Preedited Case Study

I. INTRODUCTION That's the scary thing about heart disease.
You can be fine one minute and dead the next. This basically acts as an early warning system for people who can then watch their lifestyles or habits down the road. Because a lot of people are not aware that they could be at risk of heart disease until its too late. ~ Salgo and Hlatky, 2010
The quotation would conspicuously state how heart diseases can be tricky and very unpredictable. And true enough; the adage would emphasize the importance of watching ones habits that would mean maintaining a healthy lifestyle which really affects a persons health condition. The abovementioned statements are proofs that indeed heart problems are not just occurring but are the major causes of mortality in the world. This is where the importance of taking precautionary measures to maintain the health of a persons heart condition takes place.
According to Fox (2004) as cited by Marshall (2011) in the acute phase of Coronary Heart Disease known as Acute Coronary Syndrome which describes a spectrum of clinical conditions namely: ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina (which is Acute Coronary Syndrome without cardiac enzymes or troponin release). Moreover, chest pain is the main symptom that is associated to Acute Coronary Syndrome. The electrocardiogram results would then categorize if a patient is having ST elevation or non ST elevation (Bassand et al 2007). Focusing on Non- ST segment elevation myocardial infarction, patients with such condition are expected to have typical acute chest pain for more than 20 minutes and without persistent ST segment elevation where the coronary artery supplying a large area of myocardium with blood is completely
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occluded which is the absolute opposite of ST segment elevation myocardial infarction. Then, basing from the results of the Troponin tests, the initial working diagnosis of non ST elevation Acute coronary syndrome can be further categorized as Non- ST segment elevation myocardial infarction or unstable angina. At this point, the very aim of the management of such group of patients is to prevent and current further ischemia, relieve symptoms, monitor serial ECG recordings and repeat biochemical markers that would help one identify the extent of myocardial necrosis. (Bassand et al (2007). According to American Heart Association, the best drug of choice for Acute Coronary Syndrome would be platelet aggregate inhibitors. And the gold standard care would be to decrease activities that would increase oxygen demand because the main goal in Acute Coronary Syndrome is to lessen further ischemia to the heart.
Talking about heart diseases, Cardiomyopathy is one of the most common diseases of the heart muscle wherein, the heart loses its ability to pump blood and, in some instances, heart rhythm is disturbed, leading to irregular heartbeats, or arrhythmias. Usually, the exact cause of the muscle damage is never found. (Retrieved at http://www.healthnewsflash.com/conditions/cardiomyopathy. php, accessed on
January 2, 2012) Whereas, Zuger (2007) would define Pneumonia as the accumulation of fluid in the lungs brought about by infectious agents such as viruses, fungi and bacteria and he also attested that it makes sense that pneumonia might worsen preexisting cardiac problems and bring new ones to light. But no direct relationship between heart disease and Pneumonia have been confirmed.
As for the Epidemiology, Ischemic heart disease is the leading cause of death worldwide. Cardiovascular diseases cause 12 million deaths throughout the world each year, according to the third monitoring report of the World Health Organization, 2008-10. (Retrieved from http://emedicine.medscape.com/article/155919-overview#a0156 on
November 15, 2011 at 7:22PM). In the United States; approximately 1.5 million cases of myocardial infarction occur annually in the United States; the yearly incidence rate is approximately 600 cases per 100,000 people.Cardiovascular disease is the leading
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cause of morbidity and mortality among black, Hispanic, and white populations in the United States. Moreover, the American Heart Associations Statistical Fact Sheet 2012 Update would reflect how in 2008, the estimated prevalence of CHD in Asian adults is 4.9%, compared to 7.0% of the total population. CHD resulted in 2,448 deaths among Asians, MI caused the death of 601 Asians.
Current Trends:
Kark (2011) in his study The relationship between moderate alcohol intake and coronary health would claim how moderate alcohol intake, though not regular heavy drinking, is protective for acute coronary syndrome. The purpose of the study was to assess the association of alcohol drinking frequency and quantity with acute coronary syndrome (ACS) in a predominantly Muslim southeast European population, where heavy drinkers drink consistently. This led to the conclusion that among the men in this transitional Mediterranean population, a strong protective effect associated with both moderate frequency and quantity of intake. The unique context of our study reinforces the case for causality in the relationship between moderate alcohol intake and coronary health. (Retrieved from www.cinahl.com/cgi-
bin/refsvc?jid=1049&accno=2011205653accessed on January 2, 2012) Another research by the American College of Cardiology Foundation to determine if statin treatment may be associated with lower mortality in patients with ischemic and nonischemic cardiomyopathy. It was found out that mortality risk was significantly lower in those taking a statin. Statin use is associated with reduced allcause mortality in Heart Failure patients. Statins appear to benefit patients with nonischemic and ischemic cardiomyopathy similarly (Retrieved at
http://cme.medscape.com/viewarticle/547058, accessed on January 2, 2012). Watson (2011), stated on his article You may overlook these pneumonia symptoms that it is especially important to note all patients with a productive cough of discolored phlegm, fever, shaking, and chills. She explained how elderly and/or
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immune-compromised patients are at high risk for getting pneumonia. She also warned that, If misdiagnosed or undiagnosed, this population can become septic,. Sepsis is a serious, life-threatening illness that will require critical care from a team of multidisciplinary professionals., she added.
Undeniably, it is very imperative to be dynamic in the field of medicine for medical practitioners to incessantly have the drive to learn and wider their horizon, especially in the very competitive world of medicine. This kind of disease involving the heart is somewhat usual in many people probably because of their lifestyle. With this, it is essential for us member of the medical team to deepen our knowledge about this condition in order to decrease or lessen the morbidity and mortality rate. The group has seen that there is an increasing prevalence of cases of heart related diseases that cause millions of death in the entire world. Thus, each of the members of the group realized that there is an importance for them to equip themselves of the appropriate knowledge that would very much help in making them competent enough as far as managing and assessment heart related problems are concerned. By this we can help our patient to prevent the occurrence of this disease and avert its possible complications. The hearts anatomy and physiology may not be very complicated and difficult to understand for health care providers. But the group thought that considering the prevalence and epidemiology of heart diseases, it is imperative that health care providers widen their horizon and learn from different situations of even patients with same cases. Making a comprehensive and on hand handling of the case Acute Coronary Syndrome, Non ST Segment Elevation Myocardial Infarction, Hypertensive Cardiovascular Disease, with Left Dilated Cardiomyopathy, and Community Acquired Pneumonia Moderate Risk together with reading different reliable reading materials and published books, studies and journals would very much help the student nurses in widening their horizon as far as clinical competence equipped with proficient knowledge is concerned.
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OBJECTIVES Nurse Centered After the completion of the case study, the nurse-researcher will be able to: Comprehensively explain the statistics and new trends regarding the patients case; Thoroughly assess the personal history and pertinent family health-illness history of the patient that had contributed to his present condition; Carefully assess the patients history of past and present illnesses; Scrupulously perform a comprehensive physical assessment; Scientifically know the different diagnostic and laboratory procedures performed, their indications and interpretation in relation to the disease of the patient; Exhaustively discuss the pathophysiology of the case and develop a schematic diagram; Methodically define the illness; find out the modifiable and non-modifiable factors as well as the signs and symptoms and the corresponding rationale; Precisely formulate significant nursing diagnoses with significantly related nursing care plans; Accurately identify treatment, their indications, and the response of the patient; and, Correctly formulate conclusion and recommendations with reference to the case study being conducted.
Patient Centered After the completion of the case study, the patient will be able to: gained proper knowledge regarding his disease condition; comply with the prescribed treatment;
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conform to the health teaching provided; identify potential complications and how to initiate preventive measures; recognize own psychological response and initiate appropriate coping action; and, identify corrective/adaptive measures for individual situation established self-reliance.
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II. NURING ASSESSMENT A. Personal Data 1. Demographic Data To protect and maintain strict confidentiality, the researchers named the client Mr. Cardio Nstemi which is derived from his diagnosis. Mr. Cardio Nstemi is a 74 year old male Filipino and affiliated to the Roman Catholic community and was born on March 25, 1937 in La Union. He is the fifth among the seven siblings. Originally he was from La Union but decided to move in Angeles City to stay with his daughter on August 20, 2011. According to his daughter, she needed someone to look after her kids because she works as a call center agent. On November 6, 2011, Mr. Cardio Nstemi was admitted in a government hospital in Angeles City complaining of chest pain and difficulty of breathing. The working diagnosis was Acute Coronary Syndrome Non ST Elevation Myocardial Infarction, KILLIP 1, Hypertensive Cardiovascular Disease. After two days, his daughter decided to transfer him to a Tertiary hospital for further assessment and better management. On November 8, 2011, Mr. Cardio Nstemi was admitted in a Tertiary hospital in Angeles City at exactly 7:00pm. He was given the same diagnosis since the same physician handled him. He was initially admitted to the Intensive Care Unit where he stayed for three days. On November 11, 2011, he was transferred to his room of choice and was discharged on November 15, 2001 with the final diagnosis of ACUTE CORONARY SYNDROME NON ST SEGMENT ELEVATION DISEASE MYOCARDIAL WITH INFARCTION DILATED
HYPERTENSIVE
CARDIOVASCULAR
LEFT
CARDIOMYOPATHY WITH COMMUNITY ACQUIRED PNEUMONIA MODERATE RISK.
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2. Socioeconomic and Cultural Factors Mr. Cardio Nstemi lives with his wife, daughter, son in law and three grandchildren. He finished his primary schooling at a school in Ilocos where he was naturally born in the year 1949 and finished his secondary schooling in the year 1953 at the same school. After high school he stopped schooling and decided to help his father who was a farmer during that time. According to him his work in the farm includes planting and cultivating rice and sugarcanes. He usually wakes up at around 5am in the morning to help his father in the said work and they would usually end up working at around 3pm for most days of the week. In the year 1955, he took vocational classes specifically tailoring in Technical Education and Skills Development Authority or TESDA in Quezon Avenue, La Union. In1957, he graduated from his vocational course. After a few months he was called by the TESDA office to become a teacher of the said course. He worked as a teacher in TESDA for forty five years. Mr. Cardio Nstemi is married to Mrs. Nstemi. He met his better half because she was his co-teacher back then in TESDA. They were married on March 15, 1966 and and they were blessed with one daughter Cory Nstemi who was born on November 3, 1974. Mrs. Nstemi stopped teaching in order to care and look after their daughter. According to Mr. Cardio Nstemi he used to work for at least 8 to 9 hours a day five times a week. He admitted that being a teacher is quiet a tough work because you have to prepare for your students, need to supervise them and sometimes you even take home your school works just to finish them. He also mentioned that he needs to prepare some lesson plans for his lectures, discussion and demonstrations. He added that usually he sleeps approximately 4-5 hours a day. After teaching, he goes directly to their house and helps his wife in doing some of the household chores like cooking, cleaning the house and washing the dishes. When asked what he usually does during his free time, Mr. Cardio Nstemi stated that he would most often just bond with his wife and their child whenever he is available. According to him, during his younger years he did not regularly visit the clinic or hospital for check-up but rather they would usually consult
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herbolaryos or traditional healer as they take some herbal medicines primarily because of financial constraints. According to Mr. Cardio Nstemi, he admitted that he is fond of eating fatty foods such as chicharon sinigang na baboy and bulanglang, and salty foods such as bagoong and tuyo since he was a child. According to him, his wife would always go to the wet market to buy their weekly food and shes the one who prepares their food. Currently, when asked if he still eats this kind of foods despite of his condition he said that it is hard for him to avoid eating those foods that is why sometimes he cannot help but to eat. According to Mr. Cardio Nstemi he used to earn 12,000 pesos per month for being a teacher in TESDA institute. They are considered not poor because they went
above the criteria set by the NEDA which is Php. 2,768.60 for each individual. The individual budget of every member was Php 4,000. He verbalized that most of the money that he earned during that time went to the schooling of his daughter who finished Mass Communication and expenses in their house such as electric bill and water bill. Mr. Cardio Nstemi decided to retire from his work in 2002. Presently, his daughter is working as a call center agent and is the only source of income of Mr. Cardio Nstemi and his wife. They receive Php 15,000.00 from her every month for their everyday expenses and she sometimes give Php1,000.00 as an additional allowance. According to Mr. Cardio Nstemi their estimated expenses every month include: for their food they spend Php8,000.00 a month; their water bill costs Php5, 00.00 a month; for Mr. Nstemis check-up they spend Php 5,000.00 per month; while for their electric bill they spend Php 2,000.00 per month and lastly for Mr. Nstemis medicines they spend about Php 3,000.00 a month. In totality they spend approximately Php 14, 000.00 a month. Currently when asked what Mr. Cardio Nstemi usually does or his routine activities back home, his daughter verbalized that his father most of the time watches TV after eating their breakfast. Mr. Cardio Nstemi sleeps approximately 9-10 hours a
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day. Furthermore, his daughter added that at times Mr. Cardio Nstemi bonds with his three grandchildren and play with them but not often because of his condition rather he just look after them while playing. During afternoons, after taking his lunch he usually rest and takes a nap and shares story with his wife then they will eat their dinner together and according to his daughter he usually sleeps early. At present,the family is residing in an urban community. Their house is a two-story building made of concrete. It is approximately 90 square meters with two bedrooms and one bathroom. The house is well ventilated and well lighted, it has 4 windows and 3 light bulbs and I fluorescent. Upon the home visit the group observed that there are no environmental hazards such as poor environmental sanitation, breeding sites of vectors such as mosquitoes and their garbage are well disposed.
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B. Family Health-Illness History The Nstemi Family Grandfather (+)Died old age
(Died) Grandfather
Grandmother (+) Died-old age
Grandfather (+) Died-heart attack
Grandmother (+) Died-old age
Uncle (No known illnesses)
Father (+) CVA and HPN
Auntie (No known illness)
Uncle (No known illnesses)
Uncle (No known illnesses
Mother (+) Died-old age
Brother Sister Sister (+) TB 77 y.o
Brother (No known illnesses
Mr. Cardio Nstemi (ACS, NSTEMI, HCVD, with left dilated cardiomayopat hy with Community Acquired Pneumonia, 74
y.o)
Brother Sister
(+) old age, 80 y.o
(+) stab wound, 22 y.o present: 76 y.o
(+) heart attack 65 y.o
(No known illnesses,
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indicates female indicates male + - died This is the family constellation of Mr. Cardio Nstemi. It depicts the family history of illnesses and gives an overview on their current and past health status. His grandfather and grandmother on the father side died because of old age.. His Father is hypertensive who died because of brain attack or stroke. Mr. Cardio Nstemis grandfather, his father and his younger brother has a common denominator and that is their disease conditions which are hypertension and heart attack which could have a great factor while Mr. Nstemi is suffering from the said illness. On the other side of the genogram, his grandfather on his mother side died because of stroke and her grandmother died because of old age and his mother died because of old age. In conclusion, Mr. Cardio Nstemi has members in his family which could have contributed to his being at risk to havinga heart disease.
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C. History of Past Illness According to Mr. Cardio Nstemi, when he was a child he had his measles and chicken pox but he could not remember anymore what management was done to him. He also experienced mild cough, colds and fever. According to him, his mother gave him paracetamol 500mg tablet and took 2 to 3 tablets a day until the fever will subside. They also take lagundi leaves which they prepare by boiling a handful of lagundi leaves and drank it twice a day until cough and colds subsided. He stated that he takes over the counter drugs such as paracetamol for fever, Loperamide capsule once a day for diarrhea and mefenamic acid 500mg for pain every 6 hours. According to him on 2005, he experienced a persistent pain on his left leg that prompted him to consult a doctor. After diagnostics procedures were done, he said that he remembers the doctor telling him that his uric acid level was high and after which he was given a diagnosis of gouty arthritis. It was revealed that his uric acid was above the normal level and the doctor prescribed allopurinol 300mg once a day which according to him provided relief. The doctor advised him not to eat too much food rich in purine such as beans, sardines, mushroom, spinach, cauliflower, and organ meats. He also used salon pas which also relieves aches and pains in the muscles and joints. D. History of Present Illness
In 2006, Mr. Nstemi experienced easy fatigability, nape pain, dizziness, headache and a blood pressure which he said he does not remember anymore but is around 160/100 mmHg. He was then admitted in a tertiary hospital in La Union for 4 days and was diagnosed of Hypertension stage 2. Mr. Nstemi said that he was given this diagnosis because his blood pressure barely went down to normal his entire hospitalization. He said it would remain around 160/100 mmHg. He was given Neobloc and Norvasc, the dosages he could not remember anymore. He was also asked to avoid food high in salt and fats. After which, he was advised to seek consultation in a tertiary hospital in Manila. And so in the same year, Mr. Nstemi went to Manila and had 2D echo though the results were in La Union and were not seen by the student nurses,
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the daughter said that upon being admitted in the same hospital in Manila due to chest pain and difficulty of breathing, nape pain, dizziness, headache and blood pressure around 160/100 mmHg. He was diagnosed with Hypertensive Cardiovascular Disease and stayed there for 1 week. Mr. Nstemi claims to not recall the results of the 2D Echo anymore. The following medications were given: Diovan 80mg OD, Aspirin 80mg OD, Neobloc OD and Carvedilol. He responded well with the treatment as he was able to
initially maintain his blood pressure within normal range, regain his energy and his chest pains and difficulty of breathing did not occur initially. However, between the years 2006-2010 he experienced the same complaints, chest pain which would always occur after doing some tough work such as doing household chores like cleaning the house, sweeping the floor, doing the laundry and being exposed too much under the heat of the sun which would usually be followed by difficulty of breathing, nape pain, dizziness, and a high blood pressure. According to him, he regularly takes his medicines but would sometimes fail to comply with his scheduled medical check-up because of the proximity of the hospital from their house and he sometimes does not have anyone to accompany him to the hospital. He attested that there were no noted hospitalizations from 20072009, just chest pains, nape pain, dizziness and a high blood pressure that he experienced. Nevertheless, when these symptoms occur, the first thing that his SOs would do is to let Mr. Cardio Nstemi rest for a while but if it persists and worsens they will rush him to the nearest hospital. On December 2010, he was admitted in a hospital in La Union because of complaints of chest pain with shortness of breath and was admitted at the ICU for five days and another three days in a regular private room. There are some modifications to Mr. Cardio Nstemis lifestyle and this includes his diet which is low fat and sodium and avoiding too much tough work that usually exacerbates his condition or make him experience chest pain, difficulty of breathing, nape pain and the like. The doctor also advised him not get tired too much and not to be stressed. He was asked to continue the management that was given to him in Manila namely; Diovan, Neobloc, Carvedilol and Aspirin.
Then, on the morning of November 6, 2011, after having a walk outside of

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their house, Mr. Cardio Nstemi suddenly experienced chest pain, nape pain, dizziness and difficulty of breathing. Because his daughter was not around he decided to seek help from their neighbor and asked her if she can bring him to the nearest hospital. Mr. Cardio Nstemi was admitted with a diagnosis of Acute Coronary Syndrome Non ST Elevation Myocardial Infarction, KILLIP 1, Hypertensive Cardiovascular Disease in a government hospital in Angeles City. Complete Blood Count, Serum Potassium, Blood Chemistry: Creatinine and Blood Urea Nitrogen where ordered in the government hospital which led to the diagnosis of the patients condition. He was then given the following medications: Morphine 5mg, Aspirin 80 mg, Clopidogrel 75 mg/tab, Bisoprolol 5mg/tab. According to Cory NSTEMI, the patient was not responding well with the management because she could not see any improvement on her father so they decided to transfer him to another hospital because the services in the present hospital are poor and no improvement were seen on the patients present condition. He was transferred on November 8, 2011 with some pallor, easy fatigability and difficulty of breathing and high blood pressure of 160/110. He was admitted in a tertiary hospital and had an initial diagnosis of acute coronary syndrome Acute Coronary Syndrome Non-ST segment elevation Myorcardial Infarction Killip I Hypertensive Cardiovascular Disease. After being observed with his present condition and diagnostic procedures such as biocardiac markers, 2D-Echo, electrocardiogram, chest x-ray and serum potassium and creatinine were done, Mr. Cardio Nstemi final diagnosis is ACUTE CORONARY SYNDROME NON ST SEGMENT ELEVATION MYOCARDIAL
INFARCTION, HYPERTENSIVE CARDIOVASCULAR DISEASE WITH LEFT DILATED CARDIOMYOPATHY WITH COMMUNITY ACQUIRED PNEUMONIA MODERATE RISK was confined in the intensive care unit for 4 days and later on stayed or transferred to a regular room of choice for another four days. He was given the management of Arixtra 2.5mg SC OD, Morphine 5mg IV now, Lexotan 1.5mg/tab TID, Bisoprolol 5mg/tab OD, Clopidogrel 75mg/tab OD, Vastarel 35mg/tab BID, Pantoprazole 40mg/tab BID, Avamax 40mg/tab HS, Lifezar 50mg/tab TID, Zertin 300g OD, Aldazide 1 tab BID, Lactulose 30cc at HS, Lanoxin 0.25mg 1 tab 2x a day half OD and was adviced to observe a low salt low fat diet. He responded well on the treatment because of the
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absence of chest pains and difficulty of breathing from November 9, 2011 until the patient was discharged.
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E. Physical Examination (IPPA Cephalocaudal Approach)
November 8, 2011 (Tuesday, 7:00pm, Lifted from the chart)
Vital Signs:
BP = 160/110 mmHg PR = 76 bpm RR = 31 cpm T = 36.5 C/ axilla With complaints of chest pain noted
November 9, 2011 (Wednesday- first nurse-patient interaction)
Vital Signs: BP = 110/70 mmHg PR = 64 bpm RR = 18 cpm T = 36 C/ axilla
General appearance: Patient was seen in a semi-fowlers position conscious and coherent wearing hospital gown with brown shorts. He manifested generalized body weakness, easy fatigability and cannot tolerate supine position. A) Integumentary SKIN: His skin is brown in complexion and has good skin turgor. Dry skin was noted on the lower extremities.
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NAILS: Fingernails and toenails are untrimmed and pale in color. Texture of the nails is smooth and its shape is convex. Capillary refill time of less than 3 seconds. HAIR: Evenly distributed and black in color. B) Head SCALP: No presence of lesion, dandruff and pediculosis. Texture of his scalp is smooth and white in color. There are no palpable scars, wounds or depression/ protrusion. SKULL: The shape of the skull is round and normocephallic and has a smooth skull contour. There are no depression and protrusion. EYES: His eyes can accommodate light when the light was introduces, (+) normal light reflex. Eyes are also symmetrical and no abnormal protrusion. EYEBROWS: Hair is evenly distributed, symmetrically aligned and has equal movement. EYELASHES: Equally distributed and curled slightly outward. EYELIDS: Eyelids close symmetrically, with intact skin and no discharge and discoloration noted. BULBAR CONJUNCTIVA: Transparent, capillaries sometimes evident, sclera appears white and no lesions or nodules note. PALPEBRAL CONJUNCTIVA: Shiny and pink in color. LACRIMAL SAC AND NASOLACRIMAL DUCT: No edema and tearing noted. CORNEA: transparent, shiny and smooth details of iris are visible. C) Ears INTERNAL: No presence of cerumen was observed upon inspection.
EXTERNAL: No presence of tenderness, lesions and other abnormalities Ears are parallel to the eyebrow. Auricles are smooth, mobile, firm and not tender upon palpation. Pinna recoils after it is folded. Normal voice
tone audible as evidence by responding when called by name.

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D) Nose Nasal septum intact and midline, no tenderness and lesions noted. Air moves freely to both nasal cavity, with patent airway.
E) Mouth and Throat LIPS: pinkish in color, moist and symmetrical. BUCCAL MUCOSA: pinkish in color, smooth, moist and without lesions. F) Neck Sternocleidomastoid muscle is equal in size and neck is on the center no enlargement of lymph nodes; trachea is centered and at the midline of neck, was able to flex, hyperextend, laterally flex and laterally route the head. Thyroid gland ascends during swallowing and it is not visible, neck veins are not distended.
G) Thorax and Lungs Spine is vertically aligned and straight, symmetric chest expansion, abnormal breath sounds (rales) noted and no tenderness or masses noted. HEART: Irregular rhythm noted (Premature ventricular contractions) and murmurs noted. H) Gastrointestinal ABDOMEN: Uniform in skin color, no presence of rashes or lesions noted scaphoid (concave in shape), presence of hypoactive bowel sounds and no tenderness noted in the four quadrants. I) Musculoskeletal EXTREMITIES: Hair is evenly distributed on both upper and lower extremities. With pain noted on the big toe of the feet.
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BACK AND SPINE: Stands erect without postural abnormalities with good spine alignment. J) MENTAL STATE Mr. Cardio Nstemi was conscious and coherent, with appropriate affect when telling information to the student nurses. Can identify person, date, time and can recall information from the past by recalling previous health history.
CRANIAL NERVE ASSESSMENT CRANIAL NERVE TYPE FUNCTION CRANIAL NERVE I: Sensory Olfactory Smell AND ASSESSMENT PROCEDURE The Student Nurse asked the client to close both eyes and asked to identify aromas such as perfume and soap. The Student Nurse asked the patient to read some printed words from a handout and identify some colors. The client was asked to look straight. Then with use of a penlight, light was passed on the right eye and was also done on the left eye. NORMAL FINDINGS Client will be able to identify the different odors present with eyes closed. ACTUAL RESULTS He was able to identify different aromas that the Student Nurse prepared which were perfume and soap. He was able to read some words from the handout and was able to identify the colors blue green and orange. The dilated pupil gradually constricted upon the introduction of light with the use of a penlight and was able to open and close
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CRANIAL NERVE II: Sensory Optic Vision
Client will be able read words from the handout and identify colors.
CRANIAL NERVE III: Motor Occulomotor Extra-ocular movement & pupils
Pupils react to light & accommodation and able to open and close eyelids.
CRANIAL NERVE IV: Motor Trochlear Extra-ocular movement of eyes in downward & inward movement
The client was asked to follow the direction of the penlight in an upward and downward movement without moving her head.
Eyes will be able to move in an upward and downward direction without moving her head.
CRANIAL NERVE V: Motor and Sensory Trigeminal Sensation of Cornea, skin of face & jaw movement
Student Nurse made use of a clean wisp and gently stroked clients eyelashes to elicit corneal reflex. Also, the Student Nurse asked the client to close his eyes to determine if the object is sharp or dull. The Student Nurse also asked her to move her jaw side to side and chew. CRANIAL NERVE VI: Motor Student Nurse Abducens Extra-ocular asked the movement of eyes patient to follow in a lateral the direction of movement penlight in a lateral movement. CRANIAL NERVE VII: Motor and Sensory Facial Movement of facial muscles and sense of taste on the anterior portion of the tongue Student Nurse asked the client to raise her eyebrows, smile, frown, show teeth and puff
Client will be able to elicit corneal reflex and identify the sensation of dull or sharp object. The client must be able to close and open, move side to side his jaw and make some mastication.
eyelids. He was able to move his eyes upward and downward by following the direction of motion of the penlight without moving his head. He responded to the cotton wisp by blinking his eyes, was able to identify the difference between sharp and dull objects, was able to move his jaw from side to side and can chew.
Eyes will be able to move in lateral movement without moving the head.
Client will be able to raise eyebrows, smile, frown, show teeth, puff out cheeks and
He was able to follow the direction of the penlight in a lateral movement without moving his head. He was able to follow the directions given by the Student Nurse; he was able raise his
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out his cheeks and to identify various taste on the tips of the tongue like sweet and salty.
CRANIAL NERVE VIII: Sensory Vestibulocochlear/acou Hearing stic equilibrium
and
CRANIAL NERVE IX: Motor and Sensory Glassopharyngeal Swallowing and gag reflex, pharyngeal movement and sense of taste on the particular portion of the tongue. CRANIAL NERVE X: Motor and Sensory Vagus Swallowing and speaking
CRANIAL NERVE XI: Motor Accessory Movement of shoulder muscles
eyebrows, smile, frown, show teeth, puff out her cheeks and identified the taste of juice and salty. Student Nurse The client will be He was able to placed a watch able to hear the hear the ticking with a second- watch tick watch. hand near the ears of the client and asked him if he could hear the tick. Student Nurse The client will be He was able to asked the client able to say ahh say ahh and to say ahh and and yawn, elicit yawn; the yawn; pressed gag reflex. palate rose the posterior symmetrically tongue with with the uvula tongue and in the depressor. midline and elicit gag reflex. Student Nurse The client will be He has no asked the client able to swallow difficulty in to swallow and and speak swallowing and asked a without thyroid glands question hoarseness. moved upward during swallowing; there was no hoarseness of voice noted. Student Nurse The client will be He was able to asked the client able to shrug move head to move head shoulders and from side to from side to side move head from side and was and asked to side to side able to elevate elevate her against applied shoulders shoulders resistance. against against the resistance of resistance the hands of introduced by the Student
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identify various tastes on the tips of the tongue like sweet and salty.
the Student Nurse. CRANIAL NERVE XII: Motor Student Nurse Hypoglossal Movements and asked the client strength of tongue to move tongue from side to side and in and out.
Nurse. The client will be able to protrude tongue and move it from side to side He was able to move the tongue from side to side and in and out.
November 10, 2011 (Thursday-Second nurse-patient interaction) Vital Signs: BP = 130/90 mmHg PR = 67 bpm RR = 21 cpm T = 37 C/ axilla
General appearance: Patient was seen in a semi-fowlers position conscious and coherent wearing hospital gown with brown shorts, able to ambulate but usually would result to easy fatigability manifesting slowed movement and difficulty of breathing. Generalized body weakness was noted upon assessment. Pain on the soles of the feet was also present. A) Integumentary SKIN: His skin is brown in complexion and has good skin turgor. Dry skin was noted on the lower extremities. NAILS: Fingernails and toenails are untrimmed and pale in color. Texture of the nails is smooth and its shape is convex. Capillary refill time of less than 3 seconds HAIR: Evenly distributed and black in color.
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B) Head SCALP: No presence of lesion, dandruff and pediculosis. Texture of his scalp is smooth and white in color. There are no palpable scars, wounds or depression/ protrusion. SKULL: The shape of the skull is round and normocephallic and has a smooth skull contour. There are no depression and protrusion. EYES: His eyes can accommodate light when the light was introduces, (+) normal light reflex. Eyes are also symmetrical and no abnormal protrusion. EYEBROWS: Hair is evenly distributed, symmetrically aligned and has equal movement. EYELASHES: Equally distributed and curled slightly outward. EYELIDS: Eyelids close symmetrically, with intact skin and no discharge and discoloration noted. BULBAR CONJUNCTIVA: Transparent, capillaries sometimes evident, sclera appears white and no lesions or nodules note. PALPEBRAL CONJUNCTIVA: Shiny and pink in color. LACRIMAL SAC AND NASOLACRIMAL DUCT: No edema and tearing noted. CORNEA: transparent, shiny and smooth details of iris are visible. C) Ears INTERNAL: No presence of cerumen was observed upon inspection.
tone audible as evidence by responding when called by name. D) Nose Nasal septum intact and midline, no tenderness and lesions noted. Air moves freely to both nasal cavity, with patent airway.
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E) Mouth and Throat LIPS: pinkish in color, moist and symmetrical. BUCCAL MUCOSA: pinkish in color, smooth, moist and without lesions.
F) Neck Sternocleidomastoid muscle is equal in size and neck is on the center no enlargement of lymph nodes; trachea is centered and at the midline of neck, was able to flex, hyperextend, laterally flex and laterally route the head. Thyroid gland ascends during swallowing and it is not visible, neck veins are not distended. G) Thorax and Lungs Spine is vertically aligned and straight, symmetric chest expansion, abnormal breath sounds (rales) noted and no tenderness or masses noted. HEART: Irregular rhythm note (Premature ventricular contractions) and murmurs. H) Gastrointestinal ABDOMEN: Uniform in skin color, no presence of rashes or lesions noted scaphoid (concave in shape), audible bowel sounds and no tenderness noted in the four quadrants. I) Musculoskeletal EXTREMITIES: Hair is evenly distributed on both upper and lower extremities. With a muscle strength of grade 4 as evidenced by a reduced muscle strength but still with muscle contraction and can still move joints against resistance. BACK AND SPINE: Stands erect without postural abnormalities with good spine alignment.
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J) MENTAL STATE Mr. Cardio Nstemi was Conscious and coherent, with appropriate affect when talking with the student nurses. Can identify person, date, time and can recall information from the past by recalling previous health history. CRANIAL NERVE ASSESSMENT CRANIAL NERVE CRANIAL Olfactory NERVE TYPE AND PUNCTION I: Sensory Smell ASSESSMENT PROCEDURE The Student Nurse asked the client to close both eyes and asked to identify aromas such as perfume and soap. The Student Nurse asked the patient to read some printed words from a handout and identify some colors. The client was asked to look straight. Then with use of a penlight, light was passed on the right eye and was also done on the left eye. The client was asked to follow the direction of the penlight in an upward and downward NORMAL FINDINGS Client will be able to identify the different odors present with eyes closed. ACTUAL RESULTS He was able to identify different aromas that the Student Nurse prepared which were perfume and soap. He was able to read some words from the handout and was able to identify the colors blue green and orange. The dilated pupil gradually constricted upon the introduction of light with the use of a penlight and was able to open and close eyelids. He was able to move his eyes upward and downward by following the direction of
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CRANIAL NERVE II: Optic
Sensory Vision
CRANIAL NERVE Occulomotor
III: Motor Extra-ocular movement & pupils
CRANIAL Trochlear
NERVE
IV: Motor Extra-ocular movement of eyes in downward & inward
movement
movement without moving her head. Client will be able to elicit corneal reflex and identify the sensation of dull or sharp object. The client must be able to close and open, move side to side his jaw and make some mastication.
CRANIAL Trigeminal
NERVE
CRANIAL Abducens
NERVE
Student Nurse made use of a clean wisp and gently stroked clients eyelashes to elicit corneal reflex. Also, the Student Nurse asked the client to close his eyes to determine if the object is sharp or dull. The Student Nurse also asked her to move her jaw side to side and chew. VI: Motor Student Nurse Extra-ocular asked the movement of patient to follow eyes in a the direction of lateral penlight in a movement lateral movement. Motor and Sensory Movement of facial muscles and sense of taste on the anterior portion of the tongue Student Nurse asked the client to raise her eyebrows, smile, frown, show teeth and puff out his cheeks and to identify various taste on the tips of the tongue like sweet and salty.
V: Motor and Sensory Sensation of Cornea, skin of face & jaw movement
motion of the penlight without moving his head. He responded to the cotton wisp by blinking his eyes, was able to identify the difference between sharp and dull objects, was able to move his jaw from side to side and can chew.
CRANIAL NERVE VII: Facial
Client will be able to raise eyebrows, smile, frown, show teeth, puff out cheeks and identify various tastes on the tips of the tongue like sweet and salty.
He was able to follow the direction of the penlight in a lateral movement without moving his head. He was able to follow the directions given by the Student Nurse; he was able raise his eyebrows, smile, frown, show teeth, puff out her cheeks and identified the taste of juice
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CRANIAL NERVE VIII: Sensory Vestibulocochlear/acoustic Hearing and equilibrium
CRANIAL NERVE Glassopharyngeal
IX: Motor and Sensory Swallowing and gag reflex, pharyngeal movement and sense of taste on the particular portion of the tongue. CRANIAL NERVE X: Vagus Motor and Sensory Swallowing and speaking
and salty. Student Nurse The client will be He was able to placed a watch able to hear the hear the ticking with a second- watch tick watch. hand near the ears of the client and asked him if he could hear the tick. Student Nurse The client will be He was able to asked the client able to say ahh say ahh and to say ahh and and yawn, elicit yawn; the yawn; pressed gag reflex. palate rose the posterior symmetrically tongue with with the uvula tongue and in the depressor. midline and elicit gag reflex.
Student Nurse asked the client to swallow and asked a question
The client will be able to swallow and speak without hoarseness.
CRANIAL Accessory
NERVE
CRANIAL NERVE Hypoglossal
XI: Motor Student Nurse Movement of asked the client shoulder to move head muscles from side to side and asked to elevate her shoulders against the resistance introduced by the Student Nurse. XII: Motor Student Nurse Movements asked the client
The client will be able to shrug shoulders and move head from side to side against applied resistance.
He has no difficulty in swallowing and thyroid glands moved upward during swallowing; there was no hoarseness of voice noted. He was able to move head from side to side and was able to elevate shoulders against resistance of the hands of the Student Nurse.
The client will be He was able to able to protrude move the

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and strength to move tongue tongue and move tongue from of tongue from side to side it from side to side to side and and in and out. side in and out.
November 14, 2011 (Monday) Third Nurse-Patient Interaction Vital signs: BP: 130/80 mmHg PR: 79 cpm RR: 34 bpm Temperature: 36 C/ axilla
General appearance: Patient was seen in a high fowlers position conscious and coherent wearing hospital gown with brown shorts. Generalized weakness and easy fatigability were noted upon assessment. A) Integumentary SKIN: His skin is brown in complexion and has good skin turgor. Dry skin was noted on the lower extremities. NAILS: Fingernails and toenails are untrimmed and pale in color. Texture of the nails is smooth and its shape is convex. Capillary refill time of less than 3 seconds. HAIR: Evenly distributed and black in color. B) Head SCALP: No presence of lesion, dandruff and pediculosis. Texture of his scalp is smooth and white in color. There are no palpable scars, wounds or depression/ protrusion.
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SKULL: The shape of the skull is round and normocephallic and has a smooth skull contour. There are no depression and protrusion. EYES: His eyes can accommodate light when the light was introduces, (+) normal light reflex. Eyes are also symmetrical and no abnormal protrusion. EYEBROWS: Hair is evenly distributed, symmetrically aligned and has equal movement. EYELASHES: Equally distributed and curled slightly outward. EYELIDS: Eyelids close symmetrically, with intact skin and no discharge and discoloration noted. BULBAR CONJUNCTIVA: Transparent, capillaries sometimes evident, sclera appears white and no lesions or nodules note. PALPEBRAL CONJUNCTIVA: Shiny and pink in color. LACRIMAL SAC AND NASOLACRIMAL DUCT: No edema and tearing noted. CORNEA: transparent, shiny and smooth details of iris are visible. C) Ears INTERNAL: No presence of cerumen was observed upon inspection.
E) Mouth and Throat LIPS: pinkish in color, moist and symmetrical. BUCCAL MUCOSA: pink in color, smooth, moist and without lesions. F) Neck
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Sternocleidomastoid muscle is equal in size and neck is on the center no enlargement of lymph nodes; trachea is centered and at the midline of neck, was able to flex, hyperextend, laterally flex and laterally route the head. Thyroid gland ascends during swallowing and it is not visible, neck veins are not distended. G) Thorax and Lungs Spine is vertically aligned and straight, symmetric chest expansion, abnormal breath sounds (rales) noted and no tenderness or masses noted. HEART: No irregular rhythm noted, with murmurs upon auscultation. H) Gastrointestinal ABDOMEN: Uniform in skin color, no presence of rashes or lesions noted scaphoid (concave in shape), audible bowel sounds and no tenderness noted in the four quadrants. I) Musculoskeletal EXTREMITIES: Hair is evenly distributed on both upper and lower extremities. With a muscle strength of grade 4 as evidenced by a reduced muscle strength but still with muscle contraction and can still move joints against resistance. BACK AND SPINE: Stands erect without postural abnormalities with good spine alignment. J) MENTAL STATE Mr. Cardio Nstemi was Conscious and coherent. Can identify person, date, time and can recall information from the past by recalling previous health history. He also manifested restlessness.
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CRANIAL NERVE ASSESSMENT CRANIAL NERVE CRANIAL Olfactory NERVE TYPE AND PUNCTION I: Sensory Smell ASSESSMENT PROCEDURE The Student Nurse asked the client to close both eyes and asked to identify aromas such as perfume and soap. The Student Nurse asked the patient to read some printed words from a handout and identify some colors. The client was asked to look straight. Then with use of a penlight, light was passed on the right eye and was also done on the left eye. The client was asked to follow the direction of the penlight in an upward and downward movement without moving her head. NORMAL FINDINGS Client will be able to identify the different odors present with eyes closed. ACTUAL RESULTS He was able to identify different aromas that the Student Nurse prepared which were perfume and soap. He was able to read some words from the handout and was able to identify the colors blue green and orange. The dilated pupil gradually constricted upon the introduction of light with the use of a penlight and was able to open and close eyelids. He was able to move his eyes upward and downward by following the direction of motion of the penlight without moving his head. He responded to the cotton
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Sensory Vision
CRANIAL Trochlear
NERVE
IV: Motor Extra-ocular movement of eyes in downward & inward movement
CRANIAL Trigeminal
NERVE
V: Motor and Student Nurse Client will be able Sensory made use of a to elicit corneal
CRANIAL Abducens
NERVE
clean wisp and gently stroked clients eyelashes to elicit corneal reflex. Also, the Student Nurse asked the client to close his eyes to determine if the object is sharp or dull. The Student Nurse also asked her to move her jaw side to side and chew. VI: Motor Student Nurse Extra-ocular asked the movement of patient to follow eyes in a the direction of lateral penlight in a movement lateral movement. Motor and Sensory Movement of facial muscles and sense of taste on the anterior portion of the tongue Student Nurse asked the client to raise her eyebrows, smile, frown, show teeth and puff out his cheeks and to identify various taste on the tips of the tongue like sweet and salty.
Sensation of Cornea, skin of face & jaw movement
reflex and identify the sensation of dull or sharp object. The client must be able to close and open, move side to side his jaw and make some mastication.
wisp by blinking his eyes, was able to identify the difference between sharp and dull objects, was able to move his jaw from side to side and can chew.
CRANIAL NERVE VIII: Sensory Student Nurse The client will be Vestibulocochlear/acoustic Hearing and placed a watch able to hear the equilibrium with a second- watch tick hand near the ears of the client
He was able to follow the direction of the penlight in a lateral movement without moving his head. He was able to follow the directions given by the Student Nurse; he was able raise his eyebrows, smile, frown, show teeth, puff out her cheeks and identified the taste of juice and salty. He was able to hear the ticking watch.
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and asked him if he could hear the tick. CRANIAL NERVE IX: Motor and Student Nurse Glassopharyngeal Sensory asked the client Swallowing to say ahh and and gag yawn; pressed reflex, the posterior pharyngeal tongue with movement tongue and sense of depressor. taste on the particular portion of the tongue. CRANIAL NERVE X: Vagus Motor and Student Nurse Sensory asked the client Swallowing to swallow and and speaking asked a question
The client will be able to say ahh and yawn, elicit gag reflex.
He was able to say ahh and yawn; the palate rose symmetrically with the uvula and in the midline and elicit gag reflex.
CRANIAL Accessory
NERVE
XI: Motor Student Nurse Movement of asked the client shoulder to move head muscles from side to side and asked to elevate her shoulders against the resistance introduced by the Student Nurse. XII: Motor Student Nurse Movements asked the client and strength to move tongue of tongue from side to side and in and out.
He has no difficulty in swallowing and thyroid glands moved upward during swallowing; there was no hoarseness of voice noted. He was able to move head from side to side and was able to elevate shoulders against resistance of the hands of the Student Nurse. He was able to move the tongue from side to side and in and out.
The client will be able to protrude tongue and move it from side to side
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November 15, 2011 (Tuesday) Fourth Nurse-Patient Interaction Vital Signs: BP: 120/80 mmHg PR: 72bpm RR: 18cpm Temperature: 36 C/ axilla
General appearance: Patient was seen in a semi-fowlers position conscious and coherent wearing hospital gown with brown shorts. No episodes of chest pain noted. A) Integumentary SKIN: His skin is brown in complexion and has good skin turgor. Dry skin was noted on the lower extremities. NAILS: Short and clean fingernails noted and slighlty pale. Texture of the nails is smooth and its shape is convex. Capillary refill time of less than 3 seconds HAIR: Evenly distributed and black in color. B) Head SCALP: No presence of lesion, dandruff and pediculosis. Texture of his scalp is smooth and white in color. There are no palpable scars, wounds or depression/ protrusion. SKULL: The shape of the skull is round and normocephallic and has a smooth skull contour. There are no depression and protrusion. EYES: His eyes can accommodate light when the light was introduces, (+) normal light reflex. Eyes are also symmetrical and no abnormal protrusion. EYEBROWS: Hair is evenly distributed, symmetrically aligned and has equal movement. EYELASHES: Equally distributed and curled slightly outward. EYELIDS: Eyelids close symmetrically, with intact skin and no discharge and discoloration noted.
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BULBAR CONJUNCTIVA: Transparent, capillaries sometimes evident, sclera appears white and no lesions or nodules note. PALPEBRAL CONJUNCTIVA: Shiny and pink in color. LACRIMAL SAC AND NASOLACRIMAL DUCT: No edema and tearing noted. CORNEA: transparent, shiny and smooth details of iris are visible. C) Ears INTERNAL: No presence of cerumen was observed upon inspection.
E) Mouth and Throat LIPS: pink in color, moist and symmetrical. BUCCAL MUCOSA: pink in color, smooth, moist and without lesions.
F) Neck Sternocleidomastoid muscle is equal in size and neck is on the center no enlargement of lymph nodes; trachea is centered and at the midline of neck, was able to flex, hyperextend, laterally flex and laterally route the head. Thyroid gland ascends during swallowing and it is not visible, neck veins are not distended.
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G) Thorax and Lungs Spine is vertically aligned and straight, symmetric chest expansion, abnormal breath sounds (rales) noted and no tenderness or masses noted. HEART: no irregular rhythm noted, murmurs were noted upon
auscultation. H) Gastrointestinal ABDOMEN: Uniform in skin color, no presence of rashes or lesions noted scaphoid (concave in shape), audible bowel sounds and no tenderness noted in the four quadrants. I) Musculoskeletal EXTREMITIES: Hair is evenly distributed on both upper and lower extremities. With a muscle strength of grade 4 as evidenced by a reduced muscle strength but still with muscle contraction and can still move joints against resistance. BACK AND SPINE: Stands erect without postural abnormalities with good spine alignment. J) MENTAL STATE Mr. Cardio Nstemi was Conscious and coherent with appropriate affect. Can identify person, date, time and can recall information from the past by recalling previous health history.
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CRANIAL NERVE ASSESSMENT CRANIAL NERVE CRANIAL Olfactory NERVE TYPE AND PUNCTION I: Sensory Smell ASSESSMENT PROCEDURE The Student Nurse asked the client to close both eyes and asked to identify aromas such as perfume and soap. The Student Nurse asked the patient to read some printed words from a handout and identify some colors. The client was asked to look straight. Then with use of a penlight, light was passed on the right eye and was also done on the left eye. The client was asked to follow the direction of the penlight in an upward and downward movement without moving her head. NORMAL FINDINGS Client will be able to identify the different odors present with eyes closed. ACTUAL RESULTS He was able to identify different aromas that the Student Nurse prepared which were perfume and soap. He was able to read some words from the handout and was able to identify the colors blue green and orange. The dilated pupil gradually constricted upon the introduction of light with the use of a penlight and was able to open and close eyelids. He was able to move his eyes upward and downward by following the direction of motion of the penlight without moving his head. He responded
Page | 38
Sensory Vision
CRANIAL Trochlear
NERVE
IV: Motor Extra-ocular movement of eyes in downward & inward movement
CRANIAL
NERVE
V: Motor
and Student
Nurse Client will be able
Trigeminal
CRANIAL Abducens
NERVE
made use of a clean wisp and gently stroked clients eyelashes to elicit corneal reflex. Also, the Student Nurse asked the client to close his eyes to determine if the object is sharp or dull. The Student Nurse also asked her to move her jaw side to side and chew. VI: Motor Student Nurse Extra-ocular asked the movement of patient to follow eyes in a the direction of lateral penlight in a movement lateral movement. Motor and Sensory Movement of facial muscles and sense of taste on the anterior portion of the tongue Student Nurse asked the client to raise her eyebrows, smile, frown, show teeth and puff out his cheeks and to identify various taste on the tips of the tongue like sweet and salty.
Sensory Sensation of Cornea, skin of face & jaw movement
to elicit corneal reflex and identify the sensation of dull or sharp object. The client must be able to close and open, move side to side his jaw and make some mastication.
to the cotton wisp by blinking his eyes, was able to identify the difference between sharp and dull objects, was able to move his jaw from side to side and can chew.
CRANIAL NERVE VIII: Sensory Student Nurse The client will be Vestibulocochlear/acoustic Hearing and placed a watch able to hear the equilibrium with a second- watch tick hand near the
He was able to follow the direction of the penlight in a lateral movement without moving his head. He was able to follow the directions given by the Student Nurse; he was able raise his eyebrows, smile, frown, show teeth, puff out her cheeks and identified the taste of juice and salty. He was able to hear the ticking watch.
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ears of the client and asked him if he could hear the tick. CRANIAL NERVE IX: Motor and Student Nurse Glassopharyngeal Sensory asked the client Swallowing to say ahh and and gag yawn; pressed reflex, the posterior pharyngeal tongue with movement tongue and sense of depressor. taste on the particular portion of the tongue. CRANIAL NERVE X: Vagus Motor and Student Nurse Sensory asked the client Swallowing to swallow and and speaking asked a question
The client will be able to say ahh and yawn, elicit gag reflex.
He was able to say ahh and yawn; the palate rose symmetrically with the uvula and in the midline and elicit gag reflex.
CRANIAL Accessory
NERVE
XI: Motor Student Nurse Movement of asked the client shoulder to move head muscles from side to side and asked to elevate her shoulders against the resistance introduced by the Student Nurse. XII: Motor Student Nurse Movements asked the client and strength to move tongue of tongue from side to side and in and out.
He has no difficulty in swallowing and thyroid glands moved upward during swallowing; there was no hoarseness of voice noted. He was able to move head from side to side and was able to elevate shoulders against resistance of the hands of the Student Nurse. He was able to move the tongue from side to side and in and out.
The client will be able to protrude tongue and move it from side to side
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Diagnostic and Laboratory Procedures
Diagnostic/ Laboratory Procedures Hgb (Hemoglobin) - A complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs.
Date ordered and date result(s) in
Indication(s) or purpose
Results
Normal Values
Analysis and interpretation of results The result is below the normal range which indicates that there is inadequate oxygen being carried by the cells. Based on the patient pathophysiology of the disease, there is alteration of supply and demand of oxygen as evidenced by
Page | 41
Date ordered:
Hemoglobin
130mg/L
M: 140-180mg/L F: 120-160mg/L
November 6, 2011 measures the 1:10am amount of oxygen carrying protein in Date results in: the blood. It is
November 6, 2011 comprised of an iron containing pigment (heme) and a protein (globulin). This is done to evaluate blood loss, anemia and response to therapy and erythropoietic
activity.
compression of the heart that interfere its pumping of blood and the patient manifested irritability which aggravate the need for oxygen to meet the demand of organs. The patient was also observed to have pale skin, pale lips and pale fingernails and toenails which are all indications of ineffective tissue perfusion.
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Hct (Hematocrit) A measure of the packed cell volume of red cells, expressed as a percentage of the total blood volume.
The hematocrit determines the percentage of red blood cells in the plasma. This indicates anemia, blood loss, and blood replacement therapy and fluid balance. It also screens red blood cell status. It is useful in evaluating dehydration and hypervolemia. Lowered hematocrit could indicate hemorrhage.
0.39L/L
M: 0.40-0.54L/L F: 0.37-0.47L/L
The result is Below the normal range which signifies that the percentage of red blood cells in the patients blood is insufficient causing lack of normal oxygen carrying capacity of the blood.
RBC (Red Blood
An RBC count is a 4.55x1012L
M: 4.5-6.3x1012L
The result is
Page | 43
Cells) A cell that contains hemoglobin and can carry oxygen to the body.
blood test that tells how many red blood cells (RBCs) you have. RBCs contain hemoglobin, which carries oxygen. How much oxygen your body tissues get depends on how many RBCs you have and how well they work. The test can help diagnose anemia and other conditions affecting red blood cells. 8.5 x109L
F: 4.2-5.4x1012L
within normal range which indicates the presence of adequate number of circulating RBCs in the blood.
WBC (White
WBC count is a
5-10x109L
The result is
Page | 44
Blood Cells) A white blood cell, one of the formed elements of the circulating blood system.
blood test to measure the number of white blood cells which are being innervated when there is an impending infection within the body. This is done to determine the capability of the body to destroy cells that are infected with the virus or other infectious organisms.
within the normal range which signifies that there is no presence of invading microorganisms in the body which causes inflammation and infection.
Lymphocytes A small agranulocytic
It determines the bodys ability to defend itself
0.31
0.20-0.35
The result is within the normal range which

Page | 45
lymphocytes originating from fetal stem cells and developing in the bone marrow.
against diseases.
means these are not yet released on the onset of infection. But there is also indication that the bacterium within the patients lungs begins to multiply, and other WBC differential starts to react because of occurring infection.
Segmenters A type of white blood cell, specifically a form of granulocyte, filled with
It is done to determine the presence of bacterial infection
0.69
0.50-0.70
The results are within the upper limit boundary which indicates that the client has infection that is
Page | 46
neutrally-staining granules, tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis
bacterial in nature. And this may indicate the Segmenters reacted of the bacteria that invade the patients body and thus begin to multiply.
Hgb (Hemoglobin) - A complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon dioxide away from
Date ordered:
Hemoglobin
The result is below the normal range which 120mg/L M: 140-180mg/L F: 120-160mg/L indicates that there is inadequate oxygen being carried by the cells. Based on the patient
Page | 47
November 6, 2011 measures the 5:10am amount of oxygen carrying protein in Date results in: the blood. It is
November 6, 2011 comprised of an iron containing pigment (heme) and a protein (globulin). This is
the cells to the lungs.
done to evaluate blood loss, anemia and response to therapy and erythropoietic activity.
pathophysiology of the disease, there is alteration of supply and demand of oxygen as evidenced by compression of the heart that interfere its pumping of blood and the patient manifested anxiety and irritability which aggravate the need for oxygen to meet the demand of organs.
Hct (Hematocrit) A measure of the
The hematocrit determines the
0.36L/L
M: 0.40-0.54L/L F: 0.37-0.47L/L
The result is Below the

Page | 48
packed cell volume of red cells, expressed as a percentage of the total blood volume.
percentage of red blood cells in the plasma. This indicates anemia, blood loss, and blood replacement therapy and fluid balance. It also screens red blood cell status. It is useful in evaluating dehydration and hypervolemia. Lowered hematocrit could indicate hemorrhage An RBC count is a 4.20 x1012L blood test that tells how many M: 4.5-6.3x1012L F: 4.2-5.4x1012L
normal range which signifies that the percentage of red blood cells in the patients blood is insufficient causing lack of normal oxygen carrying capacity of the blood.
RBC (Red Blood Cells) A cell that
The result is Below the normal range

Page | 49
contains hemoglobin and can carry oxygen to the body.
red blood cells (RBCs) you have. RBCs contain hemoglobin, which carries oxygen. How much oxygen your body tissues get depends on how many RBCs you have and how well they work. The test can help diagnose anemia and other conditions affecting red blood cells.
which indicates the presence of inadequate number of circulating RBCs in the blood.
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WBC (White Blood Cells) A white blood cell, one of the formed elements of the circulating blood system.
WBC count is a blood test to measure the number of white blood cells which are being innervated when there is an impending infection within the body. This is done to determine the capability of the body to destroy cells that are infected with the virus or other infectious organisms.
6.0x109L
5-10x109L
The result is within the normal range which signifies that there is no presence of invading microorganisms in the body which causes inflammation and infection.
Complete Blood Count (CBC) A determination of number of red and white blood cells per cubic millimetres of blood. A CBC is one of the most routinely performed tests in a clinical laboratory and one of the most valuable screening and diagnostic techniques.
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Lymphocytes A small agranulocytic lymphocytes originating from fetal stem cells and developing in the bone marrow.
It determines the bodys ability to defend itself against diseases.
0.28
0.20-0.35
The result is within the normal range which means these are not yet aggravate released on the onset of infection. But there is also indication that the bacterium within the patients lungs begins to multiply, and other WBC differential starts to react because of occurring infection.
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Segmenters A type of white blood cell, specifically a form of granulocyte, filled with neutrally-staining granules, tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis
It is done to determine the presence of bacterial infection
0.72
0.50-0.70
The results are above the normal rage which indicates that the client has infection that is bacterial in nature. And this may indicate the Antibiotic drugs prescribed reacted of the bacteria that invade the patients body and thus begin to multiply thus helping the WBC differential to fight against the microorganism.
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NURSING INTERVENTIONS BEFORE: Check the doctors order Check the clients name or identification band Explain the purpose and procedure of Complete Blood Count Test Notify the pt. that she may feel a bit of pain while puncturing Gather all supplies and equipment and bring to the patient's bedside. Assist the patient to a comfortable position. If the patient is uncooperative or disoriented, get someone to help you. NURSING INTERVENTIONS DURING: Provide comfort Do not leave the pt. while the procedure is ongoing Ensure sub dermal bleeding has stopped before removing pressure NURSING INTERVENTIONS AFTER: Handle the blood sample carefully If hematoma develops on the puncture site, apply warm soaks.
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Diagnostic/ Laboratory Procedures URINALYSIS
Date ordered and date result(s) in Date ordered: November 6, 2011
Results
Normal Values
Analysis and interpretation of results
Urinalysis can disclose evidence of diseases, even some that have not caused
Date results in: November 6, 2011
significant signs or symptoms. Therefore, a urinalysis is commonly a part of routine health screening. Normal urine is straw yellow to amber in color. Abnormal pigments may result from Color: Light yellow Pale yellow to amber The urine is within the normal range of color which suggest no blood present or increased albumin
Page | 55
medications, dietary sources, or diseases. Turbid (cloudy) urine may be caused by either normal or abnormal processes. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. Any urinalysis values outside of that range can indicate a problem with acidity or alkalinity. pH: 6.0 4.5-8.0 Transparency : Clear Clear
or urobilinogen level in the patients urine . The transparency of the urine is clear this indicates that there are no presence of blood cells, yeast, and bacteria.
The pH level is within normal range. There is no problem with acidity or alkalinity.
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The specific
Specific Gravity:
1.015-1.025
The specific gravity is below the normal range. This could indicate that the urine is diluted. This also indicated as an abnormal concentrating and excretory power of the kidney. This may also suggest that the patient is not normally hydrated. This may happen in a patient having heart disease, because the kidneys are one of
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gravity of urine is a 1.005 measure of the concentration of dissolved solutes (substances in a solution), and it reflects the ability of the kidneys to concentrate the urine (conserve water).
the most sensitive organs when it comes to tissue perfusion. Decrease oxygen supply to the kidneys could lead to affectation in the normal physiology of the kidneys. Albumin is important in determining the presence of glomerular damage. Albuminuria occurs when the glomerular membrane is
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Albumin : Negative
Negative
There are no traces of Albumin. This indicates that there is no presence of glomerular damage.
damaged, a condition called glomerulonephritis. NURSING INTERVENTIONS BEFORE: Check the doctors order. Explain to the SO the procedure and purpose of urinalysis. Provide clean specimen cup. Explain to the SO to obtain midstream urine. Advise the patient to wash perineal area prior to collecting the specimen to avoid contamination with vaginal secretions. Inform them that there is no fluid and food restriction needed. Refrigerate the specimen if analysis will be delayed longer than 1 hour. NURSING INTERVENTIONS DURING: Collect the urine in a clean specimen cup. Label the specimen cup properly. NURSING INTERVENTIONS DURING: The specimen should be delivered to the laboratory within 1 hour. Obtain results and secure it to the chart. Document the procedure. Refer the results to the physician.
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Diagnosti c/ Laborator y Procedur es Troponin I
Date Indication(s) or purpose ordered and date result(s) in
Results Analysis and interpretation of results
Normal Values
Date ordered: 11-08-11
Date results in: 11-08-11
Troponin I is used to diagnosed 1.73mcg/L elevation in the cardiac markers would signify and possibly confirm presence of MI since there is no expected elevation of cardiac markers in Angina.
0-0.05mcg/L
The result is above normal range which may possibly confirms that there is myocardial iinfarction.
NURSING INTERVENTIONS BEFORE: Check the doctors order Confirms the patient identity Explain to the patient that the troponin test helps assess myocardial injury and that multiple samples may be drawn to detect fluctuations Explain to the patient that the test requires multiple blood samples NURSING INTERVENTIONS DURING: Perform venipuncture and collect the sample in a 7 ml clot activator tube Note for the date and collection on each sample NURSING INTERVENTIONS AFTER: Apply direct pressure to the venipuncture site
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Diagnosti c/ Laborator y Procedur es CKMB
Results Analysis and interpretation of results
Normal Values
9.1 Date ordered: 11-08-11 CK-MB is ordered because the patient experiences chest pain. This is to determine whether the pain is due to a heart attack. It also ordered to determine whether the patient has damage to his heart or other muscles.
0-4.3 The patients CKMB level is above the normal CKMB ratio. This will help in determining whether the chest pain felt by the client is really due to a heart attack. CK-MB is marker specific for the heart, it distinguishes the chest pain and is specific to the heart. Therefore, the increase in this cardiac marker, connotes that the presence of chest pain is due to an infarct to the heart.
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Myoglobin Date ordered: 11-08-11
As a non-specific test to 506ng/L estimate damage to skeletal or cardiac muscle tissue. Myoglobin release into the blood streams is especially important when trying to determine cardiac muscle was damaged. Therefore, myoglobin which can be detected as soon as 2 hours after the onset of chest pain and peaks in 4 hours can be useful as an early indicator of M.I.
0-107 ng/L
The result is above normal range. Significant increase in the myoglobin count is a indicator of presence of cardiac muscle damage which is expected in patients suffering from MI. Since this protein is being released when there is cardiac muscle damage, an increase in its value which is significantly high during the first hours of MI helps in the early detection of presence of cardiac infarct.
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D dimer
BNP
Date results in: 11-08-11 Date ordered: 11-08-11
D-dimer tests are ordered, along with other laboratory tests and imaging scans, to help rule out the presence of a thrombus.
163
0-400
A brain natriuretic peptide (BNP) test measures the amount of the BNP hormone in your blood. BNP is made by your heart and shows how well your heart is working. This was indicated to client because there is a suspected infarct or necrosis of some of the tissues of the heart brought about by lack of oxygenated blood delivered to the blood vessels of the heart in order for it to maintain its proper function. Increase BNP would indicate extra workload to the heart which could mean that it is trying to compensate for any lack or inadequate blood circulation.
2160
0-100
The results of the D dimer of the patient is within the normal range. This is an indication there is no thrombus formation. Since the BNP result is way too high the normal expected range. This is an indication that the heart experienced extra workload which could indicate compensatory mechanism which can be due to lack or insufficient oxygenated blood going to the heart in order for it to continue doing its function properly.
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Creatinine
This was indicated for the patient to detect kidney function of the patient.
166.56 umol/L
70-130 umo/L
Potassium
Date ordered: 11-06-11 11-08-11
Date results in: 11-06-11 11-08-11
It was indicated for the patient because smaller quantity of Potassium can also be found outside the cells, which is crucial on the activity of the muscles specifically the heart muscles. Small variations of Potassium levels in the body can signals change in the Electrocardiogram (ECG). ECG is a test that records the electrical activity of the heart.
3 g/L
3.5 5.2 g/L
The result is above normal range which possibly confirms that there is already kidney affectation which is brought about by cardiac problems, because affectation in the kidney function such as proper excretion of waste products in the urine is one of the earliest sign of poor tissue perfusion. The result was below normal range which may possibly confirms that there is affectation in the activity of the heart muscles.
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4.2 g/L
The result was within normal range and possibly confirms that there is a good amount of potassium in the patients body and the heart muscle can function well.
NURSING INTERVENTIONS BEFORE:
Confirms the patients identity Explain the purpose of the test to the patient Advise the patient that the test requires blood sample NURSING INTERVENTIONS DURING: Perform venipuncture and collect 4 ml tube with no additives Apply direct pressure to the site NURSING INTERVENTIONS AFTER: If hematoma develops apply direct pressure to the venipuncture site Send the sample to the laboratory
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Diagnos tic/ Laborat ory Procedu res
Date
Indication(s) or
Results Analysis and interpretation Normal Values of results
ordered and purpose date result(s) in
ECG
Date ordered: Nov.8, 2011
The 12 lead ECG can Complete Right be used to determine bundle branch the location of infarct block with lateral and the extent of the wall ischemia. V5damage. It is also use V6 presents T normal sinus rhythm each P wave is followed by a QRS P waves normal for the subject P wave rate 60 - 100 bpm with <10% variation rate <60 = sinus bradycardia rate >100 = sinus
The results of the patients
ECG shows a COMPLETE BLOCK IN THE RIGHT BUNDLE, it is reasonable to
Date results in: Nov.8, 2011
to
help
in
the wave inversion.
identification of possible No ST segment myocardial ischemia. In elevation the case of the patient, an ECG is important to be able to identify the kind of ACS that is present. The patient
say that there is an of interruption the
stimulation of by the right bundle for the ventricles

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was presented to have
chest pain unrelieved by medications of and ECG the
tachycardia variation >10% = sinus arrhythmia normal QRS axis normal P waves height < 2.5 mm in lead II width < 0.11 s in lead II for abnormal P waves see right atrial hypertrophy, left atrial hypertrophy, atrial premature beat, hyperkalaemia normal PR interval 0.12 to 0.20 s (3 - 5 small
to properly.
function This
performance would
impairment could lead to of
strengthen
diagnosis of the patient. It would also give the health care providers an idea of the specific
interruption
that blood flow leaves and goes back to the
disease condition of the client as for them to be able provide care
heart. Ischemia and necrosis of the heart muscle can occur
accordingly.
because of this. These conditions reflected are In
altered Q wave, T wave on the 12 and lead even ECG ST
elevation but in
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squares) for short PR segment consider Wolff-ParkinsonWhite syndrome or LownGanong-Levine syndrome (other causes Duchenne muscular dystrophy, type II glycogen storage disease (Pompe's), HOCM) for long PR interval see first degree heart block and 'trifasicular' block normal QRS complex < 0.12 s duration (3 small squares) for abnormally wide QRS
the case of the patient is not This
observed.
can also mean that as far as severity patients condition is less severe because of the absence of ST elevation. is
concerned. The
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consider right or left bundl e branch block, ventricular rhythm, hyperkalaemia, etc. no pathological Q waves no evidence of left or right ventricular hypertrophy normal QT interval Calculate the corrected QT interval (QTc) by dividing the QT interval by the square root of the preceeding R - R interval. Normal = 0.42 s. Causes of long QT interval myocardial infarction,
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myocarditis, diffuse myocardial disease hypocalcaemia, hypothyrodism subarachnoid haemorrhage, intracerebralhaemorrhage drugs (e.g. sotalol, amiodarone) hereditary Romano Ward syndrome (autosomal dominant) Jervill + Lange Nielson syndrome (autosomal recessive) associated with sensorineuressormal ST
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segment no elevation or depression causes of elevation include acute MI (e.g. anterior, inferior), left bundle branch block, normal variants (e.g. athletic heart, Edeiken pattern, high-take off), acute pericarditis causes of depression include myocardial ischaemia, digoxin effect, ventricular hypertrophy, acute posterior MI, pulmonary embolus, left bundle branch block
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normal T wave causes of tall T waves include hyperkalaemia, hy peracute myocardial infarction and left bundle branch block causes of small, flattened or inverted T waves are numerous and include ischaemia, age, race, hyperventilation, anxiety, drinking iced water, LVH, drugs (e.g. digoxin), pericarditis, PE, intraventricular conduction delay (e.g. RBBB)and electrolyte disturbance. normal U wave
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Nursing Responsibilities: Before: Check the doctors order Prepare all the materials Explain the procedure and its purpose to the client that ECG evaluates the heart electrical activity Provide privacy Advise the patient that he doesnt need to restrict food and fluids for the test except for coffee or smoking prior to the test Make sure that the patient does not come in contact with any metal because this may interfere in the results of the ECG During: Place the client in supine position if he cannot tolerate lying flat help him assumes semi fowlers position Have the patient expose the chest, both ankles and both wrist for electrical placement If patient is a woman, provide chest drape until the chest lead are applied Proper placement of the leads are very much important in this test After: Disconnect the equipment, remove the electrodes and wipe the gel from the patient Label each ECG strip with the patient name and room number, date and time of the procedure
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Diagnosti c/ Laborator y Procedur es
Results Analysis and interpretation of Normal Values results
2D Echo
Date ordered: Nov.8, 2011
An echocardiogram is used to Dilated provide pictures of the hearts ventricle valves and chambers, evaluate normal the pumping action of the heart thickness and to evaluate blood flow generalized across the hearts valves.
left with wall and No abnormal timing of various cardiac events specifically the filling and to emptying of chambers with The results of the 2d Echo would show dilation of some chambers of the heart and thickening in some parts where reflected, therefore explaining the reason for the damage that is being experienced by the patients
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Date results in: Nov.8, 2011
severe hypokinesia akinesia consistent dilated cardiomyopathy with global function. decreased systemic An
ischemic etiology cant be totally
heart.
excited. Dilated Left Atrium Atheroscle rotic aortic root normal dimension s Aortic sclerosis with aortic regurgitatio n but no restrictions of motion mild with
of the csps noted

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Mitral sclerosis with aortic regugitatio ns and low flow configurati on consistent with increased diastolic pulling pressure mild
Thickened tricuspid valve with mild tricuspid regurgitatio

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n but no restrictions of and prolapse noted Structurally normal pulmonic valve with pulmonic regurgitatio n Normal rigfht ventricular dimension with normal contractility Normal
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motion no
right atrium and main
pulmonary dimension Mild pulmonary hypertensi on with
systolic pulmonary artery pressure of 49 mmHG by peak
tricuspid regurgitatio n gradient Minimal posterior pericardial effusion

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No thrombus noted
The part of the findings are unremarkable
NURSING RESPONSIBILITIES BEFORE Check the doctors order. Explain the procedure to the patient Assure the patient that it would be painless Complete the request for 2d echo, including pertinent patient history. Explain the procedure to the client.
NURSING RESPONSIBILITIES DURING Note that this procedure usually takes approximately 45 minutes and is performed by an ultrasound technician in a darkened room within the cardiac laboratory or radiology department. Position the client in supine. Tell the patient that there would be no discomfort associated with the study but the gel transmission could be little cold than the body temperature.
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NURSING RESPONSIBILITIES BEFORE
Remove the gel from patients chest wall. Refer the results to the physician.
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Diagnosti c/ Laborator y Procedur es
Results Analysis and interpretation of Normal Values results
Chest
Date
Chest X-ray
Consolidation in
is the STANDARD LATERAL CHEST RADIOGRAPH left side of the chest against filmholder (cassette); beam from right at a distance of six feet; lesion located behind the left side of the heart or
Pneumonia,
right
X- ray ordered: APL view Nov.8, 2011
- Due to the differences in their seen composition (and, therefore, middle
middle and upper lobes, pleural minimal effusion,
lobe.
varying degrees of penetration Increased density of the X-ray beam), the lungs, is likewise seen Date results in: Nov.8, 2011 heart, aorta, and bones of the at the right upper chest each can be distinctly paramediastinal visualized on the chest X-ray. area. The rest of The X-ray film records these the differences to produce an clear. lungs There are is
hazy opacities and atherosclerotic aorta.
image of body tissue structures pleural-
based
and these are shadows seen density at the left on the X-ray. lower and
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posterior hemithorax. Pulmonary vessels normal.
in the base of the lung are often invisible on the PA are view because the heart or
Mediastinum and diaphragm diaphragm unremarkable. The are shadow hides it; the left lateral will
visualized generally show
bone are intact. such lesions; the The soft tissues left lateral is thus do not appear the customary lateral view as it is the best view to visualize lesions in the left thorax. Also, the heart is less magnified when it is closer to the film.
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unusual.
Good for viewing area behind heart (retrosternal airspace between the heart and sternum). Marked with a "R" or "L" according to whether the right or the left side of the patient was against the film left lateral or right lateral.
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Nursing Responsibilities: Before: Explain the procedure to the patient. Tell the patient that no fasting is required. Instruct the patient to remove clothing to the waist and put on an x-ray gown. Instruct the patient to remove all metal objects so that they do not block visualization of part of the chest. Tell the patient that he or she will be asked to take a deep breath and hold it while the x-ray films are taken. During: After the patient is correctly positioned, tell him or her to take a deep breath and hold it until the x-ray films are taken. Note that x-ray films are taken by a radiologic technologist in several minutes. Inform the patient that no discomfort is associated with the procedure. After: Note that no special care is required following the procedure.
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III- Anatomy and Physiology A. Functions, Size, form and location of the heart The heart weighs between 7 and 15 ounces (200 to 425 grams) and is a little larger than the size of your fist. By the end of a long life, a person's heart may have beat (expanded and contracted) more than 3.5 billion times. In fact, each day, the average heart beats 100,000 times, pumping about 2,000 gallons (7,571 liters) of blood (Marek, 2010).
Figure 1: The Heart, its size and form Your heart is located between your lungs in the middle of your chest, behind and slightly to the left of your breastbone (sternum). A double-layered membrane called the pericardium surrounds your heart like a sac. The outer layer of the pericardium surrounds the roots of your heart's major blood vessels and is attached by ligaments to your spinal column, diaphragm, and other parts of your body. The inner layer of the pericardium is attached to the heart muscle. A coating of fluid separates the two layers of membrane, letting the heart move as it beats, yet still be attached to your body(Marek, 2010).
Your heart has 4 chambers. The upper chambers are called the left and right atria, and the lower chambers are called the left and right ventricles. A wall of muscle
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called the septum separates the left and right atria and the left and right ventricles. The left ventricle is the largest and strongest chamber in your heart. The left ventricle's chamber walls are only about a half-inch thick, but they have enough force to push blood through the aortic valve and into your body (Marek, 2010).
Anatomy of the heart The heart is surrounded by the pericardial cavity. The pericardial cavity is formed by the pericardium, or pericardial sac, which surrounds the heart and anchors it within the mediastinum. The pericardial cavity, located between the visceral and parietal pericardia, is filled with a thin layer of pericardial fluid produced by the serous pericardium. The pericardial fluid helps to reduce friction as the heart moves within the pericardial sac ( Seeley et. al, 2007).
Figure 2: The anatomy of the heart The right and left atria are located t the base of the heart, and the right and left ventricles extend from the base of the heart toward the apex. A coronary sulcus extends around the heart, separating the atria from the ventricles ( Siddhart et. al, 2007).
Six large veins carry blood to the heart: the superior vena cava and the inferior vena cava carry blood from the body to the right atrium, and four pulmonary veins carry
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blood from the lungs to the left atrium. Two arteries, the pulmonary trunk and the aorta, exit the heart. The pulmonary trunk, arising from the right ventricle, splits into the right and left pulmonary arteries, which carry blood to the lungs. The aorta, arising from the left ventricle, carries blood to the rest of the body ( Siddhart et. al, 2007). The atria of the heart receive blood from the veins. The atria function primarily as reservoirs, where blood returning from veins collects before it enters the ventricles. The superior vena cava and the inferior vena cava drain blood from most of the body, and the smaller coronary sinus drains blood from most of the heart muscle ( Seeley et. al, 2007). The ventricles of the heart are its major pumping chambers. They eject blood into the arteries and force it to flow through the circulatory system. The atria open into the ventricles, and each ventricle has one large outflow route located superiorly near the midline of the heart. The right ventricle pumps blood into the pulmonary trunk, and the left ventricle pumps blood into the aorta. The two ventricles are separated from each other by the muscular interventricular septum ( Gayson, 2008). The wall of the ventricle is thicker than the wall of the right ventricle and the wall of the ventricle contracts more forcefully and generates a greater blood pressure than the wall of the right ventricle. However, the left and the right ventricles pump nearly the same volume of blood ( Seeley et. al, 2007). The atrioveticular valves are located between the right atrium and the right ventricle and between the left atrium and left ventricle. Each ventricle contains cone shaped muscular pillars called papillary muscles. When the ventricles contract, the papillary muscle contract and prevent the valves from opening into the atria by pulling on the chordate tendineae attached to the valve cusps. Blood flows back from the aorta or pulmonary trunk toward the ventricles, and enters the pockets of the cusp, causing them to bulge toward and meet in the center of the aorta or pulmonary trunk, thus closing the vessels and blocking blood flow back into the ventricles (Gayson et. al, 2008).
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A plate of fibrous connective tissue, sometimes called the cardiac skeleton, consisting mainly of fibrous rings around the atrioventricular and semilunar valves, provides a solid support for the valves. This connective tissue plate also serves as electrical insulation between the atria and the ventricles and provides a rigid site of attachment for cardiac muscle ( Seeley et. al, 2007). Route of blood flow through the heart The left and the right sides of the heart can be considered separate pump. Blood flows from the systemic vessels to the right atrium and from the right atrium to the right ventricle. From the right ventricle blood flows to the pulmonary trunk and from the pulmonary trunk to the lungs. From the lungs blood flows through the pulmonary veins to the left atrium, and from the left atrium blood flows to the left ventricle. From the left ventricle blood flows into the aorta and then through the systemic vessels ( Guyson, 2008).
Figure 3: The route of blood flow through the heart Blood supply to the heart
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The coronary arteries originate from the base of the aorta, just above the aortic semilunar valves. The left coronary artery originates on the left side of the aorta. It has three major branches: the anterior interventricular artery lies in the anterior interventricular sulcus, the circumflex artery extends around the coronary sulcus on the left to the posterior surface of the heart, and the left marginal artery extends inferiorly along the lateral wall of the left ventricle from the circumflex artery. The branches of the left coronary artery supply much of the anterior wall of the heart and most of the left ventricle. The right coronary artery originates on the right side of the aorta. It extends around the coronary sulcus on the right to the posterior surface of the heart and gives rise to the posterior interventricular artery, which lies in the posterior interventricular sulcus. ( Seeley et. al, 2007).
Figure 4: the different blood supply in the heart The cardiac veins drain blood from the cardiac muscle. Their pathways are nearly parallel to the coronary arteries and most drain blood into the coronary sinus, a large vein located within the coronary sulcus on the posterior aspect of the heart. Blood flows from the coronary sinus into the right atrium. Some small cardiac veins drain directly into the right atrium ( Seeley et. al, 2007). Histology of the heart
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Four types of valves regulate blood flow through your heart: The tricuspid valve regulates blood flow between the right atrium and right ventricle. The pulmonary valve controls blood flow from the right ventricle into the pulmonary arteries, which carry blood to your lungs to pick up oxygen. The mitral valve lets oxygen-rich blood from your lungs pass from the left atrium into the left ventricle. The aortic valve opens the way for oxygen-rich blood to pass from the left ventricle into the aorta, your body's largest artery, where it is delivered to the rest of your body.
Figure 5: Histology of the heart
The chambers of the heart alternately contract and relax in a rhythmic cycle. During the period of contraction (systole), the heart pumps blood out through the arteries; during the period of relaxation (diastole), the heart fills with blood. One complete sequence of filling and pumping blood is called a cardiac cycle, or heartbeat(Marek, 2010).
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The heart's rhythm of contraction is controlled by the sinoatrial node (SA node), often called the pacemaker. This node is part of the heart's intrinsic conduction system, which is made up of specialized myocardial cells called nodal cells. The heart will beat without input from the nervous system and will continue to beat, even outside the body, as long as its cells are alive. The automatic nature of the heartbeat is referred to as automaticity. Automaticity is due to the spontaneous electrical activity of the SA node. Electrical impulses generated from the SA node spread through the heart via a nodal tissue pathway that coordinates the events of the cardiac cycle(Marek, 2010).
The activity of the conduction system, muscles, and valves of the heart are synchronized so that the heart can operate as a pump. The conduction system initiates and coordinates the muscular activity of the heart. Pressure differentials that result from muscle activity actuate the opening and closing of valves. The opening and closing of valves directs the flow of blood through the heart(Marek, 2010).
Electrical impulses from your heart muscle (the myocardium) cause your heart to contract. This electrical signal begins in the sinoatrial (SA) node, located at the top of the right atrium. The SA node is sometimes called the heart's "natural pacemaker." An electrical impulse from this natural pacemaker travels through the muscle fibers of the atria and ventricles, causing them to contract. Although the SA node sends electrical impulses at a certain rate, your heart rate may still change depending on physical demands, stress, or hormonal factors (Marek, 2010). The heart wall is composed of the three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium is a thin serous membrane forming the smooth outer surface of the heart. The thick middle layer of the heart is the myocardium and is composed of cardiac muscle cells and is responsible for contractions of the heart chambers. The endocardium is the inner surface of the heart chambers. The endocardium allows blood to move easily through the heart. The heart
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valves are formed by folds of endocardium that include a thick layer of connective tissue ( Black, 2008). Cardiac muscles are elongated, branching cells that contain one, or occasionally two, centrally located nuclei. The cardiac muscle cells contain actin and myosin myofilaments organized to form sarcomeres, which are joined end to end to form myofibrils. The actin and myosin myofilaments are responsible for muscle
contraction, and their organization gives cardiac muscle a striated appearance much like that of skeletal muscle. In cardiac muscle, each action potential consists of depolarization phase, followed by a rapid, but partial early repolarization phase. This is followed by a longer period of slow repolarization, called a plateau phase. At the end of plateau phase, a more rapid final repolarization phase takes place. During the final repolarization phase, the membrane potential achieves its maximum degree of repolarization ( Black, 2008). Action potentials in cardiac muscle exhibit a refractory period. The refractory period lasts about the same length of time as the prolonged action potential in cardiac muscle. The prolonged action potential and refractory period allow cardiac muscle to contract and almost complete relaxation to take place before another action potential can be produced. Also, the long refractory period in cardiac muscle prevents titanic contractions from occurring, thus ensuring a rhythm of contraction and relaxation for cardiac muscle. The sinoatrial node, which functions as a pacemaker of the heart, is located in the superior wall of the right atrium and initiates the contraction of the heart. The SA node is the pacemaker because it produces action potentials at a faster rate than other areas of the heart ( Seeley et. al, 2007). A second area of the heart, the atrioventricular node, is located in the lower portion of the right atrium. When the action potentials reach the AV node, thy spread slowly through it and then into the bundle of specialized cardiac muscle called atrioventricular bundle. The slow rate of action potential conduction in the AV node allows the atria to complete their contraction before action potentials are delivered to the ventricle ( Seeley et. al, 2007).
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The AV bundle then divides into two branches of conducting tissue called the left and right bundle branches. At the tips of the right and left bundle branches, the conducting tissue forms many small bundles of Purkinje fibers. They pass to the apex of the heart and then extend to the cardiac muscle of the ventricle wall ( Seeley et. al, 2007). Electrocardiogram The normal ECG consists of a P wave, a QRS complex, and a T wave. The P wave results from depolarization of the atrial myocardium, and the beginning of the P wave precedes the onset of atrial contraction. The QRS complex results from depolarization of the ventricles, and the beginning of the QRS complex precedes ventricular contraction. The T wave represents repolarization of the ventricles, and the beginning of the T wave precedes ventricular relaxation ( Seeley et. al, 2007).
Figure 6: The normal Electrocardiogram The time between the beginning of the P wave and the beginning of the QRS complex is the PR interval. During the PR interval the atrial contract and begin to relax. At the end of the PQ interval the ventricles begin to depolarize. The QT interval extends from the beginning of the QRS complex to the end of the T wave and represents the
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leght of time required for ventricular depolarization and repolarization ( Seeley et. al, 2007). Cardiac Cycle Cardiac cycle refers to repetitive pumping process that begins with the onset of cardiac muscle contraction and ends with the beginning of the next contraction. Atrial systole refers to contraction of the two atria. Ventricular systole refers to contraction of the two ventricles. Atrial diastole refers to relaxation of the two atria, and ventricular diastole refers to relaxation of the two ventricles ( Seeley et. al, 2007).
Figure 7: The cardiac Cycle In systole, contraction of the ventricles pushes blood toward the atria, causing the AV valves to close as the pressure begins to increase. While in diastole, the pressure in the ventricles decreases below the pressure in the aorta and pulmonary trunk. And the end of ventricular diastole, the atria contract ant then relax. Atrial systole
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forces additional blood to flow into the ventricles to complete their filling ( Seeley et. al, 2007).
Heart sounds The first heart sound can be represented by the syllable lubb, and the second heart sound can be represented by dupp. Abnormal heart sounds called murmurs are usually a result of faulty valves. A murmur caused by an incompetent valve makes a swishing sound immediately after closure of the valve. When the opening of the valve is narrowed, or stenosed, a swishing sound precedes closure of the stenosed valve ( Seeley et. al, 2007).
Figure 8: The different heart sounds Regulation of heart function Cardiac output is the volume of blood pumped by either ventricle of the heart each minute. Cardiac output can be calculated by multiplying the stroke volume times
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the heart rate. Stroke volume is the volume of blood pumped per ventricle each time the heart contracts, and the heart rate is the number of times the heart contracts each minute ( Seeley et. al, 2007).
Figure 9: Regulation of heart function Symphathetic stimulation increases stroke volume and heart rate;
parasympathetic stimulation decreases heart rate. The baroreceptor reflex detects changes in blood pressure and causes a decrease in heart rate and stroke volume in response to a sudden increase in blood pressure or an increase in heart rate and stroke volume in response to a sudden decrease in blood pressure. Alterations in the body fluid levels of carbon dioxide, pH, and ion concentrations, as well as changes in body temperature, influence heart function ( Seeley et. al, 2007). The Physiology of Circulation Closed cardiovascular system
The cardiovascular systems of humans are closed, meaning that the blood never leaves the network of blood vessels. In contrast, oxygen and nutrients diffuse across the blood vessel layers and enters interstitial fluid, which carries oxygen and nutrients to the
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target cells, and carbon dioxide and wastes in the opposite direction. The other component of the circulatory system, the lymphatic system, is not closed(Marek, 2010).
Blood Pressure
The red blood cells transport oxygen and waste products by flowing through the blood vessels. What causes blood to flow through the vessels is blood pressure. Just as water flows through pipes from areas of greater pressure too lesser, so too the blood flows through the body from areas of higher pressure to areas of lower pressure. Blood pressure is measured both as the heart contracts, which is called systole, and as it relaxes, which is called diastole. A systolic blood pressure of 120 millimeters of mercury is considered right in the middle of the range of normal blood pressures, as is a diastolic pressure of eighty. In common terms, this normal measurement would be stated as "120 over 80"(Marek, 2010).
Normal blood pressure is important for proper blood flow to the body's organs and tissues. Each heartbeat forces blood to the rest of the body. The force of the blood on the walls of the arteries is called blood pressure. Blood pressure moves from high pressure near the heart to low pressure away from the heart. Blood pressure depends on many factors, including the amount of blood pumped by the heart. The diameter of the arteries through which blood is pumped is also an important factor. Generally, blood pressure is higher when the heart pumps more blood, and the diameter of an artery are narrow. Systolic pressure is measured when the heart ventricles contract. Diastolic pressure is measured when the heart ventricles relax. Stressful situations can result in a temporary increase in blood pressure. If an individual were to have a consistent blood pressure reading of 140 over 90, he would be evaluated for having high blood pressure. If left untreated, high blood pressure can damage important organs, such as the brain and kidneys as well as lead to a stroke (Marek, 2010).
Effects of aging on the heart

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The normal aging heart can maintain an adequate cardiac output under ordinary circumstances but may have limited ability to respond to situations that caused physical and emotional stress. In an elderly person who is less active the left ventricle may become smaller as a consequence of physical deconditioning. Aging also results from decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, an increased connecting tissue in the SA and AV nodes and bundle branches ( Smeltzer et. al, 2007).
Figure 10: Effects of aging on elders heart These changes lead to decreased myocardial contractility, increased left ventricular ejection time and delayed conduction. Therefore, stressful physical and emotional conditions, especially those that occur suddenly, may have adverse effects on the aged person. The heart cannot respond to such conditions with an adequate rate increase and needs more time to return a normal resting rate after even a minimal increase heart rate. In some patients, the added stress may precipitate heart failure( Smeltzer et. al, 2007). B. STRUCTURE OF THE RESPIRATORY SYSTEM
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Figure 11: The respiratory system and its structure The respiratory system is composed of the upper and lower tracts. Together, the two tracts are responsible for ventilation. The upper tract, known as the upper airway, warms and filters air so that the lower respiratory tract can accomplish gas exchange. Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. The respiratory works together with the cardiovascular system; the respiratory system is responsible for ventilation and diffusion, and the cardiovascular system is responsible for perfusion ( Smeltzer, 2007). The respiratory system consists of the lungs, a pair of elastic organs housed in the chest cavity, and the air passages leading to them. The air inhaled into the lungs provides oxygen to cells throughout the body. Air forced out of the lungs removes carbon dioxide from the body( Phipp, 2010).
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Air enters the respiratory system through the nose or mouth. It then travels through the larynx (voice box) and into the trachea (windpipe). At about the middle of the chest, the trachea divides into two tubes, the right and left bronchi. The right bronchus carries air to the three lobes of the right lung. The left bronchus supplies air to the two lobes of the left lung. Respiratory System, in anatomy and physiology, organs that deliver oxygen to the circulatory system for transport to all body cells. Oxygen is essential for cells, which use this vital substance to liberate the energy needed for cellular activities. In addition to supplying oxygen, the respiratory system aids in removing of carbon dioxide, preventing the lethal buildup of this waste product in body tissues. Day-in and day-out, without the prompt of conscious thought, the respiratory system carries out its life-sustaining activities. If the respiratory systems tasks are interrupted for more than a few minutes, serious, irreversible damage to tissues occurs, followed by the failure of all body systems, and ultimately, death (Huether, 2009).
UPPER AIRWAYS The airways are the region in which air passes on its way to the exchange areas of the lungs. The upper airways consist of the nasal cavities, pharynx, and larynx (Black and Hawks,2008).
Nasal cavity
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Bone and cartilage formed the nose. The nasal bone forms the bridge, and the remainder of the nose is composed of the cartilage and connective tissue. Each opening of the nose on the face (nostrils or nares) leads to a cavity (vestibule). Along the sides of the vestibule are turbinates, mucous membrane-covered projections that contain rich blood supply from the internal and external carotid arteries.
Figure 13: The nasal cavity They warm and humidify inspired air. Paranasal sinuses, open areas within the skull, are named from the bones in which they lie: frontal, ethmoid, sphenoid and maxillary. Passageways from Paranasal sinuses drain into the nasal cavities. The nasolacrimal duct which drains tears from the surface of the eyes also drain into the nasal cavity. The mouth is considered part of the upper airway but only because it can be used to deliver air into the lungs when the nose is obstructed or when high volumes of air are needed, such as during exercise (Black and Hawks,2008). Pharynx The pharynx is a extends from the nose nasopharynx is located soft palate and receives funnel-shaped tube that to the larynx. The
above the margin of the air from the nasal cavity.

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The oropharynx serves both respiration and digestion. It receives air from the nasopharynx and food from the oral cavity(Black and Hawks,2008).
Figure 14: The pharynx Larynx The larynx is also called the voice box. It connects the pharynx and trachea. The cartilages that the larynx is composed are attached to the hyoid bone above and below the trachea by muscles and ligaments, all of which prevents the larynx from collapse during inspiration and swallowing. The slit between the vocal cords forms the glottis. The epiglottis, a leaf shaped structure immediately posterior to the base of the tongue, lies above the larynx. When food or liquids are swallowed, the epiglottis closes over the larynx, protecting the lower airways from aspiration. The thyroid cartilage protrudes in front of the larynx , forming the adams apple.
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Figure 15: The larynx The cricoid cartilage lies just below the thyroid cartilage and is the anatomic site for an artificial opening into the trachea. The internal portion of the larynx is composed of muscles that assist with swallowing, speaking and respiration and that contribute to the pitch of the voice. The blood supply to the larynx is through the branches of the thyroid arteries. The nerve supply is through the recurrent laryngeal and superior laryngeal nerves (Black and Hawks,2008). LOWER AIRWAYS The lower airway, or tracheobronchial tree, is composed of the trachea, right and left mainstream bronchi, segmental bronchi, subsegmental bronchi, and terminal bronchioles (Black and Hawks,2008).
Figure 16: The lower airways Trachea

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The trachea extends from the larynx to the level of the seventh thoracic vertebra, where it divides to two main bronchi. The point at which the trachea divides is called carina (Black and Hawks,2008).
Figure 17: The trachea
Bronchi and bronchioles Bronchi
A bronchus (plural bronchi) is a caliber of airway in the respiratory tract that conducts air into the lungs. No gas exchange takes place in this part of the lungs. The trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the right, at the level of the sternal angle. The right main bronchus is wider, shorter, and more vertical than the left main bronchus. The right main bronchus subdivides into three segmental bronchi while the left main bronchus divides into two. The lobar bronchi divide into tertiary bronchi. Each of the segmental bronchi supplies a bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum. This property allows a
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bronchopulmonary segment to be surgically removed without affecting other segments. There are ten segments per lung, but due to anatomic development, several segmental bronchi in the left lung fuse, giving rise to eight. The segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to several respiratory bronchioles, which go on to divide into 2 to 11 alveolar ducts. There are 5 or 6 alveolar sacs associated with each alveolar duct. The alveolus is the basic anatomical unit of gas exchange in the lung (Huether, 2009) .
There is hyaline cartilage present in the bronchi, present as irregular rings in the larger bronchi (and not as regular as in the trachea), and
as small plates and islands in the smaller bronchi. Smooth muscle is present continuously around the bronchi. In the mediastinum, at the level of the fifth thoracic vertebra, the trachea divides into the right and left primary bronchi. The bronchi branch into smaller and smaller passageways until they terminate in tiny air sacs called alveoli (Huether, 2009). Alveoli
An alveolus (plural: alveoli) is an anatomical structure that has the form of a hollow cavity. Mainly found in the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood. The alveoli are found in the respiratory zone of the lungs. The lungs contain about 300 million alveoli, representing a total surface square meters (m2). Each fine mesh of capillaries
area of approx. 70-90 alveolus is wrapped in a covering about 70% of its
area ( Phipp, 2010).
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Figure 18: The bronchi and bronchioles
LUNGS AND ALVEOLI Lungs The lungs lie within the thoracic cavity on either side of the heart. They are cone shaped with the apex above the first rib and the base resting on the diaphragm. The right lung has three lobes while the left has only two. The lungs contain gas, blood, thin alveolar walls, and support structures.
Figure 19: The lungs and its alveoli The alveolar walls contain elastic and collagen fibers that allows the lung to inflate in all directions. These fibers are capable of stretching when a pulling force is exerted on them outside of the body or when they are inflated from within. The elastic recoil helps return the lungs to their resting volume (Black and Hawks,2008).
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Alveoli The blood supply flowing toward the alveoli comes from the right ventricle of the heart. The entire alveolar unit is made up of respiratory bronchioles, alveolar ducts, and alveolar sacs. The alveolar walls are extremely thin, with an almost solid network of interconnecting capillaries. Because of the extensiveness of the capillary system, the flow of blood in the alveolar wall has been described as a sheet of flowing blood (Black and Hawks,2008).
Figure 20: The alveoli THORAX The bony thorax provides protection for the lungs, heart and great vessels. The outer shell of the thorax is made up of 12 pairs of ribs. The ribs connect posteriorly to the transverse processes of the thoracic vertebrae of the spine. Anteriorly, the first seven pairs of ribs are attached to the sternum by the cartilage. The 8 th, 9th, and 10th ribs are attached to each other by costal cartilage. The 11th and 12th ribs allow full chest expansion because they are not attached in any way to the sternum (Black and Hawks,2008).
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Figure 21: The thorax DIAPHRAGM The diaphragm is the primary muscle of breathing and serves as the lower boundary of the thorax. Contraction in the diaphragm pulls the muscle downward, increasing the thoracic space actively inflating the lungs (Black and Hawks,2008).
Figure 22: The diaphragm
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PLEURAE The pleurae are serous membranes that enclose the lung in a double-walled sac. The visceral pleura cover the lung and the fissures between the lobes of the lung. The parietal pleura cover the inside of each hemithorax, the mediastinum, and the top of the diaphragm; it joins the visceral pleura at the hilus (Black and Hawks,2008).
Figure 23: The pleurae FUNCTION OF THE RESPIRATORY SYSTEM The respiratory system enhances gas exchange. Inspiration brings oxygen rich air into the alveoli. The upper and lower airways filter and humidify inspired air. Gas exchange between the air and the blood occurs in the alveolus. The carbon dioxide enriched air is removed from the body during expiration (Black and Hawks,2008).
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Figure 24: The gas exchange
VENTILATION Ventilation of the lungs is carried out by the muscles of respiration. Ventilation occurs under the control of the autonomic nervous system from parts of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected brain cells within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups. This section is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped and/or shaken violently( Phipp, 2010). Compliance It refers to the ease of which the lung expands and indicates the relationship between the volume and the pressure of the lungs (Black and Hawks,2008). Surface Tension It is the result of the air liquid interface at each alveolus, restricts alveolar expansion on inspiration and aids alveolar collapse on expiration (Black and Hawks,2008). Muscular Effort Muscular effort is also required in ventilation. The pressure within the alveoli must be less than atmospheric pressure for inspiration to occur. During exhalation, the inspiratory muscles relax. Elastic recoil of the lung tissue increases alveolar pressure above atmospheric pressure and causes air to move out of the lungs. Air flow stops
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when the recoil pressure of the lungs balances the muscular and elastic forces of the chest. Contraction of the abdominal muscles forces the diaphragm upward to its dome shaped position. Contraction of the internal intercostal muscles pulls the ribs inward, thus decreasing the anteroposterior diameter of the chest wall (Black and Hawks,2008). RESPIRATORY CONTROL Central Nervous Control The dorsal respiratory group primarily provides for inspiration. The ventral respiratory group is normally quiet unless increased ventilation is needed or if active exhalation is performed. Output from the respiratory neurons, located in the medulla, descends via the ventral and lateral columns of the spinal cord of the phrenic motor neurons of the intercostal muscles. The result is rhythmic respiratory movements. The cortex also allows voluntary control of breathing (Black and Hawks,2008). Reflex Control Inhaled irritants and mucus excite rapidly adapting pulmonary stretch receptors concentrated in the region of the carina and the large bronchi (Black and Hawks,2008).
Figure 25: The respiratory control Peripheral Control Peripheral control of respiration is due to the sensing of the partial pressure of oxygen and the partial pressure of carbon dioxide in the blood (Black and Hawks,2008).
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GAS EXCHANGE AND TRANSPORT Respiration is the exchange of oxygen and carbon dioxide at the alveolar capillary level and at the tissue cellular level. During respiration, body tissues are supplied with oxygen for metabolism and carbon dioxide is released (Black and Hawks,2008).
Figure 26: The gas exchange and transport Oxygen transport After diffusing into the pulmonary capillaries, the oxygen is transported throughout the body by the circulatory system. The oxygen is dissolved in the plasma or bound in the ferrous iron-containing protein hemoglobin. Carbon monoxide and other chemicals impair the ability of hemoglobin to transport oxygen in the blood (Black and Hawks,2008). Carbon Dioxide Transport Carbon dioxide is carried by the blood through the following ways: combined with water as carbonic acid, coupled with hemoglobin or dissolved in plasma. Red blood cells contain the enzyme carbonic anhydrase, which rapidly breaks down carbon dioxide into hydrogen ions and bicarbonate ions. When venous blood enters the lungs for gas exchange , the reaction reverses, forming carbon dioxide, which is exhaled (Black and Hawks,2008). Respiration
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Breathing is an automatic process controlled by the respiratory center in the brain, called the medulla. Intercostal muscles around the chest cavity are stimulated by the medulla, causing them to contract and relax. The intercostal muscles increase thoracic volume by raising the top border of the thorax, while the diaphragm increases it by lowering the bottom border of the thorax. This contraction and relaxation draws air into and forces air out of the lungs. Breathing occurs in two phases: inspiration and expiration. During inspiration, the diaphragm and intercostal muscles contract and air is drawn into the lungs. During expiration, the diaphragm and intercostal muscles relax and air is forced out of the lungs. Air flow occurs only when there is a difference in pressure. Air naturally flows from a region of high pressure to one of low pressure, and the bigger the difference in pressure, the faster the flow. Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute. Its time period is 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and the strap muscles of the neck( Phipp, 2010).
Exhalation
Exhalation is generally a passive process, however active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. During this process air is forced or exhaled out. The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium. During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles
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generate abdominal and thoracic pressure, which forces air out of the lungs (Huether, 2009).
Relationship between Ventilation and Perfusion The relationship between ventilation and perfusion determines the efficiency of gas exchange. The ventilation-perfusion balance differs from the top to the base of the lungs. Blood flow and ventilation are greater in the more dependent lung segments at the base of the lung. The ventilation perfusion balance is controlled at both the airway and vascular levels. Hypoxia, resulting from underventilation of an alveolar region, causes vasoconstriction, which redirects blood to well-ventilated alveoli. Carbon dioxide in the airways dilates the airway smooth muscle. Poorly perfused alveoli have low carbon dioxide levels, and the resultant airway constriction directs ventilation to better perfused alveoli (Black and Hawks,2008). REGULATION OF ACID-BASE BALANCE The lungs, through gas exchange, have a key role in regulating the acid-base balance of the body. (Black and Hawks,2008).
Figure and Gerontological Considerations
27:
Acid
base regulation
A gradual decline in respiratory function begins in early and middle adulthood and affects the structure and function of the respiratory system. The vital capacity of the lungs and strength of the respiratory muscles peak between 20-25 years of age and decrease thereafter. With aging, changes occur in the alveoli that reduce the surface area available for exchange of oxygen and carbon dioxide. At approximately 50
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years of age, the alveoli begin to lose elasticity. A decrease in vital capacity occurs with loss of chest wall mobility which restricts the tidal flow of air. The amount of respiratory dead space increases with age. These changes result in a decreased perfusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Elderly people have a decreased ability to rapidly move air in and out of the lungs ( Smeltzer, 2007).
Figure 28: The effects of aging in the respiratory system
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Pathophysiology ( Book Based )

Non Modifiable Age Gender Race Family History
Modifiable Alcohol Cigarette smoking Diabetes Diet Elevated serum cholesterol Hypertension Obesity Physical inactivity Stress
Arterial damage
Injury of the endothelial cells lining the artery Platelet adhesion and aggregation Migration of leukocyte to the area
Weakened Vessels
Aortic aneurysm and dissection, Cerebral hematoma, nephropathy, And diabetic retinopathy
Creation of oxidized LDL and further injury to the vessl
LDL enters intima
Oxidized LDL causes adhesion
Monocyte differentiate into macrophages and then consume large amount of LDL
Foam cells ae transformed and relaeses cytokines that encourages atherosclerosis
Abnormal proliferation of smooth muscle cells and connective tissue within the vessel wall
Enlargement of smooth muscles and accumulation of lipid
Fibrous plaque development
Atheroma formation
Accelerated atherosclerosis Decrease antithrombolic effect
Coronary
Cerebral carotid
Aorta
Plaque rupture
Platelet activation and aggregation A
thrombosis
Aortic aneurysm and dissection
Release of tissue factor and activation of coagulation cascade
Coronary thrombosis
atheroembolus
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Coronary thrombosis
Small thrombus
Partially occlusive thrombus
Occlusive thrombus
No ECG changes
St segment depression and or T wave inversion
ST Elevation
Healing and plaque enlargement
ST segment elevation MI
Unstable angina
Non St segment elavation MI
Partial occlusion of the blood vessels
Inability to dilate in response to increase O2 demand
Rupture of the lesion
Clotting cascade and rapid thrombus formation Thrombus progression and occludes blood flow O2 deprivation on affected myocardial cells
Myocardial cell death
Myocardial infarction
Depletion of O2, glycogen and ATP stores

Production and accumulation of hydrogen ions and lactic acid
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Cellular acidosis
Increased cellular damage
Impaired repolarization of myocardium
Release of lysosomal enzyme
Decrease cardiac contrctility
Myocardial irritability
Tissue necrosis
ECG changes
Increased cardiac markers
Decrease ventricular function
Irregular heart beats
Pericarditis
Decrease stroke volume
Increase ventriculat filling
Left ventricle dilatation
Decrease forward cardiac output
Mitral regurgitation
Decrease forward cardiac output
Rise in intravascular volume
Regurgitation of the blood into the left atrium

The regurgitant volume returns to the left ventricle during each diastole Further decreases forward stroke volume into the aorta and systemic circulation An even greater volume load is presented to the dilated left ventricle
Burdens ventricles
Pulmonary congestion
Increase vascular permeability Increase secretions of fluids Community Acquired Pneumonia
Dilated cardiomyopathy
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B. Synthesis of the Disease (BOOK BASED)
b.1. Definition of the Disease The atherosclerotic process starts with injury to the vascular endothelium, which is made more permeable by a variety of factors, including systemic inflammation and oxidative stress. Lipoproteins then enter the intima via the vascular endothelium. Modified lipoproteins and systemic oxidative stress and inflammation induce cytokine production and increase the expression of cell adhesion molecules, on the vascular endothelium, allowing circulating white blood cells to adhere to damaged endothelial surfaces. The release of chemotaxins directs migration of these leukocytes to the vascular intima. In this inflammatory environment, there is increased expression of scavenger receptors on monocytes/macrophages that ingest modified lipid lipoprotein particles, promoting the development of foam cells. Vascular smooth muscle cells then proliferate and may migrate from the media into the intima. These muscle cells produce extracellular matrix, which accumulates in the plaque with the formation of fibro-fatty lesions. This results in vessel wall fibrosis and consequent smooth muscle cell death. Calcification may occur, producing a plaque with a fibrous cap surrounding a lipid-rich core ( Munjen, 2007). In acute coronary syndromes, it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (clumping), thrombus (clot) formation, and vasoconstriction. The amount of disruption of the atherosclerotic plaque determines the degree of obstruction of the coronary artery and the specific disease process (unstable angina or myocardial infarction [MI]). NSTEMI, is chest pain or discomfort that occurs at rest or with exertion and causes marked limitation of activity. An increase in the number of attacks and an increase in the intensity of the pain characterize NSTEMI. Myocardial infarction (MI) occurs when myocardial tissue is abruptly and severely deprived of oxygen. When blood flow is acutely reduced by 80% to 90%, ischemia develops. Ischemia can lead to injury and necrosis (infarction) of myocardial tissue if blood flow is not restores. This further increases the pressure within
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the heart which will eventually lead to progressive dilation of the ventricles without thickening the walls( Munjen, 2007). As the disease progresses, the myocardium may get worn out and incapable of supplying the blood required. The decrease in blood supply will decrease the oxygen delivered to the myocytes that can lead to ischemia and eventually damage. This damaged cell will then regenerate and will be replaced by scarred where in fibrosis occurs. The new scarred tissue are less pliable making it ineffective in contracting which eventually leads to decreased cardiac output aggravating the damage. The
damage of the myocardium makes it ineffective to pump adequate blood decreasing its stroke volume and eventually cardiac output also decline. Because there is a decrease in the ejection fraction which decreases stroke volume, the blood stays on the ventricles , increasing pressure in the chamber. When there is a decrease blood flow to the myocardium, cardiac cells resort to anaerobic metabolism producing lactic acid. Myocardial cells are sensitive with the change in the acidity that will stimulate the nerve fibers leading to chest pain. And as ischemia progress, cell death may occur Munjen, 2007). Dilated cardiomyopathy is characterized by ventricular chamber enlargement and systolic dysfunction with greater LV cavity size .The enlargement of the remaining heart chambers is primarily due to LV failure. Dilated cardiomyopathies are associated with both systolic and diastolic dysfunction. This leads to an increase in the end-diastolic and end-systolic volumes. Progressive dilation can lead to significant mitral and tricuspid regurgitation, which may further diminish the cardiac output and increase end-systolic volumes and ventricular wall stress. In turn, this leads to further dilation and myocardial dysfunction ( Munjen, 2007). Early compensation for systolic dysfunction and decreased cardiac output is accomplished by increasing the stroke volume, the heart rate. The basis for compensation of low cardiac output is explained by the Frank-Starling Law, which states that myocardial force at end-diastole compared with end-systole increases as muscle length increases, thereby generating a greater amount of force as the muscle is
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stretched.
These compensatory mechanisms are blunted in persons with dilated
cardiomyopathies, as compared with persons with normal LV systolic function( Munjen, 2007). Dilated cardiomyopathy is a disease of the heart muscle, primarily affecting the heart's main pumping chamber (left ventricle). The left ventricle becomes enlarged (dilated) and can't pump blood to the body with as much force as a healthy heart can. Dilated cardiomyopathy is a common cause of heart failure, the inability of the heart to supply the body's tissue and organs with enough blood. Dilated cardiomyopathy may also cause irregular heartbeats (arrhythmia), blood clots or sudden death (Lilly,L. 2008). Community acquired pneumonia often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively (Lilly, L.2008). b.2. Risk Factors
Non-Modifiable Factors
Sex. As a group, men face a four times greater risk of developing heart disease than do women (Munden, J. 2007). Age. The risk for heart disease increases as a person ages. As their heart begins to have difficulty pumping blood to the different parts of the body(Munden, J. 2007). Race. African Americans, Native Americans, Mexican Americans, Native Hawaiians and some Asian Americans are at higher risk for developing heart disease. This is due in part to higher occurrences of diabetes, hypertension and obesity in these ethnic groups ( Munden, J.2007).
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Family History. If either or both of the parents have coronary artery the risk for developing heart problem is greatly increased. Genetic predisposition to diabetes, obesity, high blood pressure or high cholesterol could also increase the risk for developing ACS(Munden, J. 2007). Modifiable Factor Alcohol. Heavy drinking harms the heart; heart disease is the leading cause of death in alcoholics. Evidence suggests that people who consume more than three drinks a day have abnormal blood clotting factors. Heavy alcohol consumption can raise blood pressure, and binge drinking may increase the risk for hemorrhagic stroke (caused by bleeding in the brain). Large doses of alcohol can trigger irregular heartbeats, which can be dangerous in people with existing heart disease (Lewis et al., 2007) In general, moderate drinking is considered to be no more than one drink/day for women and no more than two drinks/day for men. Numerous mechanisms have been proposed to explain the benefit of light-to-moderate alcohol on the heart, including an increase of protective high-density lipoprotein (HDL) cholesterol, reduction in blood clotting propensity, improvement in endothelial function, reduction of inflammation, and promotion of antioxidant effects.Heavy drinking is anything more than moderate drinking. Binge drinking is a pattern of alcohol consumption leading to a blood alcohol concentration of 0.08% or higher. This corresponds to more than four drinks on a single occasion for men or more than three drinks for women within about 2 hours.
Cigarette smoking. The three substances thought to increase the prevalence of heart disease are tar, nicotine, and carbon monoxide. Tar contains hydrocarbons and other carcinogenic substances. Nicotine increases the release of epinephrine and norepinephrine, thereby increasing the likelihood of arrhythmias and elevated heart rate, blood pressure, and oxygen consumption. Carbon monoxide decreases the oxygencarrying capacity of the blood. Smokers' risk of developing cardiovascular disease is 2 4 times that of nonsmokers. Cigarette smoking is a powerful independent risk factor for
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sudden cardiac death in patients with cardiovascular disease; smokers have about twice the risk of nonsmokers (Des Jardins T., and Burton G., 2009).
Diabetes. Diabetes frequently appears in middle-aged, overweight people. A fasting blood sugar of more than 120 mg/dl, or a routine blood sugar of 180 mg/dl and evidence of sugar in the urine, signal the presence of diabetes and represent an increased risk for ACS. Chronic elevation of blood glucose level leads to damage of blood vessels. The endothelial cells lining the blood vessels take in more glucose than normal, since they do not depend on insulin. They then form more surface glycoproteins than normal, and cause the basement membrane to grow thicker and weaker. Diabetes is also a risk factor for arterosclerosis, but measuring that risk is difficult, because diabetics frequently also suffer from other atherogenic conditions such as hypertension and dyslipidemia. It has been postulated that the increased risk relates to glycosylation of lipoproteins in diabetics (which may enchance uptake of cholesterol by scavenger macrophages or the increased platelet adhesiveness present in this condition (Monahan et al, 2007).
Diet. Diet high in fat, high sugar and low in fiber can make an individual at risk of having a heart attack. This type of diet significantly increases the lipid levels in the blood and also places a person at high risk of developing hypertension. Elevation of blood glucose level leads to damage of blood vessels since they allow the basement membrane to grow thicker and weaker (Munden N. and Chohan J., 2007).
Elevated Serum Cholesterol. An elevated serum cholesterol level definitely increases the risk of developing heart disease. A person with a serum cholesterol level greater than 259 mg/dl is three times more likely to develop ACS than one with a serum level 200 mg/dl. Cholesterol, a sterol found in animal tissue, circulates in the blood in combination with triglycerides and protein bound phospholipids. This complex is called a lipoprotein. People with high levels of HDL in proportion to LDL are less likely to develop than persons with low HDL. Cholesterol in HDL does not become incorporated into the
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fatty plaques that develop in the lining of the artery wall, as does LDL. Higher concentrations of LDL and lower concentrations of functional HDL are strongly associated with cardiovascular disease because these promote atheroma development in arteries (atherosclerosis). This disease process leads to myocardial infarction (heart attack), stroke and peripheral vascular disease. Since higher blood LDL, especially higher LDL particle concentrations and smaller LDL particle size, contribute to this process more than the cholesterol content of the LDL particles, LDL particles are often termed "bad cholesterol" because they have been linked to atheroma formation (Liliy S., 2008).
Hypertension. Blood pressure above 160/95 have a 50 percent higher chance of mortality. Although hypertension cannot always be prevented, it can and should be treated in order to lower the risk of ACS and premature death due to the hardening of the arteries. Chronic high blood pressure can lead to an enlarged heart. People with high blood pressure have an increased stiffness, or resistance, in the peripheral arteries throughout the tissues of the body. This increased resistance causes the heart muscle to work harder to pump the blood through these blood vessels. The increased workload can put a strain on the heart, which can lead to heart abnormalities that are usually first seen as enlarged heart muscle (Mc Cance K., Huether S., 2006)
Obesity. Obesity places an extra burden on the heart, requiring the muscle to work harder to pump enough blood to support added tissue mass. Obesity increases strain on the heart, raises blood pressure and cholesterol, and increases diabetes risk. The increased amount of blood means more blood has to be pumped from the heart with each beat. This makes the heart work harder. The heart stretches and expands. The extra work makes the heart muscle thicker. The thicker the heart muscle gets, the harder it is for it to both squeeze (contract) and relax. Over time, the heart may not be able to keep up with the load. Heart failure may be the result (Smeltzer el al., 2008).
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Physical Inactivity. Physical inactivity is a term used to identify people who do not get the recommended level of regular physical activity. Physical inactivity may be the most important risk factor for the general population. Less active, less-fit persons have a 30% to 50% greater risk of developing high BP, which predisposes to ACS. Lack of consistent physical activity, over time, decreases the function of the heart muscle, affects the blood vessels, including the large aortic artery to the veins and small capillaries (Doyle R., 2008).
Stress. Stress appears to be associated with elevated blood pressures. Although moderate stress plays a role in modern life, excessive stress can be a health hazard. Significant stressors include major changes in residence, occupation, or status. Stress can certainly influence the activity of the heart when it activates the sympathetic nervous system (the automatic part of the nervous system that affects many organs, including the heart). Sudden stress increases the pumping action and rate of the heart while at the same time causing the arteries to constrict, thereby restricting blood flow to the heart. A 2002 study suggested that such actions may be responsible for some incidences of acute stress that have been associated with a higher risk for serious cardiac events, such as heart rhythm abnormalities and heart attacks, and even death in people with heart disease. Emotional effects of stress alter the heart rhythms, which could pose a risk for serious arrhythmias in people with existing heart rhythm disturbances. Stress causes blood to become stickier (possibly in preparation of potential injury), increasing the likelihood of an artery-clogging blood clot. Stress
appears to impair the clearance of fat molecules in the body, raising blood-cholesterol levels, at least temporarily (Doyle R., 2008).
b.3. Signs and Symptoms with Rationale Cardiac markers Elevation. Troponin test- Troponin is released during MI from the cytosolic pool of the myocytes. Its subsequent release is prolonged with degradation of actin and myosin filaments. Differential diagnosis of troponin elevation includes acute infarction, severe pulmonary
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embolism causing acute right heart overload, heart failure, myocarditis. Troponins can also calculate infarct size but the peak must be measured in the 3rd day. released in 2 4 hours and persists for up to 7 days ( American Heart Association, 2011).
Creatine Kinase (CK-MB) test- CK-MB resides in the cytosol and facilitates high energy phosphates into and out of mitochondria. It is distributed in a large number of tissues even in the skeletal muscle. Since it has a short duration, it cannot be used for late diagnosis of acute MI but can be used to suggest infarct extension if levels rise again. This is usually back to normal within 23 days( American Heart Association, 2011).
Lactate dehydrogenase (LDH)- Lactate dehydrogenase catalyses the conversion of pyruvate to lactate. LDH-1 isozyme is normally found in the heart muscle and LDH-2 is found predominately in blood serum. A high LDH-1 level to LDH-2 suggest MI. LDH levels are also high in tissue breakdown or hemolysis( American Heart Association, 2011).
Aspartate transaminase (AST)- This was the first used. It is not specific for heart damage, and it is also one of the liver function tests ( American Heart association, 2011).
Myoglobin (Mb)- Myoglobin is used less than the other markers. Myoglobin is the primary oxygen-carrying pigment of muscle tissue. It is high when muscle tissue is damaged but it lacks specificity. It has the advantage of responding very rapidly, rising and falling earlier than CK-MB or troponin. It also has been used in assessing reperfusion after thrombolysis( American Heart Association, 2011).
Pro-brain natriuretic peptide- This is increased in patients with heart failure. It has been approved as a marker for acute congestive heart failure. Pt with < 80 have a much
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higher rate of symptom free survival within a year. Generally, pt with CHF will have > 100 ( American Heart Association, 2011).
Changes in ECG. The cardiomyocytes in the subendocardial layers are especcially vulnerable for a decreased perfusion. Subendocardial ischemia manifests as ST depression and is usually reversible. In a myocardial infarction transmural ischemia develops. In the first hours and days after the onset of a myocardial infarction, several changes can be observed on the ECG. First, large peaked T waves (or hyperacute T waves), then ST elevation, then negative T waves and finally pathologic Q waves develop ( Heart Foundation.org, 2011). Changes in 2Decho. An initial 2-D echo with regional wall motion abnormality identifies a high-risk group of patients who are likely to have AMI and important cardiac complications and may, therefore, benefit from admission to an intensive care unit ( Heart Foundation.org, 2011). Cyanosis. Blood in the arteries is normally bright red, the colour of red blood cells when the haemoglobin they contain is carrying its full quota of oxygen. In conditions of hypoxia due to altitude, lung disease, heart defects, or heart failure, the blood leaves the lungs without being fully oxygenated, and the arterial blood is less red. The degree of desaturation of haemoglobin at which such central cyanosis is detectable varies between observers as well as between patients. Detection also depends on the superficial blood vessels being well-filled; if they are largely shut down the skin is simply pale whatever the colour of the blood. Undoubtedly, however, if blueness is evident, there is significant hypoxia (Bonovan et al., 2007).
Dyspnea., Coronary arteries are the blood vessels which supply the heart muscle with blood and oxygen. When a blood clot blocks the coronary artery, the blood supply and oxygen supply to the heart muscle are cut off resulting in injury to the heart muscle. The increase in respiratory frequency during movement decreases inspiratory
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time, causing shortened muscles to contract at faster velocities. As shortening velocities increase, the pressure generating capacity of the respiratory muscles decreases. Therefore, changes in respiratory muscle length and shortening velocities may be implicated in the ventilatory limitation to in CAP. Airflow into and out of the lungs is partly blocked because of the swelling and extra mucus in the bronchi leading to insufficient oxygen supply (Monahan et al., 2007). Fever. It is one of the cardinal signs of inflammation as the inflammatory mediators stimulate the hypothalamus causing release of pyrogens. The body maintains stability within this range by balancing the heat produced by the metabolism with the heat lost to the environment. The "thermostat" that controls this process is located in the hypothalamus, a small structure located deep within the brain. The nervous system constantly relays information about the body's temperature to the thermostat, which in turn activates different physical responses designed to cool or warm the body, depending on the circumstances. These responses include: decreasing or increasing the flow of blood from the body's core, where it is warmed, to the surface, where it is cooled; slowing down or speeding up the rate at which the body turns food into energy (metabolic rate); inducing shivering, which generates heat through muscle contraction; and inducing sweating, which cools the body through evaporation. A fever occurs when the thermostat resets at a higher temperature, primarily in response to an infection (Lewis et al., 2007). Pallor .This is due to the decreased cardiac output and redirection of blood away from the skin to the major organs. The skin will also feel cool and clammy. Productive cough. Coughing is the bodys response to clear the airway of secretions. Productive cough is a reflex in order to expectorate mucus produced by the lungs. Cough is a sudden, forceful expiration of air from the lungs caused by an involuntary contraction of the muscles controlling the process of breathing. The cough is a response to some irritating condition such as inflammation or the presence of mucus (sputum) in the respiratory tract, as in infectious disease, or to heavy dust or industrial or tobacco
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smoke. If there is mucus or a foreign substance in the respiratory tract, the cough should not be hindered since by this action the offending matter is expelled from the body (Burton G., 2006).
Thick, tenacious greenish or rusty sputum. Chemical mediators such as leukotrienes and prostaglandins cause inhibition of mucus clearance and decreased mucociliary function. Greenish may be a sign of infection. Greenish or rusty phlegm or phlegm with rusty spots can also be a sign of pneumonia and/or internal micro-bleedings (Bonovan et al., 2007).
Use of accessory muscles. Use of accessory muscles for breathing due to compensated attempts to supply the cells with increased oxygen The main muscles of inspiration are the diaphragm, external intercostal muscles, and parasternal intercartilaginous muscles. However, the diaphragm is probably the single most important muscle. The accessory muscles of inspiration are the sternocleidomastoid and scalenus. Unforced expiration is a passive process and requires relaxation of the above muscles. When breathing requires extra effort, the accessory musclesthe sternocleidomastoid, scalene, pectoralis major, trapezius, internal intercostals, and abdominal muscle, stabilize the thorax during respiration. Some accessory muscle use normally takes place during such activities as singing, talking, coughing, defecating, and exercising. (Burton G., 2008).
In response to the release of catecholamines, the BP and HR may be elevated initially. Later, the BP may drop because of decreased cardiac output (CO). High Blood Pressure: As blood flows through arteries it pushes against the inside of the artery walls. The more pressure the blood exerts on the artery walls, the higher the blood pressure will be. The size of small arteries also affects the blood pressure. When the muscular walls of arteries are relaxed, or dilated, the pressure of the blood flowing through them is lower than when the artery walls narrow, or constrict. Hypertension may precipitate MI, or it may reflect elevated
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catecholamine levels due to anxiety, pain, or exogenous sympathomimetics. Blood pressure is highest when the heart beats to push blood out into the arteries (Lewis et al., 2007). Hypotension: May indicate ventricular dysfunction due to ischemia. Hypotension in the setting of MI usually indicates a large infarct secondary to either decreased global cardiac contractility or a right ventricular infarct (Bonovan et al., 2007). Decreased cardiac output despite normal blood volume, due to severe congestive heart failure, large myocardial infarction, or bradycardia, often produces hypotension and can rapidly progress to cardiogenic shock. Arrhythmias often result in hypotension by this mechanism. Beta blockers can cause hypotension both by slowing the heart rate and by decreasing the pumping ability of the heart muscle. Weakness. Reduced perfusion of skeletal muscle causes atrophy of the muscle fibres. This can result in weakness, increased fatigueability and decreased peak strength and contributing to exercise intolerance.
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Pathophysiology ( Client based )
Non Modifiable Age ( 74 yrs old) Sex( male) Family History of heart diseases
Modifiable Diet ( high in fats and salt) Hypertension( 160/110) Moderate sedentary lifestyle Stress
Injury of the endothelial cells lining the artery
Platelet adhesion and aggregation
Migration of leukocyte to the area Creation of oxidized LDL and further injury to the vessl
LDL enters intima
Oxidized LDL causes adhesion
Monocyte differentiate into macrophages and then consume large amount of LDL
Foam cells ae transformed and relaeses cytokines that encourages atherosclerosis
Abnormal proliferation of smooth muscle cells and connective tissue within the vessel wall
Enlargement of smooth muscles and accumulation of lipid
Fibrous plaque development
Atheroma formation
Accelerated atherosclerosis Decrease antithrombolic effect Platelet activation and aggregation
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Partial occlusion of the blood vessels
Non St segment elevation MI (Nov. 08)
O2 deprivation on affected myocardial cells
Myocardial ischemia
Myocardial cell death
Myocardial infarction
Depletion of O2, glycogen and ATP stores

Production and accumulation of hydrogen ions and lactic acid
Chest painpain scale of 10/10 8/10 ( 11-08-11)
Tachypnea Nov.08 ( RR : 30-24bpm)
Restlessness ( Nov.08)
Cellular acidosis
Increased cellular damage
Impaired repolarization of myocardium
Release of lysosomal enzyme
Decrease cardiac contractility
T wave inversion ( 11-08-11)
Increased CKMB, Myoglobin, Tropinin I ( 11-08-11) Decreased peripheral tissue perfusion
Decreased ejection rate
DOB ( Nov.06-08, ), weakness ( Nov. 9,10,14), Pallor ( Nov.06-15) November 6, 2011 Hgb: 120mg/L Hct: 0.36L/L RBC: 4.20 x1012L
Decreased stroke volume and decreased cardiac output
Decreased blood volume within the ventricles
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Decreased cardiac output
Increased creatinine Nov. 08 Specific gravity: 1.005 Nov.06
Decreased glomerulofiltration rate
Decreased renal perfusion
Stimulation of receptors
Regulation of body fluid volume
Baroreceptors And Chemoreceptors Stimulation of the control center of the medulla oblongata
Release of renin from juxtaglomerular apparatus
Relesae of angiotensin I
Increased Sympathetic and decreased parasympathetic
Goes to the blood stream then to the lungs Alpha 1 ACE in the lungs converts AI Increased capillary diffusion Increased conduction and heart rate Beta 2
Angiotensin II
Activation of Adrenal Cortex
Systemic Vasoconstriction
Increased Blood volume
Aldosterone Increased cardiac output Increased BP 160/110mmhg ( Nov .08)
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Incomplete emptying
Decreased left ventricular outflow
Increased pressure within the ventricles
Increased blood volume entering the ventricles during diastole
Compensatory enlargement of the ventricles
Chest painpain scale 10/108/10
Increased blood volume on the atrum
Dilation of the ventricles
Increased BNP ( Nov.08)
Increased pressure on the atrium
Decreased compliance to ventricular filling
Increased pressure in the right atrium
Dilation of the atrium
Backflow of blood during diastole
Decreased venous return

Decreased blood shifting from the atrium to the ventricles
Increased pressure within the vena cava
Compensatory enlargement of the atrium

Incomplete closure of the mitral and tricuspid valve during systole (2D echo -11-08-11)
Increased pressure within the systemic circulation
Decreased pooling of the blood
Hypertension ( Nov.06-160/100130/100) D
Increased pressure in the left atrium
Backflow of blood towards the atrium (2D echo-11-08-11)

Stretching of conduction fibers, altered conduction and automaticity
Decreased venous return
Dysrythmias ( ECG- PVC) Nov.08-11
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Increased pressure within the pulmonary veins
Increased capillary permeability
Shifting of fluid from intravascular to interstitial in the alveoli
Inflammatory response
Changes in the capillary permeability
Increased blood flow
Release of chemical mediators
Shifting of fluid in the interstitial space
RBC and fibrin moves into the alveoli
Stimulates goblet cells to release mucous
Altered oxygen and carbon dioxide exchange in the respiratory membrane
Consolidation
Accumulation of mucous secretions
Rales ( nov. 8-15), non productive cough ( nov. 08) Increased capillary permeability of the pleural membrane Dilation and congestion of the capillaries
Fluid collects in the pleural space
Pleural effusion
Further increase hydrostatic pressure in pulmonary capillaries
Oxygen diffusion difficulty O2 sat: 75% ( nov.08)
Restriction of the lungs movement during respiration

Greater force is necessary to produce adequate ventilation
Accumulation of fluids in the bronchioles
Mucosal irritation
Weakness ( Nov. 09, 10, 14),, DOB ( Nov.08)
Non productive cough ( Nov.08)
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B. Synthesis of the Disease ( Client Based) b.1. Definition of the Disease There are factors that had caused the development of the patients problem with his heart that had ended with community acquired pneumonia moderate risk. The factors were old age, being male, family history of heart diseases specifically his grandfather, father and brother, diet of high fat and high salt, stress, hypertension ,physical inactivity specifically moderate sedentary lifestyle. Due to the mentioned factors above, injury to the vascular endothelium may happen. Lipoproteins then enter the intima via the vascular endothelium. Modified lipoproteins and systemic oxidative stress and inflammation induce cytokine production and increase the expression of cell adhesion molecules, on the vascular endothelium, allowing circulating white blood cells to adhere to damaged endothelial surfaces. The release of chemotaxins directs migration of these leukocytes to the vascular intima. In this inflammatory environment, there is increased expression of scavenger receptors on monocytes/macrophages that ingest modified lipid lipoprotein particles, promoting the development of foam cells. Vascular smooth muscle cells then proliferate and may migrate from the media into the intima. These muscle cells produce extracellular matrix, which accumulates in the plaque with the formation of fibro-fatty lesions. Atheroma formation may happen and based on the patients 2dEcho and chest x-ray he has atherosclerotic aorta. Furthermore, accelerated atherosclerosis may activate platelet aggregation thus Arixtra, Aspirin and Clopidrogrel were prescribed to the patient to increase antithrombolic effect. Partial occlusion of the blood vessels as evidenced by the patient having NSTEMI on his ECG was seen. This could cause an inability of the vessels to dilate in response to oxygen demand. The oxygen deprivation on the cells could affect particularly the myocardial cells. Myocardial ischemia may happen, then myocardial cell death and eventually myocardial infarction may result. Increased depletion in oxygen, glycogen and ATP stores happen. Production and accumulation of hydrogen ions and
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lactic acid happens, as manifested by the patient having chest pain, tachypnea and restlessness. Due to lactic acid accumulation, cellular acidosis forms and increases cellular damage. Cellular damage may impair repolarization of the myocardium as evidenced by T wave inversion on his ECG, releases lysosomal enzyme particularly an increased in CK-MB ( 9.1), troponin I( 1.73 mcg/L, and myoglobin ( 506 ng/L), and a decrease in cardiac contractility. A decreased in cardiac output may decrease ejection rate and would further decrease stroke volume and decrease cardiac output. A decrease in cardiac output may decrease peripheral tissue perfusion as evidenced by difficulty of breathing, weakness and pallor. Decrease cardiac output may also decrease renal perfusion. A decrease in perfusion in the kidneys may stimulate the juxtaglomerular apparatus to release renin. The angiotensinogen that is released by the liver will then be converted to angiotensinogen I and in turn will be converted to angiotensinogen II by an enzyme called angiotensinogen converting enzyme. Angiotensinogen II is a potent vasoconstrictor that will increase the vascular resistance within the blood vessels and will stimulate the adrenal cortex to release aldosterone which will increase reabsorption of water and sodium in the tubules. This will cause the increase in the blood volume and increase in vascular resistance leading to increase in blood pressure of 160/110mmhg. Chemoreceptors and baroreceptors may also be stimulated to increase sympathetic and decrease parasympathetic. Thus, increasing heart rate, and increasing blood pressure. The damage of the myocardium makes it ineffective to pump adequate blood decreasing its stroke volume and eventually cardiac output also decline. Because there is a decrease in the ejection fraction which decreases stroke volume, the blood stays on the ventricles, increasing pressure in the chamber. This will increase pressure in the ventricles thus compensatory enlargement in the ventricles as evidenced by chest pain of 10/10 and dilation of the ventricles as evidenced by the patients 2D echo results. Decrease compliance to ventricular filling and backflow of blood during diastole may also result. Progressive dilation can lead to significant mitral and tricuspid regurgitation, which may further diminish the cardiac output and increase end-systolic volumes and ventricular wall stress. In turn, this leads to further dilation and myocardial dysfunction.
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Increased pressure within the pulmonary veins occurs because of decrease of venous return. Decreased venous blood pressure leads to increase in capillary permeability in an attempt to decrease the blood volume and at the same time blood shift from higher pressure towards area of lower pressure. Because of increase in permeability within the capillaries brought about by the increase in the blood pressure within the vessel, fluid shifts to the interstitial spaces. And as the fluids increases within the interstitial space it may shift to the alveoli. The fluid within the alveoli can cause an inflammatory response. Goblet cells may be stimulated to produce mucous secretions as evidenced by rales and non productive cough. Increase blood flow may also happen, thus RBC and fibrin moves into the alveoli and consolidation happens as evidenced by hazy opacities in the patients chest x-ray. Furthermore, an increased capillary permeability in the pleural membranes causes fluids to accumulate in the pleural spaces as evidenced by minimal pleural effusion in the patients chest x-ray. This increases hydrostatic pressure accumulates fluids in the bronchioles as evidenced by non productive cough. Restriction of the lungs movement during respiration causes a greater force to produce adequate ventilation as evidenced by weakness and difficulty of breathing. b.2. Risk Factors
Non-Modifiable Factors Age. Heart problem becomes progressively more common with increasing age. In persons aged 40-90 years ( Munden, 2007). Mr. Cardio Nstemi is a 74 year old male. His heart begins to have difficulty pumping blood to the different parts of the body. Family History. Mr. Cardio Nstemis grandfather on mother side died because of stroke .His Father is hypertensive and died because of heart attack .In the family line, Mr. Cardio Nstemi, his grandfather, his father and his younger brother has a common denominator and that is their health problem involving the heart. If either or both of the parents had heart diseases, the risk for developing heart problem is greatly increased.
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Sex. Mr. Cardio Nstemi is at increased risk for cardiovascular problem since he may be prone to more stresses in life. Men also have more limited ways to express emotional stress in the workplace than women ( Bonovan, 2010).
Modifiable Factors Diet. Fatty diet can cause atherosclerosis or fatty streaks of lipids that are deposited in the intima of the arterial wall. Mr. Cardio Nstemi likes to eat fatty foods and likes eating while seated in front of the television. When it comes to Mr. Cardio Nstemis diet, is fond of eating salty foods such as grilled fish, tuyo or dried fish, chicharon and pork chop.
Hypertension. Blood pressure above 160/95 have a 50 percent higher chance of mortality. Mr. Cardio Nstemis BP was 160/110. Chronic high blood pressure can lead to an enlarged heart. People with high blood pressure have an increased stiffness, or resistance, in the peripheral arteries throughout the tissues of the body. This increases the workload of his heart.
Physical Inactivity. An inactive lifestyle is a risk factor for cardiovascular disease. Since there is less use of skeletal muscle tendency is the heart will also be affected. Mr. Cardio Nstemi usually stays at home because of his old age. When he retired from his profession as a teacher, Mr. Cardio Nstemi started to have moderate sedentary lifestyle, and because during this time he was having a problem due to easy fatigability, his family doesnt want to make Mr. Cardio Nstemi tired so they let him to just sit and watch TV all day long. He usually stays at his room while watching television and he never exercises. Stress. Stress appears to be associated with elevated blood pressures. Mr. Cardio Nstemi is a teacher and for 45 years he experienced various stresses especially in his work as a teacher that contributed to his present condition. b.3. Signs and Symptoms with Rationale Cardiac markers Elevation.
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Troponin test ( Nov. 08, 2011)- Troponin is released during MI from the cytosolic pool of the myocytes. Its subsequent release is prolonged with degradation of actin and myosin filaments. Troponins can also calculate infarct size but the peak must be measured in the 3rd day. released in 24 hours and persists for up to 7 days ( American Heart Association, 2011). Mr. Cardio Nstemis Troponin I result is 1.73mcg/L which s above the normal, thus myocardial damage occurred.
Creatine Kinase (CK-MB) test ( Nov.08, 2011)- CK-MB resides in the cytosol and facilitates high energy phosphates into and out of mitochondria (American Heart Association, 2011). The patients CK-MB result is 9.1, which is above the normal indicating cardiac muscle damage.
Myoglobin ( Nov.08, 2011)- Myoglobin is the primary oxygen-carrying pigment of muscle tissue. The patients myoglobin is 506ng/L which is above the normal. It is high when muscle tissue is damaged but it lacks specificity. ( American Heart Association, 2011). Brain natriuretic peptide ( Nov.08, 2011)- The patients BNP is 2160 which is above the normal. This is increased in patients with heart failure. ( American Heart Association, 2011).
Changes in ECG ( Nov.08, 2011). In the first hours and days after the onset of a myocardial infarction, several changes can be observed on the ECG. Mr. Cardio Nstemis ECG result showed Complete Right bundle branch block with lateral wall ischemia. V5-V6 presents T wave inversion. No ST segment elevation.
Changes in 2Decho ( Nov.08, 2011) . An initial 2-D echo with regional wall motion abnormality identifies Mr. Cardi Nstemi as having myocardial infarction. His 2Decho showed: Dilated left ventricle with normal wall thickness and generalized severe hypokinesia to akinesia consistent with dilated cardiomyopathy with decreased global
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systemic function. An ischemic etiology cant be totally excited. Dilated Left Atrium, Atherosclerotic aortic root with normal dimensions,Aortic sclerosis with mild aortic regurgitation but no restrictions of motion of the csps noted, Mitral sclerosis with mild aortic regugitations and low flow configuration consistent with increased diastolic pulling pressure, Thickened tricuspid valve with mild tricuspid regurgitation but no restrictions of motion and no prolapse noted, Structurally normal pulmonic valve with pulmonic regurgitation, Normal right ventricular dimension with normal contractility, Normal right atrium and main pulmonary dimension, Mild pulmonary hypertension with systolic pulmonary artery pressure of 49 mmHG by peak tricuspid regurgitation gradient, Minimal posterior pericardial effusion, No thrombus noted. Chest Pain of 10/10- 8/10 ( Nov. 08, 2011). Mr. Cardio Nstemi suffered from chest pain before being admitted in the hospital. Chest pain is caused by narrowing of arterial walls that leads to inadequate blood supply that deprives the cardiac muscle cells of oxygen they needed. In an unstable angina, the pain occurs at rest with or without exertion and causes marked limitation of activity.
Dyspnea ( Nov.08,2011). Coronary arteries are the blood vessels which supply the heart muscle with blood and oxygen. When a blood clot blocks the coronary artery, the blood supply and oxygen supply to the heart muscle are cut off resulting in injury to the heart muscle. It is also due to airflow obstruction to the lower tracheobronchial tree and it is due to inadequate blood supply due to constriction of arterial walls. The narrowed airways were not sufficient because mucus blocks the passage way of oxygen. Mr. Cardio Nstemi was brought in one of the hospital in Angeles City with a chief complaint of difficulty of breathing (DOB). Dysrhythmias ( Nov. 08-11, 2011). May present as an irregular heartbeat or pulse due to altered conduction and irritability of the heart secondary to ischemia. Abnormalities of the electrical rhythm are known as arrhythmias and are among the most common clinical problems encountered. Disorders of heart rhythm result from alterations of impulse formation, of impulse conduction, or both. It occur in the patient with acute
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coronary syndromes as a result of autonomic nervous system imbalance, electrolyte disturbances, ischemia, and slowed conduction in zones of ischemic myocardium. The most common complications of acute coronary syndrome are dysrhythmias. ECG results showed that on November 08, 2011 the ECG right bundle branch block lateral wall ischemia V5-V6, T-wave inversion. During his stay in the hospital he also showed premature ventricular contractions. Hypertension (Nov. 08, 2011). Mr. Cardio Nstemi manifested hypertension. His blood pressure upon admission is 160/110 mmHg and was managed by giving him drugs like Isoket and bisoprolol Hypertension makes the heart work harder to pump blood through the body. The extra workload can make the heart muscle thicken and stretch. When the heart becomes too enlarged it cannot pump enough blood.
Non productive cough ( Nov.08,2011). The patient expectorated dry sputum due to hypersecretion of goblet cells. Coughing is a reflex that is performed in order to expectorate mucus secretions from the lungs. Pallor (Nov.08-15, 2011).Mr.Cardio Nstemi was seen with some paleness. This is due to the decreased cardiac output and decreased peripheral tissue perfusion in his body. He also has a decreased hemoglobin and hematocrit. Rales ( Nov.08-15, 2011). Mr. Cardio Nstemi has a presence of rales on the lower lung fields heard upon auscultation. Upon admission the physical assessment reveals presence of rales on both lower lung fields. On November 08, 2011 he complained of dyspnea accompanied by the following signs and symptoms likerales, tachypnea, and chest pain. While Pneumonia can be traced from the Chest X- Ray done on Nov.08, 2011. The results showed the presence of Pneumonia in right lower lungs. Tachypnea and rapid shallow breathing ( Nov.08,2011). Mr. Cardio Nstemi experienced increased respiratory rate before his admission and during his hospital stay. Tachypnea increases the so-called minute ventilation and also, if the inhale volume is smaller, tachypnea only compensates for decreased air volume, which is
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used in each respiration cycle. The patients body compensates by increasing the minute ventilation to adjust to bigger air exchange, which is needed in activity. Weakness ( Nov. 09,10,14, 2011). Reduced perfusion of skeletal muscle causes atrophy of the muscle fibres due to Mr. Cardio Nstemis decreased cardiac output from his heart. This resulted in weakness and increased fatigability thus he has difficulty doing his ADLs.
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B. NURSING MANAGEMENT NURSING CARE PLAN
Assessment
Nursing Diagnosis
Scientific Explanation
Objectives
Nursing Interventions 1.establish therapeutic
Rationale
Expected Outcome
S:
Patient Acute pain
Gout is a kind Short-term: of arthritis. It
1.to trust
get
the Short-term: and The patient have
manifested: >guarding behavior >generalized weakness >P= pain on
can cause an After 2-3 hours relationship nursing attack of of sudden burning interventions pain, stiffness, the patient will 2.assess able and swelling in be a joint, usually verbalize a big to general condition
cooperation of shall the patient verbalized
understanding 2.to have a of health
baseline data
teachings regarding his
the big toe of the feet felt
whenever moving >Q=throbbing pain >R=pain felt on only the
condition and toe. understanding health 3.monitor and 3.to have a restrictions to These attacks of record vital comparative lessen or can happen teachings over and over regarding condition unless gout is Over restrictions time, they can lessen treated. his signs and to 4.provide or comfort 4.to comfort
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data
prevent occurrence provide pain. of
soles feet
of and
the not
harm
your prevent
measures such of as linen therapeutic touch stretching and
Long-term: The shall showed patient have and
joints, tendons, occurrence and other pain.
radiate >S= 9/10 pain scale >T= pain is
tissues. Gout is most common Long-term: in men. This After 1-2 days
demonstrated different 5.in order to relaxation techniques the manage pain. to
recurrent as it is only felt
causes pain to of the patient.
nursing 5.obtain patients
interventions
properly
when moving
the patient will assessment of assess be show able to pain and underlying cause
Patient manifest: >change
may
demonstrate different 6.encourage to 6.to do to breathing exercises deep pain lessen
in
relaxation techniques manage pain.
muscle tone >diaphoresis >irritability >change in
7.assist patient 7.to in positioning
prevent
blood pressure
unnecessary falls or injury
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8.emphasize importance complete rest
8.to of fatigue
prevent
bed
9.administer analgesics ordered
9.to as pain
manage
Problem #1: Acute Pain
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Problem #2: Impaired gas exchange related to ventilation-perfusion imbalance ASSESSMEN T S: NURSING SCIENTIFIC OBJECTIVES NURSING INTERVENTIONS 1. Monitor signs. vital 1. To RATIONALE EXPECTED OUTCOME obtain Short term:
DIAGNOSIS EXPLANATION Impaired gas In ACS with Short term: After 4 hours of nursing
Dilated Cardiomyopathy to , there
baseline data The patient have
O: the patient exchange manifested: Capillary related
is intervention, patient will be of able to in
2. Monitor respiratory rate, depth and effort, including use of accessory as by of muscles, flaring abnormal breathing patterns. nasal and
2. Increased respiratory
shall
ventilation-
decreased contractility the
rate, participated in
refill time of perfusion less than 3 imbalance seconds Untrimmed finger as evidenced
use of accessory treatment muscles, nasal regimen as
myocardial participate fibers. treatment
muscle
flaring and a look evidenced by of panic in the utilization patients eyes breathing of
Because of this, regimen
nails by dyspnea there would be evidenced altered myocardial utilization breathing
and toenails and fatigue and pale in color Limited movements observed With non-
may be seen with exercises, hypoxia. effective coughing and use of oxygen.
function or there exercises, is failure in the effective pumping mechanism the causing coughing
and 3. Auscultate breath sounds
3. Presence crackles
of may Long term:
of use of oxygen. heart left Long term:
every 4 hours.
alert the student nurse to an The

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productive
patient
cough Rales heard upon auscultation With easy
atrium hypertrophy.
After 3 days of nursing
airway obstruction
shall
have
that demonstrated
Because of left intervention, atrium patient will be to
may lead to or improved exacerbate existing hypoxia. 4. Monitor patients 4. Changes behavior and behavior ventilation and adequate oxygenation of in tissues as
hypertrophy and able loss of elasticity, demonstrate there would be improved
fatigability
the
patient
backflow
of ventilation and
and evidenced by of of
may manifest: diaphoresis inability move secretions cyanosis confusion restlessness irritability to
blood in the left adequate atrium blood then oxygenation of would tissues to evidenced as by of of
mental status for onset restlessness, agitation, confusion. of
mental status can absence be early signs of symptoms impaired exchange. gas respiratory distress.
regurgitates the
pulmonary absence symptoms
circulation
causing pooling respiratory of blood in the distress. lungs. This
5. Observe
for 5. Central cyanosis in oral tongue mucosa and is of hypoxia
cyanosis in skin; especially note
pooling of blood in the lungs
color of tongue and oral mucous membranes.
indicative serious
causes pulmonary
and is a medical emergency.

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congestion. Because pulmonary congestion, oxygen not diffuse could easily to the 7. Provide rest and 7. Hypoxic minimize fatigue. has limited reserves; patient of 6. Encourage deep 6. Clear breathing and and airways facilitates
coughing every 2 hours.
oxygen delivery.
pulmonary circulation causing decreased oxygen supply.
inappropriate activity can
increase hypoxia.
8. Position in a Fowlers
patient 8. Reduces oxygen Semior consumption/ demands promotes maximal inflation. lung and
sitting position.
9. Teach
patient 9. To
help
the
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how to perform pursed-lip breathing.
patient
increase in acute
oxygenation times of
dyspnea
10. Turn the client 10. Turning every 2 hours. important prevent complications immobility.
is to
of
11. Administer humidified oxygen nasal through cannula,
11. Increases alveolar oxygen
concentration which consent reduce hypoxemia. may or tissue
as indicated.
12. Watch for onset 12. The patient may of hypoventilate

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hypoventilation as evidenced by increased somnolence after initiating oxygen.
during therapy.
oxygen
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Problem #3: Decreased Cardiac Output related to alterations in cardiac structure and function
ASSESSMEN T S>
NURSING
SCIENTIFIC
OBJECTIVES
NURSING INTERVENTIONS 1. Monitor signs.
RATIONALE
EXPECTED OUTCOME obtain Short term:
DIAGNOSIS EXPLANATION Decreased Cardiac Acute Coronary Short term: Syndrome is a weakness in the After 4 hours to muscle heart of due the of nursing
vital 1. To
baseline data The shall patient have
O>
The
pt. Output related alterations
manifested: Capillary
to interventions, the patient will in / that the
2. Observe symptoms cardiogenic
for 2. Cardiogenic of
participated in / that the of
refill time of in
cardiac inadequate
shock is a state behaviors of circulatory activities
less than 3 structure seconds
oxygen delivery participate the behaviors activities
and function to myocardium with
shock, including impaired mentation, hypotension with blood lower mmHg, decreased peripheral pressure than 90
failure from loss reduce from function associated with cardiac workload the heart.
Slightly pale as lips Untrimmed finger evidenced by
coronary reduce
cold, artery
disease workload of the
nails clammy
being the most heart. poor common cause. Because of Long term:
inadequate organ Long term: perfusion with a The high rate. mortality shall patient have
and toenails skin,
and pale in capillary color Limited
refill and low ischemia, there blood would be After 5 days of
demonstrated improved
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movements observed With easy
pressure
myocardial
nursing
pulses, clammy signs pulmonary congestion
cold skin, of
cardiac output as evidenced by clear lung sound, vital within
insult that would interventions, develop causing the patient will degeneration of demonstrate myocardial improved
fatigability
and
signs
> The pt. may manifest:
fibers. Damaged cardiac output fibers will heal as evidenced
decreased organ function.
normal limits, warm, skin, dry urine
and regenerate by clear lung arrhythmias bradycardia/ tachycardia palpitations edema fatigue jugular vein but there would sound, be formation of signs a fibrous band normal
vital 3. Auscultate heart 3. S3 may also be output of > 30 within limits, sound. noted with mitral ml/hr, insufficiency (regurgitation) that accompany severe infarction. decreased peripheral can edema neck and vein
of tissue which warm, dry skin, is not pliable. urine output of 30 ml/hr,
Because of this, >
there would be decreased decreased myocardial contractile function. Because myocardial peripheral edema neck and 4. Auscultate vein breath sounds.
distention and demonstrate
distention murmurs dyspnea oliguria prolonged capillary refill
4. Crackles
may an increase in
develop reflecting activity pulmonary congestion. tolerance
distention and of demonstrate an increase in
Page | 153
skin
color
dysfunction,
activity
5. Monitor
heart 5. Dysrhythmias may impair output. further cardiac
changes crackles cough orthopnea anxiety restlessness
there would be tolerance. decreased blood volume being
rate and rhythm
ejected from the ventricle causing decreased cardiac output. 6. Observe chest pain for 6. Chest or pain/discomfort is generally indicative of an inadequate blood supply to the
discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, indigestion, and diaphoresis, also note precipitating and factors. relieving
heart, which can compromise cardiac output.
Page | 154
7. Monitor and
intake 7. Decreased If cardiac results decreased perfusion of the kidneys, resulting decrease in urine output. with a output in
output.
client is acutely ill, hourly measure urine
output and note decreases output. in
8. Closely fluid including
monitor 8. In intake,
clients
with
decreased cardiac output,
intravenous lines. Maintain
poorly functioning ventricles not increased volumes. may tolerate fluid
fluid restriction if ordered.
9. Monitor
bowel 9. Decreased activity can cause

Page | 155
function. Caution
client strain
not
to when
constipation, well as
as pain
defecating.
medication. Straining defecating results Valsalva maneuver lead can to in when that the
dysrhythmia and decreased cardiac function.
10. Place
client
in 10. Elevating
the
semi-Fowlers or high-Fowlers position with legs down or position of comfort.
head of the bed and legs down may the
position decrease
work of breathing and may also
decrease venous
Page | 156
return preload.
and
11. Gradually increase activity when condition stabilized encouraging slower activities shorter of paced or periods with rest clients in by
11. Activity cardiac
of
the client
should be closely monitored.
activity
frequent
periods following exercise prescription; observe symptoms for of
intolerance. Take blood pressure

Page | 157
and pulse before and after activity and changes. note
12. During events,
acute 12. Restriction ensure activity
of
reduces
client remains on short-term bed
the workload of the heart.
rest or maintains activity level that does compromise cardiac output. not
13. Provide a restful 13. Rest helps lower environment minimizing controllable stressors unnecessary and by arterial pressure
and reduce the workload of the myocardium diminishing by the

Page | 158
disturbances. Schedule periods meals activities. rest after and
requirements for cardiac output.
14. Serve sodiumrestricted, cholesterol meals.
small 14. Sodium-restricted diets lowdecrease volume help fluid excess.
Low-cholesterol diets decrease atherosclerosis, which coronary disease. with disease smaller better cause artery Clients cardiac tolerate meals because
Page | 159
help
they require less cardiac output to digest.
15. If
intravenous 15. The response to rapid fluid loading can be predicted noninvasively by changes in pulse and pressure passive during leg
fluid is ordered for failure, administer cautiously circulatory
observe for signs of fluid overload. Administering excessive volume detrimental cardiac output. is to
raising in clients with acute
circulatory failure.
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Problem #4: Ineffective tissue perfusion related to decreased pumping ability of the heart and inadequate oxygen supply ASSESSMEN T S> NURSING SCIENTIFIC OBJECTIVES NURSING INTERVENTIONS 1. Monitor signs. vital 1. To RATIONALE EXPECTED OUTCOME obtain Short term:
DIAGNOSIS EXPLANATION Ineffective tissue In Coronary Syndrome, there After 4 hours to is altered of Acute Short term:
baseline data The 2. To determine the shall of appropriate interventions patient have
O>
The
pt. perfusion related decreased refill pumping
manifested: >>With capillary test of
nursing 2. Determine presence visual, sensory/motor of changes, headache, dizziness, altered status and personality changes. mental and
myocardial function.
interventions, the patient will
verbalized to knowledge of
3 ability of the Because of this, verbalize heart evidenced as there would be knowledge failed pumping treatment of regimen,
implemented and treatment to know when to regimen, refer the patient including to physician. appropriate exercise and
seconds >>fingernails and
toenails by
poor mechanism the cold Dilated is
are pale >>with hemoglobin count of 120mg/L
capillary refill,
heart. including Left appropriate also exercise
medications.
clammy skin atrium and weakness
significant
in medications.
Long term:
cardiomyopathy which will lead Long term: 3. Note history of 3. Because brief/intermittent this The patient have
The pt. may
to the backflow
suggest transient shall

Page | 161
manifest:
of blood in the After 3 days of left atrium nursing interventions,
periods confusion black out.
of or
ischemic attacks
adequate tissue perfusion as
altered mental status behavior changes changes motor response changes papillary reactions difficulty swallowing extremity weakness paralysis speech abnormalitie s in in in
causing
decreased blood the patient will pumped in the have adequate 4. Monitor patients 4. Changes systemic circulation. Decreased blood tissue perfusion evidenced as by behavior and behavior
evidenced by in warm, dry skin and and adequate
mental status for onset restlessness, agitation, confusion. of
mental status are urine output. signs of altered cerebral perfusion.
being warm, dry skin
pumped by the and adequate heart would urine output.
cause decrease cardiac and output 5. Take vital signs 5. To detect early every hours then hours patient stable. 1 to 2 signs decreased cerebral perfusion pressure. of
decreased
tissue perfusion.
initially, every 4
after become
6. Inspect for pallor, 6. Systemic

Page | 162
cyanosis, cold/clammy skin. strength Note of
vasoconstriction resulting diminished cardiac may be output be by skin and from
peripheral pulses
evidenced decreased perfusion
diminished pulses
7. Keep
patients 7. To
keep
the flow
head in neutral alignment.
carotid unobstructed, thereby promoting perfusion.
8. If
the
client 8. Postural hypotension can be detected in up of to 30% of elderly

Page | 163
experiences dizziness because
postural hypotension when getting up, teach methods to decrease dizziness, as seated such
clients.
These
methods can help prevent fall.
remaining for
several minutes before standing, flexing upward times seated, slowly, down immediately feeling and have present if feet several while rising sitting
dizzy, trying to
someone when
Page | 164
standing.
9. Encourage quiet 9. To and restful
conserve
energy in order to have adequate
environment
blood flow to the brain.
10. Maintain adequate nutrition.
10. To tissue
promote healing,
oxygenation and metabolism.
11. Take to
measures 11. To ward off increased metabolic
prevent
infection.
and
oxygen demands that can interfere with the brains metabolic needs.
Page | 165
12. Teach patient in 12. Relaxation performing relaxation techniques. techniques may
decrease oxygen supply.
13. Increase activity 13. Gradually as ordered. appropriately increasing physical
and
activity
may help the pt. gain cardiac
conditioning and improve tolerance. activity
14. Monitor
urine 14. Decreased perfusion to the kidneys may
output every 4 hours.
result in oliguria.
15. Caution client to 15. To avoid further

Page | 166
avoid that
activities increase such at
oxygen depletion.
workload as
straining
stool.
16. Instruct and members
patient 16. To increase the family in probability healthy adaptation continue. will that
ways to minimize risk factors for altered perfusion. tissue
17. Administer humidified oxygen through
17. To meet oxygen demand body. of the
nasal cannula.
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Problem #5: Activity intolerance related to mechanical dysfunction of the heart and decrease cardiac reserve ASSESSMEN T S> NURSING SCIENTIFIC OBJECTIVES NURSING INTERVENTIONS 1. Monitor signs. RATIONALE EXPECTED OUTCOME
DIAGNOSIS EXPLANATION Activity intolerance Because of the Short term: failed pumping of After 4 hours nursing
vital 1. To obtain baseline Short term: data The shall patient have
O>
the
pt. related
to mechanism
manifested:
mechanical dysfunction
the heart, there of
will be backflow interventions,
2. Determine cause 2. Determining of intolerance determine whether cause is physical, psychological or activity and
the verbalized
weakness paleness
of the heart of blood in the the patient will and left causing atrium verbalize understanding
cause of a disease understanding can help direct of the need to gradually increase activity based on and symptoms. rest for of Long term: tolerance
cold, clammy decrease skin difficulty breathing slowed movement and position change easy fatigability cardiac of reserve evidenced
appropriate interventions.
decreased blood of the need to as pumped in the gradually systemic increase activity on based
by difficulty circulation. of breathing Decreased blood
motivational.
tolerance
being and symptoms. 3. Assess the client 3. Bed daily for
pumped by the heart would Long term:
treatment
appropriateness of activity and
medical conditions is associated with The worse outcomes shall

Page | 168
cause decrease cardiac output After 4 days of
patient have
bed rest orders.
cannot tolerate supine position
and
decreased nursing
than mobilization
early participated in prescribed physical with
tissue perfusion. interventions, Since oxygen is the patient will needed for the participate production of prescribed
in 4. Observe for pain 4. Pain restricts the activity before activity. If possible, with pain activity in rate, treat before and client achieving maximal
from appropriate a changes activity heart in rate,
The pt. may manifest:
ATP, the patient physical would marked have activity
appropriate of changes
level and is often blood exacerbated movement. by pressure and respiratory rate.
alterations in heart and rate blood
limitation
ensure that the client is not
physical activity heart and activity cause
ordinary blood pressure could and respiratory fatigue, rate. and
heavily sedated.
pressure with activity abnormal heart rate
5. Observe document integrity
and 5. Activity intolerance skin several may lead to
palpitation dyspnea.
pressure Mechanical pressure, moisture, and forces
ulcers.
response to activity electrocardio graphic changes reflecting
times a day.
friction shearing all
predispose to their
Page | 169
arrhythmias electrocardio graphic changes reflecting ischemia exertional discomfort exertional dyspnea
development.
6. If mainly on bed 6. Deconditioning of rest, minimize the cardiovascular system within involves occurs days and fluid
cardiovascular deconditioning by positioning the
client in an upright position several
shifts, fluid loss, decreased cardiac output, decreased peak uptake, increased heart rate. oxygen and resting
times daily.
7. When getting a 7. When client up, observe for symptoms of intolerance such rises
an to
adult the
standing position, 300 to 800 ml of blood pools in the

Page | 170
as nausea, pallor,
dizziness, dimming impaired
visual and
lower extremities. As a result,
symptoms of CNS hypoperfusion may as occur, feelings weakness, nausea, headache, ache, lightheadness, dizziness, blurred vision and neck including of
consciousness, as well
changes in vital signs.
impaired cognition.
8. Instruct the client 8. These to stop the common symptoms
are
activity immediately and report to the
of
angina and are caused temporary

Page | 171
by
physician if the
client
is
insufficiency coronary supply.
of blood
experiencing the following symptoms: or new
Symptoms typically last for minutes opposed as to
worsened or
intensity increased frequency discomfort; tightness pressure chest, neck,
of
momentary twinges. If last
or in back, jaw,
symptoms
longer than 5 to 10 minutes, the client should be evaluated physician. by a
shoulders and or arms; palpitations, dizziness.
9. Allow for periods 9. Both physical and of rest before emotional helps rest lower
Page | 172
and after planned
exertion periods such as meals, baths, treatments and activities. physical
arterial
pressure
and reduce the workload of the myocardium.
10. Encourage families help/allow to an
10. Sometimes families believe
they are assisting by allowing clients to be sedentary. Encouraging activity does not only good of the enhances functioning bodys
elderly client to be in independent whatever
activities possible.
systems but also promotes a sense of worth.
Page | 173
11. Instruct the client 11. Illness and family in the importance maintaining proper nutrition. Instruct use of in the of suppress appetite, to
may
leading
inadequate
nutrition thus less energy to sustain activities.
dietary
supplements as indicated.
12. Instruct patient to 12. Activities avoid increasing abdominal pressure straining (e.g. during require
that holding
the breathe and bearing (valsalva maneuver) result bradycardia, temporarily reduce output cardiac and
Page | 174
down
defecation)
can in
rebound tachycardia.
13. Obtain necessary
any 13. Assistive devices can mobility increase by
assistive devices or equipment before the
helping the client overcome limitations.
needed ambulating client.
14. When appropriate, gradually increase activity, allowing the
14. Always have the client dangle at the before standing evaluate postural hypotension. Postural hypotension can
Page | 175
bedside trying to for
client to assist with positioning, transferring, and self-care possible. as
Progress
from
be detected in up to 30% of elderly clients. These
sitting in bed to dangling, standing, ambulation. to to
methods can help prevent falls.
15. Perform range of 15. To motion exercises if the client is unable to tolerate activity or is muscle
prevent atrophy
due to complete bed rest or
immobility.
mostly immobile.
16. If the client is 16. The unable to walk and has heart walked minutes
distance in 6 was
failure, use of
consider the 6-
useful in clients with ventricular dysfunction, as left
minute walk test to determine
physical ability.
well as those with

Page | 176
preserved function, and that distance was walked directly
related to rates of rehospitalization and death for 100 clients dilated cardiomyopathy. The walk shown highly reproducible in 6-minute test to was be with
determining ability to ambulate in a client with heart failure.
17. When mobilizing 17. Postural

Page | 177
the elderly client, watch orthostatic hypotension accompanied by dizziness fainting. and for
hypotension
can
be detected in up to 30% of elderly clients. these
methods can help prevent falls.
18. If
client 18. Syncope many with including vasovagal,
has causes, benign but
experiences syncope
activity, refer for evaluation by a physician.
can also be due to serious cardiac disease, resulting in death.
Page | 178
Problem #6: Altered nutrition: less than body requirements related to loss of appetite
ASSESSMENT
NURSING DIAGNOSI S
SCIENTIFIC EXPLANATION
OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
EXPECTED OUTCOME
S:
Altered nutrition:
Because patient
the Short term: has of After 4 hours
1. Monitor signs.
vital 1. To
establish Short term:
baseline data. The usual 2. Omission to entire of shall food identified patient have
O: The patient less may manifest: weakness loss appetite body
than difficulty
breathing, other of
nursing 2. Compare food food noting
requiremen manifestations of ts
interventions,
intake
related such as chest the patient will and identify this nutritional the requirements.
pyramid omitted
groups increases nutritional risk deficiencies. Long term: of requirements
to loss of pain
with capillary appetite as weakness, refill less test than of evidenced 3 by weakness causes
food groups.
patient to have decrease appetite. Because it After 3 days of Long term:
3. Observe patients ability to eat involved, (time motor
3. In order to come up proper interventions. with the The shall patient have
seconds fingernails and toenails
consumed adequate nourishment.

Page | 179
are pale generalized
requires energy nursing when eating this interventions,
skills, ability to swallow various
weakness with a BMI of 18.56 kg/m

2
causes patient become
the the patient will to consume adequate
textures of food).
4. Observe patients relationship to
4. Refusing to eat may be the only way the patient can express
exhausted thus nourishment. increasing the
respiratory rate which exacerbate difficulty breathing. of The
food. Attempt to separate physical physiological causes for from
some control and may also be a symptom depression. of
chest pain felt is also a reason for loss of the
difficulty eating.
5. If patient lacks 5. Nursing endurance, schedule periods meals. rest before assistance the energy activities. with
appetite,
patient focuses more on the
ADL will conserve patients for
pain felt rather than on eating. Loss of appetite indicates insufficient
6. Provide companionship
6. Mealtime should be a time for

Page | 180
intake nutrients
of to
at
mealtime
to
social interaction to the patient to increase appetite. his
encourage nutritional intake.
meet metabolic needs weakness more occur. likely thus is to
7. Determine of day
time 7. In order for the when patient the to have
patients appetite is greatest; offer highest calorie
appropriate
amount of calorie needed energy. for
meal at that time.
8. Offer volumes liquids as
small 8. Small volumes of of an liquids will
stimulate GI tract, enhances peristalsis motility. and
appetizer before meals.
9. Encourage social 9. This may distract interaction during or distress

Page | 181
mealtime,
but
patient, decreasing interest in eating.
avoid combining mealtimes with
other activities.
Page | 182
Problem #7: Constipation related to poor oral intake and decreased activity ASSESSMENT NURSING DIAGNOSI S S: Constipatio Constipation is a Short term: in bowel After 5 hours of nursing 2. Observe pattern defecation including time of day, amount and frequency stool, consistency stool and of diet food Long term: of 1. Monitor signs. vital 1. To establish Short term: SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME
n related to change O: The patient poor manifested: no oral normal
baseline data. The patient/SO usual 2. There often are shall of multiple reasons identified for constipation; measures that or have
intake and habits
bowel decreased
characterized by interventions, the patient/SO will be able to or identify measures that of prevent or treat or constipation.
movement for activity 3 days loss appetite generalized weakness with
as decreased frequency, difficult incomplete passage stool,
evidenced of by hypoactive bowel sounds
the first step is prevent assessment of treat
usual patterns of constipation bowel elimination. after 5 hours of nursing
limited and
passage of dry,
activities noted
absence of hard stool. Poor Long term: bowel movement food intake and decreased of After 4-5 days fluid of nursing
interventions.
including intake.
The
patient for days
four intake
may manifest:
decreased bulk interventions,
3. Auscultate bowel 3. In patients with The

Page | 183
patient
in the stool so the patient will decreased frequency passage stool change usual pattern dry, hard in eating of of the feces tend to have be dry and hard elimination causing decreased frequency of pattern within
sounds, percuss for dullness and palpate abdominal distention. for
constipation, the shall have his abdomen is often elimination distended with a pattern within palpable colon. normal limits
normal limits.
after 4-5 days of nursing
passage of stool and during defecation. straining
4. Monitor record
and 4. Inadequate patients
fluid interventions.
intake contributes to dry feces and constipation. Monitoring fluid
fluid intake and out
formed stool decreased intake of fluid straining during defecation hypoactive bowel sounds severe flatus distended abdomen abdominal
balance ensures adequate intake promotes elimination. fluid and
5. Provide for
privacy 5. Bowel elimination is a very private act, and a lack of privacy can
Page | 184
defecation.
Assist the patient to the bathroom
tenderness
and
close
the
contribute constipation.
to
door if possible.
6. Add fiber to diet 6. Fiber gradually like prevent constipation
helps
bran cereals and oatmeal.
by
giving stool bulk.
7. Encourage
fluid 7. Adequate intake necessary
fluid is to
intake of 1.5 to 2 L per day. If oral intake is low,
prevent hard, dry stools.
gradually increase intake. fluid Fluid
intake must be within the cardiac and reserve. renal
8. Encourage
8. Activity,
even
Page | 185
exercises as turning
such and
minimal, increases peristalsis, which is necessary to prevent constipation.
changing positions in bed, lifting their hips off the bed and doing active/passive range of motion exercises.
9. Initiate a regular 9. A schedule gives schedule the normal evacuation whenever possible. time for patients the client a sense of control but
defecation, using
more importantly it promotes
evacuation before drying of stool.
10. Provide laxatives 10. To
prevent
Page | 186
or
suppositories
valsalva maneuver can that
as indicated for a normal regimen. bowel
aggravate
condition.
11. Encourage patient to use the bathroom when
11. Using may normal
bedpan inhibit
defecating. Avoid use of bedpan.
positioning evacuation, thereby exacerbating constipation.
for
12. Encourage patient/SO maintain
the 12. To to
facilitate of
monitoring long-term problem.
elimination diary if appropriate.
13. Help
patient 13. To
encourage
Page | 187
understand
diet
compliance
with
modification plan. If have consult dietitian. appropriate, patient with
prescribed diet.
Page | 188
Problem #8: Anxiety related to economic status Assessment Nursing Diagnosis S: Scientific Explanation therapy Short-term: acute Objectives Nursing Interventions >establish therapeutic After 2-3 hours relationship of nursing >to trust get Rationale Expected Outcome the Short-term: and The patient have
Patient Anxiety related Initial to economic for
manifested: >feelings inadequacy >worried >verbalization of about matters feelings money
of status
coronary syndrome should on the
cooperation of shall the patient verbalized feelings >to have a anxiety
focus interventions
of
stabilizing the patient will >assess patient's be able to general condition of >monitor record signs
baseline data
therapeutically.
condition, relieving
verbalize feelings
Long-term: and >to have a The shall showed reduced >to comfort provide anxiety appeared relaxed. and patient have
ischemic pain, anxiety Patient manifest: >apprehension >helplessness >uncertainty may and providing therapeutically.
vital comparative data
antithrombotic therapy reduce myocardial damage to Long-term:
After 1-2 days >provide of nursing comfort measures such stretching and
and interventions
prevent further the patient will as ischemia. If be able to linen
Page | 189
there
are
no demonstrate
therapeutic touch
progressions or reduced complications arise anxiety and
surgical appear will relaxed. next
>be
available >in
order
to
treatment be the
to patient for give emotional listening talking and support for the patient
resort or heart transplant will
take place. In the case of the patient, manifest anxiety because he is thinking of the money that her daughter have spent because of condition. Instead of his he
>encourage patient express feelings
>to
lessen
to emotional intensity
>encourage significant
>to lessen the burden of the
others to show patient support for the patient
>give
>to
promote
Page | 190
saving their
it
for
medications as compliance ordered medical regimen
to
family,
she chose to spend it for the treatment her father. of >refer accordingly
>to
ensure of
continuity care
Page | 191
Lifezar Name of Drugs Generic name Brand name Generic name: Losartan Brand name: Lifezar DATE ORDERED: 11-08-11 DATE GIVEN: 11-08-11 (HOME MEDICATION) Mechanism of action: Angiotensin II (formed from angiotensin I), a potent vasoconstrictor, is the primary vasoactive hormone of the reninPage | 192
Date ordered Date given Date discontinued
Route of admin. Dosage and frequency of admin.
General action
Indication or purposes
Clients response to the med
100 mg/tab General Action: tab BID Therapeutic: Angiotensin II
It was given to Mr. The Cardio Nstemi the receptor of hypertension; for blood
patients pressure
treatment decreased from in 160/110 to
antagonist/antihypertensive myocardialinfarction. 110/80mmHg.
angiotensin system and an important component in the pathophysiology of hypertension. It also stimulates aldosterone secretion by the adrenal cortex. Losartan and its principal active metabolite block the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor found in many tissues .
NURSING RESPONSIBILITIES Before:

Page | 193
Assess patients blood pressure before starting therapy and regularly and pulse rate. Obtain baseline liver and renal function before therapy and regularly Assess kidney function BUN and creatinine. Monitor for possible adverse drug reaction Assess for hydration status
During: Advise patient to comply with dosage schedule, even if feeling better. Tell patient to avoid sodium substitutes because it may contain potassium which can cause hyperkalemia inpatients takingdrug. After: Evaluate if patients blood pressure is normal. Teach patient to avoid sunlight or wear sunscreen because photosensitivity may occur. Inform patient that drug can cause dizziness.
Page | 194
Check if the patient does not experience drug induced adverse reactions. Evaluate patients and family state understanding of drug therapy
ALDAZIDE
Name of Drug
Date ordered/ Date taken/ Date changed/ Date discontinued
Route of administration, Dosage and Frequency
General Action/ classification/ Mechanism of action
Indication(s) or Purpose(s)
Clients response to the medication with actual side effects
Generic Name: Spironolactone
DATE ORDERED: 11-08-11
1 tab 25mg BID
General Action: Potassiumsparring diuretic
Counteract potassium loss caused by other diuretics.
The patient had a increase urine output but maintained a potassium
Brand Name: Aldazide DATE TAKEN 11-08-11 DATE
Mechanism of action: Cause loss of sodium Use with other agents to treat hypertension.
level of 4.22. Blood pressure was also controlled as

Page | 195
STOPPED: 11-15-11
bicarbonate and calcium while saving potassium and hydrogen ions.
evidenced by a BP of 110/70mmHg on 11-09-11.
Nursing Responsibilities: Prior: 1. Monitor intake and output ratios and daily weight during therapy. 2. If medication, is given as an adjunct to antihypertensive therapy, monitor blood pressure before administering. 3. Monitor response of signs and symptoms of hypokalemia.
During: 1. Administer in the morning to avoid interrupting sleep pattern. 2. Administer with food or milk to minimize gastric irritation and to increase bioavalability.
After:Caution patient to avoid salt substitutes and foods containing high levels of potassium or sodium unless prescribed by health care professionals.
Page | 196
1. 2. Advise patient to notify health care professionals if muscle weakness or cramps; fatigue, nausea or vomiting or diarrhea occurs. 3. Hypertension: Reinforce need to continue additional thimapies fro hypertension. Medications helps control but does not cure hypertension.
BISOPROLOL
Name of Drugs (generic name and brand name) Generic name: Bisoprolol Fumarate
Date ordered Date given Date changed Date stopped DATE ORDERED: 11-08-11 DATE GIVEN: 11-08-11 DATE STOPPED: 11-08-11
Route/Dosage and Frequency of Administration
General Action Classification Mechanism of action
Indication
Clients response to medication with actual side effect.
2.5mg/tab tab BID
General action: Antihypertensive Mechanism of action: Bisoprolol selectively blocks catecholamine stimulation of 1adrenergic
It was indicated for the patient for the management and control of hypertension. To maintain effective perfusion in the patients body especially the most important organs in
The patient responded well with the treatment as evidenced by the patients blood pressure decreased from 160/100 to Page | 197 110/80mmHg. (November 8, 2011 to November 9,
Brand name: Zebeta
receptors in the heart and vascular smooth muscle. These results in a reduction of heart rate, cardiac output, systolic and diastolic blood pressure, and possibly reflex orthostatic hypotension. At higher doses (e.g. 20 mg and greater) bisoprolol may competitively block 2adrenergic receptors in bronchial and vascular smooth
the body such as heart, lungs, brain, kidneys and liver.
2011)
Page | 198
muscle causing bronchospasm and vasodilation.
Nursing Responsibilities Before: Administer Bisoprolol with meals or directly after eating.
During: After: May cause drowsiness. Caution patient to avoid activities requires alertness. Advise patient to change positions slowly to minimize orthostatic hypotension. Diabetics should closely monitor blood glucose, especially if weakness, malaise, irritability and fatigue occur. Monitor blood pressure and pulse frequently. Monitor input and output ratios and daily weight. Assess routinely for signs and symptoms of Heart failure. May increase BUN, serum lipoprotein, K, triglycerides and uric acid levels and increase blood glucose levels.
Page | 199
VIGOCID
Name of Drugs Generic name Brand name
Date ordered Date performed Date changed
Route of admin. Dosage and frequency of admin. 45 gms IV q 12
General action
Generic name: Piperacillin Tazobactam Brand name: Vigocid
DATE ORDERED: 11-10-11 DATE GIVEN: 11-10-11
General Action: Therapeutic: Antibiotic Extended spectrum penicillin, beta-
The patient was Mr. Cardio Nstemi given this drug did not experience as a prophylaxis exacerbation to growth in
prevent his pneumonia as of evidenced by of of
bacteria that may absence exacerbate patients pneumonia. Useful presumptive as the shortness breath.
DATE DISCONTINUED: 11-14-11
lactamase inhibitor
therapy
in
the
Page | 200
Mechanism action: Piperacillin to
of
indicated conditions prior the of
binds
to identification causative organisms because of
bacterial cell wall membrane, causing death. is extended compared with penicillins Tazobactam inhibits beta-lactamase, an other cell Spectrum
its
broad of
spectrum bactericidal against
activity
gram-positive and gram-
negative aerobic and anaerobic
organisms.
Page | 201
enzyme that can destroy penicillins
NURSING RESPONSIBILITIES Before: Assess patient for infection at beginning of and during therapy Obtain a history before initiating therapy to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results During: Do not administer discoloured solution.
Page | 202
After:
Check IV site during administration.
Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of
Pseudomembranous colitis. May begin up to several weeks following cessation of therapy
Page | 203
LEVOFLOXACIN Name of Drugs (generic name and brand name) Generic name: Levofloxacin Date ordered Date given Route/Dosag e and Frequency of General Action Classification Mechanism of action Indication Clients response to medication with actual side effect.
Date changed Administratio Date stopped DATE ORDERED: 11-13-11 n
500mg/tab OD General action: Therapeutic: Anti infectives
For management of Due to Mr. Cardio respiratory infection Nstemi like pneumonia. Mr. disease, Cardio Nstemi was given diagnosed he Leevox CAP was to
Brand name: Levox DATE GIVEN: 11-13-11 (HOME MEDICATION ) Mechanism of action: The drug interferes with DNA gyrase, an Pharmacologic: fluoroquinolone
with prevent the increase
CAP based on his of bacteria causing chest x-ray results his on Nov. 08, 2011. infection. respiratory
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enzyme needed for replication, transcription, repair of and bacterial
DNA. Causes death of bacteria. susceptible
NURSING RESPONSIBILITIES
Before: Assess for infection (vital signs; sputum, urine, and stool; WBC) for baseline data. Monitor intake and output and daily weight to assess hydration status and renal function. Verify doctors order.
During: Maintain aseptic technique. Check for the placement of NGT, crush the tablet. Observe signs and symptoms of anaphylaxis.
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After: Monitor patient for fever and diarrhea; note the characteristics of the stool. Discontinue the treatment if pt. experiences rashes and tendon pain. Document time and date in the chart.
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DIGOXIN Name of Drugs (generic name and brand name) Generic name: Digoxin Date ordered Date given Route/Dosag e and Frequency of General Action Classification Mechanism of action Indication Clients response to medication with actual side effect.
Date changed Administratio Date stopped DATE ORDERED: 11-08-11 n 0.25 mg/tab tab OD
General Action: Therapeutic: antiarrhythmics, inotropics
Indicated increase output
to Mr.
Cardio
Nstemi
cardiac heart rate returned to and slow normal range.
heart rate. It was given to Mr. Cardio Nstemi because he experienced MI and
Brand name: Lanoxin DATE GIVEN: 11-08-11
Pharmacologic: digitalis glycosides
displayed premature ventricular contractions.
DATE STOPPED:
General Action: Increases the force

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11-08-11
of
myocardial
contraction. Prolongs refractory period of the AV node.
Decreases conduction through
SA and AV nodes
Before: Monitor for blood pressure and heart rate note if apical pulse is <60bpm. Monitor renal function and serum electrolytes especially potassium. Verify doctors order. Monitor intake and output ratios and daily weights. Assess for peripheral edema, and auscultate lungs for rales or crackles throughout therapy.
During: Monitor ECG throughout administration. Observe IV site for redness, infiltration; extravasation can lead to tissue irritation and sloughing.
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After:
Check for the placement of NGT, crush the tablet (should be taken with meals). Administer oral preparations consistently with regards with meals. Tablets can be cruhed and administered with food or fluids if patient has difficulty of swallowing.
Check blood pressure and pulse rate. Caution patient to change position slowly to prevent orthostatic hypotension. Monitor for serum digoxin levels. Teach patient to take pulse and to contact health care professional before taking medication if pulse rate is <60 or >100. Review fall prevention strategies with older adults and their families.
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ISOSORBIDE DINITRATE Name of Drugs (generic name and brand name) Generic name: Isosorbide Dinitrate Route/Dosag e and Date given Frequency of Date changed Administratio n Date stopped DATE ORDERED: 11-08-11 DATE GIVEN: Brand name: Isoket 11-08-11 DATE CONSUMED: 11-09-11 Isoket drip 10 mg in 90 cc D5W at 20cc/hour Date ordered General Action Classification Mechanism of action Indication Clients response to medication with actual side effect.
General Action: Therapeutic: Antianginal Pharmacologic: Nitrates Mechanism of action: produce vasodilation. Increase coronary blood flow by dilating coronary arteries and improving collateral flow
The drug was indicated for the patient for the management of uncontrolled pain of cardiac origin. It was administered as a side drip for acute treatment of chest pain and for prophylactic management of angina pectoris.
The chest pain was relieved and the BP was decreased from 160/110 to 110/80 mmHg. (November 8, 2011) Furthermore there were no side effects experienced by the patient such as headache, dizziness, weakness, fainting, nausea, vomiting and diarrhea.
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Before: Assess location, intensity, duration and precipitating factors of anginal pain. Check the drug three times before administering Inform the purpose of the drug to the patient Assess location, duration, intensity and precipitating factors of the patients angina pain. Monitor blood pressure before and after administration.
During: If chest pain occurs, seek emergency medical help at once. Report acute headache, rapid heartbeat, unusual restlessness or dizziness, muscular weakness, or blurring vision. After: Caution patient to make position changes slowly to minimize orthostatic hypotension. Caution patient to avoid driving or other activities which requires alertness since the drug may cause dizziness or drowsiness. Inform patient that headache is a common side effect that should decrease with continuing therapy.
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ISOSORBIDE MONONITRATE
Name of Drugs (generic name and brand name) Generic name: Isosorbide Mononitrate
Date ordered Date given
Route/Dosag e and Frequency of
Indication
Date changed Administratio Date stopped DATE ORDERED: 11-09-11 n 30 mg tab BID
General action: Therapeutic: Anti Anginals Pharmacologic:
The
drug
was Mr. Cardio Nstemis per chest pain AEB was he
administered
orem to Mr. Cardio controlled Nstemi prophylactic management
for did not complain of his chest pain and he of did not experience any discomfort. The client did not
Brand name: Imdur
DATE GIVEN: 11-09-11 DATE STOPPED:
nitrates
angina attacks.
complain of any side Mechanism of action: Produce vasodilation effects retrostrnal

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such
as
11-15-11
and myocardial consumption. Increase
reduced oxygen
discomfort, palpitations, hypotension syncope. and
coronary
blood flow by dilating coronary arteries and improving flow of conateral ischemic
organs.
Before: Assess location, duration, intensity and precipitating factors of the patients angina pain. Monitor blood pressure before and after administration. Verify doctors order.
During: For PO, the drug should be taken on empty stomach. For sublingual, Instruct patient tablet should be held under tongue until dissolved and avoid eating and drinking. Avoid eating, drinking, or smoking until tablet is dissolved. Replace tablet if inadvertently swallowed.
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After: Monitor for dry mouth or blurred vision occurs. Caution patient to change position slowly to prevent orthostatic hypotension. Inform patient that headache is a common side effect. Advise patient to relax and report if pain is not relieved.
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TRIMETAZIDINE Name of Drugs (generic name and brand name) Generic name: Trimetazidine Route/Dosag e and Date given Frequency of Date changed Administratio n Date stopped DATE ORDERED: 11-08-11 Brand name: Vastarel MR DATE GIVEN: 11-08-11 DATE STOPPED: 11-15-11 HOME MEDICATION 35 mg/ tab OD Date ordered General Action Classification Mechanism of action Indication Clients response to medication with actual side effect.
General action: Therapeutic: Anti-anginal Mechanism of action: Increase in glucose oxidation for better energy production under ischaemic conditions. By preserving the energy metabolism in cells exposed to hypoxia or
This drug is indicated for the patient as a prophylactic management for chest pain. Generally this drug is used for the treatment of ischemic heart disease, angina pectoris, sequelae of infarction. Moreover the drug was administered
Mr. Cardio Nstemi sometimes still experience chest pain even with the administration of other anti anginal drugs so the doctor decided to add vastarel in the treatment for his chest pain. The client responded well with the treatment as evidence by the patient chest pain
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ischaemia, trimetazidine prevents a decrease in intracellular ATP levels, thereby ensuring the proper functioning of ionic pumps.
to improve perfusion in the heart as well as on the peripheral parts of the patients body.
decreased upon taking the medication.
Before: Assess location, duration, intensity and precipitating factors of the patients angina pain. Monitor blood pressure and heart rate before and after administration. Verify doctors order.
During: Inform the patient to swallow the tablet whole. Do not crush the medication.
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After: Monitor for untoward reactions to the drug. Caution patient to change position slowly to prevent orthostatic hypotension. Document time and date in the chart.
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ERDOSTEINE Name of Drugs (generic name and brand name) Generic name: Erdosteine Date ordered Date given Route/Dosag e and Frequency of General Action Classification Mechanism of action Indication Clients response to medication with actual side effect.
Date changed Administratio Date stopped DATE ORDERED: 11-08-11 n 300mg cap BID
General Action: Therapeutic:
As a mucolytic in Mr. the treatment
Cardio
Nstemi
of was able to expel the
productive cough. It excessive mucus in lungs by as the
Mucolytic, cough and was given to Mr. his cold preparations Cardio
Brand name: Zertin DATE GIVEN: 11-08-11
Nstemi evidenced
because he still had presence of thick and sputum discharges yellowish Mechanism of action: Anesthesizes cough characterized thick and as discharges. dry. sputum
(Home Medication)
or stretch receptors in vagal nerve
Through this drug, he could easily the

Page | 218
afferent fibers found
expectorate
in lungs, pleural, and thick, clear sputum respiratory passages. without needing too May also decrease much effort for him transmission of the leading to decrease cough centrally. reflex oxygen demand.
Before: Assess frequency and nature of cough, lung sounds, and amount and type of sputum produced. Unless contraindicated, maintain fluid intake of 1500-2000ml to decrease viscosity of bronchial secretions.
During: Capsule should be swallowed whole. Do not chew, because may cause local anesthetic effect and choking.
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After: Caution patient not to chew capsules. Instruct patient to cough effectively. Sit upright and take several deep breaths before attempting to cough. Advise patient to minimize cough by avoiding irritants such as smoking, fumes and dust. Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication.
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AVAMAX
Name of Drugs (generic name and brand name)
Date ordered Date given Date changed Date stopped
Route/Dosage and Frequency of Administratio n 40mg/ tab at HS
Indication
Generic name: Atorvastatin
General Action: Therapeutic: lipid-lowering agents
Adjunct therapy
to in
dietary Mr. Cardio Nstemi did the not experience
management primary
of increase in lipid profile and recurrence of MI but he still
Brand name: Avamax DATE GIVEN: 11-08-11 (Home Medication)
hypercholesterolemi Pharmacologic: HMG-CoA inhibitors Mechanism of action: Inhibit an enzyme, 3Hydroxy-3reductase a and
mixed experiences weakness and mild
dyslipidemias.
Reduction of lipids/ chest pains. cholesterol reduces the risk of
recurrence of MI and stroke sequelae.

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methylglutarylcoenzyme A (HMGCoA) reductase, which is responsible an for early
catalyzing
step in the synthesis of cholesterol.
Nursing Responsibilities
PRIOR: Check the Doctors order. Ensure that it is the right drug, right dosage, and right time to give drug. Check for the expiration date. Explain the importance of taking the drug. Assess for hypersensitivity reactions before administering the drug.
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DURING: Administer once daily in the evening. May be administered without regard to food.
AFTER: Medication should be used in conjunction with diet restrictions, exercise and cessation of smoking. Caution patient to wear protective clothing use sunscreen to prevent photosensitivity reactions. Document it properly.
CLOPIDOGREL
Name of Drug
Date ordered/ Date taken/ Date changed/ Date discontinued
Route of administration, Dosage and Frequency
General Action/ Functional classification/ Mechanism of action
Indication(s) or Purpose(s)
Clients response to the medication with actual side effects
Page | 223
Generic Name: Clopidogrel
75 mg/tab OD
General Action: Platelet aggregation inhibitors
Reducton of atherosclerotic events including recent MI, acute acute coronary
Mr. Cardio Nstemi did not experience thrombus formation and recurrence of MI but he still experiences weakness and mild chest pains.
Brand Name: Plavix DATE GIVEN: 11-08-11 Mechanism of action: Inhibits platelet (Home Medication) aggregation by irreversibly inhibiting the binding of ATP to platelet receptors.
syndrome, and cardiovascular disease.
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Nursing Responsibilities: Before: Assess patient for symptoms of stroke, periphimal vascular disease, or MI periodically during therapy. Monitor patients for signs of thrombotic purpura (thrombocytopenia, microangiopathic hemolytic anemia, neurologic findings, renal dysfunction, fever). Monitor CBC with differential and platelet count periodically during therapy. Neutropenia and thrombocytopenia may rarely occur.
During: Administer once daily without regard to food.
After: Advise patient to notify health care professional promptly if fever, chills, sore throat, or unusual bleeding and bruising occurs. Advise patient to notify health care professional of medication regimen prior to treatment or surgery. Advise patient to avoid taking OTC medications containing aspirin or NSAIDs without consulting health care professional.
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ASPIRIN
Name of Drugs (generic name and brand name) Generic name: Aspirin
Date ordered Date given
Route/Dosag e and Frequency of
Indication
Date changed Administratio Date stopped DATE ORDERED: 11-08-11 n
80 mg /tab OD General Action: Therapeutic: Antiplatelet
The drug is used to Patient took aspirin prevent platelet aggregation. further after patient manifest experienced meals. did The not or
Brand name: Asaprim DATE GIVEN: 11-08-11 Pharmacologic: Salicylates
thrombus formation. The client did not manifest effects nausea, Mechanism of action: Produce analgesia
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any such
side as
epigastric and
discomfort hemorrhage.
and inflammation fever
reduce and the of It platelet
inhibiting
production protaglandins. decreases aggregation.
Before: Inform the purpose of the drug to the patient Assess pain and limitation of movement; note type, location, and intensity before and at peak after administration. Assess fever and note associated signs (diaphoresis, tachycardia, malaise, chills).
During: Administer after meals or with food or an antacid to minimize gastric irritation. Instruct patient not to chew enteric coated tablets Use lowest effective dose for shortest period of time. Do not crush or chew enteric-coated tablets.
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After: Assess pain and limitation of movement; note type, location and intensity before the peak after administration. Instruct patient to take with a full glass of water and to remain in an upright position for 15 30 min. after administration. Teach patient on sodium restricted diet to avoid effervescent tablets or buffered aspirin preparations. Tablets with an acetic (vinegar-like) odor should be discarded. Caution patient to avoid concurrent use of alcohol with this medication to minimize possible gastric irritation.
ARIXTRA
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Route/Dosa ge and Frequency of Administrati on 2.5 Sc OD
Indication
Generic name: Fondaparinux Sodium
General Action: Therapeutic: Anti coagulant
The drug was indicated and given to the patient to help open a blocked heart artery due to
The client responded well with the treatment as evidenced by no further exacerbation on the blockage brought about by atherosclerotic plaque. No further blockage on the coronary artery on the heart as evidenced by absence of cyanosis and altered level of consciousness.
Brand name: Arixtra DATE GIVEN: 11-08-11 Mechanism of action: Fondaparinux is the first in a class of DATE DISCONTINUE D: 11-12-11 antithrombotics that selectively inhibits Factor Xa, a central protein in the coagulation process. In the treatment of thrombosis, Factor Xa
atherosclerotic plaque.
Page | 229
plays a central role in the generation of thrombin, a protein in blood that facilitates blood clotting.
NURSING RESPONSIBILITIES Before: Assess for any allergy to the medication. Assess for any allergy to any other substances, such as foods, preservatives or dyes.
During: After: Assess pain and limitation of movement; note type, location and intensity before the peak after administration. Instruct patient to take with a full glass of water and to remain in an upright position after administration. Caution patient to avoid concurrent use of alcohol with this medication to minimize possible gastric irritation. Caution patient not to chew or crush preparation
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SENOKOT
Date ordered Date Given Date changed Date Stopped
General action
Generic name: Senokot Brand name: Senna
DATE ORDERED: 11-08-11 DATE GIVEN: 11-08-11 DATE DISCONTINUED: 11-08-11
2 tabs at HS
General Action: Therapeutic: Laxatives Mechanism of action: Senokot is a stimulant laxative. It works by irritating bowel tissues, resulting in bowel movements.
It was given to Mr. Cardio Nstemi as a prophylactic management for constipation. Hence, it prevents Mr. Cardio Nstemi to strain which could stimulate valsalva thus causing aggravation to his heart condition.
Within the administration of Senokot Mr. Cardio Nstemiwas able to pass out stool. (November 8, 2011). On 1108-11, the patient did not manifest and experience constipation, due to this event, the doctor hold the dosage of Senokot and he
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was able to pass stool without doing the act of straining. NURSING RESPONSIBILITIES Before: Assess for any allergy to the medication. Assess for any allergy to any other substances, such as foods, preservatives or dyes.
During: Take Senokot by mouth with or without food. Take Senokot with a full glass of water (8 oz/240 mL). Drink extra fluids while you are taking Senokot, unless instructed differently by your doctor. It is best to take Senokot at bedtime. If you miss a dose of Senokot, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. After: A bowel movement usually occurs in 6 to 12 hours.
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Do not use for longer than 1 week without checking with your doctor. Using Senokot for a long time may result in loss of normal bowel function. Do not take additional laxatives or stool softeners with Senokot unless directed by your doctor.
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LACTULOSE
Name of Drugs (generic name and brand name) Generic name: Lactulose
Route/Dosag e and Date given Frequency of Date changed Administratio n Date stopped DATE ORDERED: 11-08-11 30 cc at HS
Date ordered
Indication
General action: Therapeutic: Laxatives Pharmacologic: Osmotics Mechanism of action: Lactulose is a synthetic sugar used in the treatment of constipation. It consists of the
This drug is indicated for the patient as a prophylactic management for constipation. It also prevents the stimulation of valsalva maneuver thus preventing excessive drop on the blood pressure or causing
Mr. Cardio Nstemi was able to pass out soft stool without too much straining preventing valsalva stimulation thus preventing alteration in blood pressure.
Brand name: Duphalac
DATE GIVEN: 11-08-11 DATE HOLD: 11-09-11 DATE CONTINUED: 11-12-11 HOME
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MEDICATION
monosaccharides fructose and galactose. In the colon, lactulose is broken down primarily to lactic acid, and also to small amounts of formic and acetic acids, by the action of via evolved-beta galactosidase from colonic bacteria, which results in an increase in osmotic pressure and slight acidification of the colonic contents. This in turn causes an increase in stool water content and
bradycardia.
Page | 235
softens the stool. Furthermore, it is thought that lactulose draws out ammonia from the body in the same way that it draws out water into the colon.
Before: Assess for abdominal distension, presence of bowel sounds, and normal bowel function. Assess color, consistency and amount of stool produced. Monitor for hydration status, and serum electrolytes. Assess mental status before and throughout course of therapy.
During: Darkening of solution does not alter potency. Mix with fruit juice, water, milk, or carbonated citrus beverage to improve flavour.
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After:
Administer with a full glass of water or juice. May be administered on an empty stomach for more rapid results.
Assess for abdominal cramping, belching and flatulence. Encourage patient to use other forms of bowel regulation such as increasing bulk in the diet and increasing fluid intake. Advise patient to notify health care provider if diarrhea, flatulence, or abdominal cramping occurs.
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PANTOPRAZOLE
Name of Drugs Generic name Brand name Generic name: PantoprazoleSodium
Date ordered Date performed Date changed DATE ORDERED: 11-08-11
Route of admin. Dosage and frequency of admin. 40mg/tab 1 tab OD
General action
General Action: Therapeutic: Anti-ulcer drug Pharmacologic:
It is indicated for the patient as a prophylactic management for GI disturbance such as Ulcer
Mr. Cardio Nstemi responded well with the treatment as evidenced by the patient did not develop GI disturbance such as ulcer formation. Moreover, the patient has chest pain of cardiac origin.
Brand name: Pantoloc DATE GIVEN: 11-08-11
Proton pump inhibitor Mechanism of
formation thus suppressing gastric secretion and GI irritation. Furthermore it was indicated to differentiate GERD or heart burn to chest pain of cardiac
DATE DISCONTINUED: 11-14-11 HOME
action: Binds to an enzyme on gastric parietal cells in the presence of
Page | 238
MEDICATION
acidic gastric acid pH, preventing the final transport of hydrogen ions in to the lumen.
origin.
Nursing Responsibilities: Before: Identify patient Check the drug three times before administering Inform the purpose of the drug to the patient
During: Should be taken on an empty stomach Instruct patient to take the medicine 1 hr before meals. Swallow whole, do not chew/crush
After: Instruct patient to take medication s directed for the full course of therapy, even if feeling better. Caution patient to avoid driving or other activities requiring alertness since the drug may cause occasional
Page | 239
drowsiness or dizziness.
LEXOTAN
Route/Dosage and Frequency of Administratio n 1.5 mg/tab TID
Indication
Generic name: Bromazepam
General Action: Therapeutic: Anti-anxiety agents, anticonvulsants, sedative/hypnotics, skeletal muscle relaxants (centrally acting)
It was indicated for the patient as a prophylactic management for anxiety, thus causing relaxation of skeletal muscles.
The client responded well with the treatment as evidenced by, Mr. Cardio Nstemi had become relaxed and was noted to be relaxed with absence of anxiety and even restlessness, (November 8, 2011)
Page | 240
Brand name: Lexotan
DATE GIVEN: 11-08-11 DATE STOPPED: 11-15-11
HOME MEDICATION
Pharmacologic: Benzodiazepines
furthermore the patient seems drowsy upon taking the medication.
Mechanism of action: Depresses the CNS, probably by GABA, an inhibitory neurotransmitter. Has anticonvulsant properties due to enhanced presynaptic inhibition.
Before: Monitor blood pressure, pulse, and respiratory rate prior to and periodically throughout therapy and frequently
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therapy. Assess muscle spasm, associated pain, limitation of movement prior to and through out therapy. Assess degree of anxiety and level of sedation (ataxia, dizziness, slurred speech) prior to and periodically throughout therapy. Assess risk for falls and institute fall prevention strategies especially for geriatric patients.
During: Tablets may be crushed and taken with food or water if patient has difficulty swallowing. Resuscitation equipment should be available when Lexotan is administered IV. Do not dilute with other solutions, IV fluids, or medications.
After: Instruct patient to take medication exactly as directed and not to take more than prescribed. Abrupt withdrawal of Lexotan may cause insomnia, unusual irritability or nervousness, and seizures. Medication may cause drowsiness, clumsiness, or unsteadiness. Advise patient to avoid activities needing alertness. Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication. Emphasize the importance of regular follow-up exams to determine progress during therapy.
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C. DIET LOW SALT AND LOW FAT Type of Diet Date ordered Date started Date changed Low Salt and Low Fat DATE ORDERED: 11-08-11 Foods that are low in It is ordered It is General Description Indication (s) or Purpose (s) Specific foods taken Clients response and or reaction to the diet a Mr. Cardio Nstemi
salt and low in fat should because be taken. Fat to of can that the should other taken are
foods concentrated food did not manifest salty that has low any further
contribute formation
not
be saturated fats like complications Use of related to
because butter.
DATE STARTED:
complications cardiovascular
of salt attracts water unsalted or salt aspiration, disease which may cause reduced abdominal cramping, nausea
Page | 243
and controlling fat intake increase in blood
11-08-11
may
prevent of
the volume and then alternatives. such cause increase in The blood pressure. foods not be
and vomiting. He was able to
development complications. sodium
tolerate the type of diet prescribed by the physician.
restrictions Fatty
depend on the kidneys should
ability to excrete sodium. taken because it Limiting sodium intake causes helps hypertension. threat atherosclerosis that leads to
blockage of the arterial walls.
Before: Check for the doctor's order on patients diet. Explain the importance and purpose of the prescribed diet to the patient and significant others. Reinforce to patient and significant others the need to comply with the specified diet of the patient.
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During: Observe patients tolerance to diet. Monitor patient closely for compliance of the diet. Verify the order on the patients medication record by checking it against the doctors order.
After: Assess for patients condition, how he respond to the diet Monitor the reaction of the patient. Refer to the physician about any untoward response of the patient with the prescribed diet.
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D. ACTIVITY / EXERCISE Type Exercise of Date Ordered Date Started Date Changed Complete rest bed DATE ORDERED: 11-08-11 The patient should This helps the patient to regain The patient was able to General Description Indications/Purposes Clients Response or Reaction to Exercise
without
remain in bed, to gain and have enough energy to be comply AEB complete energy since the patient able to perform activities of daily bedrest and participation is weak to stand or even living. move. in every as interventions assisting in
bathroom privileges
such
DATE STARTED: 11-08-11
changing of clothes.
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NURSING RESPONSIBILITIES FOR THE EXERCISE
BEFORE: Check physician order about the specific activity Instruct the patient about the require activity to be perform
DURING: Assist pt. in doing activities of daily living Observe for any precaution Dont leave patient alone
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AFTER: Encourage the pt. to follow to the activity Encourage verbalization of feeling Evaluate for how the patient responded to the activity
MORPHINE SULFATE
Page | 248
Date ordered Date performed Date changed
Generic name: Morphine sulfate Brand name: Morphine sr
DATE ORDERED: 11-08-11 5 mg IV STAT
Relieves pain by Pain from MI is Mr. Cardio Nstemi stimulating opiate often intense and chest pain was receptors in CNS. requires and prompt decreased upon
adequate taking Morphine. The
analgesia. DATE GIVEN: 1111-08-11
agent of choice is morphine sulfate, given initially IV.
NURSING RESPONSIBILITIES: Before: Assess for history of hypersensitivity to opioids and seizure disorders
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Assess skin color, texture, lesions, orientation, reflexes, BP, auscultation,ECG
During: Chek IV site while admimistering the drug.
After: Reassure patient that they are unlikely to become addicted Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, OTC drugs. You may experience these side effects: nausea, loss of appetite, constipation, drowsiness, impaired visual acuity Report severe nausea, vomiting, constipation, SOB, DOB
Page | 250
November 9, 2011 S: Parang nanghihina ako, O: Received patient on bed in a semi-fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM, with an ongoing IVF #1 D5 NM 1L at 90cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis or infiltration, with pale nail beds, with capillary refill of less than 3 seconds, with good skin turgor, with guarding behavior, with generalized body weakness as evidenced by slowed movement and position change, easy fatigability, cannot tolerate supine position, with isolated premature ventricular contractions, rales noted upon auscultation; with vital signs noted as follows: BP: 110/70 PR: 64 RR: 18 T: 36 ; with GCS of 15 (E4 M5 V6) A: #4 Ineffective tissue perfusion r/t inadequate oxygen supply as evidenced by acute coronary syndrome P: After 2-3 hours of nursing interventions the patient will be able to understand health teachings regarding therapeutic restrictions Interventions: monitored vital signs, intake and output, neurovital signs assessed peripheral circulation assessed for any signs of hypoxia such as respiratory distress, restlessness and unstable vital signs comfort measures rendered such as stretching linen and therapeutic touch emphasized importance of complete bed rest encouraged deep breathing exercises kept O2 in place kept IVF regulated assisted in changing position, bedside commode made available
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E: Goal met AEB patients understanding of health teachings regarding therapeutic restrictions. S: O: Received patient on bed in a semi-fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM, with an ongoing IVF #1 D5 NM 1L at 90cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis or infiltration, with generalized weakness as evidenced by slowed movement and position change, easy fatigability, cannot tolerate supine position, with dry skin on the lower extremities, fingernails and toenails are untrimmed and pale in color, with abnormal breath sounds (rales) noted upon auscultation on BLF, with slightly pale lips, with vital signs noted as follows: BP: 110/70 PR: 64 RR: 18 T: 36 ; with GCS of 15 (E4 M5 V6) A: #5 Activity intolerance r/t imbalance between myocardial oxygen demand and supply P: After 2-3 hours of nursing interventions the patient will be able to understand health teachings regarding activities that are contraindicated for his present condition Interventions: Assessed signs of hypoxia such as respiratory distress, restlessness and unstable vital signs Monitored vital signs, intake and output, neurovital signs, assessed general condition, >provided comfort measures such stretching linen and therapeutic touch emphasized importance of bed rest assisted patient in changing position encouraged deep breathing exercises kept IVF regulated as ordered promoted passive range of motion such as extension and flexion of extremities instructed to dangle feet, bedside commode made available
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E: Goal met AEB patients understanding of health teachings regarding activities contraindicated for his present condition. S:
O: Received patient on bed in a semi-fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM, with an ongoing IVF #1 D5 NM 1L at 400cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis or infiltration, with pale nail beds, with capillary refill of less than 3 seconds, with good skin turgor, with guarding behavior, with generalized body weakness as evidenced by slowed movement and position change, easy fatigability, cannot tolerate supine position, with isolated premature ventricular contractions, rales noted upon auscultation; with hypoactive bowel sounds and unable to pass stool for 3 days, with vital signs noted as follows: BP: 110/70 PR: 64 RR: 18 T: 36 ; with GCS of 15 (E4 M5 V6)
A: #7 Constipation r/t decreased activity
P: After 4 hours of nursing interventions the patient will demonstrate behaviors or lifestyle changes to prevent the recurrence of the problem.
Interventions: established a therapeutic relationship assessed general condition monitored and recorded vital signs monitored and recorded intake and output palpated abdomen, noted color, odor, consistency, amount, and frequency of stool encouraged eating of foods rich in fiber promoted adequate fluid intake, including high fiber fruit juices encouraged early ambulation as necessary
Page | 253
due meds given.
E: Goal met, the patient demonstrated behaviors or lifestyle changes to prevent the recurrence of the problem. S: Nanghihina ako O: Received patient on bed in a semi fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM with an ongoing IVF #2 D5 NM 1L at 400cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis and infiltration, with pale nail beds, with good skin turgor, dry skin noted on lower extremities, body weakness noted, slowed movement, with easy fatigability, facial grimace noted, rales noted upon auscultation, afebrile; vital signs noted as follows: BP: 130/90 RR: 67 PR: 21 T: 37 with GCS of 15 (E4 M5 V6) A: Activity intolerance r/t imbalance between myocardial oxygen demand and supply P: After 2-3 hours of nursing interventions the patient will be able to understand health teachings regarding activities that is indicated for his present condition Interventions: Monitored vital signs, intake and output, neurovital signs assessed general condition assessed signs of hypoxia such as respiratory distress, restlessness and unstable vital signs provided comfort measures such stretching linen and therapeutic touch emphasized importance of bed rest assisted patient in changing position kept O2 in place, kept IVF regulated promoted passive range of motion such as extension and flexion of extremities encouraged deep breathing exercises instructed to dangle feet, bedside commode made available
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E: Goal met AEB patients understanding of health teachings regarding activities indicated for his present condition.
S: O: received patient on semi fowlers position with an ongoing IVF #2 of D5NM 1L @ 400cc level regulated @ 100cc/hr infusing well on the right hand without signs of IV infiltration, with dry skin and untrimmed and pale finger nails and toenails, slightly pale lips, with non-productive cough, rales heard upon auscultation, with limited movements and fatigability. With vital signs taken and recorded as follows: T = 37 C/ axilla, PR = 67 bpm, RR = 21 cpm, BP = 130/90 mmHg A: Risk for impaired skin integrity related to decreased tissue perfusion and activities P: After 3 hours of NI, the patient will not develop any further skin breakdown during her stay at the facility. Interventions: Established therapeutic communication. Monitored and recorded Vital signs Obtained history of the condition Assessed general condition Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors. Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours Avoid massaging around the site of skin impairment and over bony prominences. Assess client's nutritional status Reposition the pt at least once every two hours.
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Keep the skin clean and dry Monitor skin condition at least once a day for color or texture changes, dermatological conditions, or lesions.
E: Goal met as evidenced by patient did not develop any skin breakdown during her stay at the facility. S: O: received patient on semi fowlers position with an ongoing IVF of D5NM 1L @ 560cc level regulated @ 100cc/hr infusing well on the right hand without signs of IV infiltration, with dry skin and untrimmed and pale finger nails and toenails, slightly pale lips, with non-productive cough, rales heard upon auscultation, with limited movements and fatigability noted, with presence of pain felt on the big toe of the feet, with a PQRST of: Provocation =pain on the big toe of the fee when moving, Quality=throbbing pain, Radiation= pain only felt on the big toe of the feet and does not radiate, Severity= 9/10, Time= pain is recurrent as it is only felt when moving. . With vital signs taken and recorded as follows: T = 37 C/ axilla, PR = 67 bpm, RR = 21 cpm, BP = 130/90 mmHg A: #1 Acute pain P: After 2 hours of NI, the patient will demonstrate techniques on how to perform diversion activities that would alleviate pain Interventions: Established therapeutic communication. Monitored and recorded vital signs Obtained history of the condition Assessed general condition Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain.
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Consider cultural influences on pain response. Reduce or eliminate factors that precipitate or increase pain experience (e.g., fear, fatigue, monotony, and lack of knowledge). Teach the use of non-pharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures.
Create a quiet, non- disruptive environment with dim lights and comfortable temperature when possible. Individualize the content of the relaxation intervention. Demonstrate and practice the relaxation technique.
E: Goal met as evidenced by patient demonstrated techniques on how to perform diversion activities that would alleviate pain S: O: Received patient on bed in a semi-fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM, with an ongoing IVF #2 D5 NM 1L at 400 cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis or infiltration, with pale nail beds, with capillary refill of less than 3 seconds, with good skin turgor, with generalized body weakness as evidenced by slowed movement and position change, easy fatigability, cannot tolerate supine position, with isolated premature ventricular contractions, rales noted upon auscultation; with vital signs noted as follows: BP: 110/70 PR: 64 RR: 18 T: 36 ; with GCS of 15 (E4 M5 V6) A: #3 Decreased Cardiac Output related to alteration in cardiac structure and function P: After 4 hours of nursing intervention, the patient will be able to maintain cardiac output AEB stable vital signs. Interventions: Established therapeutic communication.
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Monitored and recorded Vital signs Obtained history of the condition Assessed general condition Assess patient respirations by observing respiratory rate and depth and use of accessory muscles Observe patient for changes in skin color, moisture, temperature and capillary refill time Observed patient for restlessness, agitation, confusion and (late stages) lethargy Auscultated lungs for presence of normal or adventitious lung sounds Assessed for mental status changes. Assessed patient for chest pain or discomfort noting location, severity, duration, quality and radiation Elevated legs when in sitting position and edematous extremities when at rest Observed patient for sleep apnea Kept back dry Monitor adequate rest periods
E:Goal met, the patient maintain cardiac output AEB stable vital signs. S: O: Received patient on bed in a semi-fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM, with an ongoing IVF #2 D5 NM 1L at 400cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis or infiltration, with pale nail beds, with capillary refill of less than 3 seconds, with good skin turgor, with generalized body weakness as evidenced by slowed movement and position change, easy fatigability, cannot tolerate supine position, with isolated premature ventricular contractions, rales noted upon auscultation; with vital signs noted as follows: BP: 110/70 PR: 64 RR: 18 T: 36 ; with GCS of 15 (E4 M5 V6) A: # 2 Impaired gas exchange related to ventilation-perfusion imbalance
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P: After 4 hours of nursing intervention, the patient will demonstrate ways on how to perform techniques that will facilitate for improvement of gas exchanges within the body. Interventions: Established therapeutic communication. Monitored and recorded Vital signs Obtained history of the condition Assessed general condition Assess patient respirations by observing respiratory rate and depth and use of accessory muscles Observe patient for changes in skin color, moisture, temperature and capillary refill time Observed patient for restlessness, agitation, confusion and (late stages) lethargy Auscultated lungs for presence of normal or adventitious lung sounds Assessed for mental status changes. Assessed patient for chest pain or discomfort noting location, severity, duration, quality and radiation Elevated legs when in sitting position and edematous extremities when at rest Observed patient for sleep apnea Kept back dry Monitor hourly urine output Provided adequate rest periods
E: Goal met as evidenced by not doing work that would increase oxygen demand.
S: O: Received patient on bed in a semi-fowlers position conscious and coherent with an O2 inhalation via nasal canula at 2-3 LPM, with an ongoing IVF #2 D5 NM 1L at 400cc level regulated at 10cc/hr infusing well over his right arm without any signs of phlebitis
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or infiltration, with pale nail beds, with capillary refill of less than 3 seconds, with good skin turgor, with generalized body weakness as evidenced by slowed movement and position change, easy fatigability, cannot tolerate supine position, with isolated premature ventricular contractions, rales noted upon auscultation; reluctance to eat with vital signs noted as follows: BP: 110/70 PR: 64 RR: 18 T: 36 ; with GCS of 15 (E4 M5 V6); with a BMI of 18.56 kg/m2 A: #6 Altered nutrition less than body requirements related to loss of appetite. P: After 4 hours of nursing interventions the patient will verbalize understanding of causative factors when known and necessary interventions. Interventions: established a therapeutic relationship assessed general condition monitored and recorded vital signs monitored and recorded intake and output determined ability to chew, swallow and taste food determined clients likes and dislikes evaluated total daily food intake stayed with the client during meals encouraged eating nutritious foods promoted hygiene.
E: Goal met as evidenced by the patient verbalized understanding of causative factors when known and necessary interventions
November 14, 2011 S: hapong hapo nga ako eh

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O: Received on bed on supine position, conscious and coherent, with an ongoing IVF of D5W 500cc x 10 cc/hr @ 350 cc level infusing well on patients right hand; capillary refill time of less than 3 seconds, fingernails and toenails are pale, limited movement observed, easy fatigability also noted, negative chest pain, (-) DOB. With vital signs as follows: BP:120/80 mmHg, Temperature: 36 degrees celcius/axilla , PR: 72bpm, RR: 18cpm. A: #4 Ineffective tissue perfusion related to decreased pumping ability of the heart as evidenced by easy fatigability, paleness secondary to ACS NSTEMI, HCVD P: after 4 hours of Nurse patient interaction, the patient will be able to demonstrate, ways on how to improve blood circulation such as performing massage over the lower extremities, performing passive or even active range of motion exercises if tolerable. Interventions: Established therapeutic communication Assessed general condition Monitored and recorded vital signs Performed morning care Checked and reviewed laboratory results Assessed for paleness, easy fatigability Noted for capillary refill time Checked for presence of DOB an chest pain Performed massage therapy to improve blood circulation and relaxation behaviors Positioned high fowlers for maximum lung expansion Assisted with passive range of motion and observed in performances Emphasized importance of turning patient side to side to promote proper blood circulation Instructed S.O to assist patient in performance of tolerable ROM Emphasized diet of low salt, low fat
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E: Goal met, the patient demonstrated ways on how to improve blood circulation as the patient performed massage over the lower extremities and performed passive or even active range of motion exercises as tolerated. S: O: Received patient on bed on supine position, conscious and coherent, with an ongoing IVF of D5W 500cc x 10 cc/hr @ 350 cc level infusing well on patients right hand, with sleep disturbance, with capillary refill time of less than 3 seconds, fingernails and toenails are pale, with generalized weakness, with negative chest pain, with negative difficulty of breathing, with restlessness. With vital signs taken and recorded as follows: Temperature: 36 degrees celcius/axilla; PR: 72bpm; RR: 18cpm; BP:120/80 mmHg. A: #8 Anxiety related to economic status. P: After 4 hours of nursing interventions the patient will identify healthy ways to deal with and express anxiety. Interventions: Established a therapeutic relationship. Assessed general condition. Monitored and recorded vital sign. Observed for verbal/non-verbal signs of anxiety. Stayed with the patient. Oriented pt/SO to routine procedures and expected activities Provided privacy for patient and significant others Provided rest periods, uninterrupted sleep and quiet surroundings Emphasized importance of adequate nutritional intake. Administered medications as ordered.
E: Goal met as evidenced by the patient identified healthy ways to deal with and express anxiety.
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November 15, 2011 S: O: Received patient on bed on supine position, conscious and coherent, without contraptions with pale palpebral conjunctiva with pale buccal mucosa, gums and lips, with pale skin and capillary refill time of 3 seconds, fingernails and toenails are also pale, limited movement observed, easy fatigability also noted, (-) chest pain, (-) DOB, with non-productive cough, with vital signs taken and recorded as follows: T= 36.5 C; P= 80 bpm; R=22 cpm; BP= 120/80 mmHg. A: Readiness for Enhanced Therapeutic Management P: After 3 hours of NPI, the patient will be able to verbalize understanding of the importance of religiously following treatment regimen. METHOD: M: Levox 500 mg/tab OD for 5 days, Indur 30 mg /tab tab twice a day Lanoxin 0.25mg/tab tab OD, Lifezar 100 mg /tab tab BID, Vastarel MR 35 mg/tab, 1 tab BID Clopigrodel 25mg/tab 1tab OD Aspirin 80 mg/tab OD Aldazide 1 tab OD Avamex 40 mg/tab OD HS Zertin 300 mg /cap BID Pantaloc 40 mg/tab OD Lexotan 1.5 mg tab OD HS Lactulose 30cc BID
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E: May walk around the room Instructed pt. to avoid strenuous activities.
T: For home maintenance and management H: Instructed to perform tolerable active range of motion exercises to promote blood circulation educated about importance of following treatment and diet regimen provided health teachings and demonstrated ways to decrease unnecessary work load of the heart such as stress management techniques, relaxation activities, walking slowly instead running. O: For follow up check up on November 19, 2011 D: The patient was instructed to follow low salt, low fat diet at home. E: Goal met as evidenced by the patient verbalized understanding of the importance of religiously following treatment regimen.
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BIBLIOGRAPHY
Books
Black, J., Hawks, J.H., Keene, A., 2008 Medical- Surgical Nursing 8th edition. C and E Publishing. Bonovan Monahan, Frances, Marianne Neighbors, Judith K. Sands, Jane F. Marek, and Carol J. Green. Phipp Medical Surgical Nursing Health and Illness Perspectives. 8th ed. Canada: Mosby Elsevier, 2007. Chohan, Waina D., and Julie Munden. Nurse's 5 Minute Clinical Consult Treatments. USA: Lippincott Williams and Wilkins, 2007. Jardins, Terry Des, and George G. Burton. Clinical Manifestations and Assessment of Respiratory Disease. 5th ed. USA: Mosby Inc, 2006. Lilly, Leonard S. Pathophysiology of Heart Disease. 6th ed. USA: Williams and Wilkin, 2008. Munden, Julie. Professional Guide to Pathophysiology. 2nd ed. USA: Lippincott Williams and Wilkins, 2007. Smeltzer, Suzanne C., Brenda G. Bare, Janice L. Hinkle, and Kerry H. Cheever. Brunner and Suddarth's Textbook of Medical-Surgical Nursing Eleventh Edition Volume 1. USA: Lippincott Williams and Wilkins a Wolters Kluwers business, 2008. Smeltzer, S., Bare, B., 2007 Textbook of Medical Surgical Nursing Lippincott Williams and Wilkins.
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Electronic Sources
Fenton, Drew Evan. Acute Coronary Syndrome. Nov. 2011. <http://emedicine.medscape.com/article/756979-overview>. "Heart Disease." 2011. Imaginis.com. <http://www.imaginis.com/heartdisease/heartattack.asp>. "Lungs and Respiratory System." 2011. Kidshealth. < http://kidshealth.org/kid/htbw/heart.html>. MacNee, William. "Cardiovascular Injury Disease." 2011. The American Thoracic Society. <http://pats.atsjournals.org/cgi/content/full/5/8/824#FIG1>. "Philippine Journal of Cardiology." <http://www.who.int/chp/chronic_disease_report/philippines.pdf>. "Your Heart and Circulatory System." 2010. Kidshealth. <http://kidshealth.org/kid/htbw/heart.html>.
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VII. LEARNING DERIVED Case study is indeed a very challenging job. It entails a lot of work, time and efforts. In the beginning of the process, objectives were set that had served as guidelines with regards to proper nursing assessment and also in implementing optimum nursing care. Through its utilization, the group was able to acquire knowledge that can help them gain a deeper understanding of the diagnosis. The nurse with the cooperation of the patient and the family members should be one in attaining holistic care. Therapeutic measures should be implemented. Before, all we know about Acute Coronary Syndrome is very simple. Through the case study, my understanding about it went to a deeper sense. I learned how people acquire this disease, what the predisposing and precipitating factors are, the signs and symptoms and the management. Before, all I knew was the physical state of a person with ACS. Now, I became aware of the different signs and symptoms, current trends and the statistics that significantly plays a role in the occurrence of ACS throughout the world. Through the case study, my nursing skills have improved especially in the nursing process: assessment, planning, implementation and evaluation. I had learned on how to do comprehensive assessment of our patient through interview, observations and physical assessment. Making pathophysiology is one of the hard tasks in this case study but doing it has improved my critical thinking and youve been discovering new information. In making this case study, there are many problems that you can encounter but through progression of the making of the case study, I learned to beat these odds because I know that this is just the stepping stone of a more greater challenge, so as early as now, I should learn to solve problems that will come our way especially when I
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become nurses in the future.
Roxas, Mark Anthony P.
You can teach a student a lesson for a day; but if you can teach him to learn by creating curiosity, he will continue the learning process as long as he lives. ~Clay P. Bedford I believe that every hardship brings something good to a person, like this case presentation studying such disorder isnt that easy but in the end we have been able to gather information which we all know that soon enough well be able to use especially if we would encounter the same disorder as nurses in the future. Also I learned to appreciate and be thankful with my life now because having a family member of yours in the hospital doesnt only affect the physical and financial aspect but also the emotional aspect of the patient and the family. With this said I can say that I and my family are truly blessed. Another thing that I have learned is that knowing such risk factors that led to our patients illness could serve as a warning for us to prevent the occurrence of such disease condition. And lastly, since I knew the management for certain disease condition I can now render effective nursing care to my future patients with the same disease condition. Medina, Donna Althea D. From this case study I was able to realize the importance of living a healthy life. I also recognize the importance of knowing Acute Coronary Syndrome. Furthermore I therefore conclude that Acute Coronary Syndrome is the most common and has greatest mortality rate in the Philippines. With this case study I was able to see the importance of eating healthy food such as eating more vegetables, fruits and lessen the intake of fatty foods and meat, from my understanding one of the risk factors for Acute Coronary Syndrome is consuming too much fatty foods that may in turn develop into atherosclerosis (hardening of the arteries due to fats and cholesterol). The study itself shows how, why this condition happens and what treatment modalities that were done
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to alleviate or solve the problem. With this study it has contributed to the development of my knowledge about Acute Coronary Syndrome and Myocardial Infarction. I was able to foresee the importance of my responsibility as a student nurse is to understand how we can help people to live the healthy lives they want and create the conditions to enable them to make healthy decisions. Mendoza, Anella V. As a student nurse it is a must to become aware of clinical manifestations and the complications that may arise from the disease that we encounter everyday, and also those ceases which are rare. Being a knowledgeable student nurse about the risk factors involved in the occurrence of the disease it is important that we should put it into application in order for us to help improve the condition of our patients. Knowing that this maybe our last case study as a student nurse, it is very challenging and it entails a lot of work, perseverance and a lot of patience. It made me value more life and appreciate things Ive learned as a student nurse specially the knowledge that I acquired in lecture and hospital duty. For all the sacrifices and the sleepless nights that the group had and with each others support, in return it helped the group to become more conscious of the disease that the patient is experiencing. The group was able to acquire knowledge and have a deeper understanding why such disease condition occurs. With these knowledge, skills and attitude the group, as future nurses some day may be able to render the proper quality nursing care to the groups future patients experiencing the same condition. Jaime, Jaimee L.
We have been grateful for the exchange of ideas and from what we have learned from the work of early nurses. It is our beliefs that offering care to patients is no longer just another evolving specialty in nursing, but rather it is the umbrella under which all areas of providing care should practice. Doing such interventions and sharing a part of what we have learned is an opportunity for me to develop skills and knowledge as to
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what a future nurse of oneself is truly is. It helps me to grasp the certainty that learning doesnt end on the four corners of the classroom with the pile and stocks of bulky manuscript over the edge. Instead, learning is best assessed if you have applied it to the lives of other people. It was an undeniable feeling seeing the patient youve touched that somehow, improved his health and life in a satisfying and acceptable way that student nurse had shared. But it was a more overwhelming feeling knowing that you added change to a patients life not because it was required to, not because your heart calls for it and you unconsciously share and even give a part of what and who you are. Cooperation among group mates is the most important thing that you need to consider whenever you need to pass a requirement as a group. It is better to do your assigned task and give your best shot in everything you do. This enhances and challenges us as a student nurses but also a professional nurses in the near future. In this regard, I want to thank my dear group mates for making this requirement a very meaningful to each one of us Celestial, Misky Joy B. When our group gets the case,, Im hesitated to it, because its a new case for me because I never handle patient or I never had a case study with my previous group such like this. Ive learned a lot in this case study; it gives additional information on what we can do as nurses in order to improve his status or how we can help him to promote good and healthy life. In our lives, there are things that we need to experience in life. It can be good or bad experience. At this moment, after our exposure at AUFMC; Special Ward, I can say that it is truly a good experience for us as a student nurses. We learn a lot in this duty, not just with ourselves, but also in our chosen case. I learned how to deal with other people, how to share what we already know on how to improve and maintain their health. We also appreciate the simple things that we took for granted.
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Being a student nurse is not easy at all, there are a lot of things to do in the ward like charting, giving medications, checking the regulation of IVF, and we must understand and be more patience with our patient. The Health teachings that we give to them are very important, because they can apply it to their daily life. Even though we do not exist, they must continue do the good nursing interventions that we shared to them to improve their health more and be more effective individual. Santos Stephanie Erika T. The case that was chosen by the group was the case of a 74 year old which is Acute Coronary Syndrome Non ST Segment Elevation Myocardial Infarction Hypertensive Cardiovascular Disease with Right Dilated Cardiomyopathy with Community Acquired Pnuemonia Moderate Risk. The case is familiar but I can say that it is somewhat complicated because of the different illnesses attached to it. Nevertheless, coming up with this kind of a case study made the group learn how to work hard together, search for information to give a broader justification of this disease and they had the chance to bond together while learning. In the end the group learned a lot and they are ready to face more challenging case studies in the future. Furthermore, in doing this case study it enhanced the social communication skills and data gathering efficiency of the student nurse as she tried to gather all the needed information they have acquired will reflect how effective we are as student nurses. It also honed the truthful person within the group because they tried their very best to provide all the accurate and truthful information in this study. This goes along with their beliefs and properly trained ethics that it is a nurses responsibility to always uphold the truth, and take in full confidentiality whatever information he/she has.
Mungcal, Carmela D.
Being a student nurse we should be mindful enough that, we need to learn the diseases we encounter in the hospital thoroughly in view of the fact that this would serve as the
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foundation for us to become promising Nurses in the future-- for us, we need to find out something that would help us in its realization in our situation, doing a case study is the solution. Doing this case study enables us to better understand this particular disease, it help us to gain enough knowledge to become competent future Nurses concerning facts, liberating the community people on how to avoid, prevent and the proper management of this disease. Doing a case study permits us to communicate, cooperate and collaborate accordingly within our group, thus allowing us to realize the other importance of doing it, relating it to our chosen career, nursing, it will help us to deliver the best care possible to our patient by giving the right interventions and managements throughout proper communication, cooperation and collaboration to the health care team. The heart is one of the critical organs of an persons body, as it pumps oxygenated blood to feed the body's biological functions. The cessation of the heartbeat, referred to as cardiac arrest, is a critical emergency. Without intervention, death can occur within minutes of cardiac arrest since the brain requires a continuous supply of oxygen and cannot survive for long if that supply is cut off. These components of our bodies, both the respiratory system and the heart of the circulatory system, are vital to our survival. A problem with either one would pose a serious threat to our lives. Our client was diagnosed with Acute Coronary Syndrome Non ST Segment Elevation Myocardial Infarction Hypertensive Cardiovascular Disease with Left Dilated Cardiomyopathy with Community Acquired Pneumonia Moderate Risk.So he was diagnosed with problems not only in one system but two. Being exposed in the intensive care unit, we can learn many things. In this unit, we must keep you emotions to ourself. Yes, these patients are experiencing sufferings, some at a young age. But we must keep in mind that our emotions could not change their condition. Instead, we must help the clients by giving them the proper care they need that they deserve and we
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must also help the family of the client by giving them the support and empathy that they need. Pineda, Jonalene O.
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VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL 1. Clients Daily Progress Chart Days Admission November 8, 2011 1st NPI November 9, 2011 2nd NPI November10, 2011 3rd NPI November 14,2011 (6am-2pm) (2pm-10pm) 4th NPI November 15, 2011 (6am-2pm)
(7:00pm) Nursing problems:
(2pm-10pm)
1. Acute pain
2: Impaired gas exchange related to ventilation-perfusion imbalance
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3.
3. Decreased Cardiac Output related to alterations in cardiac structure and function
4. Ineffective tissue perfusion related to inadequate oxygen supply and decreased pumping ability of the heart
5. Activity intolerance related to imbalance between myocardial oxygen demand and supply
6. Altered nutrition: less than body requirements related to

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loss of appetite
7. Constipation related to poor oral intake and decreased activity
8. Anxiety related to economic status
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Vital signs Temperature 36.5 axilla C/ 36 C/ axilla 37 C/ axilla 36 C/ axilla 36.5 C/ axilla
Pulse rate 64 bpm 76 bpm
67 bpm
72bpm,
80 bpm
Respiratory rate 31 cpm
18 cpm
21 cpm 18cpm 22 cpm
Blood Pressure 110/70 mmHg 160/110 mmHg 130/90 mmHg 120/80 mmHg 120/80 mmHg.
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Diagnostic/Lab Procedures: Creatinine 166.56 ------CKMB 9.1 -------------------------------
Troponin I
500 above
BNP
1.73
D-dimer
2160
Myoglobin
163
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Potassium
4.24
Medical Management: IVF D5 NM 1Lx10cc/ hr
IVFs
IVF D5 NM 1Lx10c c/hr
IVF D5 NM 1Lx10cc /hr
IVF of D5W 500cc x 10 cc/hr
Drugs Isoket
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Aspirin
Morphine Sulfate
Isosrbide Mononitrate Aldazide
Pantoprazole Bisoprolol Vastarel

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Lactulose
Lexotan
Arixtra Senokot Lifezar
Vigocid
Digoxin Zertin
Avamax
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Clopidogrel
Diet:
Low Salt and Low Fat
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I. INTRODUCTION That's the scary thing about heart disease.

CARDIOMYOPATHY WITH COMMUNITY ACQUIRED PNEUMONIA MODERATE RISK.

Grandmother (+) Died-old age

Grandfather (+) Died-heart attack

Grandmother (+) Died-old age

Uncle (No known illnesses)

Father (+) CVA and HPN

Auntie (No known illness)

Uncle (No known illnesses)

Uncle (No known illnesses

Mother (+) Died-old age

Brother Sister Sister (+) TB 77 y.o

Brother (No known illnesses

(+) old age, 80 y.o

(+) stab wound, 22 y.o present: 76 y.o

(+) heart attack 65 y.o

(No known illnesses,

Then, on the morning of November 6, 2011, after having a walk outside of

E. Physical Examination (IPPA Cephalocaudal Approach)

November 8, 2011 (Tuesday, 7:00pm, Lifted from the chart)

November 9, 2011 (Wednesday- first nurse-patient interaction)

Vital Signs: BP = 110/70 mmHg PR = 64 bpm RR = 18 cpm T = 36 C/ axilla

tone audible as evidence by responding when called by name.

CRANIAL NERVE II: Sensory Optic Vision

CRANIAL NERVE III: Motor Occulomotor Extra-ocular movement & pupils

CRANIAL NERVE VIII: Sensory Vestibulocochlear/acou Hearing stic equilibrium

CRANIAL NERVE XI: Motor Accessory Movement of shoulder muscles

CRANIAL NERVE II: Optic

CRANIAL NERVE Occulomotor

III: Motor Extra-ocular movement & pupils

IV: Motor Extra-ocular movement of eyes in downward & inward

CRANIAL NERVE VII: Facial

CRANIAL NERVE VIII: Sensory Vestibulocochlear/acoustic Hearing and equilibrium

CRANIAL NERVE Glassopharyngeal

Student Nurse asked the client to swallow and asked a question

The client will be able to swallow and speak without hoarseness.

CRANIAL NERVE Hypoglossal

The client will be He was able to able to protrude move the

CRANIAL NERVE II: Optic

CRANIAL NERVE Occulomotor

III: Motor Extra-ocular movement & pupils

IV: Motor Extra-ocular movement of eyes in downward & inward movement

Sensation of Cornea, skin of face & jaw movement

CRANIAL NERVE VII: Facial

The client will be able to swallow and speak without hoarseness.

CRANIAL NERVE Hypoglossal

CRANIAL NERVE II: Optic

CRANIAL NERVE Occulomotor

III: Motor Extra-ocular movement & pupils

IV: Motor Extra-ocular movement of eyes in downward & inward movement

Nurse Client will be able

Sensory Sensation of Cornea, skin of face & jaw movement

CRANIAL NERVE VII: Facial

The client will be able to swallow and speak without hoarseness.

CRANIAL NERVE Hypoglossal

Diagnostic and Laboratory Procedures

Date ordered and date result(s) in

RBC (Red Blood

An RBC count is a 4.55x1012L

Lymphocytes A small agranulocytic

It determines the bodys ability to defend itself

The result is within the normal range which

It is done to determine the presence of bacterial infection