58654960 case-study-acute-mi

I. INTRODUCTION

A.) OVERVIEW OF THE STUDY

Acute myocardial infarction (MI) is defined as death or necrosis of

myocardial cells. It is a diagnosis at the end of the spectrum of myocardial

ischemia or acute coronary syndromes. Myocardial infarction occurs when

myocardial ischemia exceeds a critical threshold and overwhelms myocardial

cellular repair mechanisms that are designed to maintain normal operating

function and hemostasis. Ischemia at this critical threshold level for an extended

time period results in irreversible myocardial cell damage or death.

Critical myocardial ischemia may occur as a result of increased myocardial metabolic demand and/or decreased delivery of oxygen and nutrients to the myocardium via the coronary circulation. An interruption in the

supply of myocardial oxygen and nutrients occurs when a thrombus is

superimposed on an ulcerated or unstable atherosclerotic plaque and results in

coronary occlusion. A high-grade (> 75%) fixed coronary artery stenosis due to

atherosclerosis or a dynamic stenosis associated with coronary vasospasm can

also limit the supply of oxygen and nutrients and precipitate an MI. Conditions

associated with increased myocardial metabolic demand include extremes of

physical exertion, severe hypertension (including forms of hypertrophic

obstructive cardiomyopathy), and severe aortic valve stenosis. Other cardiac valvular pathologies and low cardiac output states associated with a

decreased aortic diastolic pressure, which is the prime component of coronary

perfusion pressure, can also precipitate MI

Myocardial infarction can be subcategorized on the basis of anatomic,

morphologic, and diagnostic clinical information. From an anatomic or

morphologic standpoint, the two types of MI are transmural and nontransmural. A

transmural MI is characterized by ischemic necrosis of the full thickness of the

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affected muscle segment(s), extending from the endocardium through the

myocardium to the epicardium. A nontransmural MI is defined as an area of

ischemic necrosis that does not extend through the full thickness of myocardial

wall segment(s). In a nontransmural MI, the area of ischemic necrosis is limited

to either the endocardium or the endocardium and myocardium. It is the

endocardial and subendocardial zones of the myocardial wall segment that are

the least perfused regions of the heart and are most vulnerable to conditions of

ischemia. An older subclassification of MI, based on clinical diagnostic criteria, is

determined by the presence or absence of Q waves on an electrocardiogram

(ECG). However, the presence or absence of Q waves does not distinguish a

transmural from a non-transmural MI as determined by pathology

A more common clinical diagnostic classification scheme is also based on

ECG findings as a means of distinguishing between two types of MI—one that is

marked by ST elevation and one that is not. The distinction between an ST-

elevation MI and a non-ST-elevation MI also does not distinguish a transmural

from a non-transmural MI. The presence of Q waves or ST segment elevation is

associated with higher early mortality and morbidity; however, the absence of

these two findings does not confer better long-term mortality and morbidity.

The most common etiology of MI is a thrombus superimposed on a

ruptured or unstable atherosclerotic plaque.

.

Myocardial infarction is the leading cause of death in the United States

(US) as well as in most industrialized nations throughout the world.

Approximately 800,000 people in the US are affected and in spite of a better

awareness of presenting symptoms, 250,000 die prior to presentation to a

hospital.4 The survival rate for US patients hospitalized with MI is approximately

90% to 95%. This represents a significant improvement in survival and is related

to improvements in emergency medical response and treatment strategies.

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http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/acutemi/acutemi.htm#ref4%23ref4

In general, MI can occur at any age, but its incidence rises with age. The

actual incidence is dependent upon predisposing risk factors for atherosclerosis,

which are discussed below. Approximately 50% of all MI's in the US occur in

people younger than 65 years of age. However, in the future, as demographics

shift and the mean age of the population increases, a larger percentage of

patients presenting with MI will be older than 65 years

B.) OBJECTIVES OF THE STUDY

The main reason and purpose student nurses conduct care study and

exposure in the clinical area is for them to identify problems encountered by the

clients; this is one of their tools of learning knowledgeably and skillfully.

We, as health care providers, it is indeed our vocation to adjoined hands

w/ the health team for the promotion of wellness of our clients. Our main

objectives for this study are the following:

To identify the chief complaints and admitting diagnosis of our patient so

that we can give specific nursing interventions.

To determine the family and personal health history of our patient that

may affect present health condition

To identify the cause and effect of the main problem through a correct

analysis of the pathophysiology of the case.

To determine the medical management given through identifying the

significant implication of the laboratory and diagnostic examinations

ordered as well as the medical orders and its rationale.

To make a nursing care plan for the different health problems

encountered by the client.

To establish an ideal plan of care for a specific diagnosis or problem of

the client.

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To evaluate the effectiveness of the actual nursing care plan that was

established.

To impart health teachings to the client giving emphasis on his

medications, exercises, treatment, out- patient follow- up and diet

To give referrals and follow-up for the health promotion of the client.

In general, this study aims to enhance the skills and knowledge of the

students in providing holistic care to the patient. Students logically search further

knowledge in order to attain the desired goal and intervention for the wellness of

the patient.

C.) SCOPE AND LIMITATION

Prior to the day of duty, the group has already chosen a patient for care

study. They performed a physical assessment to the patient to properly identify

the nursing problems, which require necessary and direct interventions and

medical regimen. The study on medications and doctor’s order were limited to

our chosen patient

The preventive care and anticipatory guidance are integral to nursing

practice. Thus, this care study focuses on the particular case of the patient. Since

the patient’s diagnosis is more on cardiovascular disease, the group has focused

on acute myocardial infarction as one of his admitting diagnosis. However, the

group did not just limit the interventions on monitoring cardiac activity of the

patient. Any symptoms and unusualties were kept watch and monitored. Any

Referrals and follow-up, so as with the nursing management were fully granted

and analyzed for the said case.

Supposedly, this case study should be focused on Gynecology concept

but due to the unavailability and presence of gyne patient in Cagayan de Oro

Polymeric General Hospital, the concept is focused on medical from Station 7.

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The care for our chosen patient is only limited for 2 days of duty excluding the

physical assessment done prior to the day of duty.

II. HEALTH HISTORY

A.) PATIENT’S PROFILE

Name of Patient: ?

Sex: Male

Age: 64 years old

Religion: Roman Catholic

Civil Status: Married

Occupation: ?

Income: P 6,000/ month

Nationality: Filipino

Date Admission: June 29, 2007

Time: 09:40 pm

BASELINE VITAL SIGNSTemperature: 36.6 C

Pulse Rate: 54 bpm

Respiratory rate: 18 cpm Blood Pressure: 130/100 mmHg

Height: 5’3’’

Weight: 55.5 kgs

Chief complaints: epigastric pain

Admitting Diagnosis: Acute myocardial infarction;

Hypertensive cardiovascular disease;

ruled out PUD; diabetic neprhopathy

Attending Physician: Dr. Alenton

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B.) FAMILY AND PERSONAL HEALTH HISTORY

?, 64-year-old, male, a resident of ? has a critical health problem. He said

that he was an alcohol drinker during his adolescence and late adulthood and

confessed that he only drinks 2-6 glasses even more on occasional basis;

however, he has no history of cigarette smoking. At fist, he experienced

hypertension in the year 1998 when he was still 55 years old. On the year 2006,

because of over workload and emotional stress, Mr. Agustin has experienced

severe chest pain and that same year he was diagnosed of having Diabetes

Nephropathy and Chronic Renal Insufficiency and was admitted at Northern

Mindanao Medical Center. During his admission last 2006, Mr. Sarmiento has

been transfused with 5 bags of Packed Red Blood Cell and there were no reports

of allergic reaction. At that time, he was advised by the doctor to have his

monthly check-up for his health problems.

According to the patient’s wife, there is no history of health problems from

their family. Nobody aside from Mr. Agustin Sarmiento has been admitted for

chronic illness. His children were neither non-smoker nor alcoholic but they do

drink alcohol occasionally Although there were presence of minor illnesses

before like cough, colds, LBM but they were able to catch on the treatment

regimen as a home care management.

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C.) CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

On the 29th of June, Mr. ? has experienced chest pain with complaints of

acute epigastric pain, growing in character and on and off. The patient was

anorexic and hypertensive (180/ 60 mm Hg). With the help of his family he went

to the hospital for check-up, they thought that it was just an ulcer, but the doctor

came out to have a diagnosis of Acute myocardial infarction; Hypertensive

cardiovascular disease; ruled out PUD; diabetic neprhopathy, and due to the

severity of pain he was prompted for admission in the Polymedic General

Hospital.

III. DEVELOPMENTAL STATUS

ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY

Later Maturity (60 y.o- )

The fact that man learns his way through life is made radically clear by

consideration of the learning tasks of older people. They still have new

experiences ahead of them, and new situations to meet. At age sixty-five when a

man often retires from his occupation, his changes are better than even of living

another ten years. During this time the man or his wife very likely will experience

several of the following things: decreased income, moving to a smaller house,

loss of spouse by death, a crippling illness or accident, a turn in the business

cycle with a consequent change of the cost of living. After any of these events

the situation may be so changed that the old person must learn new ways of

living.

The developmental tasks of later maturity differ in only one fundamental respect

from those of other ages. They involve more of a defensive strategy--of holding

on the life rather than of seizing more of it. In the physical, mental and economic

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spheres the limitations become especially evident; the older person must work

hard to hold onto what he already has. In the social sphere there is a fair chance

of offsetting the narrowing of certain social contacts and interests by the

broadening of others. In the spiritual sphere there is perhaps no necessary

shrinking of the boundaries, and perhaps there is even a widening of them.

Our patient Agustin Sarmiento is already at the later maturity stage. At

his age he will be adjusting in decreasing physical strength and health, adjusting

to retirement and reduced income, adjusting to death of spouse, establishing an

explicit affiliation with one's age group, meeting social and civic obligations,

establishing satisfactory physical living arrangements: The principal values that

older people look for in housing, according to studies of this matter, are: quiet,

privacy, independence of action, nearness to relatives and friends, residence

among own cultural group, closeness to transportation lines and communal

institutions like libraries, shops, movies, churches, etc.

ERIK ERICKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

Ego Integrity vs Despair (65-)Erik Erikson adapted and expanded Freud’s theory of development to

include the entire life span, believing that people continue to develop throughout

life. He describes eight stages of development. Erikson envisions life as a

sequence of levels of achievement. Each stage signals a task that must be

achieve. The resolution of the task can be complete, partial or unsuccessful.

Erikson believes that the greater the task achievement, the healthier the

personality of the person; failure to achieve the task influences the person’s

ability to achieve the new task. This developmental task can be viewed as a

series of crisis and successful resolution of this crisis and successful resolution of

these crisis is supportive to the person’s ego failure to resole the crisis is

damaging to the ego.

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Our patient Agustin Sarmiento belongs to the older adult stage. His

central task is Ego Integrity versus Despair. Ego integrity is the ego's

accumulated assurance of its capacity for order and meaning. Despair is signified

by a fear of one's own death, as well as the loss of self-sufficiency, and of loved

partners and friends. He must learn to accept the life that he has led (good and

bad) to have a life in facing death. As he learns to live with his choices and the

certainty of death, he fined a inner-strength to go on with integrity. Some despair

is inevitable, a he mourn his own deaths. When he recognizes all that he have

been, are and will be, then we show his wisdom.

KOHLBERG’S STAGES OF MORAL DEVELOPMENT

Post conventional (Universal Ethical and Principle Orientation

Lawrence Kohlberg’s theory specifically addresses moral development in

children and adults. The morality of an individual’s decision was not Kohlberg’s

concern; rather he focused on the reasons of an individual makes a decision.

According to Kohlberg, moral development progress to three levels and six

stages. At Kohlberg first level, called the premolar or preconventional level,

children are responsive to cultural rules and labels of good and bad, right and

wrong. However, children interpret these terms of the physical consequence of

their action, that is, punishments or reward. At the second level, the conventional

level, the individual is concerned about maintaining the expectation of the family,

group or nation and sees this is right. The emphasis at third level is conformity

and loyalty to one’s own expectation as well as society’s. level three is called the

post conventional, autonomous or principal level. At this level people make an

effort to define valid values and principles without regard to outside authority or to

the expectation of others.

Our patient Agustin Sarmiento belongs to the Post Conventional level

and on the Universal Ethical principle orientation stage. His decisions and

behaviors re based on internalized rules, on conscience rather than social laws,

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and on self- chosen ethical and abstract principles that are universal,

comprehensive and consistent.

IV. MEDICAL MANAGEMENTA.) DOCTOR’S ORDER

DATE DOCTOR’S ORDER RATIONALE

June 29, 20079:50pm

Hgt:188mgs/dL

BP: 180/60mmHg

HR:92bpm

Please admit under the serviceof Dr. Alenton

Secure consent to care

TPR qh

Diabetic diet

Lab. CBC, crea,K,Hgt stat.FBS, lipid profile, ECG

IVF PNSS1L @ 10gtts/min

Meds. ISMO 60gIsordil 5g SL PRN

Zantac IVT now then q8h

For proper monitoring of the patient’s condition

To have consent in rendering medical treatment to patient

To have baseline data and monitor patient’s condition

Diet prescribed in treatment of type 2 Diabetes mellitus

To have baseline data in planning of giving treatment and care to the patient

To keep vein open; to have patent line in cases of administering IVT drugs

Antianginals; to prevent situations that may cause anginal attacks of the patient

Antiulcer drug; to reduce gastric acid secretions

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11:07pm

June 30,200711:00am

2:55pmBP:180/100mmHg

8:00pm

Please refer accordingly

Troponine T now

Blood typing now Cross-matching now

Transfuse 2’U’ PRBC

Repeat ECG in AM

Tramadol 50mg IVT now

Pantoprazole (Ulcepraz) 40g IVT OD,start now

Please give captopril 25mg tab SL now

Get BP & HR after 15 minutes

Tramadol 50mg IV now then PRN

Arixtra 25mg SC now then OD

Plavix 75mg 4 tabs now then 1tab OD

To measure levels of cardiac troponins

To determine blood type of the patient & the presence of ABO and Rh factor

For blood replacement

For continued surveillance of the heart’s electrical activity

Relieve of moderate to severe pain

Inhibits proton pump activity thus suppresses gastric acid secretion

To lower down BP of the patient

To determine the effectivity of the medication (captopril)

Relieve of moderate to severe pain

Anticoagulant drug; to maintain arterial patency

To reduce the thrombotic events in patient with

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July 1. 2007

July 2, 200712:20am BP: 190/90mmHg

10:25amBP: 160/80mmHg

HR: 88bpm

BP: 200/80mmHg

O2 inhalation 2L/min

Repeat ECG in AM

VS qh & record

Lipitor 1 tab OD start tonight

CBC after 2’U’ PRBC

Give captopril 25mg tab SL now, T.O. Dr. Taboclaon

Give captopril 25mg SL now, T.O.

Dr. Espina


Give captopril 25mg

atherosclerosis

Increases myocardial oxygen supply & relieves pain


To monitor the health status of the patient & have baseline data in giving medications

Adjunct to diet to reduce LDL cholesterol, total cholesterol, and to increase HDL cholesterol of the patient

To determine the level of the blood components of the patient after transfusion

Antihypertensive drug; to lower the BP of the patient



Antihypertensive drug;

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HR: 94bpm

July 3, 2007BP: 200/110mmHg

12:50pm

5:30pm

tab SL now

Bepridil (Vascor) 10 mg. 1 tab now then OD P.O.

O2 inhalation 2l/min

Give Isordil 5mg tab SL for 3 doses q 5 minutes if chest pain is not relieved

Increase O2 inhalation to 4L/min

Give captopril 25mg tab SL now

Give Isordil 5mg SL now

Repeat ECG in AM

Therabloc 50mg 1tab now then OD


to lower the BP of the patient

For hypertension; For chronic stable angina, used alone or in combination ĉ B-blockers nitrates


Antianginal; to reduce cardiac oxygen demand by decreasing preload and afterload.



Antianginal; to reduce cardiac oxygen demand by decreasing preload and afterload




B.) LABORATORY AND DIAGNOSTIC EXAMINATIONS

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RESULTS IMPLICATIONS1.) HEMATOLOGYDate: June 30, 2007Time: 3: 46 pm

Cross- matiching Patient’s blood type Donor’s blood type

Bag serial # (s)35147 segment 3635302235260 segment36352489

Re-screening Blood component Remarks Method

Blood Rh (D) positiveBlood Rh (D) positive

Not donePacked red blood cell

CompatibleDia- med microsystem

RBCs have antigen- can initiate antibodies reaction

RESULTS REFERENCE VALUES

IMPLICATIONS

1.) BLOOD CHEMISTRYDate: June 30, 2007Time: 5:00 am

Lipid Profile Triglycerides

HDL

LDL

221.64 mgs/dl

28.39 mgs/dl

166.01 mgs/dl

44.33 mgs/dl

<200.00

30.00 – 85.00

<150.00

0.00- 40.00

Increased- Risk of atherosclerotic occlusive coronary diseases and peripheral vascular diseaseDecreased- HDL cholesterol is lower in patients with increased risk for coronary heart disease Increased- higher in patients with increased risk for coronary heart disease

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VLDL

Fasting blood sugar

106.18 mgs/dl

.

70.00- 99.00

Increased- Risk of nephrotic syndromeIncreased- risk for diabetes mellitus and chronic renal insufficiency

3.) HEMATOLOGYDate: June 30, 2007Time: 1:02 am

Troponin- T

Blood group

Increased

ABO + RhBlood Rh (D) positive

Troponin levels rise rapidly and are detectable within 1 hour of myocardial cell injury and renal diseases

4.) CHEMISTRYDate: June 29, 2007Time: 11:43 pm

Creatinine6.17 mgs/ dl 0.90 – 1.50 Increased- risk

of nephritis; chronic renal insufficiency; diabetic nephropathy; reduced renal blood flow

5.) HEMATOLOGYDate: June 29, 2007Time: 11:43 pm

Complete blood count Total RBC

2.57x 10^9/L 5.0- 10.0 Decreased- risk of renal failure and dietary

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Hgb

Hct

MCV

MCHC

Differential count Neutrophils

g/dl

28.0

108.9

28.2

70.9

13.70- 16.70

40.00- 49.70

70.00- 97.00

32.0- 35.0

54.0- 67.0

deficiencyDecreased- risk of kidney disease and dietary deficiencyDecreased- risk of nutritional deficiencyIncreased- RBC is macrocytic; risk of foilc acid deficiencyDecreased- risk of iron deficiency anemia

Increased- acute bacterial infection, physical or emotional stress

6.) HEMATOLOGYDate: July 1, 2007Time: 6: 36 pm

Complete Blood Count Total RBC

Hgb

Hct

Differential count Neutrophils

3.49 x10^ 9/L

11.1 g/dl

32.5

66.0

15.4

3.69- 5.90

13.70- 16.70

40.0- 49.70

54.0- 62.0

20.0- 40.0

Decreased- risk of renal failure; dietary deficiencyDecreased- risk of dietary deficiency and kidney diseaseDecreased- risk of nutritional deficiency

Increased- acute bacterial infection; physical or emotional stress

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Lymphocytes

Monocytes

13.1 4.0- 10.0 Increased- viral infectionIncreased- viral infection; other chronic disease

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C.) DRUG STUDYName of Patient: SARMIENTO, AGUSTIN M.Name of Drug

Generic (Brand)

DateOrdered

Classification Dose/Frequency

Route

Mechanism of Action

Specific Indication

(why drug is ordered)

Contraindication Side Effects/Toxic Effects

Nursing Precaution

Isosorbide dinitrale (Isordil)

7-2-07 Antianginals 5 mg tabSL for 3

doses every 5minutes if

chest pain is not relieved

Thought to reduce cardiac oxygen demand by decreasing preload & afterload: also, may increase blood flow through the collateral coronary vessels

Acute anginal attacks

Contraindicated potentials ĉ hypersensitivity or idiosyncrasy to nitrates & in those ĉ severe hypolension

Flushing, vascular headache, cerebral ischemia associated ĉ postural hypotension, N/V weakness, restless, pallor, persipiration & collapse

To prevent tolerance a nitrate-free interval of 8 to 12 hours per day is recommended.

Bepridil(Vascor)

7-2-07 Calcium Channel Blocker

Antianginal Antihypertensive

10 mg. 1 tab now then OD

P.O.

Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces, relaxation of coronary vascular muscle diseases coronary vascular arteries, myocardial 02

delivery in pts ĉ vasospastic angina SA/AV node conduction inhibits fast sodium current.

Hypertension For chronic stable angina, used alone or in combination ĉ B-blockers nitrates

Pts. ĉ history of angineurotic edema & other allergic reactions due to ACE inhibitors: pregnancy lactation

Rarely: fatigue, dizziness, hot-flush, diarrhea, nausea, vomiting Discomfort in the throat, non-productive cough, palpitation headache & rash

CHF, hypotension, hepatic injury, pregnancy C, lactation, renal disease, concomitant B-blocker therapy

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DRUG STUDY

Name of Patient: SARMIENTO, AGUSTIN M.

Name of DrugGeneric (Brand)

DateOrdered


Route

Mechanism of Action

Specific Indication



Nursing Precaution

RanitidineHydrochloride(Zantac)

6-29-079:45 pm

Anti-ulcer drug 50 mg IV q 8H

6-2-10

Completely inhibits action of histamine on the H2 at receptors sites of parietal cells, decreasing gastric acid secretion

NSAID-associated peptic ulceration

Contraindicated in patients hypersensitive to drug and those ĉ acute porphyria acute dosage in pt. ĉ impaired renal function

Occasionally, reversible hepatitis. Rarely agranulocytosis, acute pancreatic, hypersensitivity, reversible mental confusion, skin rash; headache

Assess pt. for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate

Olmesartain Medoxomil (Olmetec)

6-29-07 ACE inhibitors antihypertensive

20 g/mL1 tab OD

Selectively blocks the binding of angiotensin to specific issue receptors found in the vascular smooth muscle & adrenal gland this action blocks the vasoconstriction effect of the rennin. Angiotensin system as well as the release of aldosterone to decrease BP.

For hypertension, alone or in combination ĉ other antihypertensive

Contraindicated ĉ hypersensitivity to any component of the drug, pregnancies lactation

Use caution ĉ renal dysfunction

CNS: headache CU: hypertension SKIN: rash, dry GI: diarrhea, abdominal pain nausea, constipation

Respiratory URL, symptoms, bronchitis, cough, angioedema, flue like symptoms

Administers regard to meals

Monitor pt. closely in any situation that may lead to a decrease BP 20 to seduction in fluid volume

DRUG STUDY

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Name of Patient: SARMIENTO, AGUSTIN M. Name of Drug

Generic (Brand)

DateOrdered


Route

Mechanism of Action

Specific Indication



Nursing Precaution

tramadol HCI(Dolmal)

6-30-07 Opioid Analgesics

50 mg IV now then PRN for moderate to severe pain

A centrally acting synthetic analgesic compound not chemically related to opioid. Thought to bind to opioid receptors & of norepinephrine & serotonin

For moderate to severe pain

Contraindicated in patients hypersensitive to drug or other opioids, in breast feeding women and in those ĉ acute intoxication from alcohol use cautiously in pts. at risk for renal or hepatic impairment

Respiratory depression, palpitations, chills, chest pain, decrease in BP, arrhythmia, vomiting, nausea, GI distention, borborygymi, urticaria, excessive bronchial secretions

Releases pt’s level of pain at least 30 min. after administration. Monitor CV and respiratory status w/hold dose & notify prescribe if RR is below 12 cm. Monitor bowel & bladder function anticipate need for laxative for better analgesic effect give drug before onset of pain.

pantoprazole sodium(ulcepraz)

6-30-07 Antiulcer drugs

40 mg IV OD(-6)

Inhibits proton pump activity by finding to hydrogen potassium oderosine triphosphatase, located at secretory surface of gastric parietal cells, to suppress gastric acid secretion

Doudenal & gastric ulcer in combination ĉ 2 appropriate antibiotics for the reduction of H Pylon in pts. ĉ peptic ulcer of the objective of reducing the recurrence of duodemal are unknown

Contraindicated in pts. hypersensitive to any component of the formulation safety & efficacy of using the IV for mutation to start, therapy for GERD are unknown.

Headache, diarrhea, rarely, nausea, upper abdominal pain, flatulence, skin rash, pruritus or dizziness, edema, fever, onset of depression & disturbance in vision

Stop treatment ĉ IV pantoprazole when P.O. form is warranted drug can’t be given regard to meals symptomatic response to therapy doesn’t preclude the presence of gastric malignancy.

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DRUG STUDY



DateOrdered


Route

Mechanism of Action

Specific Indication



Nursing Precaution

captopril(Capoten)

7-2-07 Antihypertensive 1. 25 mg Tab SL now 12:10 pm

2. 25 mg ½ tab SL now

Inhibits ACE, preventing conversion of Angiotensin II, a potent vasoconstrictor less angiotensin II decreasing aldosterone secretion, which reduces sodium & water retention & lowers blood pressure.

Hypertension diabetic nephropathy

Contraindicated in pts. hypersensitive to drug or ACE inhibitors use cautiously in pts. ĉ impaired renal function

CNS: dizziness fatigue; rash, pruritus, flushing, angioedema, loss of taste perception; stomatitis, GI irritation & abdominal pain; leucopenia; cough

Monitor patient’s blood pressure & pulse rate frequently elderly pts may be moiré sensitive to drug’s hypotensive effects in patients ĉ impaired renal function or collagen vascular disease, monitor WBC and differential counts before starting treatment, every 2 wks for the first 3 months of therapy and periodically thereafter.

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DRUG STUDY



DateOrdered


Route

Mechanism of Action

Specific Indication



Nursing Precaution

atenol (Therabloc)

7-3-07) Antihypertensives 50 mg 1 tabnow then OD

(-6-)

A beta-blocker that selectively blocks beta-adrenergic receptors, decreases cardiac output and cardiac oxygen consumption and depresses rennin secretion

Hypertension Angina Pectoris, Acute MI

Contraindicated in patients ĉ sinus bradycardia, heart blocker greater than first degree overt cardiac failure, or cardiogenic shock use cautiously in pts at risk for heart failure diabetes & impaired renal function

CNS: fatigue dizziness CV: hypotension heart failure GI: nausea, diarrheaMusculoskeletal: leg pain Respiratory bronchospasm Skin: rash

Check apical pulse before giving drug if slower than 60 beats /min. withhold drug & call prescriber. Monitor pts blood pressure drug may mask signs & symptoms of hypoxemia in diabetic pts drug may cause changes in exercise tolerance & ECG

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DRUG STUDYName of Patient: SARMIENTO, AGUSTIN M.Generic name

of Ordered Drug

Brand Name

Date Ordered Classification Dose/Frequency/

Route

MechanismOf

Action

Specific Indication

Contra-Indication

SideEffects/Toxic

Effects

NursingPrecaution

Senna Senokot 7-3-07 Laxatives 2 tabstonight -9 pm

Stimulant laxative that increases peristalsis, probably by relaxing the effect on smooth muscle of the intestine. Drug also promotes fluids accumulation in colon and small intestine.

Acute constipation preparation, for bowel elimination

Contraindicated in pts. ĉ ulceration bowel lesions, fecal infaction, S/sx of appendicitis, acute surgical abdomen, N/V abdominal pain

GI: nausea, abdominal crampsGU: red-pink discoloration in alkaline urine, yellow brown discoloration in acid urine

Before giving drug for constipation determine whether pt. has adequate fluid intake exercise & dietLimit diet to clear liquids after X-prep liquid is taken.

fondaparimuxsodium

Arixtra 6-30-07 Anticoagulants 2.5 mgs SC now then OD 9 pm-8 am

Binds to antithrombin III (at-III) and potentates the neutralization of factor Xa by III which interrupts coagulation and inhibits formation of thrombin and blood clots.

To prevent deep-vein thrombosis (VDT) w/c may lead to acute pulmonary embolism

Contraindicated in pts with creatirine clearance less than 30 mL/min. and in those who are hypertensive to the drug or weigh less than 50 kgs.

CNS: fever, dizziness, confusionCU: hypotension, edemaGI: nauseaGU: UTI, urine retentionHematologic: hemorrhage, thrombocylopenia

Give by S.C. injection only never I.M. Don’t mix ĉ other injections or infusions to avoid loss of drug don’t expel air bubble from the syringe

clopidogrelbisulfate

Plavix 6-30-07 Antiplatelet agents

45 mgs, 4 tabs now, then 1 tab OD P.O. 10-6

Inhibits the binding of adenosine diphosphale to its platelet, receptors infecting ADP-mediated activation and subsequent platelet aggregation clopedogiel irreversibly modifies the platelet ADP receptor

To reduce thrombotic events with acute coronary syndrome, ĉ atherosderosis documented by recent MI, or established peripheral artenal disease.

Contraindicated in patients hypersensitive to drug or its components and in those with pathologic bleeding (such as peptic ulcer) use cautiously in patients at risk for increased bleeding from trauma or other pathologic conditions

GI Bleeding purpora, bruising, hematoma, epistaxis, hematutia, ocular hemorrhage intracranial bleeding, abdominal pain, dyspepsia gastritis & constipation, rash, pruritus

Platelet aggregation wont return normal for at least 5 days after drug has been stopped

Don’t confuse plavix with Paxil

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DRUG STUDYName of Patient: SARMIENTO, AGUSTIN M.

Generic name of Ordered

Drug

Brand Name

Date Ordered

Classification Dose/Frequency/

Route

MechanismOf

Action

Specific Indication

Contra-Indication

SideEffects/Toxic

Effects

NursingPrecaution

isosorbide mononitate

Imdur 6-30-07 Anti-anginal 60 mgs 1 TabOD P.O.-6-60 mgs ½ tabOD P.O.-6-

Thought to reduce cardiac oxygen demand by decreasing preload and afterload.. drug also may blood through collateral coronary vessels

Acute anginal attacks, post-MI angina; to prevent situations that may cause anginal attacks

Contraindicated in pts. hypersensitive or idiosyncratic to nitrates & in those ĉ severe hypotension or acute MI ĉ low left ventricular filling pressure.

CNS: headache CV: orthostatic hypotension, tachycardia, palitations, edema nausea

To prevent tolerance a nitrate free interval of 8 to 12 hours per day is recommended. The regimen for isosobide mononitrate (1 tab.) on awakening with the second dose in 4 hrs. or 1 extended release tab. Daily is intended to minimize nitrate to tolerance by providing a substantial nitrate free interval Monitor BP and intensely and duration of drug response

atorvastatin Lipitor 6-30-07 Antilipemics 80 mgs 1 tabOD tonight

Inhibits HMG-COA reductase, an early (and rale-limiting) step in cholesterol biosynsthesis

Reduction of elevated total L LDL cholesterol, apolipoprotein B & triglycerides & increase HDL cholesterol in pts. ĉ primary hypercholesterolemia

Withhold or stop drug in pts. at risk for renal failure caused by rhabdomyolysis resulting from trauma, in serious acute conditions like myopathy

GI disturbances, headache, myalgia asthenia, insomnia muscle cramps, bronchitis, rash infection, flu like syndrome allergic reactions

Use only after diet & other condition therapy prove infective Pt should follow a standard low cholesterol diet before & during therapy.Before starting treatment assess pt for underlying causes for hypercholesterolemia.

24

IV. ANATOMY AND PHYSIOLOGY

Human system is also called our cardiovascular system, and is composed of

our heart plus our arteries and veins. In a person’s heart, the atria (plural of atrium)

receive blood from the veins and the ventricles send blood to the arteries. As the

arteries become more finely divided, they are called arterioles. The finest divisions of

our vascular system are called capillaries. As the vessels get larger again, the smallest

are called venules which join and enlarge to form veins. Note that the distinction

between arteries and veins is by direction of blood flow, not oxygen content. Veins

carry blood toward the heart and arteries carry it away from the heart. Because of this,

not all arteries carry oxygenated blood. The two major exceptions, in which arteries

are carrying deoxygenated blood are the pulmonary artery which carries

deoxygenated blood from the heart to the lungs (to pick up oxygen there) and the

umbilical arteries which carry deoxygenated blood away from the baby’s body to the

placenta (to pick up oxygen there). We have double circulation: we have a separate

pulmonary circuit to the lungs and a systemic circuit to the body.

25

The path of blood flow in a human, then, is as follows:

1. The superior (a) and inferior (b) vena cava are the main veins that receive blood from the body. The superior vena cava drains the head and arms, and the inferior vena cava drains the lower body.

2. The right atrium receives blood from the body via the vena cavae. The atria are on the top in the heart.

3. The blood then passes through the right atrioventricular valve, which is forced shut when the ventricles contract, preventing blood from reentering the atrium.

4. The blood goes into the right ventricle (note that it has a thinner wall; it only pumps to lungs). The ventricles are on the bottom of the heart.

5. The right semilunar valve marks the beginning of the artery. Again, it is supposed to close to prevent blood from flowing back into the ventricle.

26

6. The pulmonary artery or pulmonary trunk is the main artery taking deoxygenated blood to the lungs.

7. Blood goes to the right and left lungs, where capillaries are in close contact with the thin-walled alveoli so the blood can release CO2 and pick up O2.

8. From the lungs, the pulmonary vein carries oxygenated blood back into the heart.

9. The left atrium receives oxygenated blood from the lungs.

10.The blood passes through the left atrioventricular valve.

11.The blood enters the left ventricle. Note the thickened wall; the left ventricle must pump blood throughout the whole body.

12.The blood passes through the left semilunar valve at the beginning of the aorta.

13.The aorta is the main artery to the body. One of the first arteries to branch off is the coronary artery, which supplies blood to the heart muscle itself so it can pump. The coronary artery goes around the heart like a crown. A blockage of the coronary artery or one of its branches is very serious because this can cause portions of the heart to die if they don’t get nutrients and oxygen. This is a coronary heart attack. From the capillaries in the heart muscle, the blood flows back through the coronary vein, which lies on top of the artery.

14.The aorta divides into arteries to distribute blood to the body.

27

15.Small arteries are called arterioles.

16.The smallest vessels are the capillaries.

17.These join again to form venules, the smallest of the veins.

These, in turn, join to form the larger veins, which carry the blood back to the superior

and inferior vena cava.

PHYSIOLOGY OF THE HEART

The work of the heart is to pump blood to the lungs through pulmonary

circulation and to the rest of the body through systemic circulation. This is

accomplished by systematic contraction and relaxation of the cardiac muscle in the

myocardium.

Conduction System An effective cycle for productive pumping of blood requires that the heart be

synchronized accurately. Both atria need to contract simultaneously, followed by

contraction of both ventricles. Specialized cardiac muscle cells that make up the

conduction system of the heart coordinate contraction of the chambers.

Cardiac Cycle The cardiac cycle refers to the alternating contraction and relaxation of the

myocardium in the walls of the heart chambers, coordinated by the conduction system,

during one heartbeat. Systole is the contraction phase of the cardiac cycle, and

diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8

second.

28

Heart Sounds The sounds associated with the heartbeat are due to vibrations in the tissues

and blood caused by closure of the valves. Abnormal heart sounds are called

murmurs.

Heart Rate The sinoatrial node, acting alone, produces a constant rhythmic heart rate.

Regulating factors are reliant on the atrioventricular node to increase or decrease the

heart rate to adjust cardiac output to meet the changing needs of the body. Most

changes in the heart rate are mediated through the cardiac center in the medulla

oblongata of the brain. The center has both sympathetic and parasympathetic

components that adjust the heart rate to meet the changing needs of the body.

Peripheral factors such as emotions, ion concentrations, and body temperature may

affect heart rate. These are usually mediated through the cardiac center.

29

PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTION

Cardiac output

Diastolic Filling

Afterload

Decreased Myocardial Tissue

Per.

Stimulation of Baroreceptors

Myocardial Conractility

Myocardial Oxygen supply

Stimulation of Sympathetic Receptors

Altered Cell Membrane Int.

Cellular HypoxiaMyocardial ischemia

Peripheral vasoconstriction

Arterial Pressure

Heart rate

Myocardial Oxygen Demand

Myocardial Contractility

Predisposing factors Age- 64 y.o Hypertension High HDL; Low LDL Diabetes Mellitus

Precipitating Factors: Coronary atherosclerotic heart

disease Coronary thrombosis/ embolism Decreased blood flow

Increased myocardial oxygen demand

S/Sx:- chest pain, oliguria, ECG changes, Elevated CK-M, Troponin T, LDH, AST

30

Mechanisms of Occlusion

Most MIs are caused by a disruption in the vascular endothelium

associated with an unstable atherosclerotic plaque that stimulates the formation

of an intracoronary thrombus, which results in coronary artery blood flow

occlusion. If such an occlusion persists long enough (20 to 40 min), irreversible

myocardial cell damage and cell death will occur.5

The development of atherosclerotic plaque occurs over a period of years

to decades. The initial vascular lesion leading to the development of

atherosclerotic plaque is not known with certainty. The two primary

characteristics of the clinically symptomatic atherosclerotic plaque are a

fibromuscular cap and an underlying lipid-rich core. Plaque erosion may occur

due to the actions of metalloproteases and the release of other collagenases and

proteases in the plaque, which result in thinning of the overlying fibromuscular

cap. The action of proteases, in addition to hemodynamic forces applied to the

arterial segment, can lead to a disruption of the endothelium and fissuring or

rupture of the fibromuscular cap. The degree of disruption of the overlying

endothelium can range from minor erosion to extensive fissuring that results in

an ulceration of the plaque. The loss of structural stability of a plaque often

occurs at the juncture of the fibromuscular cap and the vessel wall—a site

otherwise known as the plaque's "shoulder region." Any amount of disruption of

the endothelial surface can cause the formation of thrombus via platelet-

mediated activation of the coagulation cascade. If a thrombus is large enough to

completely occlude coronary blood flow for a sufficient time period, MI can result.

Mechanisms of Myocardial Damage

The severity of an MI is dependent on three factors: the level of the

occlusion in the coronary artery, the length of time of the occlusion, and the

presence or absence of collateral circulation. Generally speaking, the more

proximal the coronary occlusion, the more extensive is the amount of

31

http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/acutemi/acutemi.htm#ref5%23ref5

myocardium at risk of necrosis. The larger the MI, the greater is the chance of

death due to a mechanical complication or pump failure. The longer the time

period of vessel occlusion, the greater the chances of irreversible myocardial

damage distal to the occlusion.

The death of myocardial cells first occurs in the area of myocardium that

most distal to the arterial blood supply—that is, the endocardium. As the duration

of the occlusion increases, the area of myocardial cell death enlarges, extending

from the endocardium to the myocardium and ultimately to the epicardium. The

area of myocardial cell death then spreads laterally to areas of watershed or

collateral perfusion. Generally, after a 6- to 8-hour period of coronary occlusion,

most of the distal myocardium has died. The extent of myocardial cell death

defines the magnitude of the MI. If blood flow can be restored to at-risk

myocardium, more heart muscle can be saved from irreversible damage or

death.

VII. NURSING MANAGEMENT

A.) IDEAL NURSING CARE PLAN

32

Nursing Diagnosis:

Acute pain may be related to tissue ischemia secondary to coronary artery occlusion

Possibly evidenced by

Reports of pain with our without radiationFacial grimacingRestlessness, changes in level of consciousnessChanges in pulse, BP

Desired outcomes

Patient will verbalize relief control of painDemonstrate use of relaxation techniquesDisplay reduced tension, relaxed manner, ease of movement

INTERVENTIONS RATIONALEIndependent 1. Obtain full description of pain from patient including location, intensity (0-10), duration; quality (dull/crushing); and radiation

2. Instruct patient to report pain immediately

3. Provide quiet environment, calm activities, and comfort measures (e.g., dry/ wrinkle—free linens, backrub). Approach the patient calmly and confidently

4. Assist/ instruct in relaxation techniques, e.g, deep/ slow breathing, distraction behaviors, visualization, guided imagery

Collaborative

Pain is a subjective experience and must be described by the patient. Assist patient to quantify pain by comparing it to other experiences.

Delay in reporting pain hinders pain relief/ may require increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnosis and relief of pain.

Decreases external stimuli, which may aggravate anxiety and cardiac strain and limit coping abilities and adjustment to current situation.

Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation, increase in positive attitude.

33

5. Administer supplemental oxygen by means of nasal cannula

Administer medications as indicated, e.g.:

Antianginals, e.g nitroglycerin (Nitro-Bid, Nitro-stat, Nitro-Dur)

Beta-blockers, e.g., atenolol, pindolol, propanolol

Analgesics, e.g., morphine sulfate (Demerol)

Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia

Nitrates are useful for pain control by coronary vasodilating effects, which may increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial work and oxygen demand.

Important second-lineagents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand.

Although IV morphine is the usual drug of choice, other injectable narcotics may be used in acute phase/ recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload.

Nursing diagnosis

Risk for decreased cardiac output may include changes in rate, rhythm, electrical conduction, reduced preload/ increased SVR, infracted/dyskinetic muscle


Presence of signs and symptoms establishes actual diagnosis Desired outcomes

Patient will demonstrate hemodynamic instability, e.g., BP, cardiac output within normal range, adequate urinary output, decreased/ absent dysrhythmias,

34

Report decreased episodes of dyspnea,anginaDemonstrate an increase in activity tolerance

INTERVENTIONS RATIONALEIndependent1. Evaluate quality and equality of

pulses, as indicated

2. Auscultate heart sound Note development of S3,S4

3. Monitor heart rate and rhythm. Document dysrhythmias via telemetry

4. Provide small/ easily digested meals. Restrict caffeine intake, e.g., coffee, chocolate, cola

Collaborative5. Administer antidysrhythmics drugs and ACE inhibitors as indicated

Decreased cardiac output results in diminished weak/ thready pulses. Irregularities suggest dysrhythmias, which may require further evaluation. Monitoring.

S3 is usually associated with HF, but it may also be noted with mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction.S4 may be associated with myocardial ischemia, ventricular stiffening and pulmonary or systemic hypertension

Heart rate and rhythm respond to medication and activity, as well as developing complications/ dysrhythmias, which could compromise cardiac function or increase ischemic damage.

Large meals may increase myocardial workload and cause vagal stimulation resulting in bradycardia/ ectopic beats. Caffeine is direct cardiac stimulant that can increase heart rate.

Dysrhythmias are usually treated symptomatically, except for PVCs, which are often treated prophylactically. Early inclusion of ACE inhibitor therapy enhances ventricular output, increases survival and may slow progression of heart failure.

Nursing diagnosis

Tissue perfusion, altered, risk factors may include reduction/ interruption of blood flow, e.g., vasoconstriction, hypovolemia/ shunting and thromboembolic formation

35

Possibly evidence by

Presence of signs and symptoms establishes an actual diagnosis

Desired outcome

Patient will demonstrate adequate tissue perfusion as individually appropriate, e.g. skin warm and dry, peripheral pulses present/strong, vital signs within patient’s normal range, patient alert/ oriented, balanced intake/ output,absence of edema, free of pain/ discomfort.

INTERVENTIONS RATIONALEIndependent1. Inspect for pallor, cyanosis,

mottling, cool/ clammy skin. Note strength of peripheral pulses

2. Encourage active/ passive leg exercises, avoidance of isometric exercises

3. Monitor respirations, note work of breathing

4. Monitor intake, note changes in urine output. Record urine specific gravity

Collaborative5. Administer medications, e.g.:

Ranitidine (Zantac), antacids

Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses.

Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption.

Cardiac pump failure may precipitate respiratory distress, sudden/ continued dyspnea may indicate thromboembolic pulmonary complications

Decreased intake/ persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function.

Reduces or neutralizes gastric acid, preventing comfort or gastric irritation, especially in presence of reduced mucosal circulation

36

Nursing diagnosis

Activity intolerance may be related to imbalance between myocardial oxygen supply and demand; presence of ischemia/necrotic myocardial tissues; cardiac depressant effects of certain drugs (Beta- blockers, antidysrythmics)


Alterations in heart rate and BP with activityDevelopment of dysrythmiasChanges in skin color/ moistureExertional anginaGeneralized weakness

Desired outcomes

Patient will demonstrate measurable/ progressive increase in tolerance for activity with heart rate/ rhythm and BP within patient’s normal limits and skin warm, pink, dry.Report pain absent/ controlled within time frame for administered medications

INTERVENTIONS RATIONALEIndependent1. Promote rest (bed/ chair) initially.

Limit activity on basis of pain/ hemodynamic response. Provide nonstress diversional activities.

2. Instruct patient to avoid increasing abdominal pressure, e.g., straining during defecation

3. Explain pattern of graded increase of activity level, e.g., getting up in chair when there is no pain, progressive ambulation, and resting for 1 hour after meals

Reduces myocardial workload. Oxygen consumption, reducing risk of complications (e.g., extension of MI)

Activities that require holding the breath and bearing down (Valsalva maneuver) can result in bradycardia, temporarily reduced cardiac output, and rebound tachycardia with elevated BP.

Progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion

37

4. Limit visitors and or/ visit by patient, initially

Collaborative5. Refer to cardiac rehabilitation program

Lengthy/ involved conversations can be very taxing for the patient; however, periods of quiet visitation can be therapeutic

Provides continued support/ additional supervision and participation in recovery and wellness process

Nursing diagnosis

Anxiety may be related to threat to or change in health and socioeconomic status; threat of loss/ death; unconscious conflict about essential values, beliefs, and goals of life


Fearful attitudeApprehension, increased tension, restlessness, facial tensionUncertainty, feelings of inadequacySomatic complaints/ sympathetic stimulationFocus on self, expressions of concern about current and future eventsFight or flight behavior

Desired outcomes

Patient will recognize feelings; identify causes, contributing factors; verbalize reduction of anxiety/ fear; demonstrate positive problem- solving skills; identify/ use resources appropriately

INTERVENTIONS RATIONALEIndependent1. Maintain confident manner (without

false reassurance)

2. Accept but do not reinforce use of denial. Avoid confrontations.

Patient and SO can be affected by the anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety.

Denial can be beneficial in decreasing anxiety but can postpone dealing with the reality of the current situation. Confrontation can promote anger and increase use of denial, reducing

38

3. Encourage patient/ SO to communicate with one another, sharing questions and concerns

4. Provide rest periods/ uninterrupted sleep time, quiet surroundings, with patient controlling type, amount of external stimuli

Collaborative5. administer antianxiety/ hypnotics as indicated, e.g., diazepam (Valium), lorazepam (Ativan), flurazepam (Dalmane)

cooperation and possibly impeding recovery.

Sharing information elicits support. Comfort and can relieve tension of unexpressed worries

Conserves energy and enhances coping abilities

Promotes relaxation/ rest and reduces feelings of anxiety

B.) ACTUAL NURSING MANAGEMENT(SOAPIE FORM)

S“Ah! Dili jud makatarong ug tulog. Maka mata-mata man jud labi

na dini sa hospital. Ug tigulang naman “ as verbalized by the

patient

O verbalizations of interrupted sleep complaints of not feeling rested yawning pain/ discomfort

ASleep pattern disturbance related to internal factors such as illness, psychologic stress and external factors such as facility routines

P At the end of 2 days, the patient will be able to report improvement of sleep/ rest pattern and verbalize increased sense of well- being and feeling rested.

At the end of 4 hours, the patient will be able to get enough uninterrupted sleep/ rest.

39

I

1. provided comfortable bedding and some of own possession, e.g., pillows

Rationale: Increases comfort for sleep as well as physiologic and psychologic support

2. Maintained environment conducive to sleep/ rest (e.g. quiet comfortable temperature, ventilation and closed door)

Rationale:This Provides atmosphere conducive to sleep

3. Encouraged position of comfort, assist in turning

Rationale:Repositioning alters areas of pressure and promotes rest

4. Provided nursing aids (e.g. back rub, bedtime care, pain relief, comfortable position [semi- fowler’s], relaxation techniques)

Rationale:To promote rest, relaxation; to induce sleep

5. Attempted to allow for sleep cycles for at least 90 minutes

Rationale:Experimental studies have indicated that 60- 90 minutes are needed to complete one sleep cycle and the completion of an entire cycle is necessary to benefit from sleep.

E

At the end of 4 hours, the patient was able to have sleep and verbalized of feeling rested.

At the end of 2 days, the patient was able to verbalize a fair improvement of his sleep/ rest pattern in between his medication/ treatment regimen.

S “Dili ko palakwon sa doctor kay dili pwede sa ako mangusog kay

sakit akong heart” as verbalized by the patient

40

O patient report chest pain with radiation to epigastrium

pain scale of 6

facial grimaces

changes in vital signs, baseline: HR=54 bpm, BP=140/90

mmHg

A -Acute pain related to tissue ischemia of myocardial tissue

secondary to myocardial infarction.

P At the end of 30 minutes, patient will be able to verbalize relief of

pain, display reduced tension, relaxed manner and ease of

movement

I

1.) Obtained full description of pain from patient including

location, intensity (0-10), duration, quality and radiation.

Rationale:

Pain is a subjective experience and must be described by the pt.

Assist pt. to quantify pain by comparing it to other experiences.

2.) Maintained bed rest at least during periods of pain.

Rationale:

To reduce workload of the heart

3.) Positioned patient comfortably, in moderate high back rest

Rationale:

This allows for lung expansion by lowering the diaphragm

4.) Instructed patient in relaxation techniques, i.e., deep/slow

41

breathing

Rationale:

Helpful in decreasing perception of/ response to pain. Provides a

sense of having some control over the situation, increase in

positive attitude.

COLLABORATIVE

5.) Administered supplemental oxygen by means of nasal

cannula @ 3L/min.

Rationale:

Increases amount of oxygen available for myocardial uptake and

thereby may relieve discomfort associated with tissue ischemia

Administered medications as indicated such as:

Isosorbide dinitrate (Isordil) 5 mg tab SL for 3 doses every

5 minutes if chest pain is not relieved

Isosorbide mononitrate (Imdur) 60 mg ½ tab

OD P.O

Rationale: to reduce cardiac oxygen demand by decreasing

preload and afterload. Increases blood flow through the

collateral coronary vessels.

E At the end of 30 minutes, patient was able to verbalize a slight

relief of chest pain and demonstrated the use of relaxation

techniques.

S “Dili ko pwede mangusog kay magsakit akong heart.” as verbalized by

the patient.

O weakness

42

Patient’s report of pain

Changes in v/s

A Ineffective cardiopulmonary tissue perfusion related to reduced

coronary blood flow.

P At the end of 2 hours, patient will verbalize a relief from pain and

discomfort.

I

1.) Initially assess document and report to the following physician.

Patients description of chest discomfort, including location, intensity,

radiation, duration and factors that affect it. Other symptoms such as

nausea, diaphoresis complains of universal fatigue.

2.) Monitored respiration and note work of breathing.

3.) Assess GI functions and monitor fluid intake and urine output.

4.) Obtained a 12- lead ECG recording during the symptomatic event

as prescribed to determine extension of infarction

COLLABORATIVE:

5.) Administered oxygen @ 3L/min via nasal cannula.

Rationale:

Increases amount of oxygen available for myocardial uptake and

thereby may relieve discomfort associated with tissue ischemia

E At the end 2 hours, patient verbalizes the relief from discomfort around

43

the chest.

S “Hypertensive nako dugay ra kadto pa ning 55 anyos pa ako edad.” as

verbalized by the patient.

O

Elevated BP=140/90 mmHg

Increased creatinine= 6.17 mgs/dl

Urine output of less than 30 ml/hr

A Decreased cardiac output related to diminished blood flow caused by

increased vascular resistance.

P At the end of 1 hour, patient will be able to achieve and maintain BP

within acceptable range.

I

1.) Monitored BP using proper equipment with cuff bladder that is two-

thirds diameter.

Rationale:

To detect changes from baseline that indicate changes in

cardiovascular status

2.) Maintained fluid and dietary sodium restrictions.

Rationale:

To reduce fluid restriction which contributes to hypertension

3.) Discouraged intake of coffee, tea, cola and chocolate which are

44

high in caffeine.

Rationale:

Caffeine stimulates sympathetic nervous system

4.) Maintained physical and emotional rest.

Rationale:

Sedatives can be used to reduce stress and associated

vasoconstriction; to reduce cardiac workload

5.) Administered antihypertensive as prescribed:

atenol (Therabloc) 50 mg 1 tab now then ODRationale: A beta-blocker that selectively blocks beta-adrenergic receptors,

decreases cardiac output and cardiac oxygen consumption and

depresses rennin secretion

E At the end of 1 hour, patient was able to maintain BP within

individually acceptable range.

VIII. REFERRALS AND FOLLOW – UP(Health teaching)

Medication

Advised patient to take prescribed medication at regular basis;

Atenolol( therabloc) 50 mg.tab once a day P.OClopidogiel ( plavix) 75 mg. tab once a day P.OISMN ( Imdur) 60 mg tab once a day P.OAtorvastatin calcium ( lipitor) once a day P.O

Exercise

At the hospital, patient is advised to initiate gradual exercise such as;

a) Lying or sitting exercises ( arms, legs, trunk)b.) Exercise progress to standing and slow walking in

the hall. c.) Exercise must be done twice a day for about 20

45

minutes d.) Exercises (Deep, pursed lip or deep breathing

exercises)

Treatment

In the hospital, patient is provided with the following treatment ;

a.)Supplemental oxygen by nasal cannula @ 2-4 L/min.b.)Cardiac monitoring for continued surveillance of hearts activity.c.)Frequent monitoring of vital signs including temperature , pulse rate ( apical/ radial) and blood pressure and intake and outputd.)Pharmacologic management to stabilize client condition.

Out patient When the patient will be discharge, out patient program consist of supervised , oven ECG monitored , exercised training based on the results of exercised stress test .support and guidance related to the treatment of the disease and education and counseling related to lifestyle modification .

Diet

Client is advised to follow the prescribed recommended diet ;

a) Diabetic diet: eat complex CHO foods with high fiber content avoid added sugar and concentrated sweets and all other CHO foods and eat regularly.

b) Eat foods low in calorie, saturated fats and cholesterol; restriction of sodium; avoidance of spicy foods soft fiber food and take small frequent feedings

Recommendation s Advised the patient for followed up check up from his assigned physician.

Advised patient peer for frequent monitoring of his vital sign to avoid any risk

and possible complication

46

Explain the purpose and preparation for diagnostic test to have clear

understanding of procedures and what is happening increase feeling of

control and lessens anxiety.

Provide positive reinforcement for gains/ improvement and participation in self

care/treatment program. This encourages continuation of healthy behavior.

Advice patient to take his medication at home as prescribed by the physician

for continues medication treatment.

Suggest engaging in relaxing, non strenuous activity to avoid any risk due to

over stress

Teach client on coping mechanisms with recurring pain and other clinical

manifestations

Encourage patient to eat nutritious food like vegetable fruits, foods the high

fiber contain like cereal and foods rich in protein.

IX. EVALUATION & IMPLICATION (PROGNOSIS)

This case study was done successfully although we experienced some

difficulties analyzing the health status of the client and understanding the medical

orders given. Using our critical thinking, we were able to carefully identify the

problem of our patient who needs direct interventions for the wellness of his

health. Moreover, the group was able to discuss some health teachings as stated

above for the improvement of the client’s health and fast recovery.

The patient was able to understand the imparted health teachings and

verbalized to consistently follow his treatment regimen in home care

management. Although patient’s blood pressure did not lower down to his normal

range of blood pressure, other clinical manifestations such as severe chest pain

was not subjectively verbalized by the patient and labored breathing was not

evident. Still, patient has unproductive, dry cough. Mr. Sarmiento is progressing

well in his health condition and is for discharge any soon. Patient may have an

47

uncomplicated episode of myocardial infarction and may return to normal

activities and lifestyle with moderation and modification to some of those.

X. DOCUMENTATION

Upon assessment last July 3, 2007, patient X was received with a diagnosis

of Acute myocardial infarction; Hypertensive cardiovascular disease; ruled out

PUD; diabetic nephropathy. Pt. was sitting on bed and complaint on pain on

chest area upon coughing was noted. Instructed to do deep, breathing exercises

everytime chest pain is recurring. Pertinent data about the patient’s family and

personal health history were gathered.

The next day on the group’s duty, pt. has oxygen inhalation regulated at

3l/min via nasal cannula and vital signs were monitored every 4 hours with

special consideration to the client’s blood pressure. Due medication were

properly given and kept patient in moderate, high back rest and kept comfortably

on bed, keeping back dry. Pt. was observed for any unsualties during the shift.

No further complaints were noted from the patient.

On the 2nd day of duty the doctor ordered that client may go home the next

day if stable. So, the group imparted health teachings important for the client to

follow as his home care management. We helped the client in discharged

planning and reminded them the health teachings that we had discussed.

This study also tests our abilities and skills on how to find answers to the

patient’s problem, what action to be done in order to solve it and how to properly

and correctly use our initiative for the success and for the good outcome of our

care study. This is one of our tasks as a student or future nurses and it serves as

our training ground backed up with strict training in order for us to become

equipped, productive, efficient, and world-class nurses in the future.

48

B I B L I O G R A P H Y

Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10th edition) Lippincott-Raven Publisher.Copyright 1996

Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education Inc.,Copyright 2000

Mosby’s Pocket Dictionary of Medicine, Nursing and Allied Health (4 th edition) Elsevier(Singapore) PTE LTD> Copyright 2002

Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing Patient Care(6th edition) F.A Davis Company. Copyright 2000

Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition). Addison esley Longman Inc. 1998.

MacMahon, S. Blood pressure and the risk of cardiovascular disease. N Engl J Med 2000; 342:50

HTML1Rollins Gina. "With smoking cessation drugs, dosing is key", ACP-

ASIM Observer, 22(4); 1,16-17.

W E B L I O G R A P H Y

http://biology.clc.uc.edu/courses/bio105/circulat.htm

wwwmedlib.med.utah.edu\webpath\TUTORIAL\MYOCARD\MYOCARD

Research Paper help https://www.homeworkping.com/

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58654960 case-study-acute-mi

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