Final Case Study - CAD

 

 ANGE  AN GELE LES S UN UNIV IVER ERSI SITY TY FO UN UNDA DATI TION ON COLLEGE OF NURSING S.Y. 2013  –  2014

CASE STUDY ABOUT CORONORY ARTERY DISEASE WITH UNSTABLE ANGINA

SUBMITTED BY: BUENAFE, PATRICIA MARIE MANALANG, MA. CLARELLE SULA, JANNICA BSN III  –  3 (GROUP 11)

SUBMITTED TO: DENNISON JOSE C. PUNSALAN, RN, MN CLINICAL INSTRUCTOR

OCTOBER 11, 2013

 

 

I. INTRODUCTION “Every man's disease is his personal property.”   -Alonzo Clark

 A person should be able to take care of his body in order to maintain a healthy life. It is because health because health refers to the levels of functional or metabolic metabolic efficiency  efficiency of   living living beings. In humans, humans,   it is the general condition of a person's mind and body, usually meaning to be free from from illness,  illness, injury  injury or needless needless pain.  pain. That  That is why the quote said that a sick person is in his personality. During the Ottawa Charter for Health Promotion in 1986, the WHO said that health is a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities (http://www.medicalnewstoday.com/articles/150999.php) but since health is a basic need of a person and it does not mean that if you are not sick, you are healthy, it is now presented as a complete physical, mental and social well-being and not merely the absence of disease or infirmity or simply health is the wholeness of one person. As a person is growing up, he or she cannot prevent a certain disease coming from his body parts like the brain and heart. The etiology may be coming from the hereditary/genetics, age or idiopathic. That is a disease is being manifested by a person whether it is symptomatic or asymptomatic. (http://www.medicalnewstoday.com/articles/150999.php) Coronary Artery Disease happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls. This buildup is called atherosclerosis. called  atherosclerosis.    As it grows, gro ws, less b blood lood can flow through the a arteries. rteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain (angina) (angina) or  or a a heart  heart attack. attack.   Most heart attacks happen when a blood a  blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage. Over time, this can also weaken the heart muscle  

 

and contribute to heart failure and arrhythmias. arrhythmias.   Heart failure means the heart can't pump blood well to the rest of the body. Arrhythmias are changes in the normal beating rhythm of the heart. The most common disease of the coronary arteries is arteriosclerosis, commonly called "hardening of the arteries." Plaque — a combination of cholesterol and other fats, calcium and other elements carried in the blood — builds up in the small blood vessels that feed the heart. When this condition exists in other parts of the body, it is called atherosclerosis. This plaque buildup can, in time, narrow the arteries so severely that blood flow to the heart is inadequate and symptoms of insufficient blood flow — called angina —  develop. Angina is a term meaning strangling or oppressive heaviness and pain, but it has become synonymous with angina pectoris or chest pain caused by lack of oxygen to the heart due to poor blood supply. In addition to angina or chest pain, arteriosclerosis can produce fatigue, shortness of breath and an abnormal heart beat or arrhythmia. Plaque also can tear the artery walls and form blood clots that can lead to a heart attack. Often, there are no symptoms

of

arteriosclerosis

until

a

heart

attack

occurs.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/signs_and_symptoms.ht ml)   ml)  Arteriosclerosis is diagnosed through various tests including:  



Coronary

Angiography

—  Coronary

angiography,

also

called

cardiac

catheterization, is a minimally invasive study that is considered the gold standard for diagnosing coronary artery disease. This test is performed under local anesthesia and involves injecting X-ray dye or contrast medium into the coronary arteries via tubes called catheters. An X-ray camera films the blood flow to show the location and severity of artery narrowing. This test can show if the blood vessels in your heart have narrowed, your heart is pumping normally and blood is flowing correctly and your heart valves are functioning properly. It also can  

 

identify any heart abnormalities you may have been born with or congenital abnormalities.  



Echocardiogram (ECHO) — This non-invasive test translates sound waves from your chest into pictures of your heart. It provides information about how the heart is pumping, how blood flows in the heart and blood vessels, how large the heart is and how the valves are working.

 



Electrocardiogram (ECG or EKG) —  The electrocardiogram records the heart's electrical activity. Small patches called electrodes are placed on your chest, arms and legs, and are connected by b y wires to the ECG machine. Your heart's electrical impulses are translated into a wavy line on a strip of paper, enabling doctors to determine the pattern of electrical current flow in the heart and to diagnose arrhythmias and heart damage.

 



Stress Echocardiogram —  Stress tests are performed to see how the heart performs under physical stress. The heart can be stressed with exercise on a treadmill or in a few instances, a bicycle. If you can't exercise on a treadmill or bicycle, medications can be used to cause the heart rate to increase, simulating normal reactions of the heart to exercise. During the stress test, you will wear ECG electrodes and wires while exercising so that the electrical signals of your heart can be recorded at the same time.

 



Stress Thallium Test — Stress thallium tests have two components — a treadmill stress test and heart scan after injection of a radionuclide material, such as thallium, which allows doctors to see the coronary arteries and the shape and function of the heart. It has been used in this manner safely for many years to demonstrate the amount of blood the heart is getting under various conditions —  rest

and

stress.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/diagnosis.html)   (http://www.ucsfhealth.org/conditions/coronary_artery_disease/diagnosis.html) Medications and sometimes lifestyle changes, such as quitting smoking or losing weight, can help improve heart efficiency to reduce angina but can't eliminate the plaque blockages. Medications may include cholesterol-lowering drugs, Beta-

 

 

blockers, nitroglycerin, calcium channel blockers, angiotensin-converting enzyme inhibitors and others. These are the other management for CAD:   Plaque Removal - to remove plaque from arteries, the follow following ing procedures are



performed:  



 Angiopl  Angi oplasty asty - also called percutaneous transluminal coronary angioplasty or PTCA, involves inserting a long flexible tube called a catheter into a blood vessel through a small incision in your skin. The catheter has a deflated balloon on its tip. Once the catheter reaches the blocked blood vessel, the balloon is inflated and compresses the plaque against the sides of the blood vessel. The balloon may be inflated and deflated several times. Often, the procedure is done in conjunction with a small metal tube called a stent that is left in the artery to serve as a scaffold to keep the artery open and prevent the plaque from springing back toward the center of the vessel.

 



Coronary Artery Bypass Graft surgery - an open-heart operation in which an artery or a piece of vein taken from your leg is attached to the blood vessel to detour blood around the blockage. During part of the operation, your heart will be stopped and a heart-lung machine will be used to pump your blood and help you breathe. As with most major large incision operations, it takes about six weeks to recover. CABG is the most successful and most common major heart surgery in the Western world.

 



Coronary Stent - a small, latticed, high-grade stainless steel tube that is used to hold the coronary artery open and minimize the chance of abrupt closure after angioplasty. It is placed in the coronary artery using the same procedure as the angioplasty. The stent is typically positioned at the narrowed area of the artery. When the catheter's balloon is inflated, the stent expands and is pressed against the vessel wall. The balloon is deflated and withdrawn, leaving the stent permanently in place. After a stent is placed, you will be prescribed an antiplatelet medication, Clopidogrel, also known as Plavix, for one month. This is used to minimize the risk of clot formation in the stent while tissue grows around the stent to incorporate it into the blood vessel wall. Within a month, the body no

 

 

longer "sees" the stent, and the medication is no longer needed. You should continue to take aspirin, if it has been prescribed, along with the Clopidogrel.  



Rotational Atherectomy - widens narrowed arteries using a high-speed rotational device to "sand" away plaque. This technique is used in particular situations, such as with plaque with large amounts of calcium or to widen blockages

within

a

stent.

(http://www.ucsfhealth.org/conditions/coronary_artery_disease/treatment.html)  Although CAD can be a life-threatening condition, the outcome of the disea disease se is in many ways up to the patient. Damage to the arteries can be slowed or halted with lifestyle changes, including smoking cessation, dietary modifications and regular exercise, or by medications to lower blood pressure and cholesterol levels. Additional goals of treatment, which may involve medication and sometimes surgery, are to relieve symptoms,

ease

circulation

and

prolong

life.

(http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html)   (http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html)

A. Current trends

MANILA, Philippines - Recent data last July 9, 2012, from the National Statistics Office (NSO) showed that five out of 10 deaths in the country were of cardiovascular causes. The NSO reported that 100,908 people died of heart diseases in 2009. This accounted for 21 percent of all deaths in the country. It was followed by cerebrovascular disease, which claimed 56,670 lives in the same year. It accounted for 11.8 percent of all deaths in 2009. "Within three years (2007-2009), the top five causes of deaths remained on their posts and proved to be fatal among other causes of deaths," the NSO said. The World Health Organization (WHO) has said that an estimated 17 million people die of cardiovascular diseases every year. Most of these were heart attacks and strokes. "A substantial number of these deaths can be attributed to tobacco smoking,  

 

which increases the risk of dying from coronary heart disease and cerebrovascular disease 2 –3 fold. Physical inactivity and unhealthy diet are other main risk factors which increase individual risks to cardiovascular diseases," the WHO said. The NSO also reported that most females die in their older age compared to their male counterparts. "It was noted that the most number of deaths was at the age of 80 and over with 85,705 or 17.8 percent. From these, 59.6 percent (51,074) were females while the remaining 40 percent (34,631) were males," the NSO said. The age group 10 to 14 had the least number of deaths, accounting for only 1 percent of all total deaths. "It has been observed that as the age increases, the rate of dying also increasing. From age group 10 onwards it shows that the number of deaths continuously increase though a slight decrease were seen at ages 75-79 then it went up again at age 80 and over," the NSO said. Deaths in 2009 reached 480,820, which was 4.2 percent higher than the previous year. The most number of deaths in the country occurred in the National Capital Region, which accounted for 75,019 or 15.6 percent of all deaths in the country. Learn about coronary artery disease, its symptoms and about the latest developments in treatment. Coronary artery disease is caused when plaque buildup creates blockages or narrowing in the arteries. The blockages restrict blood flow and reduce the amount of oxygen delivered to the heart, potentially putting a person at risk for a heart attack. Common symptoms of coronary artery disease include chest pain, shortness of breath, fatigue and overall weakness. Simple lifestyle changes can help prevent and manage coronary artery disease. These include managing obesity and high blood pressure, living an active lifestyle, making

healthy

dietary

choices

and

stopping

smoking.

(http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heartdisease-nso)   disease-nso)

Improved Treatments 

Staying on top of the latest medical advances helps ensure you and loved ones secure the best treatment available.  

 

Last March 28, 2013, a new treatment was found for patients with CAD. One advancement in treatment is supported by new results from the FAME 2 Study funded by St. Jude Medical and published in the New England Journal of Medicine. The study found that use of a blood-flow measurement technology, called Fractional Flow Reserve (FFR) during treatment of stable coronary artery disease will result in better health outcomes. FFR technology offers physicians a better assessment of where blood flow blockages occur in the coronary arteries and whether treatment to open an artery narrowing, along with medication, can help lower a patient's risk of chest pain and heart attack. From less likelihood of a patient being readmitted to the hospital for urgent care, to a reduction in health care costs, FAME 2 research demonstrates that patients who receive FFR-guided treatment experienced better outcomes than those treated with medication alone. The FAME 2 Study results offer further evidence that FFR should be considered the standard of care for treating patients with coronary heart disease," said Frank J. Callaghan, president of the Cardiovascular and Ablation Technologies Division at St. Jude Medical.

B. Statistics

Coronary artery disease (CAD) is the leading cause of death in the United States, affecting over 5 million Americans. CAD is a narrowing of the coronary arteries, the vessels that supply blood to the heart muscle, generally due to the buildup of plaques in the arterial walls, a process known as atherosclerosis. Plaques are composed of cholesterol-rich fatty deposits, collagen, other proteins, and excess smooth muscle cells.

 

 

 Atherosclerosis, which usually progresses very gradually over a lifetime, thickens and narrows the arterial walls, impeding the flow of blood and starving the heart of the oxygen and vital nutrients it needs (also called ―ischemia‖). This can

cause muscle cramp-like chest pain called angina. called angina.   Blood clots form more easily on arterial walls roughened by plaque deposits and may block one or more of the narrowed coronary arteries completely and cause a heart attack. Arteries may also narrow suddenly as a result of an arterial spasm. (Spasms are most commonly triggered by smoking.) Heart disease is the leading cause of death for both men and women. More than half of the deaths due to heart disease in 2009 were in men. About 600,000 people die of heart disease in the United States every year  –that’s 1 in every 4 deaths. Coronary heart disease is the most common type of heart disease, killing more than 385,000 people annually.  Every year about 715,000 Americans have a heart attack. Of these, 525,000 are a first heart attack and 190,000 happen in people who have already had a heart attack.  Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity. (http://www.cdc.gov/heartdisease/facts.htm)  According to the latest WHO data published in April 2011 Coronary Heart Disease Deaths in Philippines reached 57,864 or 13.73% of total deaths. The age adjusted Death Rate is 121.63 per 100,000 of population ranks Philippines #79 in the world. Review other causes of death by clicking the links below or choose the full health disease)   disease)

 

profile.

(http://www.worldlifeexpectancy.com/philippines-coronary-heart-

 

C. Reason for choosing such case for presentation

The student nurses are hopeful for the realization of the essence of this study to the involved and to those of which this study can be of any help. Since the case of Coronary Artery Disease is very rampant, the student nurses would like to be of service in decreasing the probability of what is fast occurring. The aim of the group is not just to present what we have researched or learned from time to time but to put into profession in order to be of great help to others, to increase awareness, to educate, to prevent, to promote and to restore health.

 

 

D. Objectives Short Term

During the course of the study, the student nurse will be able to:  

Establish rapport with the patient

 

Explain the purpose in conducting the interview

 

Collect information regarding the demographic data of the patient

 

Collect iinformation nformation regarding socio economic and cultural beliefs of the patient and environmental factors

 

Collect data regarding the patient’s family health illness and history, post

and present illness  

List the diagnostic procedures done and explain

 

Identify the different medical, surgical and nursing management   Emphasize the importance of health teaching

Long Term

 After the completion of the study, the student student nurse will be able to:  

Associate abnormal diagnostic findings with his disease condition

 

Demonstrate nursing interventions for procedure done

 

Formulate recommendations to be imparted to patient’s same condition  

 

Provide critical thinking skills necessary for providing safe and effective nursing care.

 

Provide a comprehensive assessment and implement care base on our knowledge and skills of the condition

 

Familiarize us with effective inter-personal skil skills ls to emphasized health promotion and illness prevention.

 

 

Impart the learning experience from direct patient care.

 

Short Term

During the course of the study, the patient will be able to:  

Develop trust with the student nurse

 

Understand the purpose in conducting such interview

 

Provide information regarding his demographic data

 

Provide information regarding his socio economic and cultural beliefs

 

Demonstrate compliance to medical regimen

 

Identify risk factors

Long Term

 After completion of the study, the patient will will be able to:

 

 

Continue cooperating with physical assessment

 

Express feelings regarding his condition

 

Will be able to accept his situati situation on and have sense of control

 

Understand his manifestation related to him condition

 

Gain the basic information concerning Coronary Artery Disease

 

Eradicate activities that may worsen his condition

 

Comply with the treatment given upon discharge

 

II. NURSING PROCESS A. Assessment 1. Personal History

a. Demographic Data

Our patient’s name is Mr. Corona D. Sease for the purpose of confidentiality and

he is 56 years o ld. He is approximately 5’2 feet in height and weighs 45 kilograms in weight. He has a pale fair skin complexion. His eyes are round and his teeth are slightly yellowish. His role in the family is to work for his family as a grass cutter at a certain subdivision. He does have 6 children. He lives in Bulaon Rest City of San Fernando, Pampanga. He was born on May 16, 1957 at their house in Del Paz Norte by Normal Spontaneous Delivery. His nationality is a Filipino and ethnicity is a Kapampangan. He was admitted September 17, 2013 at around 1:40 AM. His chief complaint was difficulty of breathing and chest tightness. He is still admitted at a local hospital in Pampanga. He was diagnosed with Coronary Artery Disease with Unstable Angina.

b. Socio-Economic and Cultural Factors

Mr. Corona D. Sease lives together with his wife and his 6 children and they are pure Kapampangan. They are currently living at Bulaon Rest City of San Fernando, Pampanga. Their house is made of sement and wood house in a 1 story building and only has 1 window. They are still living there even a typhoon already flooded and destroyed some of the parts of the house like the floors. Mr. Corona D. Sease ’s work is a grass cutter during weekdays from 7AM to 5PM at a certain subdivision. He owns 5,200 pesos every month. They are categorized as poor because each member receives 900 pesos only. According to NEDA 2004, a family must have a total income of 2768.60 per family member to be classified as not poor

and

meet

the

basic

(http://localweb.neda.gov.ph/regional.html)

 

needs

of

each

member.

 

His wife budgets the money for their basic needs. They buy their food at a local market. Their source of water is from a distilled water company. Their garbage is collected once a week by the city government entities. According to Mr. Sease, their food source comes from the ma ket and they don’t have any electricity   but they use candles as their source of light. They buy things for their hygiene purposes like shampoo, soap, tooth brush and tooth paste. They ride tricycles and jeepneys as means of transportation. They save money that was left for emergency purposes like medications. He gives money for his children’s projects and allowance.   Some of his income was given to his relatives since his h is relatives are asking. Basic Needs

Expenses (Per Week)

Food Rice

900 pesos

Viand

800 pesos

Water Supply

140 pesos

No Electricity Suppy but for Candles

60 pesos

Hygiene Suppy

200 pesos

Transportation

112 pesos

Savings for Emergency purposes

500 pesos

Education for his children

500 pesos

For his relatives

1500 pesos

Others

488 pesos

Mr. Sease only reached Grade 5 as his highest educational attainment in a public school. He was forced to stop her studies because of the financial constraint in the family. They are affliated with Roman Catholic religion and they go to mass every  

 

Sunday. Regarding their cultural factors affecting health, they take herbal medicines such as Malunggay and Bawang as an alternative of a medicine but they do not believe in faith healers. If one of the family members got sick, they immediately go to a hospital. Mr. Sease does not smoke but he drinks alcohol 4 times a week. He is fond of eating vegetables and has a high fat diet. TIME

ACTIVITIES OF DAILY LIVING OF MR. CORONA D. SEASE

4:00 AM – 6:00AM

Freshen up including dressing up for 30 minutes, Cooking and Preparing their Breakfast for 40 minutes, Breakfast for 30 minutes, Cleaning the Dishes for 15 minutes, Getting Ready for His Work for 5 minutes

6:00 AM – 6:45 AM

Travel Time Going to His Work

7:00 AM – 12:00 NN

Working Hours

12:00 NN – 1:00 PM

Lunch Break

1:00 PM – 5:00 PM

Working Hours

5:00 PM – 5:45 PM

Travel Time Going Back to His House

6:00 PM – 6:30 PM

Rest for 30 minutes

6:30 PM – 7:00 PM

Dinner

7:00 PM – 7:30 PM

Doing Household Chores

7:30 PM – 10:00 PM

Bonding with Family for 30 minutes, Going to His Friend’s House and Drinks  Alcohol for 2 ½ Hours

10:00 PM – 4:00 AM

 

Sleeping Hours

 

C. Environmental Factors

Sease’s family live in Bulaon Rest, City of San Fernando, Pampanga. Their

house is a sement and wood type of house. h ouse. It is a 1-storey building house. ho use. They have 1 window and 1. They are still living their even there was a typhoon that flooded the house. His wife cleans the house every week.

3. History of Past Illness Illness

Mr. Corona D. Sease is complete with his immunizations when he was 1 year old at the year of 1958. He experienced tigdas  at the age of 10 years old at the year of 1967 and did not have any chicken pox and mumps during his childhood years. He does not have any allergies like in dust, pollens and foods such as shrimps or chickens. Sometimes, he experience fever. His highest temperature when he experiences his fever on October 2005 was 38.5 degree Celsius. His wife only did tepid sponge bath and bed rest. When he has cough and colds and flu, he drinks Lagundi   as his alternative medicine when they lack of financial resources. If he is severe ill, he immediately goes to the hospital.

4. History of Present Illness   Mr. Corona D. Sease experienced chest pain or angina pectoris in medical term when he was 55 years old on December 2012. He experienced chest pain again last January and August 2013 and was brought at a local hospital in Pampanga. He did not buy his take home medications because of lack of financial resources. The day before his admission, last September 17, 2013 at around 4:30 PM, he experienced sudden difficulty of breathing and chest tightness when he was still in work. He was brought to a local hospital here in Pampanga at around 6:30 PM by the worker, where he was  

 

working. His chief complaint was difficulty of breathing and chest tightness. He admitted that before the day of admission, he ate high fat foods like chicharon and sisig and he drank alcohol straight 4 days in that week. The physician made the admitting and final diagnosis as Coronary Artery Disease. Hence, he was admitted on September 17, 2013.

5. Physical Examination

(September 17, 2013 – Lifted from the chart)

  Skin: (-) Dermatitis



  Head-EENT: AS, PPC



  Lymph Nodes: (-) Claps



 



Chest:

Lungs - SF, Crackles in BLF

Cardiovascular: Angina Pectoris   Abdomen: Flat, Soft

o

  Musculoskeletal: (+) grade # edema

o

  Admitting Impression: T/c ACS with CHF

o

(September 18, 2013 – First Day of Assessment) General Appearance:

Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500 cc, with an O 2  Inhalation. He looks weak in appearance. He has pale skin and conjunctiva.  

 

Vital Signs

  Temperature: 36.5 degree Celsius



  Pulse rate: 74 bpm



  Respiratory rate: 31 cpm



  Blood Pressure: 110/80 mmHg



  Hair – Short, black hair, no pediculosis and lesions noted, evenly distributed

o

  Skin – Pale complexion, good skin turgor, absence of edema and jaundice

o

  Nails – Long and untrimmed

o

  Head – Round, smooth without lesions

o

  Eyes – Pale palpebral conjunctiva, round eyes

o

  Ears – No presence of discharge

o

  Mouth – No sores, reddish in color

o

  Nose – No nasal discharge

o

  Lips – Pale and slightly dry

o

  Neck – No lymph nodes were palpated

o

  Heart – Diminished in heart rate, irregular heart rhythm

o

  Lungs – Crackles and rales were auscultated in BLF

o

  Abdomen - Skin is as the same color as with that of that body or lighter. Hair is

o

evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds are 15 per minute/quadrant. Pain is not felt during urination.   Legs and feet – Negative Homan’s sign, edema

o

(September 19, 2013 – Second Day of Assessment) General Appearance:

Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500 cc, with an O 2  Inhalation. He looks weak in appearance. He has pale skin and conjunctiva.  

 

Vital Signs

  Temperature: 35.8 degree Celsius



  Pulse rate: 77 bpm



  Respiratory rate: 31 cpm



  Blood Pressure: 110/80 mmHg



 

Hair – Short, black hair, no pediculosis and lesions noted, evenly distributed

 

Skin – Pale complexion, good skin turgor, absence of edema and jaundice

 

Nails – Long and untrimmed

 

Head – Round, smooth without lesions

 

Eyes – Pale palpebral conjunctiva, round eyes

 

Ears – No presence of discharge

 

Mouth – No sores, reddish in color, had excessive sputum

 

Nose – Presence of nasal discharge

 

Lips – Pale and slightly dry

 

Neck – No lymph nodes were palpated

 

Heart - Diminished in heart rate, irregular heart rhythm

 

Lungs – Crackles and rales were auscultated in BLF

 

Abdomen - Skin is as the sa same me color as with that of that body or lighter. Hair iis s

o

o

o

o

o

o

o

o

o

o

o

o

o

evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds are 15 per minute/quadrant. Pain is not felt during urination.  

o

Legs and feet – Negative Homan’s sign, edema

(September 20, 2013 – Third Day of Assessment) General Appearance

Mr. Corona D. Sease is lying on bed, with an IVF of 5% Dextrose in Water 500 cc, with an O 2  Inhalation. He looks weak in appearance. He has pale skin and conjunctiva.  

 

Vital Signs

  Temperature:36.8 degree Celsius



  Pulse rate: 78 bpm



  Respiratory rate: 26 cpm



  Blood Pressure: 120/80 mmHg



 

Hair – Short, black hair, no pediculosis and lesions noted, evenly distributed

 

Skin  –  Slightly pale complexion, good skin turgor, absence of edema and

o

o

 jaundice  

Nails – Long and untrimmed

 

Head – Symmetrical, round, smooth without lesions

 

Eyes – Slightly pale palpebral conjunctiva

 

Ears – No presence of discharge

 

Mouth – No sores, reddish in color

 

Nose – Presence of nasal discharge

 

Lips – Pale and slightly dry

 

Neck – No lymph nodes were palpated

 

Heart - Diminished in heart rate, irregular heart rhythm

 

Lungs – Crackles and rales were auscultated in BLF

 

Abdomen - Skin is as the sa same me color as with that of that body or lighter. Hair iis s

o

o

o

o

o

o

o

o

o

o

o

evenly distributed. Bluish discoloration of the umbilicus is not presence. Bowel sounds are 15 per minute/quadrant. Pain is not felt during urination. Legs and feet – Negative Homan’s sign, edema o 

 

 

Diagnostic/Laboratory Date Ordered Procedures

> Complete Blood

Date

Indications or

Results

Purposes

Resulted

Normal

Analysis and

Values/

Interpretation of results

Units used

(Client-centered)

in Hospital

Count Hemoglobin

DO: 09-17-

Measures the

2013

amount of Hgb,

seen by client having the

DS: 09-18-

protein found in RBC in the blood

absence of dehydration

2013 Hematocrit

DO: 09-17-

Measures the

2013

proportion of the

DS: 09-182013 White Blood Cells

0.38 – 0.48

Same of Hgb, hydration status is normal

up of RBC Numerates the

2013

number of WBC in

2013

0.44

115 – 155 g/L The result is normal, normal, c can an be

blood that is made

DO: 09-17-

DS: 09-18-

130

7

5 – 10 x

The client did not acquire

10^9/L

any infections as a result to

the blood, a

normal WBC

decrease and increase in this may suggest presence of

 

 

illness Neutrophils

0.49

0.45 – 0.65

Client did not manifest

DO: 09-17-

This test

2013

measures the

infection as evidenced by

amount of

normal neutophils

DS: 09-182013

neutrophils type of WBC in the blood if disease or toxicity is suspected

Lymphocytes

0.27

0.20 – 0.35

The amount of lymphocytes

DO: 09-17-

This test measures

2013

amount of

in the blood is normal as

neutrophils type of

evidenced by clients

WBC in the blood

absence of infection; this is

if disease or

related to WBC and

DS: 09-182013

toxicity is

neutrophils since

suspected

neutrophils and lymphocytes are types of WBC

 

 

Platelet

DO: 09-17-

To determine any

2013

bleeding disorders

DS: 06-182013 > Blood Chemistries

298

150 – 400 x

The client did not have any

10^9

spontaneous bleeding, bone

or bone marrow

marrow disorder or

diseases and for

leukemia which results to a

unexplained

normal platelet count

bruises Fasting Blood Sugar

DO: 09-17-

This is to measure

2013

the amount of

DS: 09-182013 Blood Urea Nitrogen

4.1 – 9.00

Client’s glucose level is

mmol/L

within normal range. No signs of diabetes

glucose present in the body

DO: 09-17-

Measures amount

2013

of urea nitrogen is

DS: 09-18-

6.02

4.1

1.7/8.3mmol/

Result is normal as

L

evidenced by client’s normal

kidney function

the blood

2013 Creatinine

DO: 09-17-

Measures the

2013

amount of

DS: 09-182013

130.8

58-

The client is dehydrated. His

120mmol/L

urine is tea-colored. Pain is

creatinine present

felt when urinating but there

is the blood and/or

is no presence of blood.

urine

 

 

Sodium (Na)

DO: 09-17-

Measures the level

2013

of Na is the blood

146.6

135 – 145

Client is in good hydration

mmol/L

status

3.55 – 5

Client’s K level is within

DS: 09-182013 Potassium (K)

DO: 09-17-

Measures the

4.23

2013 DS: 09-182013 Urinalysis

mmol/L

amount of K

normal range

present is the blood

DO: 09-17-

Urinalysis can

2013

reveal diseases

DS: 09-182013

Color

Normal

Yellow to

Patient has lightyellow color

that have gone

amber in

urine.

unnoticed because

color

Yellow

they do not

There is presence of

produce striking

suspended particles in the

signs and Transparency

symptoms

urine such as normal urine crystals and mucus because of inflammation of the

Determination of

gallbladder.

 

 

urine composition

Turbid

Clear

and possible abnormal components (e.g. protein or glucose) or infection

Normal This means that the patient has normal Specific Gravity

hydration status AEB patient didn’t manifest

signs of dehydration such as poor skin turgor, etc.

 

 

1.013

1.010 – 1.025

Normal Sugar

There is absence of sugar in the urine which means that the patient is not indicative of diabetes.

 

 

Negative

Negative

Microscopic Findings Pus

The patient has mild inflammation of the

Cells

gallbladder and mild infection.

0-1 /hpf

0-1/hpf

RBC

The patient has mild inflammation of the gallbladder and mild infection.

 

 

1 – 2

(Negative or Rare)

Normal This indicates that the patient is not Epithelial Cells

indicative of inflammation in the bladder and present of epithelial cells represent possible contamination of the specimen with skin bacteria

Few

Bacteria Few

Rare

Bacteria in urine are unusual, but few bacteria can due to contamination None

 

 

 



Electrocardiogram

There is an Elevated ST Segment which means independent of changes in ventricular activation and that may be the result of global or segmental pathologic processes that affect ventricular repolarization and has Occasional Pulmonary Vascular Resistance.

 

 

7. ANATOMY AND PHYSIOLOGY

The heart is located in the chest between the lungs behind the sternum and above the diaphragm. It is surrounded by the pericardium. Its size is about that of a fist, and its weight is about 250-300 g. Its center is located about 1.5 cm to the left of the midsagittal plane. Located above the heart are the great vessels: the superior and inferior vena cava, the pulmonary artery and vein, as well as the aorta. The aortic arch lies behind the heart. The esophagus and the spine lie further behind the heart. (Williams and Warwick, 1989).

The walls of the heart are composed of cardiac muscle, called myocardium. It also has striations similar to skeletal muscle. It consists of four compartments: the right and left atria and ventricles. The heart is oriented so that the anterior aspect is the right ventricle while the posterior aspect shows the left atrium. The atria form one unit and

 

 

the ventricles another. This has special importance to the electric function of the heart, which will be discussed later. The left ventricular free wall and the septum are much thicker than the right ventricular wall. This is logical since the left ventricle pumps blood to the systemic circulation, where the pressure is considerably higher than for the pulmonary circulation, which arises from right ventricular outflow. The cardiac muscle fibers are oriented spirally and are divided into four groups: Two groups of fibers wind around the outside of both ventricles. Beneath these fibers a third group winds around both ventricles. Beneath these fibers a fourth group winds only around the left ventricle. The fact that cardiac muscle cells are oriented more tangentially than radially, and that the resistivity of the muscle is lower in the direction of the fiber has importance in electrocardiography and magneto cardiography. The heart has four valves. Between the right atrium and ventricle lies the tricuspid valve, and between the left atrium and ventricle is the mitral valve. The pulmonary valve lies between the right ventricle and the pulmonary artery, while the aortic valve lies in the outflow tract of the left ventricle (controlling flow to the aorta). The blood returns from the systemic circulation to the right atrium and from there goes through the tricuspid valve to the right ventricle. It is ejected from the right ventricle through the pulmonary valve to the lungs. Oxygenated blood returns from the lungs to the left atrium and from there through the mitral valve to the left ventricle. Finally blood is pumped through the aortic valve to the aorta and the

systemic circulation.

 

 

In the heart muscle cell, or myocyte, electric activation takes place by means of the same mechanism as in the nerve cell - that is, from the inflow of sodium ions across the cell membrane. The amplitude of the action potential is also similar, being about 100 mV for both nerve and muscle. The duration of the cardiac muscle impulse is, however, two orders of magnitude longer than that in either nerve cell or skeletal muscle. A plateau phase follows cardiac depolarization, and thereafter repolarization takes place.  As in the nerve cell, repolarization is a consequence of the outflow of potassium ions. (Netter, 1971).Associated with the electric activation of cardiac muscle cell is its mechanical contraction, which occurs a little later. For the sake of comparison, Figure 6.5 illustrates the electric activity and mechanical contraction of frog sartorius muscle, frog cardiac muscle, and smooth muscle from the rat uterus (Ruch and Patton, 1982).  An important distinction between cardiac muscle tissue and skeletal muscle is that in cardiac muscle, activation can propagate from one cell to another in any direction. As a result, the activation wavefronts are of rather complex shape. The only exception is the boundary between the atria and ventricles, which the activation wave normally cannot cross except along a special conduction system, since a nonconducting barrier of fibrous tissue is present. Located in the right atrium at the superior vena cava is the sinus node (sinoatrial or SA node) which consists of specialized

muscle cells. The sinoatrial node in humans is in the shape of a crescent and is about 15 mm long and 5 mm wide (see Figure 6.6). The SA nodal cells are self-excitatory, pacemaker cells. They generate an action potential at the rate of about 70 per minute. From the sinus node, activation propagates throughout the atria, but cannot propagate directly across the boundary between atria and ventricles, as noted above. The atrioventricular node (AV node) is located at the boundary between the atria and ventricles; it has an intrinsic frequency of about 50 pulses/min. However, if the AV node is triggered with a higher pulse frequency, it follows this higher frequency. In a normal heart, the AV node provides the only conducting con ducting path from the atria to the ventricles. ven tricles. Thus, under normal conditions, the latter can be excited only by pulses that propagate through it. Propagation from the AV node to the ventricles is provided by a specialized conduction system. Proximally, this system is composed of a common  

 

bundle, called the bundle of His (named after German physician Wilhelm His, Jr., 18631934). More distally, it separates into two bundle branches propagating along each side of the septum, constituting the right and left bundle branches. (The left bundle subsequently divides into an anterior and posterior branch.) Even more distally the bundles ramify into Purkinje fibers (named after Jan Evangelista Purkinje (Czech; 17871869)) that diverge to the inner sides of the ventricular walls. Propagation along the conduction system takes place at a relatively high speed once it is within the ventricular region, but prior to this (through the AV node) the velocity is extremely slow. From the inner side of the ventricular wall, the many activation sites cause the formation of a wavefront which propagates through the ventricular mass toward the outer wall. This process results from cell-to-cell activation. After each ventricular muscle region has depolarized, repolarization occurs. Repolarization is not a propagating phenomenon, and because the duration of the action impulse is much shorter at the epicardium (the outer side of the cardiac muscle) than at the endocardium (the inner side of the cardiac muscle), the termination of activity appears as if it were propagating from epicardium toward the endocardium.

 

 

8. THE PATIENT AND HIS ILLNESS a. PATHOPHYSIOLOGY (BOOK-CENTERED) Schematic Diagram

Non-modifiable Factors:  



Modifiable Factors: 

Smoking

Gender (male and menopause



Physical Inactivity

women)



Obesity

Hereditary(Including Race)



Diabetes



Stress



Homocysteine Levels



Inflammatory Response



Menopause

 Age (older adults)

Change in the condition of the plaque in the coronary artery

 Activation latelet

Thrombus formation

M oca ocardi rdial al is isch chemi emia a

Prolonged unrelieved

 Anaerobic metabolism

Lactic Acid Production

ischemia

 Acidosis

 An ina

 

 

Myocardial cell death

 Altered re olarization

Release of lysosomal enz mes

Elevated ST segment

Conduction system disorder

D srh thmias Elevated Cardiac Biomarkers

↓ Heart Contractility 

SNS Stimulation

↓ LV Function 

Tac Ta ch ca card rdiia

Increased

Increased

Increased

Oxygen Demand

 Afterload

Preload

Tach

nea

Vasoconstriction

Decreased CO

Increased CVP and PCWP

 

 

b. Synthesis of the disease b.1. Definition of the disease

Coronary artery disease develops when your coronary arteries —  the major blood vessels that supply your heart with blood, oxygen and nutrients —  become damaged or diseased. Cholesterol-containing deposits (plaque) on your arteries are usually to blame for coronary artery disease. When plaques build up, they narrow your coronary arteries, causing your heart to receive less blood. Eventually, the decreased blood flow may cause chest pain (angina), shortness of breath, or other coronary artery disease signs and symptoms. A complete blockage can cause a heart attack. Because coronary artery disease often develops over decades, it can go virtually unnoticed until you have a heart attack. But there's plenty you can do to prevent and treat coronary artery disease. Start by committing to a healthy lifestyle. Coronary artery disease is a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart. It is caused by atherosclerosis, an accumulation of fatty materials on the inner linings of arteries. The resulting blockage restricts blood flow to the heart. When the blood flow is completely cut off, the result is a

heart attack. Coronary artery disease, also called coronary heart disease or heart disease, is the leading cause of death for both men and women in the United States. According to the American Heart Association, deaths from coronary artery disease have declined some since about 1990, but more than 40,000 people still died from the disease in 2000. About 13 million Americans have active symptoms of coronary artery disease. Coronary artery disease occurs when the coronary arteries become partially blocked or clogged. This blockage limits the flow of blood from the coronary arteries, which are the major arteries supplying oxygen-rich blood to the heart. The coronary arteries expand when the heart is working harder and needs more oxygen. Arteries expand, for example, when a person is climbing stairs, exercising, or having sex. If the  

 

arteries are unable to expand, the heart is deprived of oxygen (myocardial ischemia). When the blockage is limited, chest pain or pressure, called angina, may occur. When the blockage cuts off the flow of blood, the result is heart attack (myocardial infarction or heart muscle death). Healthy coronary arteries are clean, smooth, and slick. The artery walls are flexible and can expand to let more blood through when the heart needs to work harder. The disease process in arteries is thought to begin with an injury to the linings and walls of the arteries. This injury makes them susceptible to atherosclerosis and blood clots (thrombosis). b.2. Nonmodifiable HEREDITARY (INCLUDING RACE)

Children whose parents had heart disease are at higher risk for coronary artery disease. This increased risk is related to genetic predisposition to hypertension, elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary artery disease. For people 35 to 74 years of age, the age  – adjusted death rate from coronary artery disease for African  –  American women is 72% higher than that for white women and

Native Americans. The prevalence of coronary is lowest among Mexican American AGE 

 Age influences both the risk and the severity of coronary artery disease. Symptomatic coronary artery disease appears predominantly in people older than 40 years of age and 4 of 5 people who die of coronary artery disease are age 65 years or older. Angina and Myocardia l Infarction, however, can occur in a person’s 30s and even in one’s 20s. at older ages, women who have heart attacks are twice as likely as to die from the heart attack.

 

 

GENDER 

Coronary artery disease is the number one killer of both men and women. In 1999 mortality from coronary artery disease was almost equal for men and women. Although men are at higher risk for heart attacks at younger ages, the risk for women increases significantly at menopause, so that coronary artery disease rates in women after menopause are two to three times that of women the same age before menopause. Women who take oral contraceptives and who smoke or have high blood pressure are at greater risk for coronary artery disease. Women with an early menopause are also at higher risk than are women with a normal or late menopause.Two lifestyle changes during the past 2 decades may be responsible for the increased incidence of coronary artery disease among women. More women (many with full responsibility for the household and children) have entered the work force, and more women have begun to smoke tobacco at an earlier age. Modifiable  SMOKING

Both active smoking and passive smoking have been strongly implicated as a risk factor in the development of coronary artery disease. Currently 23% of men and 18% of

women are smokers. The prevalence of smoking is higher in people with 11 years of education or less. Smoking triples the risk of heart attack in women and doubles the risk of heart attack in men. It also doubles the risk of dying from a heart attack and may quadruple the risk of sudden death. Nonsmokers who are exposed to second  –  hand tobacco smoke at home or work may also have a higher death rate from coronary artery disease. The risk of coronary artery disease is decreased by 50% 1 year after smokers quit. The risk is further reduced to that of nonsmokers within 5 to 10 years after smoking cessation.Tar, nicotine, and carbon monoxide contribute to the damage. Tar contains hydrocarbons and other carcinogenic substances. Nicotine increases the release of epinephrine and norepinephrine, which results in peripheral vasoconstriction, elevated blood pressure and heart rate, greater oxygen consumption, and increased likelihood of dysrhythmias. In addition, nicotine activates platelets and stimulates smooth muscle cell  

 

proliferation in the arterial walls. Carbon monoxide reduces the amount of blood available to the intima of the vessel wall and increases the permeability of the endothelium. PHYSICAL INACTIVITY 

In the United States about 25% of adults report no leisure time physical activity, even though regular aerobic exercise is important in preventing heart and blood vessel disease. There is an inverse relationship between exercise and the risk of coronary artery disease. Those who exercise reduce their risk of coronary artery disease because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5) lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on most days of the week. OBESITY 

Obesity places an extra burden on the heart, requiring the muscle to work harder to pump enough blood to support added tissue mass. In addition obesity increases the risk for coronary artery disease because it is often associated with elevated serum cholesterol and triglyceride levels, high blood pressure, and diabetes. The prevalence of

obesity has increased to 30% in the years 1999 to 2002 compared to 22% from 1988 to 1994. Since 1993 the prevalence of those who are obese increased to 61%. Distribution of body fat is also important. A waist measurement is a way to estimate fat. For men a high  – risk waistline measurement is more than 40 inches and for women a high  – risk waist measurement is more than 35 inches. Body mass index is another measure to estimate body fat. A BMI from 18.5 to 24.9 is considered healthy. Extreme obesity, or a BMI greater than 40, is estimated to occur in 4.9% of the population. People can lower their heart disease risk by losing as little as 10 to 20 pounds. An altering pattern of weight gain and weight loss, however, is associated with an increased risk for coronary artery disease.

 

 

DIABETES 

Since 1990 the prevalence of people diagnosed with diabetes increased by 61%. In addition, the prevalence of diabetes has increased by 8% since 2000 to 2001. Contributing to these statistics is the increased frequency of obesity and sedentary lifestyles. A fasting blood glucose level of more than 126 mg/dl or a routine blood glucose level of 180 mg/dl and glucosuria signals the presence of diabetes and represents an increased risk for coronary artery disease. Clients with diabetes have a two  –  to four  –  fold higher prevalence, incidence, and mortality from all forms of coronary artery disease. STRESS 

 A person’s response to stress may contribute to the development of coronary artery

disease. Some researchers have reported a relationship between coronary artery disease risk and stress levels, health behaviors, and socioeconomic status. Stress response appears to increase coronary artery disease risk through its effect on major risk factors. For example, some people respond to stress by overeating or by starting or increasing smoking. Stress is also associated with elevated blood pressure. Although stress is unavoidable in modern life, an excessive response to stress can be a health hazard. Significant stressors include major changes in residence, occupation, or

socioeconomic status. HOMOCYSTEINE LEVELS

Researchers have reported that elevated levels of plasma Homocysteine (an amino acid produced by the body) are associated with an increased risk of coronary artery disease. Scientists do not know whether homocysteine directly or indirectly increases coronary artery disease risk, however, because homocysteine levels are related to renal function, smoking, fibrinogen, and C  –  reactive protein (CRP). Elevated homocysteine levels can be reduced by treatment with folic acid, vitamin B6, and vitamin B12. Experts currently recommend that homocysteine levels be measured in people with a history of premature coronary artery disease, stroke, or both in the absence of other risk factors.

 

 

INFLAMMATORY RESPONSE 

 A newly identified risk factor currently being researched is the presence of any chronic inflammatory state that leads to an increase in the body’s production of @ -

reactive protein (CRP). Too much CRP tends to destabilize plaque inside artery walls. When plaque lesions crack or break, a clot is formed and this may lead to a heart attack. Researchers have discovered that a high CRP level is a marker for coronary disease. This means that clients with chronic inflammatory diseases, such as arthritis, lupus, and autoimmune deficiency, may be at higher risk for heart attack.

MENOPAUSE

The incidence of coronary heart disease markedly increases among women after menopause. Before menopause estrogen is thought to protect against coronary artery disease risk by raising HDL and lowering LDL level. Epidemiologic studies have shown that the loss of natural estrogen as women age may be associated with increase in total and LDL cholesterol and a gradually increasing coronary artery disease risk. If menopause is caused by surgical removal of the uterus and ovaries, the risk of coronary artery disease and myocardial infarction increase.

b.3. Signs And Symptoms

If your coronary arteries become narrowed, they can't supply enough oxygen-rich blood to your heart — especially when it's beating hard, such as during exercise. At first, the decreased blood flow may not cause any coronary artery disease symptoms. As the plaques continue to build up in your coronary arteries, however, you may develop coronary artery disease symptoms, including:

Chest pain (angina). You may feel pressure or tightness in your chest, as if someone were standing on your chest. The pain, referred to as angina, is usually triggered by physical or emotional stress. It typically goes away within minutes  

 

after stopping the stressful activity. In some people, especially women, this pain may be fleeting or sharp and noticed in the abdomen, back or arm. Shortness of breath. If your heart can't pump enough blood to meet your body's needs, you may develop shortness of breath or extreme fatigue with exertion. Heart attack. If a coronary artery becomes completely blocked, you may have a heart attack. The classic signs and symptoms of a heart attack include crushing pressure in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating. Women are somewhat more likely than men are to experience less typical signs and symptoms of a heart attack, including nausea and back or jaw pain. Sometimes a heart attack occurs without any apparent signs or symptoms.

 

 

PATHOPHYSIOLOGY (CLIENT – CENTERED) Schematic Diagram

Modifiable Factors:

Non-modifiable Factors: 

 Age (older adults)



Physical Inactivity



Stress High fat diet



Gender (male)





Hereditary



 Alcohol drinking

Change in the condition of the plaque in the coronary artery

 Activation latelet

Thrombus formation M oca ocardi rdial al is isch chemi emia a Prolonged unrelieved ischemia

 Anaerobic metabolism

Lactic Acid Production

M oca ocard rdia iall cel celll dea death th  Acidosis

 Altered repolarization

 An ina On

Conduction

Release of lysosomal enzymes

September

system disorder

18, Elevated ST

the patient

segment

D srh thmias

verbalized difficulty of breathing

September 18, 2013 The

patient

2013

Heart Contractilit  

has

occasional PVC.

SNS Stimulation

 

LV Function 

 

September 18, 2013 The Increased

Decreased

manifested paleness

Oxygen Demand

CO

of skin, conjunctivas, body weakness and

September 18, 2013 The

patient

manifested

patient

dry Tachypnea

increased respiratory rate of 31cpm

mucous

membrane. and

crackles

also

heard

auscultation.

NONMODIFIABLE FACTORS (CLIENT – CENTERED) HEREDITARY

Children whose parents had heart disease are at higher risk for coronary artery disease. This increased risk is related to genetic predisposition to hypertension, elevated lipid levels, diabetes and obesity, all of which increase the risk f coronary

Rales were during

artery disease. AGE 

 Age influences both the risk and the severity of coronary artery disease. Symptomatic coronary artery disease appears predominantly in people older than 40 years of age and 4 of 5 people who die of coronary artery disease are age 65 years or older. GENDER 

Coronary artery disease is the number one killer of both men and women. In 1999 mortality from coronary artery disease was almost equal for men and women. Men are at higher risk for heart attacks at younger ages.  

 

MODIFIABLE FACTORS PHYSICAL INACTIVITY 

In the United States about 25% of adults report no leisure time physical activity, even though regular aerobic exercise is important in preventing heart and blood vessel disease. There is an inverse relationship between exercise and the risk of coronary artery disease. Those who exercise reduce their risk of coronary artery disease because they have (1) higher HDL levels; (2) lower LDL cholesterol, triglyceride and blood glucose levels; (3) greater insulin sensitivity; (4) lower blood pressure; and (5) lower body mass index. The AHA recommends 30 to 60 minutes of physical activity on most days of the week. STRESS 

 A person’s response to stress may contribute to the development of coronary artery

disease. Some researchers have reported a relationship between coronary artery disease risk and stress levels, health behaviors, and socioeconomic status. Stress response appears to increase coronary artery disease risk through its effect on major risk factors. For example, some people respond to stress by overeating or by starting or increasing smoking. Stress is also associated with elevated blood pressure. Although

increasing smoking. Stress is also associated with elevated blood pressure. Although stress is unavoidable in modern life, an excessive response to stress can be a health hazard. Significant stressors include major changes in residence, occupation, or socioeconomic status. HIGH FAT DIET 

The vessels that bring blood to the heart are called the coronary arteries. They are like narrow tubes. A fatty substance called plaque (say this: plak) can build up in these arteries and make them narrow, so less blood gets to the heart. A diet high in saturated fat greatly increases your risk of heart disease. Saturated fat increases your LDL cholesterol. LDL cholesterol is bad cholesterol. SIGNS AND SYMPTOMS

 

 

 

Pain and discomfort are the main symptoms of angina. Angina often is described as pressure, squeezing, burning, or tightness in the chest. The pain or discomfort usually starts behind the breastbone. Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. The pain may feel like indigestion. (September 18, 2013)

 

Difficulty of breathing due to tightness of chest brought about interruption in the artery.

 

Pallor manifested on September 18, 2013 due to poor perfusion, poor venous return and decreased oxygen level in the blood.

 

Restlessness manifested on September 18, 2013 caused by loss of oxy oxygen gen and nutrients to the myocardial tissue because of inadequate coronary blood flow.

 

 

PLANNING (NURSING CARE PLAN) Problem#1: Ineffective airway clearance related to retained secretions due to decreased cardiac output Assessment

Diagnosis

Scientific

Objective

Explanation

S= ∅  O=The patient may manifest: -restlessness -Increased RR -dyspnea -cyanosis -excessive sputum -rales -crackles -fatigue

 

Nursing

Rationale

Intervention

Outcome

1.

to

Ineffective

When mucus Short term:

1.

airway

secretion and

patient’s

determine

clearance

mucus

condition

possible

2.

problems

related

to clearance are

retained

not

secretions

balance, excessive

in

 After hours

2-3 of

nursing interventions , the patient

assess

monitor

Expected

and record vital

2.

signs.

baseline data

Short term:

The patient shall have

verbalized

understanding of

for

disease process.

will verbalize 3. encourage airway mucus understandin deep breathing

3. To maximize

can cause g of disease exercises serious process. 4. elevate head problems. of bed and This condition Long term: change position is called  After two every 2 hours impaired days of 5. encourage airway nursing hydration clearance. interventions 6. balance

4. to decrease

effort

pressure in the diaphragm

and

enhance ventilation loosen Long term: The patient shall secretion have maintained 6. to reduce 5.

to

 

the Excess, often sticky mucus may accumulate in

will maintain activities

7.

airway

7. position head

open airway

patency

appropriate for

8. help maintain

condition

adequate

the airways in

8.

conditions as

patient

varied

as

importance

cystic fibrosis,

ambulation

cerebral palsy,

and

chronic obstructive pulmonary disease bronchiectasi s.

Retained

secretions are

a

universal problem people

in with

 

 

artifical airways (tracheostomi es) or those who on

depend assisted

ventilation.

 As

a

consequence of

retained

mucus, breathing becomes labored. More

airway patency

patient rest periods with fatigue to

maintain

Instruct expansion the of

lung

energy

and

effort

are

required

to

take in vital oxygen to

and exhale

 

 

carbon dioxide.  Although underlying causes

are

diverse, consequence s

are

the

same: vulnerable individuals are caught up in the vicious cycle

of

recurrent, everworsening episodes

of

inflammation, pulmonary infection, increased

 

 

production of excess mucus,

and

airway obstruction, lung damage,

and respiratory failure.

 

 

Problem#2: Decreased Cardiac Output related to Increased Vascular Resistance ASSESSMENT

DIAGNOSIS

SCIENTIFIC

OBJECTIVE

EXPLANATION

S-∅  O-The

patient

may manifest: -Restlessness

-Increased BP

Decreased

CAD

cardiac

narrowing

output

r/t blood

increased

This

vascular

leads to intense

resistance

pressure exerted

clammy

skin

condition

on the walls of the blood

-Cold

vessels.

vessels.

The

body’s

compensatory mechanism is to

-Decreased peripheral pulses

increase

workload of the heart and thus the patient decreased

-Dyspnea

the

cardiac output

has

 After 2-3 hours of

determine

condition

possible

nursing

problems

interventions,

2. Monitor

understanding

record

of

signs

disease

and

3. Encourage

 After two days nursing

interventions

vital

shall

have

verbalized

obtain of disease baseline process. data

patient verbalize

patient 3. To make The shall have client to express his participated in feelings

concerns

the patient will activities

patient

Long term:

Long term:

participate

The

2. To

process.

of

Short term:

understanding

the patient will verbalize

EXPECTED OUTCOME

1.  Assess patient’s 1. To

in 4. Encourage patient to

decrease in the  

RATIONALE

INTERVENTIONS

causes Short term: of

NURSING

4. To improve to

change position

venous return

activities

to

decrease

in

the

heart’s

workload

 

every two hours

heart’s

workload

-Prolonged

5. To reduce

5. Encourage

capillary refill

patient

to

stress

do

relaxation -Jugular

techniques

vein

distention 6. Encourage -Edema

6. To

patient

to

engage

in

divertional

divert

attention and

help

patient

activities

lessen

-Weight gain

experience d pain and anxiety

-Pallor

low 7. To prevent further salt and low fat complicatio diet ns of the

7. Reinforced -Oliguria

disease.  

 

Problem#3: Ineffective Tissue Perfusion related to decreased cardiac output  ASSESSMENT

S- ∅ 

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

Ineffective

tissue During

a

PLANNING

INTERVENTIONS

OUTCOME

1. Established

chest Short term:

manifested the following: -Shortness of breath

decreased cardiac the heart, such as output

secondary the

coronary

to Coronary Artery arteries, Disease

become occluded with intravascular plaques. heart

does

absorb -Fatigue

can

through myocardial

The not blood the wall.

Short term:

therapeutic

perfusion related to pain, vessels of O- The patient

EXPECTED

 After 3 hours of nursing

2. Assessed pt.’s

interventions, the patient

will

be

able

to

demonstrate behaviors how

relationship.

to

condition. 3. Monitored and recorded vital

The pt. shall have demonstrated behaviors on how to have effective airways.

signs. on

have

effective airways.

4. Performed morning care

Long term:

5. Noted color and

The patient shall

Instead, blood is

temperature of

- The patient

pumped

the skin.

may manifest:

the heart's own

through Long term:  After 1- 2 days of

vasculature -Pallor

6. Monitored

during

the

nursing

free

from

shortness

of

breath.

peripheral pulse.

interventions, the

relaxation

be

7. Provided a

 

 

period patient

(diastole)

heart able

between -Cool

be

warmth

to

environment. 8. Encouraged

An demonstrate

beats.

temperature

will

occlusion

a adequate tissue

of

blood

vessel

is perfusion

as

by

the evidenced palpable

by

-Decrease

known clinical

pulse

designation

peripheral

"thrombus." If a pulses, plaque and

cardiac

dry

active rom. 9. Monitored urine output.

warm skin,

breaks off from adequate urinary

-Decrease

one vessel and output, and the

urine output

becomes

lodged absence

of

in another vessel, respiratory the

tissue-fed distress.

oxygen-rich blood is inadequately perfused.

 

 

Problem#4: Acute Pain ASSESSMENT

S- ∅  O- The patient

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

 Acute Pain

Coronary

PLANNING

artery

INTERVENTIONS

OUTCOME Short Term:

1. Established

disease (CAD) is

therapeutic

caused

relationship

by

EXPECTED

a  After 3 hours h ours of

Short term:

The patient shall

manifested:

have identified

narrowing of the

Nursing

arteries

Interventions,

pt.’s

supply the heart

the

patient,

condition.

muscle

with

pain scale will

3. Monitored

blood. When the

decrease from

and recorded

-Increase

arteries

8 to 6.

vital signs

respiratory rate

blood

-Pain scale of 8/10

-Chest pain

that

narrow, flow

The

reduced

blood

flow causes the heart muscle to

-The patient may

less

oxygen

than

it

properly.

When

ischemia

occurs

techniques to enhance activity

Long term:

and

 After 2 days of

intensity/seve rity

Nursing Interventions, the patient will

arising

activities.

demonstrate behavior of

activities like

being

having

 

from pain and

conversation

develop angina or

will

w/

chest

pain

from

originating

from

complications

patients -Irritability - (+) guarded behavior -(+) facial grimaces

-v/s change -Diaphoresis

of

been described as

condition.

pain

or

the

patient. 6. Stressed

to

patient

the

importance of providing

has a squeezing

period to the

or

patient.

pressure-like

quality, usually felt the

the

but

shoulders,

arms, neck, jaws, or back.

7. Administered meds ordered.

breastbone sometimes felt in

 

the

the

adequate rest

(sternum),

 

free

that

discomfort

behind -Sleep disturbance

be

the heart. It has chest -Crying

typically

have participated necessary

5. Provided diversional

relieved

The patient shall willingly in

with.

 

-Restlessness

intolerance.

pains location Long term:

needs to function manifest:

and used

4. Assessed

is

reduced.

receive

2. Assessed

as

Problem#5: Fatigue related to Poor Physical Condition ASSESSMENT

DIAGNOSIS

SCIENTIFIC

OBJECTIVE

EXPLANATION

S-The may

patient Fatigue

Fatigue

is

verbalize related to poor overwhelming physical

sense

of

lack of energy

condition

exhaustion resulting

to

decreased patient

may manifest:

capacity

to

perform

activities

at the usual level. -Lethargy or

This is due to the

drowsiness

patient’s

poor

physical condition -Disinterest

in

surroundings

brought about by the condition.

disease

RATIONALE

INTERVENTIONS

 After 2 hours of

nursing

obtain Short term:

record vital

baseline

signs

data

patient

shall

have

2. To

, the patient 2. Determine ability will be able

to

enhance

of

participate

in

commitme

and causative

to

verbalize

understandin g

understanding

to factors. promoting Long term:

condition

optimal

The

and

outcomes

shall

factors.  After 3 days nursing

performance

interventions

patient have

performed

causative Long term:

condition

nt

activities

of

of

3. To

3. Establish realistic activity goals with client

 ADLs participate

participatio

desired

n

activities/level of activity.

 

 

4. To

will be able to

perform 4. Plan care  ADLs and allow participate in individually

-Compromised

desired

adequate

concentration

activities/lev

periods,

el of activity.

schedule

client

encourage patient’s

cooperatio rest

activities periods

to

n

for when

has

the

most energy 5. To

5. Provide

maintain/in

environment conducive health

to

and

maximize

, the patient

-Introspection

The

verbalized

interventions

-Decreased

-Listlessness

EXPECTED OUTCOME

and 1. To

an Short term: 1. Monitor

overwhelming

O-The

NURSING

crease strength and

in

muscle tone and to enhance sense

of

well-being.  

 

6. Give medication 6. To as ordered

lessen

fatigue

Problem#6: Activity intolerance related to imbalance oxygen supply and demand

Assessment

Diagnosis

Scientific

Objective

Explanation

S= ∅  O=The patient may manifest: -restlessness -Increased RR -cold clammy

Coronary artery  Activity intolerance disease results related to

from the

imbalance

interruption of

oxygen

blood supply to

supply and a part of the demand

heart, causing

skin  

heart cells to

-decreased

die. Typical

peripheral

symptoms

pulses

include sudden

-pallor

chest pain

Nursing

Rationale

Intervention Short term:

 After 2-3 hours of nursing interventions, the patient will verbalize

1. assess patient’s

Outcome

1. to determine possible

condition

problems

2. monitor and

2. for baseline

record vital signs 3. encourage

Expected

data

Short term:

The patient shall have verbalized understanding of disease process.

3. to make client express his

understanding

patient to

feelings

of disease

verbalize

4. to improve

process.

concerns

 

-cyanosis -fatigue

(typically

4. encourage Long term:

radiating to the left arm or left side of the neck),

 After two days of nursing interventions

patient to change

venous return 5. to reduce stress 6. to divert

position

attention and

every two

help patient

hours

lessen

Long term:

The patient shall

shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety. Women may experience fewer typical symptoms than men, most commonly shortness of breath, weakness, a

have maintained

the patient will be able to maintain her breathing pattern as

5. encourage

pain and

pattern as

relaxation techniques

anxiety

evidenced by: vital

evidenced by: 6. Encourage patient to vital signs within the

engage in

normal range

diversional activities such as chatting with family and friends. 7. reinforced

 

feeling of

low salt and

indigestion, and

low fat diet

in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities.

 

 

her breathing

patient to do

 

fatigue resulting

experienced

8. adjust activities 9. balance rest periods with activities 10. increase activity levels gradually

7. to prevent further complications of the disease 8. to prevent overexertion 9. to reduce fatigue 10. to conserve energy

signs within the normal range

C. IMPLEMENTA IMPLEMENTATION TION 1. MEDICAL MANAGEMENT a. IVFs, NGT feeding, Nebulization, TPN, Oxygen therapy, etc Indication

Client’s Response to

Date Performed

Or

Treatment

Date Changed

Purposes

Medical

Date Ordered

Management/ Treatment

D5W 500ccx KVO

General Description

Date ordered:

D5W is initially infused, Lactated Ringer’s and Mr. Corona D. Sease

09/17/2013

it

is

an

isotonic 5%

Dextrose,

solution, but when the indicated Date performed:

dextrose

09/17/2013

metabolized, solution

is Corona D. Sease actually calories

solution

where

osmotic

pressure

into cells.

 

 

Nursing Responsibilities Prior

  Verify the Doctor’s order  



Prepare all the equipment needed

  Do not administer unless solution is clear and container is undamaged.



  Properly label the IV fluid.



  Explain the purpose of the procedure and what to expect



During 

 

Provide patient's safety

 

Locate for a good vein





  Apply antiseptic to the puncture site



  Check if it is the correct ty type pe of IV fluid



After

or

as

alkalinizing agent.

causes fluid to shift

 

Mr. good hydration status as as evidenced by good

the a source of water and skin turgor and moist

becomes hypotonic, a



to

is was able to maintain

an oral membrane.

mucous

After  

 



Secure the IV tubing

  Discard unused portion



  Regulate the IV fluid as prescribed



 



Document the procedure

 

 

Indication

Client’s Response to

Date Performed

Or

Treatment

Date Changed

Purposes

Medical

Date Ordered

Management/ Treatment

O2

Inhalation Date ordered:

regulated at 2-3 LPM

09/17/2013

General Description

Inhalation of oxygen O2

restoring indicated

aimed

at

toward

normal

Date performed:

physiologic alterations a

09/17/2013

of gas exchange in the supplementary

of a respirator, nasal catheter,

tent,

chamber, or mask.

Nursing Responsibilities Prior

  Verify the Doctor’s order  



Prepare all the equipment needed

 

 

During 

 



Provide patient's safety

  Place properly on patient’s nose 



  Regulate at 2-3LPM as ordered



source

oxygen.

system, as by the use

 

to

any Corona D. Sease

cardiopulmonary



Inhalation,

is Mr. Corona D. Sease Mr. was able to maintain as normal

respiratory

of breathing pattern.

After  

  Document and record



 

 

b. Drugs 1. Aspirin

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

Name of

Date

Drug; Generic

Ordered/

name; Brand

Date Taken

name

Date

with Actual

Changed

Side Effect

Generic name:

Date ordered:

 Aspirin

08/17/2013

(acetylsalicylic acid)

Date taken:

PO, 80 mg 1 tab , OD

the Medication

General action:

Indicated for Mr. Corona D.

NSAID;

Mr.

 Anti-platelet

D. Sease for responded well

aggregation

treatment of in the drug as

Corona Sease

to evidenced

mild

08/17/2013

normal platelet

of moderate

Brand Name:

Mechanism

 Asaphent 

action:

pain;

Inhibits

reduction

prostaglandin

risk of death

synthesis,

or

count. of

unstable

resulting in anti- angina inflammatory  

 

pectoris,

by

or

activity,

and recurrent

platelet

transient

aggregation

ischemia

inhibition;

attacks

reduces fever by (TIAs). acting

on

brain's

the heat-

regulating center to

promote

vasodilation sweating.

Nursing responsibilities Prior

  Verify the doctor's order



 



Give necessary information to the patient

  Obtain a history of previous use and reactions to medication.



During

  Administer medication as ordered



  Verify/check the medication again



 

 

After

  Monitor fungal/bacterial super infection



  Monitor sodium level



and

 

 

2. Clopidogrel Name of drug;

Date ordered/

Generic Name;

Date Taken/

Brand Name

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the medication with Actual Side Effect

Generic name: Clopidogrel

Date ordered:

PO, 75mg/tab, 1 tab General action:

09/17/2013

OD

It was indicated Mr. Corona D.

platelet for Mr. Corona D. Sease

Inhibits

for responded well

by Sease

aggregation

of in the drug as

Brand name:

Date taken:

blocking

AD prevention

Plavix

09/17/2013

Preceptors

on thrombosis along evidenced

platelets

,preventing with Aspirin and normal

clumping of platelets

to

prevent count.

vascular of ischemic events.

Mechanism action:

It was found to inhibit prostaglandin synthesis

and

to

complete for binding

 

 

at the prostaglandin receptor sites, giving analgesic

and

anti-

inflammatory effect

Nursing Responsibilities Prior

by

platelet

  Check the doctor’s order three times and verify the patient 





  Check the label of the drug, its name and its expiration date.   Explain the importance of compliance in medication regimen



  Obtain a history of previous use and reactions to medication.



During

  Instruct patient to notify prescriber if unusual bleeding or bruising occurs.



  Tell patient to inform all health care providers, including dentist, before undergoing procedures or starting new



drug.

 

 

After

  Evaluate the effect of the medication to the patient’s condition  



  Tell patient to refrain from activities in which trauma and bleeding may occur.



3. Enoxaparin Name of drugs;

Date Ordered/

Generic name;

Date Taken/

Brand name

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the Medication with Actual Side Effect

Generic name: Enoxaparin

Date ordered:

SQ, 0.4 cc, BID x 5 General action:

It was indicated Mr. Corona D.

09/17/2013

days

to

 Anti coagulant drug

prevent

Mr. Sease

Corona D. Sease responded well Brand name:

Date taken:

Mechanism

Clexane,

09/17/2013

action:

Lovenox

 

and

from absence

 Accelerates formation complications of

 

of from blood clots as evidenced by

anti-thrombin

III from angina and

chest pain.

of

thrombin and

complex heart

attacks

deactivates with oral aspirin

thrombin, preventing therapy

and

conversion

ST-

fibrinogen

of  Acute to

fibrin. segment

Drug has a higher elevation MI. anti factor Xa to antifactor IIa activity ratio than heparin.

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient 



  Check the label of the drug, its name and its expiration date.



  Explain the importance of compliance in medication regimen. regimen.



  Obtain a history of previous use and reactions to medication.



 

 

During

  Instruct patient and SO to watch for signs of bleeding or abnormal bruising and notify prescriber immediately if any



occur.   Tell patient to avoid OTC drugs containing aspirin or other salicylates unless ordered by prescriber



After

  Evaluate the effect of the medication to the patient’s condition  



 

 

4. Captopril Name of drugs;

Date Ordered/

Generic name;

Date Taken/

Brand name

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the Medication with Actual Side Effects

Generic name: Captopril

Date ordered:

PO, 25 mg/tab , 1 General action:

It was indicated Mr. Corona D.

09/17/2013

tab B.I.D

for hypertension Sease

 Antihypertensive

of Mr. Corona D. responded well Brand name:

Date taken:

Mechanism

Capoten

09/17/2013

action:

of Sease,

and

to as evidenced by

vasodilate blood lower

Inhibits

ACE, vessels so blood pressure.

preventing conversion flows

more

of angiotensin I to smoothly

and

angiotension

can

II,

a the

heart

pump

potent

vasoconstrictor. Less efficiently. angiotensin

II

decreases peripheral arterial

resistance,

 

 

decreasing aldosterone secretion,

which

reduces sodium and water retention and lowers pressure.

blood

more

blood

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient 



  Check the label of the drug, its name and its expiration date.



  Explain the importance of compliance in medication regimen. regimen.



  Obtain a history of previous use and reactions to medication.



  Instruct patient to take drug 1 hour before meals.



During

  Inform patient that light headedness is possible, especially during the first few days of therapy.





  If fainting occurs, he should stop the drug and call the prescriber.

 

 

After

  Evaluate the effect of the medication to the patient’s condition  



  Tell patient to use caution in hot weather and during exercise.



  Advise patient to report signs and symptoms of infection, such as fever and sore throat.



  Urge patient to promptly report swelling of the face, lips, mouth or difficulty breathing.



5. Rosuvastatin Name of

Date Ordered/

Drugs;

Date Taken/

Generic Name;

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the Medication with Actual

Brand Name

Side Effects

Generic name: Rosuvastatin

Date ordered:

PO,

20

09/17/2013

OD HS

mg/tab, General action:  Antilipemic

 

 

was

reduce

indicated risk

of

to Mr. Corona D. Mr. Sease

Corona D. Sease in responded well

Calcium Brand name:

It

Date taken:

Mechanism

09/17/2013

action:

of death from CV disease as

evidenced

in by

reduced

and

CV

events

Crestor

patients at high risk of cholesterol

Competiting

inhibitors HMG CoA coronary

the

to level.

This reduce total and LDL

reductase. enzyme

events,

catalyzes cholesterol,

early

rate apolipoprotein B, and

limiting step in the triglyceride levels and of increase

synthesis

HDL

cholesterol.

cholesterol

Decreased

patients with primary

cholesterol,

hyperlipidemia

triglycerides,

mixed dyslipidemia; to

VDL,LDL

and reduce

increased

HDL. density

Does basal

not

reduce cholesterol plasma patients

cortisol

level

very

in and low

lipoprotein level

in with

or dysbetalipoproteinemia

testosterone level

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient.



 

 

  Check the label of the drug, its name and its expiration date.





  Explain the importance of compliance in medication regimen.   Obtain a history of previous use and reactions to medication.



  Instruct patient to take drug in the evening.



During

  Teach patient about proper dietary management of cholesterol and triglycerides



  Tell patient to inform prescriber iiff adverse reactions occur, particularly muscle aches and pains or tenderness or



weakness with malaise or fever. After

  Evaluate the effect of the medication to the patient’s condition  



 

 

6. Lactulose Name of Drugs;

Date Ordered/

Generic Name;

Date Taken

Brand Name

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the Medication with Actual Side Effects

Generic name: Lactulose

Date ordered:

PO, 30CC, OD HS

09/17/2013

General action:

Indicated for Mr. Mr. Corona D.

Laxatives

Corona D. Sease Sease prevent experiences

to Brand name:

Date taken:

Mechanism

Lilac, Rilax

09/17/2013

action:

of constipation and regular

prevent movement.

to

Produces an osmotic straining effect

while

colon; defecating

in

distention could

resulting

that

increase

promotes peristalsis. the workload of decreases the heart.

 Also ammonia,

probably

as a result of bacterial degradation, lowers

the

which pH

 

 

colon contents.

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient 



  Check the label of the drug, its name and its expiration date.



of

bowel

  Explain the importance of compliance in medication regimen



  Obtain a history of previous use and reactions to medication.



During

  Monitor mental status and potassium levels



  Replace fluid loss



  Instruct patient not to take other laxatives dur during ing lactulose therapy.



After

  Evaluate the effect of the medication to the patient’s condition  



 

 

7. Furosemide Name of Drugs;

Date Ordered/

Generic Name;

Date Taken/

Brand Name

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the Medication with Actual Side Effects

Generic name: Furosemide

Date ordered:

IV, 40 mg, every 6 General action:

Indicated for Mr. Mr. Corona D.

09/17/2013

hours for 3 days

Corona D. Sease Sease

Loop Diuretic

to Brand name:

Date taken:

Mechanism

Lasix

09/17/2013

action:

 Acts

by

treat

of blood

pressure

and to prevent within

normal

the accumulation

luminal Na-K-2Cl luminal  Na-K-2Cl

of

Henle. Henle.   failure.

tubules

is

independent of any

 

 

of edema

can

be

limb of cause by heart

The action on the distal

range

fluid of the body noted.

symporter in the the thick  thick that ascending

a

pressure blood

inhibiting excessive

NKCC2,

the the  loop

high established

and

no was

inhibitory

effect

on

carbonic

anhydrase

or aldosterone; it also abolishes

the

corticomedullary osmotic gradient and blocks negative, as well as positive, free positive, free water clearance.  clearance. 

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient 



  Check the label of the drug, its name and its expiration date.



  Explain the importance of compliance in medication regimen



  Obtain a history of previous use and reactions to medication.



  Instruct patient to take drug 1 hour before meals,



During

  Inform patient that light headedness is possible, especially during the first few days of therapy.



  If fainting occurs, he should stop the drug and call the prescriber.



 

 

After

  Evaluate the effect of the medication to the patient’s condition  



  Tell patient to use caution in hot weather and during exercise.



  Advise patient to report signs and symptoms symptoms of infection, such as fever and sore throat.



  Urge patient to promptly report swelling of the face, lips, mouth or difficulty breathing.



8. Salbutamol  Name of

Date Ordered/

Drugs; Generic

Date Taken/

Route, Dosage

Name; Brand

Date Changed

and Frequency

General Action,

Indication or

Client’s

Mechanism of Action

Purposes

Response to the Medication with Actual

Name

Side Effects

Generic name:  Albuterol Sulfate

Date ordered:

Nebulizer

09/18/2013

doses minutes

X

every

3 General action: 15 Bronchodilator

Indicated for Mr. Mr. Corona D. Corona D. Sease Sease to

relieve cooperated with

Brand name:

Date taken:

Mechanism of action:

bronchospasm

medication and

09/18/2013

 A

brought

substance

the

improvement

that dilates that  dilates the the bronchi  bronchi

compensatory

with

and bronchioles, and  bronchioles,  

mechanism

about shown a slight

 

 

 Accuneb

of pattern

decreasing resistance lungs to maintain in

the respiratory adequate oxygen the respiratory

airway and increasing supply. airflow to the lungs. the lungs.  

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient 



  Check the label of the drug, its name and its expiration date.



  Explain the importance of compliance in medication regimen



During

  Position patient on high back rest



 

 

After

  Evaluate the effect of the medication to the patient’s condition  



  Do back tapping



  Instruct patient to take food immediately.



breathing

9. Hydrocortisone Name of Drugs;

Date Ordered/

Generic Name;

Date Taken/

Brand Name

Date Changed

General Action,

Indication or

Client’s

Route, Dosage

Mechanism of

Purposes

Response to

and Frequency

Action

the Medication with Actual Side Effects

Generic name: Hydrocortisone

Date ordered:

IV, 100mg , PRN

09/18/2013

General action:

Indicated for Mr. Mr. Corona D.

Corticosteroid

Corona D. Sease Sease to relieve from cooperated with

Brand name:

Date taken:

Mechanism

Hydrotex,

09/18/2013

action:

of short-term

inflammation.

medication and relieved

 

 

Synacort

Enter

cells

where

they

combine

with

steroid receptors in cytoplasm  combination nucleus

enters

where

it

controls synthesis of protein,

including

enzymes regulate

that vital

cell

activities over a wide range

of

metabolic

functions including all aspects inflammation.

Nursing Responsibilities Prior

  Check the doctor’s order three times and verify the patient 



  Check the label of the drug, its name and its expiration date.



  Explain the importance of compliance in medication regimen



 

 

of

inflammation.

During

  Watch out for adverse reactions



After

  Evaluate the effect of the medication to the patient’s condition  



 

 

C. DIET Date ordered/ Type of Diet

Date started/

General

Indication/

Specific Food

Client’s Response to

Description

Purpose

Taken

Treatment

Date changed

Low Salt, Low Fat Diet

Date ordered: 08/17/2013

 A type of diet It was indicated which in food to prevent Mr. provided

the Corona

D.

client is low Sease to have fat and a fluid retention Date started: 08/17/2013

sodium

and decreased

content, with in a

strict demand.

precaution to aspiration which

metabolic

the

Rice and fish

Mr.

Corona

D.

Sease

responded well on the diet by not eating food that are salty and fatty and by just eating such as boiled food.

patient be

must

position

 

 

into

semi-

fowler’s or the

head is being elevated.

Nursing Responsibilities: Prior

  Check physician’s order  



  Inform the patient’s SO about the type of diet.  



  Explain the purpose of the the diet ordered the consequences of not following such diet and how it will be



implemented.

During

  Monitor if the patient c complies omplies w with ith the given diet.



  Monitor intake and output.



 

 

After

  Monitor patient’s reaction and compliance with diet. 



  Instruct patient to maintain the optimal nutritional status



  Provide oral hygiene after meals



 

 

D. ACTIVITY/EXE ACTIVITY/EXERCISE RCISE Type

Date Ordered/

General Description

Indications/ Purposes

Client’s Response/ Reaction 

Performed/ Changed

Bed

Rest Date ordered:

with bathroom

09/17/2013

privilege

Confined him on bed to Indicated to restore the energy rest but can do some light and

activities like going to the Corona bathroom

Date performed:

promote

Having

and some

D.

rest

Sease

of that

Mr. to

walking. decreased the workload of limited heart.

Mr. Corona D. Sease complied on the instructed exercise AEB he limits his activity and was able to take a rest and sleep properly to promote wellness

strenuous movement.

09/17/2013

Nursing Responsibilities: Prior

  Check physician’s order  



  Inform the patient’s SO about the type of activity. 



 

 

  Explain the purpose of the activity ordered the consequences of not following such diet and how it w will ill be



implemented.   Provide proper positioning.



During

  Assist the client in doing any activities.



After

  Document response of the patient.



2. SURGICAL MANAGEMENT

  No surgical management was done



 

 

3. NURSING MANAGEMENT (ACTUAL SOAPIERs)

 

SEPTEMBER 18, 2013

S= “Medyo nahihirapan akong huminga‖ as verbalized by the patient.  

O=Received patient in sitting position, conscious and coherent with an IVF of D5 in

water x KVO @ 4500cc level, with 02 inhalation of 2-3LPM, with signs of fatigue, with pale palpebral conjunctivas, with prolonged capillary refill, body weakness, cold clammy skin, VS as follow: T= 36.5C, HR=74bpm, RR=31bpm, BP=110/80mmHg.

A= Decreased cardiac output related to altered cardiac function secondary to CAD

P= After 2 hours of nursing interventions patient will be able to verbalized

understanding and importance of hemodynamic stability

I= INDEPENDENT > Established rapport  > Monitored and recorded VS

> Provided bed side care > Oral medications given and noted

 

 

> Kept client on semi – fowler’s position  > Evaluated client’s reports and evidence of extreme fatigue  

> Monitored cardiac rhythm continuously > Scheduled activities and assessment > Assisted patient in performing self-care > Provided health teachings in reducing activities that may stimulate an increase in oxygen demand >Provided adequate rest > Assisted patient in changing position DEPENDENT

>For 2Decho/requested

E= Patient verbalized understanding and importance of hemodynamics stability

 

SEPTEMBER 19, 2013 

S= ―Agad akong napapagod‖ as verbalized by the patient 

O= Received patient on a sitting position, conscious and coherent, with ongoing IVF

of D5W x KVO @ 450cc level, with O2 inhalation of 2-3 LPM, with foley catheter draining on a yellowish brown output @ 800cc level, with pale nail beds, seemed weak and restlessness, with presence of productive cough, move with assistance, VS taken as follows: T= 35.3C, HR=91bpm, RR=28bpm, BP=110/80mmHg.

 

 

A=  Fatigue related to decreased muscle strength as evidenced by decreased in

performance

P= After 3 hours of nursing interventions the patient will participate in desired

activities of level ability

I= INDEPENDENT

>Establishes rapport >Provided morning care >Assessed general condition

> Monitored and recorded VS > Instructed to have adequate rest > Encouraged to practice deep breathing technique > Encouraged to have passive range of motion exercise > Provided support when moving > Instructed to avoid foods with caffeine or high sugar > Oral medications given as ordered DEPENDENT

>For 2Decho-advised E= Patient participated to the desired activities at level ability

 

 



  SEPTEMBER 20, 2013 

S= O

O= Received patient on a lying position, conscious and coherent, with ongoing IVF

of D5W x KVO @ full level, with foley catheter draining on a yellowish brown output @ 100cc level, with pale nail beds, seemed weak and restlessness, with presence of productive cough, move with assistance, with excessive sputum seen in a cup at the bed side, rales and crackles are heard during auscultation VS taken as follows: T= 36.8C, HR=78bpm, RR=26bpm, BP=120/80mmHg.

A= Ineffective airway clearance related to retained secretions as evidenced by

excessive sputum seen in a cup at the bed side.

P= after 3 hours of nursing interventions the patient will verbalize understanding of

causes and therapeutic management regimen.

I= INDEPENDENT

>Establishes rapport  >Provided morning care > Kept patient comfortable >Assessed general condition > Monitored and recorded VS

 

 

> Instructed to have adequate rest > Encouraged to practice deep breathing technique > Elevate head of bed and change position every 2 hours > Encouraged increase fluid intake

E= the patient verbalized understanding of causes and therapeutic management

regimen.

 

 

D. EVALUATION

Client’s Daily Progress  ADMISSION

1s  NPI

2n NPI

3r   NPI

9/17/13

9/18/13

9/19/13

9/20/13

Airway

✓ 

✓ 

✓ 

✓ 

Cardiac

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

DAYS

Nursing Problems

1.

Ineffective

Clearance 2.

Decreased

Output 3.

Ineffective

Perfusion

Tissue

✓ 

X

X

X

✓ 

✓ 

X

X

✓ 

✓ 

X

X

Temperature

36.5’C 

35.8’C 

36.8’C 

Pulse Rate

74 bpm

77 bpm

78 bpm

Respiratory Rate

31 bpm

31 bpm

26 bpm

Blood Pressure

110/80

110/80

120/80

mmHg

mmHg

mmHg

4. Acute Pain

5. Activity Intolerance 6. Fatigue

Vital Signs

DX/Lab Procedures

>Blood Chemistry Hgb

130

 

 

Hct WBC

0.44 7

Neutrophils

0.49

Lymphocytes

0.27

Platelet

298

Fasting Blood Sugar

6.02

BUN

4.1

Creatinine

130.8

Sodium

146.6

Potassium

4.23

>Urinalysis Color

Yellow

Transparency

Turbid

Specific gravity

1.013

Sugar

Negative

Medical Management:

>D5W

✓ 

✓ 

✓ 

✓ 

>Aspirin

✓ 

✓ 

✓ 

✓ 

>Clopidogrel

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

>Furosemide

✓ 

✓ 

✓ 

✓ 

>Salbutamol

X

✓ 

✓ 

✓ 

X

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

✓ 

Drugs

>Enoxoparin >Captopril >Rosuvastatin >Lactulose >Lanoxin

 

 

>Hydrocortisone Diet

>LSLF with SAP

Activity/Exercise

> CBR with BRP

 

 

2. DISCHARGE PLANNING

a. General Condition of Client Upon Discharge The patient prior to discharge demonstrated the following indications of good health and alleviation from the previous diagnosis:   - Patient was able to cope up with his/her ADL’s  - Patient was able to return to normal appetite to increase body nutrition - Patient was able to verbalize needs - Patient was portraying absence or decreased pain - Patient together with the S.O was able to comply with health teachings

given prior discharge

b. METHODS

M(edications) – Instructed the patient to continue medication as ordered

1. Salbutamol Neb 1 Neb twice a day 2. Aspirin 80 mg/tab 1 tab once a day 3. Clopidogrel 70 mg/tab 1 tab once a day 4. Enalapril 5 mg/tab 1 tab once a day 5. Atovastatin80mg/tab 1 tab once a day 6. Lactulose 30cc once a day 7. Lanoxin 0.25gmg/tab once a day 8. Acetylcysteine 200mg/sachet 1 sachet in 1 glass water three times a day 9. Prednisone 20mg/tab two times a day E(xercise) – Instructed the patient to do exercise as tolerated such as walking

 

 

-Instructed patient to obtain adequate rest periods T(reatment) – Instructed patient to continue medication H(ealth Teachings) – Encouraged patient to increase fluid intake

-

Encourage patient to eat foods rich in vitamins especially vitamin C and nutritious foods

-

Encouraged patient to avoid salty and fatty foods

-

Instructed patient to limit her activ activity ity for 24 to 48 hours after discharge

O(ut-patient Department)  –  Advised patient to have OPD follow-up check up on

September 27, 2013 at 10 am D(iet) – Encouraged patient to eat smaller than normal amounts of food at meal time

-

Encourage Low Salt Low Fat Diet