Harrison’s Internal th Medicine, 5 Edition
rest
13. Encourage patient to maintain positive attitude; suggest use of relaxation techniques such as visualization or guided imagery as appropriate R: Enhance sense of wellbeing 14. Administer supplemental oxygen, as indicated R: Increases amount of .oxygen available for
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myocardial uptake, reducing ischemia and resultant dysrhythmias. 15. Maintain IV access as indicated R: Patent line is important for administration of emergency drugs in presence of persistent dysrhythmias or chest pain.
Source: - Nursing Care Plan, 4th Edition by Doenges - Nurse’s Pocket Guide, 8th Edition by Doenges
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PROGNOSIS MI may be associated with a mortality rate as high as 30%, with more than half of deaths occurring in the prehospital setting. Prognosis is highly variable and depends on a number of factors related largely on infarct size, left ventricular function and the presence or absence of ventricular arrhythmias. Prognosis is significantly worsened if a mechanical complication (papillary muscle rupture, myocardial free wall rupture, and so on) were to occur. Overall, the prognosis is poor. This is for the reason that the patient’s condition has been transpiring for years. He had attacks in the past and his condition has complications already. Regardless of the patient’s willingness to comply with all the medical regimens that would possibly help his condition there is only small hope that normal cardiac rate and rhythm would be achieved basing on the amount of myocardial tissue that has already been damaged. The family also lacks the financial support that they would need for medical intervention and this is also with respect to the patient’s age. CRITERIA
ACTUAL Poor Fair Good
Duration of illness
√
Willingness to take medication
√
Age
Expectations
√
to
√
JUSTIFICATION The patient already had four attacks prior to the present hospitalization. This implies that the condition of the patient continuously deteriorates every after the attack. In addition, it only indicates that the patient is unable to meet the necessary interventions to prevent having another attack. The patient is very willing to take all the available prescribed medications. In fact, he always asks questions regarding it. He would ask for the purpose of his medicines before taking it. The patient is not getting any younger and at his current age (60 y.o.) there is a higher risk for acquiring such illness. Since the patient’s immune system and other bodily functions deteriorates as he continuously age he will no longer be able to fight against infection or inflammation that could also trigger the aforementioned illness. The patient wanted to go home with ordered medications however, he is also aware of the
illness
Environment
Family support
√
√
reality that his condition is worsening. He and his family still hopes that Mr. Perfecto would fully recover from his illness. The patient lives in an air conditioned room and is provided with his oxygen tank. There is no air pollutant present that could worsen his respiratory problems and the patient already stopped all his vices ever since he had his attack. The family is always there to provide assistance and support the patient. Although this is the case the family still lacks assistance on other matter such as financial aid. The help the patient gets from his daughter is not enough to sustain all that should necessarily be done to achieve optimal health.
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BIBLIOGRAPHY Harrison’s Internal Medicine Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Geissler-Murr, Nurses’ Pocket Guide, Diagnoses, Interventions and Rationales. 9th Edition Marilynn E. Doenges, Mary Frances Moorehouse, Alice C. Geissler-Murr, Nursing Care Plan Guidelines for Individualizing Nursing Care 6th Edition Nowak, Thomas. Pathophysiology: Concepts and Application for Health Care Professionals, 3rd Edition Rod Seeleys, Trent D. Stephens, Philip Tate, Essentials of Anatomy and Physiology 4th Edition Suzanne C. Smeltzer, Brenda G. Bare, Brunner and Suddhart’s Textbook on Medical-Surgical 10th Edition Sylvia A. Price, Lorraine M. Wilson, Pathophysiology Clinical Concepts of Disease Process 4th Edition Wilson, et al. Harrison’s Principles of Internal Medicine, 12th Edition http://www.geocities.com/baddarni/Myocardial-Infarction.html http://members.tripod.com/~dgholgate/four.html http://biology.about.com/library/organs/heart/blheartintro.htm http://texasheart.org/HIC/Anatomy/Anatomy.cfm http://www.cvphysiology.com/Heart%20Disease/HD002.htm http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/complications/complicati ons.htm http://www.emedicine.com/EMERG/topic327.htm http://en.wikipedia.org/wiki/Myocardial_infarction http://circ.ahajournals.org/cgi/content/abstract/111/25/3481 http://training.seer.cancer.gov/module_anatomy/unit7_1_cardvasc_intro.html http://filer.case.edu/~dck3/heart/intro.html http://webschoolsolutions.com/patts/systems/heart.htm http://en.wikipedia.org/wiki/Cardiovascular_system http://www.kidshealth.org/teen/your_body/body_basics/heart.html http://www.americanheart.org/scientific/statements/1994/079402.html http://circ.ahajournals.org/cgi/content/full/102/18/2284 http://supplements.inq7.net/mindandbody/main.php?content=health003 http://library.thinkquest.org/C003758/Function/How%20Cardiac%20Muscle%20Contracts.htm http://www.jdaross.cwc.net/cardiac_cycle.htm
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