Documente Academic
Documente Profesional
Documente Cultură
MYOCARDIAL INFARCTION
In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING
Abdullah, Asniah
Amano, Amirah
Chinchuntic, Joan
Cornell, Nur Muhammad
Etulle, Earl Juffeny
Borres, Mary Rucile
Bughaw, Alvin Miko
Largo, Ditchen
OCTOBER 2018
TABLE OF CONTENTS
I. TITLE PAGE
II. TABLE OF CONTENTS
III. LIST OF TABLES
IV. LIST OF FIGURES
V. OBJECTIVES 1
General Objective
Specific Objectives
VI. DEFINITION OF TERMS 2
VII. INTRODUCTION 3-5
VIII. NURSING HEALTH HISTORY
Vital information 6
History of present health concern 7
Past history 8
Genogram 9
Physical assessment and review of systems 10-15
Gordons assessment 16-17
Diagnostic tests 18-20
IX. NORMAL ANATOMY AND PHYSIOLOGY 21-24
X. PATHOPHYSIOLOGY 25-26
XI. NURSING CARE PLANS 27-33
XII. DISCHARGE PLAN 34-46
XIII. REFERENCES 47
LIST OF TABLES
1 GENOGRAM 9
2 PATHOPHYSIOLOGY 25-26
OBJECTIVES
General Objectives:
At the end of one and a half hour of case presentation, the participants will be able to
learn about the disease process of Acute Coronary Syndrome and Myocardial
Infarction.
Specific Objectives:
At the end of one and a half hour of case presentation, the participants will be able to:
1. Relate the health history of the patient to Acute Coronary Syndrome and
Myocardial Infarction;
2. Categorize the physical assessment and review of system involved Acute
Coronary Syndrome and Myocardial Infarction.
3. Numerate at least 5 diagnostic tests related to Acute Coronary Syndrome and
Myocardial Infarction.
4. Discuss the anatomical structure and functions involved in Acute Coronary
Syndrome and Myocardial Infarction.
5. Summarize the pathophysiology, risk factors and manifestations of Acute
Coronary Syndrome and Myocardial Infarction.
6. Formulate appropriate nursing process for the client with Acute Coronary
Syndrome and Myocardial Infarction.
7. Organize a health education and discharge plan.
1
DEFINITION OF TERMS
(Tortora,2011)
of contractility. (Tortora,2011)
Hypoxia- lack of adequate tissue oxygen at the tissue level. (Hinke, 2014)
Necrosis- a pathological type of cell death that results from disease, injury, or lack of
blood supply in which many adjacent cells swell, burst, and spill their contents into
(Tortora,2011)
Transmural- existing or occurring across the entire wall of an organ or blood vessel.
(Tortora,2011)
2
INTRODUCTION
A heart beat signifies life, from the day it starts to beat in the worm, till it
stops, and where death conquers us. The heart beats not only to one tune but it also
responds to the tune of emotions and physical stress. As some of us may have also
experience moments of joy or sorrow and the heart may feel pain or pleasure. In
medicine, an acute disease is a disease with a rapid onset or a short course. The term
“Acute” may often be confused by the general public to mean “severe”, however, this
has a different meaning. Coronary, may refer to as “heart” or “relating to the heart”.
While syndrome is define as a set of signs and symptoms that tend to occur together
and which reflect the presence of a particular disease or an increased chance of
developing a particular disease.
The most serious acute coronary syndrome is MI, often referred to as a “heart
attack”. Undiagnosed or untreated angina can lead to this very serious health
problems.
3
zones: (1) the zone of injury, tissue that is injured but nit necrotic, and (2) the zone of
ischemia, tissue that is oxygen deprived.
Infarction is a dynamic process that does not occur instantly; rather, it evolves
over a period of several hours. Hypoxia (decreased oxygen) from ischemia may lead
to local vasodilation of blood vessels and acidosis. Potassium, calcium, and
magnesium imbalances, as well as acidosis at the cellular level, may lead to
suppression of normal conduction and contractile functions. Automaticity and ectopy
are enhanced. Catecholamines (epinephrine and norepinephrine) released in response
to hypoxia and pain increase the heart’s rate and contractility and afterload. These
factors increase oxygen requirements in tissue that is already oxygen deprived. The
area of infarction may extend into the zones of injury and ischemia. The actual extent
of the zone of infarction depends on three factors; collateral circulation, anaerobic
metabolism, and workload demands on the myocardium.
Obvious physical changes do not occur in the heart until 6 hours after the
infarction, when the infarcted region appears blue and swollen. After 48 hours, the
infarct turns gray with yellow streaks as neutrophils invade the tissue and begin to
remove the necrotic cells. By 8 to 10 hours days after infarction, granulation tissue
forms at the edges of necrotic tissue. Over a 2 to 3-month period, the necrotic area
eventually develops into shrunken, thin, firm scar. Scar tissue permanently changes
the size and shape of the entire left ventricle (ventricle remodelling). Remodelling
may decrease left ventricle function, cause heart failure, and increase morbidity and
mortality.
4
ventricular heart failure a d ventricular dysrhythmias because a large segment of the
left ventricle wall may have been damaged.
The circumflex supplies the lateral wall of the left ventricle and possibly
portions of the posterior wall or the sinoatrial (SA) and atrioventricular nodes. Clients
with obstruction of the circumflex artery may experience a posterior wall MI
(PWMIs) or a lateral wall MI (LWMIs) and sinus dysrhythmias.
In most people, the right coronary artery perfuses the SA and AV nodes as well as the
right ventricle and inferior or diaphragmatic portion of the left ventricle. Clients with
obstruction of the right coronary artery often have inferior wall MIs. Inferior wall MIs
(IWMIs) account for about 17% of all MIs and have a mortality rate of about 10%.
Up to50% of all inferior wall MIs are associated with an occlusion of the right
coronary artery causing significant damage to the right ventricle (Litton, 2015).
Many people die from coronary heart disease without being hospitalized.
Most of these are sudden deaths caused by cardiac arrest, usually resulting from
ventricular fibrillation. On the basis of data from NHANES 2011 to 2014, an
estimated 16.5 million Americans ≥20 years of age have CHD.This year, ≈720 000
Americans will have a new coronary event (defined as first hospitalized myocardial
infarction [MI] or CHD death), and ≈335 000 will have a recurrent event.Whites had
a higher rate of recognized MI than blacks (5.04 versus 3.24 per 1000 person-years)
in the Atherosclerosis Risk in Communities Study.In individual’s ≥45 years of age,
median survival (in years) after a first MI is 8.4 for white males, 5.6 for white
females, 7.0 for black males, and 5.5 for black females. Individuals self-reporting low
income and low education have twice the incidence of CHD as those reporting high
income and high education (10.1 per 1000 person-years versus 5.2 per 1000 person-
years, respectively).
5
VITAL INFORMATION
Code Name: Mr. X
Age: 45
Gender: Male
Civil status: Married
Date of birth: March 5, 1973
Place of birth: Sta. Filomena Iligan City
Race: Filipino
Cultural or ethnic background: Cebuano
Primary language: Bisaya
Secondary language: English, English
Religion: Roman Catholic
Highest educational attainment: College Graduate
Occupation: Welder/Installment
Usual health care provider: Attending Physician
Date of admission: October 2, 2018 11pm
Date of discharge: Transported in ward on October 04, 2018
Source of history: Patient 50%, Nurse 3%, Chart 47%
6
HISTORY OF PRESENT ILLNESS
Mr. Q was admitted last August 19, 2018 in Intensive Care Unit for 1 week. He
manifested squeezing chest pain with the pain scale of 9/10, duration of 5 seconds
with the interval of 5 minutes. He described that the pain will radiate to left
shoulder, to back portion, going back to his chest. The pain was associated with cool,
clammy skin, diaphoresis and pale appearance. He also felt nauseated, body
weakness, and restlessness. The symptoms worsened, hence prompted for admission.
He was diagnosed with Myocardial infarction ST elevation and Hypertension. He
was given maintenance medication: Enalapril 50mg I tab OD, Atorvastatin 80 mg
OD, Carvedilol, 6.25 mg, 1 tab, BID , Isosorbidemononitrate 30 mg, 1 tab BID. He
stated that he is compliant with his medications religiously.
7 hours prior to admission, Mr. X drinks a half cup of soda and minutes after, he
experienced chest pain, described as tight, squeezing, pain scale of 6/10, with the
duration of 3 seconds and interval of 5 minutes. It radiates on his left shoulder, to
back portion, going back to his chest. It was associated with cold and clammy
extremities and accompanied by weakness of both extremities. He took his
maintenance medication but was not relived. He complained of nausea and dizziness.
Persistence of symptoms, prompted for admission.
October 02, 2018, @ 11 pm, he was brought to Emergency Room and was given
Aspirin 4 tabs and supplemental oxygen @ 2L/ min. His vital signs were checked:
T:36 degreecelcius, P: 63 bpm, R: 20 bpm, BP:120/80 mmHg.
At 11:15 pm, he was admitted in Intensive Care Unit, bed4, under Dr. Capistrano.
The Dr. ordered the following: 02 inhalation @ 2 L/min via nasal cannula continous ,
low salt, low fat diet, CBR without toilet privilege, medications: Aspirin 80mg 1 tab
OD, Isosorbidemononitrate 30 mg 1 tab OD, Enalapril 5 mg, I tab BID, Carvedilol
6,25 mg BID, Atorvastatin, 80mg 1 tab OD.
7
HISTORY OF PAST ILLNESS
Mr. X was fond of eating foods high in fat and cholesterol like “ginataang
manok”, lechon, and meat products .He drinks 1 bottle of soda 3x a day and 1 cup
every day. He eats fast food most of the time because of his work (OFW). He
started started to smoke at the age of 22 consuming 1 and half pack of cigarettes a
day. He also drinks alcohol beverages occasionally. He experienced emotional stress
since he worked throughout his life as OFW.
8
Maternal Paternal
PATIENT
LEGEND:
9
PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS
AREAS PROBLEM
ASSESSE NOC SHIFT AM SHIFT IDENTIFIED
D (October 02,2018) (October 3, 2018)
10
seconds with the
interval of 5
minutes.
Objective findings:
Pale skin, dry and
warm to touch.
(Temp 36.0 Celcius)
Hematoma around right
navel because of
Angiogram
Fingernails and toenails
were pale in color and
cool to touch
11
neck? How often?
“oousahay
pagmakaunlankogtaas.”
Objective findings:
-Supple, no lymphadenopathy
Objective findings:
(-) stillness
(-) lumps
(-) vein engorgement
Objective:
No complaints of DOB
anymore
PR: 50-65 bpm
RR: 15-22bpm
Nasal flaring is not
observed.
12
RR: 13-17 bpm Objective findings: oxygen supply.
HR: 50-65 RR: 14-18 bpm
BP: 90/70-130/80 HR: 55-65bpm
O2sat: 98 % BP: 120/80 mmHg
O2sat: 98-99%
Chest pain scale of chest pain scale of 1
6/10,, described as out of 10
tight, with the
duration of 3 radiates on left
seconds and interval shoulder, to his back
of 5 minutes, portion, and back to his
radiates on the left chest -Risk for
shoulder,back impaired gas
portion, going back exchange related
to his chest to left
ECG LEAD II- ST ventricular
segment elevation failure
-
Objective findings:
Objective findings: Urinates thrice the
13
-no urine output for the whole shift -Risk for
whole shift (NOC-II) no urinary catheter imbalance fluid
-complained of weakness attached volume
of both extremities refuse to use diaper
-no urinary catheter need assistance during
attached urination
-refuse to use diaper
-need assistance during
urination
Musculosk Subjective findings: Subjective findings: Activity
eletal (Not assessed) Do you have any back intolerance
system problems?
“wala pod. Kato rang
Objective findings: hawoyakongmgatiilngadilinak
Venoclyis on the omalihok.”
left vein 1L PNSS
@ 10cc/hr via Objective findings:
infusion pump Good posture.
(+) muscle pains of Neck muscle is
both lower legs. symmetry
Numbness on both no joint deformities
extremeties motor response scale :6
obeys commands
hematomas noted
around navel.
No complaints of
weakness anymore
Neurologic Subjective findings: Subjective findings:
system (Not assessed) How would you
describe your mood?
“usahaykaydilikoganahanugdis
turbo.”
Do you feel any Anxiety related
numbness? to cardiac event
“katoraakongduhakatiilngadili and possible
nakomalihok.” death.
Objective findings:
eyes move in a smooth,
coordinated motion in
Objective findings: all directions
Anxiety Pupillary reflex: 4mm
Restlessness and (open spontaneously)
lightheadedness. eyelids blink bilaterally
client smiles, shows
teeth when he talk and
closes eyes against
resistance.
client swallows without
difficulty (soft, low
salt, low fat)
Lymphatic/ Subjective findings: Subjective findings: Risk for
Hematologi (Not assessed) Have you been tired? decreased
14
c system “gahaponkapoyjud kayo cardiac output
akonglawas.”
Do you have any lumps
in your neck,
underarms or groin? Ineffective
“wala” tissue perfusion
Objective findings:
pale lips
pinkishconjunctiva
Objective findings: cool, pale fingernails
(Not assessed) and toenails
no bowel movement
for the whole shift
no bruising, petechial
rashes and ecchymosis
on the skin.
no lymph nodes.
LABS RESULTS:
RBC: 4.90
Hemoglobin: 144.0
Hematocrit: 0.41
Uric Acid:141.8
Endocrine Subjective findings: Subjective findings:
system (Not assessed) How is your tolerance
to heat and cold
temperatures?
“dalira kayo kopanognawon,
maongakonggipapalongangairc
on.”
Do you have excessive
thirst, hunger, and
excessive urination?
“maskinunsa man akongkan
on.?
Objective findings:
-no presence of buffalo lumps -Deficient
-No wounds knowledge
-No abnormal pigmentation about post-MI
Objective findings: -No excessive sweating or self-care
(Not Applicable) flushing
-Body weakness noted
15
GORDONS ASSESSMENT
16
He is back with smoking in the year 2004
because of loneliness in work (OFW)
He drinks alcoholic beverages occasionally
He officially stopped his vices when he was
diagnosed with his current condition
ENVIRONMENTAL HAZARDS
They lives in subdivision, 1km away from the Confine to bed
highwayThe patient stated that their He is irritated and anxious and does not
surroundings are well sanitized and safe. want to be disturbed by anyone.
INTIMATE PARTNER VIOLENCE
He never mistreated his wife or forced to do His wife takes good care of him
something that does not satisfy them both. In They are so sweet, with the endearment of
fact he takes good care of him so much. “Babe, Bebe”
OCCUPATIONAL HEALTH
He started to work in Taiwan in year 1997 as
welder and installer
He was transferred by his agency in Saudi Confine to bed
Arabia in the year 2004- 2018 with the same
job
17
DIAGNOSTIC TEST
18
Segmenters 0.96 0.50-0.65 High levels usually represent
INCREASED
and ongoing infection, an
inflammation, malignancy,
19
Basophils 0 0.01 DECREASED This type could produce
histamine. Increased numbers
could represent a
myeloproliferative disorder.
Plaletet Count 195 140-450 x 10 NORMAL Implications for high levels:
g/L malignant tumors, polycythem
vera
BLOOD CHEMISTRY
TEST NORMAL RANGE RESULT IMPLICATION
20
FASTING BLOOD SUGAR LIPID PROFILE
TEST NORMAL RESULT IMPLICATION
RANGE
GLUCOSE 74-106 88 mg/dL NORMAL
URIC ACID 2.5-.6.2 8.4mg/dL Hyperuricemia
CHOLESTEROL 0-200 187mg/dL NORMAL
TRIGLYCERIDES 0-150 60mg/dL Athersclerosis
Direct HCL 40-60 38mg/dL NORMAL
LDL 60-180 137mg/Dl NORMAL
VDRL 25-50 12mg/Dl
ALT 8-52 27u/L NORMAL
ECG
Result Pre Nursing Responsibilities
Elevated ST segment -explain procedure
-tell pt to relax
-shave area of the placement if body hair is present
-remove any jewelries in the body
-tell pt not to move while procedure is ongoing
ANGIOGRAM
Result Pre Nursing Responsibilities
Blockage in left and right -instruct pt to fast usually for 8-12 hours before procedure
coronary artery -explain procedure to the pt
-reassure pt that IV medications are given to maintain comfort
-explain that sensations will be felt during procedure
-encourage pt to express fears and anxiety
21
HEART Is located in the Arterial blood (red,
mediastrium; about two oxygen-rich blood)
thirsds of its mass is to flows from the heart to
the left of the midline. each part of the body to
It is shaped like a cone provide oxygen and
lying on its side. nutrients. The venous
Its apex is the pointed, blood (blue, oxygen-
inferior parts its base is poor blood) returns
from the body to the
the broad, superior
heart. The blood then
part.
travels through the
The pericardium is the lungs to exchange
membrane that carbon dioxide for new
surrounds and protects oxygen. The heart is a
the heart. pump, which moves the
It consists of an outer blood. The arteries and
fibrous layer and inner veins are the pipes
serous pericardium, through which the
which is composed of blood flows. The lungs
parietal and a visceral provide a place to
layer. Between the exchange carbon
parietal and visceral dioxide for oxygen.
layers of the serous
pericardium is the
pericardial cavity, a
potential space filled
with a few milliliters of
lubricating pericardial
fluid that reduces
friction between the
two membranes
Three layers make up
the wall of the
heart;Epicardium
(visceral layer of the
serous pericardium),
myocardium, and
endocardium.
The epicardium
consists of
mesothelium and
connective tissue.
Themyocardium is
composed of cardiac
muscle tissue.
The endocardium
consists of endothelium
and connective tissue.
The chambers include
two superior chambers,
22
the right and left atria,
and two inferior
chambers, the right and
left ventricles. External
features of the heart
include the auricles
(flaps of each atrium
that slightly increase
their volume), the
coronary sulcus
between the atria and
ventricles, and the
anterior and posterior
sulci between the
ventricles on the
anterior and posterior
surfaces of the heart,
respectively.
The right atrium
receives blood from the
superior vena cava, and
coronary sinus.
It is separated
internally from the left
atrium by the interatrial
septum, which contains
the fossa ovalis.
Blood exits the right
atrium through the
tricuspid valve.
The right ventricle
receives blood from the
right atrium.
It is separated
internally from the left
ventricle by the
interventricular septum
and pumps blood
through the pulmonary
valve into the
pulmonary trunk.
Oxygenated blood
enters the left atrium
from the pulmonary
veins and exits through
the bicuspid (mitral)
valve.
The left ventricle
pumps oxygenated
blood through the
23
aortic valve into aorta.
The thickness of the
myocardium of the four
chambers varies
according to the
chamber’s function.
The left ventricle,
with the highest
workload, has the
thickest wall.
The fibrous skeleton of
the heart is dense
connective tissue that
surrounds and supports
the valves of the heart.
Chamber of the Heart
is a hollow, muscular
organ, which functions
as a pump for the
movement of blood
through the body. The
flow of blood through
the four chambers of the
heart is regulated by
valves. The heart valves
function like one-way
doors which allow
blood flow through in
the forward direction
but prevent the
backward flow of blood.
Venous blood returns
from the body to the
right side of the heart
which pumps the blood
to the lungs.
The oxygen-rich blood
returns from the lungs to
the left side of the heart.
The left side of the heart
pumps blood to the
entire body. As you
would expect, the left
side of the heart must
generate a much greater
pressure to pump the
blood to the body.
On the left side the
valves are called mitral
and aortic valves.
The mitral valve
24
connects the receiving
chamber from the lungs,
the left atrium, with the
pumping chamber, the
left ventricle.
The aortic valve
controls the flow of
blood out of the heart
into the aorta, the largest
artery of the body which
then gives rise to all the
other arteries.
Coronary arteries first
branches of the aorta are
arteries to the heart
muscle itself.
There are two main
coronary arteries:
The left main coronary
artery divides into two
main branches:
The left anterior
descending (LAD),
which runs down the
front of the heart, and
the circumflex artery
(CX) which runs behind
the heart. Branches of
the LAD are called
diagonalarteries and
branches of the
circumflex are called
obtuse marginal arteries
(OM).
The right main
coronary artery travels
on the right side of the
heart and gives off the
posterior descending
artery (PD).
Formation of dead
fatty core
Plaque protrudes in
lumen of vessel
Myocardial ischemia
26
Unrelieved chest pain
Ion leak
radiating to the left
Myocyte death/ necrosis shoulder
Severe anxiety
Troponin T. elevation
Myocardial infarction ST segment elevation
Angiogram: Blockage
27
NURSING CARE PLANS
28
1.3mg/Dl(7-12) adenosine diphosphate to
TRIGLYCERIDES Atorvastatin platelets, thereby preventing
60mg/Dl( 0-150) thrombus formation
Increases hepatic LDL
recapture sites, enhances
TROPONIN 1 reuptake and catabolism of
2ng/dL(<0.3) LDL; lowers triglyceride
levels.
TROPONIN T
0.1ng/dL
Collaborative:
29
Activity intolerance related STO: INDEPENDENT The patient was able to
Subjective: to decreased cardiac Determine factors maintain:
“ Dali ra kayo ko kapoyon” output and poor lung and After 3-4 hours of contributing to fatigue Provide comparative
tissue perfusion as nursing intervention Evaluate client’s perceived baseline data No complaints of
Objective: evidenced by fatigue the client will limitations by asking past DOB and fatigue
participate willingly activities and present Warm skin
in necessary and factors To reduce oxygen demand Limit activities
DOB To prevent orthostatic
desired activities Encourage to limit
Body weakness hypotension
activities
Pallor
LTO: Encourage to slowly wake
Diaphoretic Provide an increase
up in morning
Cool clammy skin oxygen supply
After or within 12 Encourage complete bed
Pale nail beds
hours of nursing rest without TP
Delayed CRT less than 2 sec Reduces myocardial
interventions the
RR of 14-18 workload
client will emphasize DEPENDENT:
the importance of
desired activation Provide and monitor
response to
Hematocrit
supplemental oxygen
0.55 (0.37-0.47) Administer prescribed
RBC meds
6.3 (4-6 x 10 12/L) Relaxes vascular smooth
Isosorbidemononitrate30mg/tab, 2tab muscle with a resultant
Hemoglobin BID
144( 110-180g/L) decrease in venous return
and decrease in arterial
ECG FINDINGS: Collaborative: BP, which reduces left
ST Segment elevation ventricular workload and
ANGIOGRAM: Nutrition diet ( Low fat, low decrease myocardial of
BLOCKAGE IN RIGHT carbs ) oxygen consumption.
30
AND LEFT VENTRICLE
31
Anxiety related to STO: INDEPENDENT The patient was able
Subjective: perceived or actual Assess the patient’s level anxiety to maintain:
“ Bag o pa death, pain, and After 3-4 and coping mechanisms To determine appropriate
ganinamatayakong Mama possible lifestyle hours of Assess the need for spiritual intervention to the problem Reduction of
unyaakonapudnaadiri ICU” changes as evidenced nursing counseling Find support in religion that may help anxiety
by restlessness intervention Observe verbal and nonverbal signs in reducing fear and anxiety Patient and wife
Objective: the client will of anxiety It may help the client to feel discuss the
display Less calm, and reassuring comforted and supported anxieties and
Irritable reduction of environement Associated with increase sympathetic illness and
Anxious anxiety activity, which increases cardiac death
Verbal expression of Offer prayer workload Appears restful
worry LTO: Consistency of routine and staff Practice stress
Stares blankly for Observe for autonomic signs and promotes trust and confidence reduction
about a minute After or symptoms for anxiety Help to divert his attentionfor time technique
within 12 being
hours of Maintain continuity of care
nursing
Provide sufficient oxygen
interventions Divert client’s attention through
Relaxes vascular smooth muscle with
the client will guided imagery and soothing music a resultant decrease in venous return
emphasize the and decrease in arterial BP, which
ECG FINDINGS: importance of reduces left ventricular workload and
ST Segment elevation desired DEPENDENT: decrease myocardial of oxygen
ANGIOGRAM: activation consumption.
BLOCKAGE IN Provide and monitor response to Reduces gastric acid secretion and
RIGHT AND LEFT supplemental oxygen @2L/min increases gastric mucus and
VENTRICLE Administer prescribed meds bicarbonate production, creating
protective coating on gastric mucosa
o Isosorbidemononitrate
30mg/tab, 2tab BID
o Pantoprazole+Domperidine
32
33
ASSESSMENTS NURSING PLANNING INT5ERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
34
Ineffective tissue STO: INDEPENDENT The patient was able
Subjective: perfusion related to Assist the client to ambulate but to maintain:
“ Bag o pa ganinamatayakong Mama myocardial injury After 3-4 hours of within his tolerance Prevent thrombus
unyaakonapudnaadiri ICU” as evidenced by nursing formation, thus, improving Reduction of
dysrhythmias intervention the Monitor and recorded intake and blood circulation anxiety
client will display output May be a sign of decreased Patient and wife
Objective:
increased tissue renal perfusion discuss the
perfusion Instructed the significant of others Prevent impairement of anxieties and
Cool, clammy skin blood flow
not to wear tight clothing illness and
Diaphoresis To prevent orthostatic
LTO: death
Body weakness hypotension
Encourage to slowly wake up in Appears restful
Nausea
After or within 12 morning Practice stress
Dizziness
hours of nursing reduction
Pale lips
interventions the Bed rest, with head slightly elevated technique
Cool to touch skin
client will maintain
peripheral Provide increase oxygen
concentration
perfusion DEPENDENT:
Inhibits platelet
aggregation by blocking
Provide and monitor response to binding of adenosine
supplemental oxygen @2L/min diphosphate to platelets,
Administer prescribed meds thereby preventing
Hematocrit o Norplat 75mg 1 tab OD thrombus formation
o Mucosta 1 tab 3x/day mucosal protective agent
0.55 (0.37-0.47)
and is postulated to
RBC increase gastric blood
6.3 (4-6 x 10 12/L) flow,prostaglandin
Hemoglobin biosynthesis and decrease
144( 110-180g/L) free oxygen radicals.
35
NURSING PLANNING INT5ERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
ASSESSMENTS
36
Risk for decreased STO: Independent:
Subjective: cardiac output Closely monitoring of the Baseline data The client was able to
“Dali rakokapoyon kung related to After 3-4 hours patient every hour maintain:
ibakod or ilakawlakaw” degeneration of nursing interventions Keep the client on complete Decreased oxygen
cardiac muscle the patient will bed rest consumption BP within
maintain or Decrease stimuli , provide Promote adequate rest normal range
Objective:
attainment of quiet environment Appears
adequate tissue Encourage changing position comfortable
HR: 64 To reduce risk for
perfusion slowly Extremities
Generalized weakness orthostatic hypotension
Instruct to avoid straining warm and dry
Cool, clammy skin To reduce oxygen
After 12 hours within normal
Diaphoretic demand
nursing intervention Provide comfort measures, color
Nauseaous Decrease discomfort and
the patient will e.g back and neck massage, Remains alert
display hemodynamic elevation of head may reduce sympathetic and oriented
stability stimulation and without
Instruct in relaxation Can reduce stressful cognitive or
techniques, guided imagery, stimuli, promotes behavioral
Hematocrit relaxation
distractions change
0.55 (0.37-0.47)
Dependent:
RBC
Administer oxygen as
6.3 (4-6 x 10 12/L) Achieve sufficient oxygen
prescribed (2-4 L/min)
Hemoglobin demand
Administer IVF as ordered Maybe necessary to
144( 110-180g/L) Administer medications as compensate for the
prescribed decreased venous return
Carvedilol 6.25 mg, I tab OD Inhibits conversion of
Enalapril 5 mg 1 tab, BID angiotensin I to
ECG FINDINGS: angiotensin II, a potent
ST Segment elevation Collaborative: vasoconstrictor;
ANGIOGRAM: Nutritional diet ( low fat, low salt) Foods high in fat nad
37
NURSING PLANNING INT5ERVENTIONS RATIONALE EVALUATION
ASSESSMENTS DIAGNOSIS
Risk for impaired STO: INDEPENDENT The patient was able
Subjective: gas exchange Encourage frequent positioning to maintain:
“ Usahay maglisod ko ginahawa’ related to alveolar- After 3-4 hours of Helps prevent atelactasis
capillary membrane nursing Maintain bed rest wih head and pneumonia Reduction of
Objective: changes intervention the elevated 20-30 degrees, semi Reduces oxygen anxiety
client will display fowler’s position. Support arms consumption Patient and wife
reduction of anxiety with pillosws Helps to relax the resp discuss the
DOB Deep breathing technique mucles anxieties and
Pallor LTO: Instruct to avoid straining To reduce myocardial illness and
Appears weak demand death
After or within 12 Appears restful
hours of nursing Practice stress
PR range- 50-65 interventions the reduction
RR- 16-22 client will technique
BP: 90/70- 130-80 emphasize the DEPENDENT:
importance of Administer oxygen as indicated, 2L/ min
desired activation via nasal cannula
Administer meds as prescribed Increases alveolar oxygen
ECG FINDINGS:
concentration which may
ST Segment elevation Isosorbidemononitrate
reduce hyposemia
ANGIOGRAM: 30mg/tab, 2tab BID
Relaxes vascular smooth
BLOCKAGE IN RIGHT muscle with a resultant
AND LEFT VENTRICLE decrease in venous return
and decrease in arterial BP,
which reduces left
ventricular workload and
decrease myocardial of
oxygen consumption
38
39
DISCHARGE PLAN
A. OBJECTIVE
1. Summarize a simple and productive health education plan;
2. Adhere prescribed medications for health maintenance and resistance;
3. Promote a health lifestyle, maximize the level of health ;
4. Gains knowledge in managing the condition; and
5. Maintain and ensure adequate intake for nourishment
B. METHOD
Medications
DRUG STUDY
Generic Classifica Indication Mechanism of Route/F Adverse Reaction Drug to Drug Interaction Patient teaching
Name tion Action requenc
y/Dosag
e
Aspirin Analgesic mild to Analgesics and 80mg/ta Acute aspirin toxicity: increased risk of take extra
moderate antirheumatic b, 1tab respiratory alkalosis, bleeding with oral precautions to
pain effects are PO OD hyperpnea, anticougulants, keep this drug out
fever attributable to tachycardia,hemorrhage,exci heparin of the reach of
inflammatory aspirin’s to inhibit tement,confusion,asterixis,p increased risk of GI children; this
conditions- the synthesis of ulmunoryedema,seizurers,tet ulceration with drug can be very
rheumatic prostaglandins, any,metabolic acidosis, steroids, dangerous for
fever, important fever, coma ,CV collapse, phenylbutazone, children
rheumatic mediators of renal and respiratory failure alcohol, NSAIDS use the drug only
arthritis, inflammation. Aspirin intolerance: increased serum as suggested;
osteoarthritis, exacerbation of salicylate levels due avoid over dose.
40
juvenile bronchospasm, rhinitis (with to decreased Avoid the use of
rheumatoid nasal polyps, asthma, salicylate excretion other over-the-
arthritis, rhinitis) with urine acidifies counter drugs
spondyloarth GI: nausea, dyspepsia, (ammonium contain aspirin,
ropathies hearburn, chloride, ascorbic and serious
epigastricdiscomfort, acid, methionine) overdose can
anorexia, hepatoxicity occur.
Hematologic: occult blood Take the
loss, hemostatic defects drug with
Hypersensitivity: food or
anaphylactoid reaction to after
anaphylactic shock meals if
GI upset
occurs.
Isosorbidem Antiangin Dinitrate: Relaxes vascular 30mg/ta CNS: headache, Increased systolic Place
ononitrate al treatment and smooth muscle b, 2tab apprehension, restlessness, BP and decreased sublingua
prevention of with a resultant BID weakness, vertigo, antianginal effects if l tablets
angina decrease in venous dezziness, faintness taken concurrently under
pectoris return and CV: tachycardia, retrosternal with ergot alkalosis your
Mononitrate: decrease in arterial discomfort, palpitations, tongue or
prevention of BP, which reduces hypotension, syncope, in your
angina left ventricular collapse cheek; do
pectoris; workload and GI: nausea, vomiting, not chew,
treatment of decrease incontinence of feces, swallow,
angina myocardial of abdominal pain, diarrhea, or crush
pectoris oxygen ulcer the tablet.
(mmonoket) consumption. GU: dysuria, impotence, Take the
Unlabeled urinary frequency isosorbide
use before
(dinitrate); chest pain
use with begins,
hydralazine when
in black activities
41
patients with or
advanced situationa
heart failure; l may
acute angle- precipitat
closure e an
glaucoma in attack.
emergent Keep life-
situations; support
achalasia equipmen
t readily
available
if
overdose
occurs or
cardiac
condition
s
worsens.
Atorvastatin Antihyper Adjunct to Inhibits HMG- 80mg/ta CNS: headache, asthenia Increased digoxin Take this drug once
lipidemic diet in CoA reductase, the b, 1tab GI: flatulence, dyspepsia, levels with possible a day, at about the
treatment of enzyme that OD q heartburn, liver failure toxicity if taken same time each
elevated total catalyzes the first HS Respiratory: sinusitis, together, monitor day, preferably in
cholesterol, step in the pharyngitis digoxin level the evening; may
serem cholesterol Increased estrogen be taken with food.
triglycerides, synthesis pathway, levels with Do not drink
and LDL resulting in a hormonal grapefruit juice
cholesterol decrease in serum contraceptives; while taking this
and to cholesterol, serum monitor patients on drug
increase LDLs (associated this combination. Institute
HDL-C in with increased risk appropriate dietary
patients with of CAD), and changes
primary increased serum Arrange to have
hypercholest HDLs (associated periodic blood test
42
erol (types II with deceased risk while you are
and IIb) and of CAD); taking this drug.
mixed increases hepatic
dyslipidemia LDL recapture
and primary sites, enhances
dysbetalipopr reuptake and
oteinemia, catabolism of
whose LDL; lowers
response to triglyceride levels.
dietary
restriction of
saturated fat
and
cholesterol
and other non
pharmacologi
c measure
has not been
adequate.
Enalapril Ace Hypertension Inhibits 5mg/tab CNS: dizziness, fatigue, Allopurinol: Assess for rapid
inihibitor conversion of , 1 tab headache, insomnia, increased risk of blood pressure drop
angiotensin I to BID drowsiness, vertigo, hypersensitivity leading to
angiotensin II, a asthenia, paresthesia, ataxia, reaction cardiovascular
potent confusion, depression, Antacids: decreased collapse, especially
vasoconstrictor; nervousness, enalapril absorption when giving with
inactivates cerebrovascular accident Cyclosporine, diuretics
bradykinin and CV: orthostatic hypotension, indomethacin, In patient with
prostaglandins. palpitations, angina pectoris, potassiumsparing renal insufficiency
Also increases tachycardia, peripheral diuretics, potassium or renal artery
plasma renin and edema, arrhythmias, cardiac supplements: stenosis, monitor
potassium levels arrest hyperkalemia for worsening renal
and reduces EENT: sinusitis Digoxin, lithium: function.
aldosterone levels, GI: nausea, vomiting, increased blood After initial dose,
resulting in
43
systemic constipation, dyspepsia, levels of these observe patient
vasodilation. abdominal pain, dry mouth, drugs, possible closely for at least
pancreatitis toxicity Diuretics, 2 hours until blood
nitrates, other pressure has
antihypertensives, stabilized. Then
phenothiazines: continue to observe
additive hypotension for additional hour.
Nonsteroidal anti-
inflammatory drugs:
decreased
antihypertensive
response Rifampin:
decreased enalapril
efficacy
Carvedilol Antihyper Hypertension Blocks stimulation 6- CNS: dizziness, fatigue, Antihypertensives: Watch for signs and
tensive of cardiac beta1- 25mg/ta anxiety, depression, additive hypotension symptoms of
adrenergic b, 1tab insomnia, memory loss, Calcium channel hypersensitivity
receptor sites and OD q nightmares, headache, pain blockers, general reaction.
pulmonary beta2- HS CV: orthostatic hypotension, anesthetics, I.V. Assess baseline
adrenergic peripheral vasoconstriction, phenytoin: additive CBC and kidney
receptor sites. angina pectoris, chest pain, myocardial and liver function
Shows intrinsic hypertension, bradycardia, depression test results.
sympathomimetic heart failure, atrioventricular Cimetidine: Monitor vital signs
activity, causing block increased carvedilol (especially blood
slowing of heart EENT: blurred or abnormal toxicity pressure), ECG,
rate, decreased vision, dry eyes, stuffy nose, Clonidine: increased and exercise
myocardial rhinitis, sinusitis, pharyngitis hypotension and tolerance. Drug
excitability, GI: nausea, diarrhea, bradycardia, may alter cardiac
reduced cardiac constipation GU: urinary exaggerated output and cause
output, and tract infection, hematuria, withdrawal ineffective airway
decreased renin albuminuria, decreased phenomenon clearance.
release from libido, erectile Weigh patient
kidney dysfunction,renal daily and measure
44
dysfunction fluid intake and
output to detect
fluid retention.
Measure blood
glucose regularly if
patient has diabetes
mellitus. Drug may
mask signs and
symptoms of
hypoglycemia.
●Instruct patient to
take drug with food
exactly as
prescribed.
Tell patient to take
extended-release
capsule in the
morning with food,
to swallow capsule
whole, and not to
chew, crush, or
divide its contents.
Mucosta Antacid Peptic ulcer Rebamipide is a 1 tab CNS: dizziness, headache, Ampicillin, Assess vital signs.
Gastritis mucosal protective 3x/day asthenia cyanocobalamin, Check for
agent and is GI: nausea, vomiting, iron salts, abdominal pain,
postulated to diarrhea, constipation, ketoconazole: emesis, diarrhea, or
increase gastric abdominal pain reduced absorption constipation.
blood Metabolic: hypomagnesemia of these drugs Evaluate fluid
flow,prostaglandin Musculoskeletal: back pain; Clarithromycin: intake and output.
biosynthesis and fractures of hip, wrist, spine increased Watch for elevated
decrease free (with long-term daily use) omeprazole blood liver function test
oxygen radicals. Respiratory: cough, upper level results (rare).
respiratory tract infection Clopidogrel: Monitor
45
Skin:rash diminished magnesium level
antiplatelet activity before starting drug
Diazepam, and periodically
phenytoin, warfarin: thereafter in
prolonged patients expected to
elimination and be on long-term
increased effects of treatment or who
these drugs take proton pump
Digoxin: increased inhibitors with
digoxin absorption other drugs such as
and blood level, digoxin or drugs
possible digoxin that may cause
toxicity Drugs hypomagnesemia.
metabolized by
CYP450 system:
competitive
metabolism
Methotrexate:
increased
methotrexate serum
level
Penicillins: serious
and occasionally
fatal
hypersensitivity
reactions including
anaphylaxis
Rifampin:
substantially
decreased
omeprazole
concentrations
Pantoprazol Anti- For the treatment of Reduces gastric 40/30m CNS: dizziness, headache Ampicillin, Assess for
46
e+Domperid Ulcerant gastroesophageal acid secretion and g 1 tab CV: chest pain cyanocobalamin, symptomatic
ine reflux disease; non- increases gastric once a EENT: rhinitis digoxin, iron salts, improvement.
ulcer dyspepsia, mucus and day GI: vomiting, ketoconazole: Monitor blood
gastric or duodenal bicarbonate diarrhea, abdominal pain, delayed absorption glucose level in
ulcer, dyspepsia, production, dyspepsia Metabolic: of these drugs diabetic patient.
bloating, fullness, creating protective hyperglycemia Atazanavir, Tell patient to
belching, NSAID coating on gastric Musculoskeletal: hip, wrist, nelfinavir: swallow
induced dyspepsia. mucosa spine fractures (with long- substantially delayedrelease
term daily use) decreased atazanavir tablets whole
Skin: rash, pruritus or nelfinavir plasma without crushing,
Other: injection site reaction concentration with chewing, or
loss of therapeutic splitting.
effect and
development of drug
resistance
Norplat Antiplatelet Recent Inhibits 75mg 1 tab OD CNS: depression, Abciximab, aspirin, Monitor
myocardial platelet dizziness, fatigue, eptifibatide, hemoglobin
infarction aggregation headache heparin, and
(MI) or by blocking CV: chest pain, heparinoids, hematocrit
stroke or binding of hypertension nonsteroidal anti- periodically.
established adenosine EENT: epistaxis, inflammatory drugs Monitor
peripheral diphosphate rhinitis (NSAIDs), patient for
arterial to platelets, GI: diarrhea, thrombolytics, unusual
disease thereby abdominal pain, ticlopidine, bleeding or
preventing dyspepsia, gastritis, tirofiban, warfarin: bruising; drug
thrombus GI bleeding increased risk of significantly
formation Hematologic: bleeding increases risk
bleeding, CYP2C19 of bleeding.
neutropenia, inhibitors (such as Assess for
thrombotic esomeprazole, occult GI
thrombocytopenic omeprazole): blood loss if
significantly patient is
47
purpura reduced clopidogrel receiving
Metabolic: antiplatelet activity naproxen
hypercholesterolem Fluvastatin, many concurrently
ia, gout NSAIDs, with
Musculoskeletal: phenytoin, clopidogrel.
joint pain, back tamoxifen, Advise patient
pain Respiratory: tolbutamide, to
cough, dyspnea, torsemide: immediately
bronchitis, upper interference with report unusual
respiratory tract metabolism of these or acute chest
infection, drugs pain,
bronchospasm respiratory
Skin: pruritus, rash, difficulty,
angioedema rash, purplish
bruises on
skin or in
mouth, purple
skin patches,
unusual
fatigue, fast
heart rate,
confusion,
signs and
symptoms of
stroke
(including
weakness on
oneside,
speech
changes), low
urine output,
unresolved
bleeding,
diarrhea, GI
48
distress,
nosebleed, or
acute
headache.
RESTRICTIONS:
1. Strenuous activities
2. Heavy lifting greater than 5kg
3. Prolonged exposure to sunlighrt
49
a) Restrict smoker
b) Crowded area
3. TREATMENTS/THERAPIES
a) Attending the follow up check up :
Educate client by adhering maintenance therapy, appropriate diet and having exercise will reduce likelihood
4. HEALTH TEACHING/EDUCATION
PREVENTION/PROMOTION
Health teaching about the disease, exercise and diet
Instructs the patient about home-made interventions in reducing blood such as:
5. OPD Visit
Instruct that they need to have a health check up
50
6. DIET
Low calories- calorie restriction in individuals with hypertension
Low fat- Advisable to reduce the fat consumption since hypertension has greater risk of atherosclerotic. Foods rich in cholesterol are liver, meat organ, egg
yolk,lobster, crabs, and prawns. Recommended: vegetable oil like sunflower and olive oil
High protein: Most high protein foods are extremely low in carbs and extremely low in saturated fat. Therefore, by eating a high protein diet loaded with high
protein foods, at the same time you’d end up eating low carbs and low saturated foods
Foods rich in potassium: tomato, watermelon, banana, apple, raw carrots, leafy vegetables and potato
r
7. SPIRITUAL CARE AND PSYCHOLOGICAL OR SEXUAL NEEDS
(/) Spiritual counseling
(/) Grief work
(/) Anger Management
(/) Confession
(/) Family therapy
(/) Reconciliation of conflicted Relationships
(/) Supportive Counseling
(/) Join church Organizations/Activities
(/) Prayer
51
(/) Meditation, Reflection, and Spiritual Devotion
(/) Religious rituals
(/) Religious/ Spiritual Materials
SEXUAL NEEDS
(/) Marriage counseling
(/) Sex Therapy
(/) Sexual Therapy
(/s) Referral to appropriate Agencies
52
References:
3. Ignatavicius & Workman (2006) Medical Surgical Nursing: Critical Thinking for
Collaborative Care. USA. Elsevier.
5. Tortora (2011). Principles of Anatomy and Physiology , 14th Edition John Wiley
& Sons, 2008.
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