Introduction

A heart beat signifies life, from the day it starts to beat in the womb, till it stops,
and where death conquers us. The heart beats not only to one tune but it also responds
to the tune of emotions and physical stress. As some of us may have also experience
moments of joy or sorrow and the heart may feel pain or pleasure.

In medicine, an acute disease is a disease with a rapid onset or a short course.

The term “Acute” may often be confused by the general public to mean “severe”,
however, this has a different meaning. Coronary, may refer to as “the heart” or “relating
to the heart”. While syndrome is defined as a set of signs and symptoms that tend to
occur together and which reflect the presence of a particular disease or an increased
chance of developing a particular disease.

Acute Coronary Syndrome is defined as a spectrum of conditions involving chest

discomfort or other symptoms caused by lack of oxygen to the heart muscle (the
myocardium). The unification of these manifestations of coronary artery disease under a
single term reflects the understanding that these are caused by a similar
pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or
rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary
arteries and impaired blood supply to the heart muscle.

According to the morbidity rate, taken from the records of the Department of
Health for region X, the occurrence of cardiovascular diseases per 100,000 populations
is 3,356. This data is taken from the 2001-2005, a 5 years average record. While the
occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373
per 100,000 populations.

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OBJECTIVES OF THE STUDY

The study aims to explore the concepts about the condition and the quality of
nursing care being rendered to our client Mrs. F that was diagnosed with Acute
Coronary Syndrome.

In order to learn more about the health condition of the patient, the study wants
to fathom about the predisposing and precipitating factors, anatomy and physiology and
the pathophysiology of the condition experienced by the client. Basically the main goal
of this study in relation to knowledge is to identify the nursing interventions after the
condition of patient Mrs. F.

The study aims to critically analyze the qualitative and quantitative data gathered
in order to establish connection between the different manifestations experienced by the
patient with that of the disease process. To be able to improve skills, the students also
endeavors to come up with nursing care plans that will alleviate Mrs. F.’s condition. The
presentors also intend to compare and contrast the ideal management for Acute
Coronary Syndrome with that of the actual management. In addition, the study seeks to
disseminate essential information to everybody for awareness.

Furthermore, by this study, the provider will be able to exercise that attitude of
determination and in order to come up with a successful study.

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SCOPE AND LIMITATIONS OF THE STUDY

This case study tackles about Acute Coronary Sydrome specifically on the case
of patient Mrs. F. It includes essential concepts in relation to the said condition such as
the patient’s profile and health history, nursing assessment and clinical manifestations,
drug study and diagnostic exams done. The anatomy and physiology is also included as
well as the pathophysiology of Acute Coronary Syndrome with its associated factors.
The Medical and Nursing Management along with the discharge plans with its referrals
are also being covered. The prognosis is also given.

The scope of the plan encompasses during the Recovery Phase which was on
February 12, 13, 14, 15, 16, 18 and 19 of year 2008 wherein the assigned students who
have assessed the client with cumulative interaction and good rapport to the patient and
significant others. Nursing Management covers the above mentioned dates which
encompasses the client’s Recovery Phase. Data gathering about the Laboratory results
covers from February 05 to February 16, 2008.

The areas of concerns are limited to the discussions of Acute Coronary

Syndrome and the quality of Nursing Care to the patient. The quantity and quality of the
information are limited to the data gathered from the client, significant others and his
medical records.

Immediate family background is limited because the patient has difficulty in

recalling necessary information that would aid in the data gathering. Data gathering was
limited in the confines of Maria Reyna Hospital, Cagayan de Oro City and Aluba,
Cagayan de Oro. Generally, the content of the report is limited to the elaboration of the
diagnosis given to the patient and the corresponding Nursing Management.

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PATIENT’S PROFILE

Name: Mrs. F
Age: 81 years old
Sex: Female
Birthday: June 3, 1926
Birth rank: 2nd to the eldest
Number of siblings: 7
Religion: Roman Catholic
Civil Status: Married
Number of children: 13, with 10 living and 3 deceased
Nationality: Filipino
Height: 5 Ft.
Weight: 73 kg
Address: Baungon, Bukidnon
Occupation: House wife
Income: Php. 15,000/ mo.
Educational Attainment: 1st year H.S.
Date Admitted: February 05, 2008
Time Admitted: 12: 05 PM
Chief Compliant: Shortness of breath and chest pain
Date Discharged: February 16, 2008
Time Discharged: 4:15 PM
Final Diagnosis: Acute Coronary Syndrome, hypertension, Myocardial
Infarction

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Significance of the study

The study is significant to the following people, the client, the client’s family, the

researchers, nursing student, and future researchers.

The study is significant to the client, because it enlightens the client’s queries and

doubts regarding her condition. Allowing her to understand the situation of her present

state, this would allow her to be more aware of the importance of following the

treatment regimen.

Client’s family must also be aware of the condition of the client. With the study,

the client’s family will be able to participate in the client’s treatment, and they will be able

realize the importance of the support system in participating in the client’s care.

The study is also important to the researchers, since it allows them to explore the

client’s condition, giving them first hand experience in observing the manifestations of

the disease condition and allowing them to apply theoretical knowledge regarding

nursing managements for the manifested signs and symptoms.

Nursing students and future researchers may use the study for reference or basis

purposes in planning an intervention or understanding a condition which could be

similar or related to the study presented.

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 Health History
Family History

History of hypertension was present to both paternal and maternal side, in

addition to the given data’s from the informant; there’s no history of CA on the clients
lineages. However, on her maternal side a history of diabetes mellitus and heart
problems was present.

Mrs. F.’s grandfather (father side) died due to liver abscess. It was known that
her grandfather was a chain tobacco smoker consuming 24 sticks or approximately
1pack of cigarette per day and drinks alcoholic beverages such as “tuba”. Additionally,
patient’s grandmother (father side) died due to normal aging with high blood pressure.
Patient’s maternal side history revealed that grandparents died due to aging.

Furthermore, patient’s father died due to normal aging with hypertension. It was
mentioned that her father was also a smoker, consuming 15-20 estimated sticks of
cigarette per day. He also drinks alcoholic beverages like “tuba”. Her mother died at her
88 years of age due to normal aging process.

On the siblings of the client’s father side, all had hypertension. Some of her
mother’s siblings had hypertension and one had CVA.

Personal Social history

Mrs. F. had her menarche at the age of 13 years old. At the age of 20 years old,
Mrs. F. met Mr. S. at Baungon, Bukidnon and got married. Mrs. F.’s reproductive profile
was G13, P13, T13, P0, A0, and L10. She has 13 children. Her first pregnancy was on
February 3, 1947 with their first child named Sohrab through Normal Spontaneous
Vaginal Hospital delivery. Sorab died on January 29, 1989 due to an accident. Second
delivery was a pregnancy uterine full term, normal Spontaneous delivery with a baby

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boy named after his father, Santiago Jr. History divulges that the patient’s second child
died after birth. Third pregnancy was still a normal spontaneous vaginal delivery. The
baby was named Leopoldo, Leopoldo died due to measles at the age of 3months. Her
fourth pregnancy was still normal named her third child Elleonor with an educational
attainment of High School level who was born February 22, 1949. Mrs. F.’s 10
remaining pregnancies were all full term and were all delivered through normal
spontaneous vaginal delivery. The remaining 10 children were the following: Gemma
who was born on December 18 1950, married and with an educational attainment of
High School Grad, Rosalina born aug. 18, 1951 with an educational attainment of High
School graduate ,married (female), Efren born Sept. 18 1952 with an educational
attainment of High School level and is married (male), Salvacion born on Feb. 15, 1953
a High School level and is married (female), Marjorie born on Oct. 16, 1962 a High
School graduate and is married (female), Jose born on 0ct. 18, 1963 a High School
level and is single (male), Marites born on Dec. 10, 1964 a High School level and is
married (female), Nancy born on Aug. 22, 1966 a college graduate and is married
(female),Edgardo born on Nov. 2 1967 a High School Grad and is single(male).

Patient’s husband, Mr. S. was the Former vice Mayor of Baungon, Bukidnon. On
the year 1963- 1965.Being a wife of the vice mayor, she participated well in politics and
has a lot of programs and campaigns for her husband. She was also a member of the
Catholic Women’s League and has done a lot of outreach programs for the church.
Their family social status was at peak that time, but then a great downfall happened in
their lives. At the age of 39 years old, Mr. Santiago was stabbed due to political conflicts
which caused his death. She hardly accepted it because of the traumatic experience
they had.

After two years, Mrs. F. got married to Mr. V. He is a Cebuano who came to
Baungon, Bukidnon in search for work and found more than what he had expected. Mr.
V was afraid in marrying her because he has to face all of her children to ask for the
hands of their mother. Luckily, all of her children understood and accepted him and they
got married. Mr. V. and Mrs. F. were not blessed with children somehow blessed with
their adopted children who were Margie and Kristine.

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 They have their own house in Baungon, Bukidnon and took cared by her adopted
daughter Margie. When visiting in Cagayan de Oro wherein her sons and daughters are
residing in the same area, they stay in her daughter’s house Marites in Aluba, Coca-cola
compound where they are warmly welcomed. Our client’s source of income is only
P15,000 pesos a month from her pension pay.

Past medical History

On 1965, the year of Mr. S.’s death, Mrs. F. had traumatic experience that
caused her psychological and physical stress. It was claimed by the informant that at
the year 1984, patient was admitted to City Hospital due to her first stroke attack. That
admission lasts for a week and she was diagnosed to have Cerebro Vascular Accident
or CVA. Her, second attack was on year 1991 at Madonna Hospital Intensive Care Unit
(ICU). After a couple of years from her 2nd admission, patient suffered from persistent
chest pain thus gave way to her third admission at Maria Reyna Hospital the year 2006.
After that admission, patient was given home medications to be maintained which are:
Telmisartan (pritor) 40mg 1 tab/day, Clopidogrel (Plavix) 75mg 1 tab OD, Metroprolol
50mg ½ tab BID, Amniodarone (Cordarone) 200mg 1 tab TID, ASA 80mg 1 tab OD,
Atorvastatin (Lipitor) 80mg 1 TAB OD @ hs, SMN (imdur) 60mg 1 TAB BID.

One year after her third admission patient underwent surgery on her left eye. An
Extra Capsular Cataract Lens Extraction (ECCLE) was done on the year 2007.

History of Present Illness

One week prior to admission patient experienced blurring of vision and headache
which continue until the day of admission. She didn’t do anything because she thought
that it’s just a symptom of her cataract. 3days prior to adm. Client took Isodril for her
moderate chest pains radiating from the left shoulder to her back but wasn’t relieved.
Informant stated that, 1 day prior to admission, patient had shortness of breath with

8
inability to lie flat on bed and the night of the same date (February 4, 2008), patient
noted and complained for moderate chest pain radiating to her left shoulder and back.
On the 5th day of February 2008, Severe Chest pain suffered by the patient persisted
with difficulty in breathing and shortness of breath which prompt her admission at Maria
Reyna Hospital and was initially diagnosed with Hypertensive Cardiovascular disease.
The client was ruled with the final diagnosis of Acute Coronary Syndrome and was
under the observation and medical treatment of Dr. Alenton.

Chief Complaint

Shortness of breath

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 Developmental Data

GROWTH AND DEVELOPMENT

Patient: Mrs. F

Gender: Female

Age: 81 years old

Psychosocial Theory – Erik Erikson

Erik Erikson’s theory of psychosocial development is one of the best-known

theories of personality in psychology. His theory describes the impact of social
experience across the whole lifespan. In each stage, Erikson believed people
experience a conflict that serves as a turning point in development. In Erikson’s view,
these conflicts are centered on either developing a psychological quality or failing to
develop that quality. During these times, the potential for personal growth is high, but so
is the potential for failure.

In this theory, the patient has the task of Integrity vs. Despair which is the final
task of psychosocial theory which ranges at 65 years old until death. This phase occurs
during old age and is focused on reflecting back on life. Those who are unsuccessful
during this phase will feel that their life has been wasted and will experience many
regrets. The individual will be left with feelings of bitterness and despair. Those who feel
proud of their accomplishments will feel a sense of integrity. Successfully completing
this phase means looking back with few regrets and a general feeling of satisfaction.
These individuals will attain wisdom, even when confronting death.

The patient has developed a feeling of despair. She’s destructed by her worries
for things that might worsen her condition and for things that might happen to her
offspring. Patient was even afraid of facing death because she felt that she hasn’t done

10
her best yet for the future of her grown children for the reason that some of her children
didn’t have a stable job and others were unemployed. Another reason of despair was
that the client wasn’t able to prepare for the current health condition she is experiencing
brought by aging. For instance, the client wasn’t able to prepare by saving or by making
investments that could have had supported her health needs and maintenance.
Normally, it is usually anticipated by any person during younger years when she/he is
still able and strong. She verbalized that these emotions triggered her to have the
disease condition.

Developmental Task theory – Robert Havighurst

Havighurst (1972) defines a developmental task as one that arises at a certain

period in our lives. The successful achievement of which leads to happiness and
success with later tasks while, failure leads to unhappiness, social disapproval, and
difficulty with later tasks. These tasks provide a framework that a nurse can use to
evaluate a person’s general accomplishments. Robert Havighurst believed that learning
is basic to life and that people continue to learn throughout life. He believed that in each
stage in a person’s life, a person has different tasks to be learned.

In later maturity (61+) where the patient belongs, there are six (6) tasks to be learned,
as follows;

1. Adjusting to decreasing physical strength and health.

2. Adjusting to retirement and reduced income.
3. Adjusting to death of a spouse.
4. Adopting and adapting social roles in a flexible way.
5. Establishing satisfactory physical living arrangements.
6. Establishing an explicit affiliation with one’s age group.

These tasks are arranged in chronological order;

(1) Adjusting to death of a spouse. At an early age of 39, she became a widow and
left with 11 children. This was not an easy situation after the tragic death of her husband

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especially raising the kids. Presently, patient is happily married with her second
husband Mr. V.

(2) Adopting and adapting social roles in a flexible way. She used to be the wife of a
vice mayor in their place. She attended most of the social functions her husband was
connected and interact very well to the constituents in the community. She remarried at
age 41 and she didn’t have a child with her present spouse. She was able to adopt her
second marriage for her husband loves her children as his and was also very
supportive.

(3) Adjusted to reduced income. Patient had stopped working at the age of 58. That
was the time when she was admitted in the hospital due to CVD. She used to work in an
eatery but due to her age and physical condition, her children advised her to stay at
home as they were grown up and would support her.

(4) Establishing physical living arrangements with her family. At present, the couple
is no longer working and is supported by the children. They are happily living together in
their house at Baungon, Bukidnon.

(5) Adjusting to decreasing physical strength and health due to her present health
condition and her old age.

(6) Establishing an explicit affiliation with one’s age group. Until now the patient has
casual communication with her age level. She still could recognize some of her friends
during her younger years and at present. Much as she wanted to be with them always
but her health and age condition would not allow anymore.

Interpersonal Theory – Harry Stack Sullivan

Harry Stack Sullivan was an American psychiatrist who extended theory of

personality development to include the significance of interpersonal relationships. He
thought that inadequate or nonsatisfying relationships produced anxiety, which he saw
as the basis for all emotional problems.

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 Sullivan saw interpersonal development as taking place over seven stages, from
infancy to mature adulthood. Personality changes can take place at any time but are
more likely to occur during transitions between stages.

In this theory, the patient falls under the final stage which is the adulthood stage
which starts from 23 years of age. This is the time when a person establishes a stable
relationship with a significant other person and develops a consistent pattern of viewing
the world. The struggles of adulthood include financial security, career, and family. With
success during previous stages, adult relationships and much needed socialization
become easier to attain. Without a solid background, interpersonal conflicts that result
in anxiety become more commonplace.

The patient has developed well according to this theory. In fact, two years after
the death of her first husband, she was able to find herself again, started a new life and
got married with her second husband. She was able to get over her first husbands
death in just 2 years.

The patient can also be considered as having a good coping mechanism

because she was able to adjust to possible crises in life. For instance, though they were
not living a lavish life, but they were able to adopt well a life that suits their resources.
As a couple, they were able to meet their basic needs in life.

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 Medical Management
Doctors Orders

DATE ORDERS RATIONALE

February 05,  Pls. admit under the  To render proper medical

2008 service of Dr. Alenton. management

2:30 pm

 Secure consent to care.  For legal purposes which

pertains to medical treatment
and procedures.

 Temperature Pulse  To obtain baseline data.

Respirations q 4 hrs.

 Nothing Per Orem  To prevent the risk for

temporary aspiration.

 Start venoclysis with D5W  For saline lock; emergency IVTT

500cc at 10cc/hr. drugs used.

 Labs.

 Complete Blood  To check for any hematologic

Count unusualities.

 Sodium  To check for serum sodium

content in the body.

 Potassium  To check for potassium content

in the body.

 Creatinine  To check for any tissue damage.

 Serum Glutamic  To check for liver functioning.

14
 Pyrovic
Transimenase

 Trop T  To detect and diagnose

(quantitative) Myocardial infarction.

 Creatinine  To immediately check for the

Kinase-MB-stat! degree of infarction

 Electrocardiogra  To monitor cardiac functioning.

m 12 Leads

 Chest X-ray –  To detect mediastinal

Antero posterior abnormalities
(portable)

 Fasting Blood  To check for blood sugar level.

Sugar

=Lipid Profile

 Med’s.

 Nitroglycerin  Treatment of Angina

(Transderm)
patches 5mg now x
12 OD.

 Aspirin 80mg 4 tabs  Treatment and prophylaxis of

now then 1 tab OD Myocardial infarction
after(pc) lunch

15
  Clopidrogrel (Plavix)  Treatment of patients with acute
75g 4 tabs now then coronary syndrome and
once a day(OD) myocardial infarction

 Captopril 25g ½ tab  Treatment for Hypertension

now then three
times a day (BID)

 Fondaparinux  Prevents the formation of

(Arixtra) 2.5mg thrombus
Subcutaneous (SQ)
now then OD

 Tramadol (Dolcet) 1  Prophylaxis for pain

cap now then three
times a day (TID)

 Tramadol (Dolcet) 1  Prophylaxis for pain

cap now then three
times a day (TID)
 Metoprolol  Prevention of reinfarction in
(Neobloc) 80mg 1 Myocardial infarction
tab now then twice a
day (BID)

 Oxygen inhalation at 2  To provide supplemental

liters/ minute via nasal oxygen.
cannula.

 Moderate high back rest  To promote lung expansion

 Complete Bed Rest without  To prevent increase workload of

toilet privilege the heart.

 Intake and Output every  To determine fluid retention and

shift. dehydration.

16
  Monitor vital signs every  To check for any unusualities
hour and record

 Will inform Attending  For proper management and

Physician care.

 Refer accordingly  To aid for further medical

intervention
5:13pm  Add’s meds.

 Atorvastatin (lipitor)  Treatment of elevated Low

80mg 1 tab now density lipoprotein
then OD at

 Lactulose 20cc OD  Prevent Constipation

at hs.

 Decrease Captopril to  Reduce the risk of hypotension

25g ¼ tab now then
every 8hour.

 Decrease Metoprolol to  Reduce the risk of hypotension

50g ½ tab then BID

 Start Isoket drip: D5W  Treatment for left ventricular

90cc +1 amp Isoket at failure secondary to acute
10cc/hr. Myocardial infarction

 Repeat ECG 12 Leads in  For comparison purposes and

morning to check for the effectivity of
drugs

 Increase Aspirin to 80mg  To attain drug efficacy level.

2 tabs OD PC lunch

 Remove transderm  Chest pain subsides; not

patch. needed for treatment.

17
  Attached to cardiac  To monitor cardiac functioning
monitor.

7:03pm  Ranitidine(Ulcin) 150g 2  Treatment for sour stomach in

tab BID PO adults

 May have soft, low salt.  To meet nutritional needs

Low fat diet. intended for MI patient

 Shift ranitidine PO to  For fast drug absorption.

50mg IVTT q 8hrs.

8:07pm  Soft diet  To meet nutritional needs

intended for MI patient.

 12 lead ECG with long  To assess cardiac status

lead 2

 FBS lipid profile, uric acid,  Aid to diagnosed for

SGPT in am hyperglycemia, hyperuricemia
and M.I

 Kalium durule 1 tab TIDx6  Treatment for hypokalemia

doses.

10:45pm  Increased Isoket  To attain drug efficacy level

to15cc/hr

 Give Tramadol 50mg  Treatment for moderate to

IVTT now severe pain

10:50pm  Increased Isoket  To attain drug efficacy level.

to20cc/hr

18
  Increased Isoket  To attain drug efficacy level.
to25cc/hr

11:00pm  Increased Isoket  To attain drug efficacy level.

to30cc/hr

 Give morphine 4mg IVTT  Relief of moderate to severe

now. acute pain
11:30pm  Shift ranitidine PO to  For fast drug absorption
50mg IVTT q 8hrs.

February 06,  Pls. Follow-up repeat  For continuous monitoring.

2008 ECG with long lead 3
care of heart station.
6:05 am

 To follow Isoket drip: D5  Left ventricular failure

water 90cc. plus 1 amp. secondary to acute Myocardial
Isokit at 30cc. / min. infarction

 Metformin (Imax) 500mg.  Oral treatment for type 2

1 tab BID diabetes

 Isoket drip to consume  To obtain effectivity of

medication

 Imdur 60mg. 1 Tab BID  Prophylaxis and treatment for

angina pectoris.

4:30 pm  IV follow-up with D5  For saline lock; emergency IVTT

Water 500cc.10cc/hour drugs used.

 Add 1 banana per meal.  Aid to increase serum

potassium level.

19
February  Limit visitors  To promote rest and decrease
07,2008 fatigue.

6:05pm

 Facilitate ECG with long  For continuous monitoring.

lead 2 in a.m

February Summary of meds:

08,2008

7:15 am

 Isosorbide  Left ventricular failure

Mononitrate secondary to acute Myocardial
(Imdur) 60mg 1 infarction
tab OD

 Isosorbide  Treatment and prophylaxis of

Dinitrate (Isordil) Myocardial infarction
5mg 1 tab 5L
PRN for chest
pain

 Aspirin 80mg 2  Treatment of patients with acute

tabs OD PC coronary syndrome and
lunch myocardial infarction

 Clopidrogrel  Treatment of patients with acute

(Plavix) 750mg 1 coronary syndrome and
tab OD myocardial infarction

 Captopril 25mg  Treatment for hypertension

¼ tab q 8hrs

 Fondaparinux  Prophylaxis of Deep Vein

(Arixtra) 2.5mg thrombosis
OD SQ

20
  Metoprolol 50mg  Prevention of reinfarction in
½ tab BID PO Myocardial infarction

 Atorvastatin  Treatment of elevated Low

(lipitor) 80mg 1 density lipoprotein
tab OD at HS.

 Lactulose 20cc  Prevent constipation

at HS hold for
BM >/= 2x/day

 Metformin  Oral treatment for Type II

500mg (Imax) 1 diabetes mellitus
tab BID PO

 Ranitidine  Prophylaxis for GI irritation

Hydrochloride
(Zantac) 150mg
1 tab BID PO

 Increase Imdur to 60mg  To attain drug efficacy level

1tab BID

 Vastaril MR 1 tab BID  Prophylaxis and treatment for

Angina pectoris.

 Now give Isordil q 5 mins  Treatment and prevention of

for 3 doses of chest pain angina pectoris
if not relieved by first
dose.

2:00pm  IVF to follow with PNSS  For saline lock; emergency IVTT
500c at 10cc/hr. drugs used.

21
February 9,  Metoclopramide (plazil)  Prevention of nausea and
2008 10mg IVTT now vomiting

1:08am

 Aluminum Magnesium  Treatment for hyperacidity

Hydroxide (maalox)
10ml now then TID

5:40am  IVF to ff: PNSS 500cc  Saline lock; for emergency IVTT
@ 10cc/hr drugs used

8:40am  Repeat ECG today  For comparison purposes and

to check for the effectiveness of
the drug

 Increase Maalox 10ml  To attain drug efficacy level.

to QID before meals
and HS

 Inform IMROD for any  For further medical

recurrence of chest pain management
and SOB
4:00pm  Off O2 – may have 02  To aid patient during SOB
PRN for dyspnea

 200mg Cordarone 1 tab  Treatment of ventricular

TID arrhythmias

February  May sit on bed with  To determine pt. ability to sit

11,2008 dangle legs. upright in her own

22
February  Summary of meds
12,2008

 Aspirin 80mg 2 tabs OD  Treatment and prophylaxis of

PC lunch PO Myocardial infarction
 Clopidogrel (Plavix)  Treatment of patients with acute
75mg 1 tab OD PO coronary syndrome and
myocardial infarction

 Captopril 25mg ¼ tab q  Prophylaxis and treatment for

8h hypertension

 Fondaparinux (Arixtra)  Prophylaxis of Deep Vein

2.5mg OD SL– Day 7 thrombosis
last dose at 6pm

 Tramadol(dolcet) 1 tab  Moderate to severe pain

TID prn for pain

 Metoprolol 50mg ½ tab  Hypertension , Angina Pectoris,

BID Prevention of reinfarction in
Myocardial Infarction

 Atorvastatin (Lipitor)  Treatment of Low density

80mg 1tab OD @ HS Lipoproteins

 Lactulose 20cc OD, hold  Prevent constipation

for BM > 2x/day

 Metformin (I-max)  Oral treatment for Type II

500mg 1tab BID diabetes
 Ranitidine (Zantac)  Prophylaxis for GI irritation
150mg 1tab BID

 Isosorbide Mononitrite  Relieve and prevent angina

(Imdur) 60mg 1tab BID

23
  Aluminum Magnesium  Neutralizes gastric acidity
Hydroxide (Maalox)
10ml QID

 Amniodarone  Treatment of ventricular

(cordarone) 200mg 1tab arrhythmias
tid

10:20am  Repeat ECG 12 leads  For comparison purposes

now

 DIET: decreased fat,  To prevent hypertension( a

decreased Na, precipitating factor)
hypertensive diet

 May sit on bedside chair  Ready for ambulation and slow

assumption of activity daily
living.

 May walk @ bedside  To promote exercise and

with assistance. prevent sudden orthostatic
hypotension.

7:55pm  ECG 12 lead now  To assess cardiac status

 Give  Prevention of nausea and

metoclopramide(Plazil) vomiting
10mg IVTT now

 Refer for recurrent of  For ocular inspection.

vomiting and save
vomitus care of IMROD

 May decrease Aspirin  To prevent the risk of bleeding.

80mg 1 tab OD pc lunch

 Hold Ranitidine  Shift to new drug ordered

Pantoprazole

24
Feb. 13, 2008  Start Pantoprazole  Prophylaxis for epigastric
(Pantoloc) 20mg 1 tab hyperacidity
now then O.D P.O

12:55p.m  May walk inside the  To promote exercise, and

ward. improved blood circulation

 B/P and Cardiac rate  To monitor cardiac changes

after walking. when doing certain activities.

Feb. 14, 2008  Discontinue Maalox  Epigastric hyperacidity

subsides.
8:10p.m

 May walk to the  Enhances self care and prevent

bathroom with from sudden orthostatic
assistance hypotension

 Give Domperidone  Treatment for flatulence

(Motilium) 1 tab am then
BID.

Feb.15, 2008  I.V.F to consume then  Patient’s fluid status is stable,

discontinue and in preparation for patients
8:00am may go home.

 May walk inside the  To promote exercise and blood

ward circulation.

 B/P and Cardiac rate  To monitor cardiac changes

after walking and record when doing certain activities.

25
12:30pm  Metoclopramide (plazil)  Prevention of nausea and
10mg. IVTT every 8 vomiting
hours prn

Feb. 16,2008  MGH  Patient may continue treatment

at home
11:02 am

 Home medications  For treatment compliance

regimen.

 Telmisartan  Treatment of essential

(Priton)40mg 1 Hypertension
tab O.D

 Clopidogrel  Treatment of patients with acute

(Plavix) 75mg 1 coronary syndrome and
tab O.D Myocardial infarction

 Metoprolol 50mg o Treatment for hypertension

½ tab BID

 Atorvastatin  Prophylaxis and treatment for

(Lipitor) 80mg 1 hyperlipidemia
tab OD @ H.S

 ISMN (Imdur)  Prophylaxis and treatment for

60mg 1 tab BID Angina pectoris

 Amniodarone  Treatment of ventricular

(Cordarone) arrhythmias
200mg 1 tab TID

 Aspirin 80mg 1  Prophylaxis for MI

tab OD pc lunch

 Metformin (Imax)  Treatment for Type II diabetes

26
 500mg 1 tab BID mellitus

 Day Feb.20, 2008 at  To evaluate for the effectiveness

MRH clinic follow-up of medical and nursing care.
check-up.

 Photocopy all labs.  For legal and documentation

Results (2copies) purposes.

Blood Chemistry

02-05-08

Test Normal Range Results Implications

Creatinine .7 - 1.2 1.3 mg/dl Myocardial Infarction

Na 137 – 145 132 mmol/L Hyponatremia

K 3.5 – 5.1 3.4 mmol/L Hypokalemia

ALT 9 – 52 3.0 u/L liver functioning

decrease r/t drugs
adverse effect and
gerontologic
consideration

CK-MB 0 – 18 7 u/L

27
 Differential Count

02-05-08

Test Normal Range Results Implications

Segmenters 55 – 65 % 46 Suggest anemia

Lymphocytes 25 – 35 % 53 Anemia

Eosinophils 1–3% 01 Reduced in Stress

Hematology

02-05-08

Test Normal Range Results Implications

HCT 35 – 50 % 29.4 Iron Deficiency

Anemia

HGB 11 – 16.5 g/dl 9.8 Iron Deficiency

Anemia

RBC 3.8 – 5.80 10/mm

WBC 5 – 10 10/mm 9,100

Platelet Count 140,000 – 440,000 333,000

28
 Chest x-ray Report

02-05-08

Examination Desired: CCXR Port

 Haziness seen in the left base

 Heart I magnified

 Aorta is calcified

 Spurs seen at the margins of the thoracic spine.

Impression:

 Probable left basal Pneumonia

 Atherosclerotic Aorta

 Thoracic Spondylosis

29
 Fasting Blood Sugar Lipid Profile

02-06-08

Test Normal Range Results Implications

Glucose 74 – 106 132 mg/dL Hyperglycemia

Uric Acid 2.5 – 6.2 8.4 mg/dL Hyperuricemia,

Cholesterol 0 – 200 187 mg/dL Hypercholesterolemia

Triglycerides 0 – 150 60 mg/dL Atherosclerosis

Direct HGL 40 – 60 38 mg/dL

LDL 60 – 180 137 mg/dL

VDRL 25 – 50 12 mg/dL

ALT 8 - 52 27 U/L

Troponin T (Quantitative)

 2.0 ng/ml
02-06-08

Interpretation of Results Rationale

1. < 0.03 ng/ml Low Cardiac Risk

2. Between 0.03 ng/ml &0.1 ng/ml Medium Cardiac Risk (Possible

Myocardial damage)

3. Between 0.1 ng/ml & 3.0 ng/ml High Risk (Myocardial damage
detected)

4. > 2.0 ng/ml Massive Myocardial damage has

been detected

30
 HGT (Hemoglucotest)

02-08-08

 94 mg/dL (N)

IVF Sheet

02-05-08

Bottle # Types of Solution Running hours Time Started Rationale

gtts/min

1 D5W 500cc 10 cc/hr 2:45 PM Isotonic solution

2 D5W 90cc + 1 amp 10 cc/hr + 1 amp 3:25 PM Isotonic solution

Isoket

3 PNSS 500cc 10 cc/hr Isotonic solution

4 PNSS 500cc 10 cc/hr 2:45 PM Isotonic solution

5 PNSS 500cc 10 cc/hr Isotonic solution

31
 Electrocardiograph tracing

ECG findings

Rhythm Sinus Axis +39

Rate: Atrial 93bpm Ventricular 93bpm Position

P.R. 0.20sec Q.R.S 0.10sec Q.T. 0.44sec Q.T. Ratio

ECG Diagnosis

- sinus rhythm

- inferolateral and anterior wall ischemia

32
ECG findings
Rhythm sinus Axis +10

Rate: Atrial 93bpm Ventricular 93bpm Position

P.R. 0.20 sec Q.R.S. 0.08 sec Q.T. 0.44 sec

ECG Diagnosis

- sinus rhythm

- anterolateral wall ischemia

- left ventricular hypertrophy by voltage criteria

33
 Pathophysiology with Anatomy and Physiology

A. Review of Anatomy and Physiology of the Organs Involved

Cardiovascular System

Heart

For all its might, the cone-shaped heart is a relatively small, roughly the same
size as a closed fist—about 12 cm (5 in) long, 9 cm (3.5 in) wide at its broadest point,
and 6 cm (2.5 in) thick. Its mass averages 250 g (8 oz) in adult females and 300 g (10
oz) in adult males. The heart rests on the diaphragm, near the midline of the thoracic
cavity. It lies in the mediastinum, a mass of tissue that extends from the sternum to the
vertebral column between the lungs. About two-thirds of the mass of the heart lies to the
left of the body’s midline. Visualize the heart as a cone lying on its side. The pointed end
of the heart is the apex, which is directed anteriorly, inferiorly, and to the left. The broad
portion of the heart opposite the apex is the base, which is directed posteriorly,
superiorly, and to the right.

In addition to the apex and the base, the heart has several surfaces and borders
9margins). The anterior surface is deep to the sternum and ribs. The inferior surface is
the part of the heart between the apex and the right border and rests mostly on the
diaphragm. The right border faces the right lung and extends from the inferior surface to
the base. The left border, also called the pulmonary border, faces the left lung and
extends from the base to the apex.

34
 Layers and Coverings of the Heart

The heart is located between the lungs in the thoracic cavity and is surrounded
and protected by the pericardium (peri- _ around). The pericardium consists of an outer,
tough fibrous pericardium and an inner, delicate serous pericardium. The fibrous
pericardium attaches to the diaphragm and also to the great vessels of the heart. Like
all serous membranes, the serous pericardium is a double membrane composed of an
outer parietal layer and an inner visceral layer. Between these two layers is the
pericardial cavity filled with serous fluid. The wall of the heart has three layers: the outer
epicardium (epi- _ on, upon; cardia _ heart), the middle myocardium (myo muscle), and
the inner endocardium (endo- _ within, inward). The epicardium is the visceral layer of
the pericardium. The majority of the heart is myocardium or cardiac muscle tissue. The
endocardium is a thin layer of endothelium deep to the myocardium that lines the
chambers of the heart and the valves.

Surface Structures of the Heart

The human heart has four chambers and is divided into right and left sides. Each
side has an upper chamber called an atrium and a lower chamber called a ventricle.
The two atria form the base of the heart and the tip of the left ventricle forms the apex.
Auricles (auricle _ little ear) are pouch-like extensions of the atria with wrinkled edges.
Shallow grooves called sulci (sulcus, singular) externally mark the boundaries between

35
the four heart chambers. Although a considerable amount of external adipose tissue is
present on the heart surface for cushioning, most heart models do not show this.
Cardiac muscle tissue that composes the heart walls has its own blood supply and
circulation, the coronary (corona_ crown) circulation. Coronary blood vessels
encompass the heart similar to a crown and are found in sulci. On the anterior surface
of the heart, the right and left coronary arteries branch off the base of the ascending
aorta just superior to the aortic semilunar valve, and travel in the sulcus separating the
atria and ventricles. These small arteries are supplied with blood when the ventricles
are resting. When the ventricles contract, the cusps of the aortic valve open to cover the
openings to the coronary arteries.

A clinically important branch of the left coronary artery is the anterior interventricular
branch, also known as the left anterior descending (LAD) branch that lies between the
right and left ventricles and supplies both ventricles with oxygen-rich blood. This
coronary artery is commonly occluded which can result in a myocardial infarct and, at
times, death.

Great Vessels of the Heart

The great veins of the heart return blood to the atria and the great arteries carry
blood away from the ventricles. The superior vena cava, inferior vena cava, and
coronary sinus return oxygen-poor blood to the right atrium. The superior vena cava
returns blood from the head, neck, and arms; the inferior vena cava returns blood from
the body inferior to the heart. The coronary sinus is a smaller vein that returns blood
from the coronary circulation. Blood leaves the right atrium to enter the right ventricle.
From here, oxygen-poor blood passes out the pulmonary trunk, the only vessel that
removes blood from the right ventricle. This large artery divides into the right and left
pulmonary arteries that carry blood to the lungs where it is oxygenated. Oxygen-rich
blood returns to the left atrium through two right and two left pulmonary veins. The blood
then passes into the left ventricle that pumps blood into the large aorta. The aorta
distributes blood to the systemic circulation. The aorta begins as a short ascending
aorta, curves to the left to form the aortic arch, descends posteriorly and continues as
the descending aorta.

36
 Internal Structures of the Heart

The heart has four valves that control the one-way flow of blood: two
atrioventricular (AV) valves and two semilunar valves (semi- _ half; lunar _ moon).
Blood passing between the right atrium and the right ventricle goes through the right AV
valve, the tricuspid valve (tri _ three; cusp _ flap). The left AV valve, the bicuspid valve,
is between the left atrium and the left ventricle. This valve clinically is called the mitral
valve (miter _ tall, liturgical headdress) because the open valve resembles a bishop’s
headdress. String-like cords called chordae tendineae (tendinous strands) attach and
secure the cusps of the AV valves to enlarged papillary muscles that project from the
ventricular walls. Chordae tendinae allow the AV valves to close during ventricular
contraction, but prevent their cusps from getting pushed up into the atria. The two
semilunar valves allow blood to flow from the ventricles to great arteries and exit the
heart. Blood in the right ventricle goes through the pulmonary (semilunar) valve to enter
the pulmonary trunk, a large artery. The aortic (semilunar) valve is located between the
left ventricle and the aorta. These two semilunar valves are identical, with each having
three pockets that fill with blood, preventing blood from flowing back into the ventricles.
The two ventricles have a thick wall between them called the interventricular septum.
Between the two atria is a thinner interatrial septum.

Coronary Circulation

There are two major coronary arteries: the right and the left. These two arteries
branch out of the aorta immediately after the aortic valve. The right coronary artery
splits into the marginal branch, which feeds blood into the right ventricle, and the
posterior interventricular branch, which supplies the left ventricle. The left coronary
artery is notably larger than the right coronary artery because it feeds the left heart,
which, as a result of it's more powerful contractions, requires a more vigorous blood
flow. The left coronary artery splits into the anterior interventricular branch and a
circumflex branch. The anterior interventricular branch runs towards the apex of the

37
heart, providing blood for both of the ventricles and the ventricular septum. The
circumflex branch, on the other hand, follows the groove between the left atrium and the
left ventricle, providing blood supply to both of these chambers until it reaches and joins
with the right coronary artery in the posterior of the heart.

The coronary arteries are especially subject to blockage and narrowing which
can cause a depletion of blood to certain parts of the heart, possibly causing a heart
attack.

Blood Flow through the Heart

The function of the right side of the heart is to collect de-oxygenated blood, in the
right atrium, from the body and pump it, via the right ventricle, into the lungs (pulmonary
circulation) so that carbon dioxide can be dropped off and oxygen picked up (gas
exchange). This happens through the passive process of diffusion. The left side (see left
heart) collects oxygenated blood from the lungs into the left atrium. From the left atrium
the blood moves to the left ventricle which pumps it out to the body. On both sides, the
lower ventricles are thicker and stronger than the upper atria. The muscle wall
surrounding the left ventricle is thicker than the wall surrounding the right ventricle due
to the higher force needed to pump the blood through the systemic circulation.

Starting in the right atrium, the blood flows through the tricuspid valve to the right
ventricle. Here it is pumped out the pulmonary semilunar valve and travels through the
pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein
to the left atrium. It then travels through the mitral valve to the left ventricle, from where
it is pumped through the aortic semilunar valve to the aorta. The aorta forks, and the
blood is divided between major arteries which supply the upper and lower body. The
blood travels in the arteries to the smaller arterioles, then finally to the tiny capillaries
which feed each cell. The (relatively) deoxygenated blood then travels to the venules,
which coalesce into veins, then to the inferior and superior venae cavae and finally back
to the right atrium where the process began.

38
Blood Vessels

Blood circulates inside the blood vessels, which form a closed transport system,
the so-called vascular system. Like a system of roads, the vascular system has its
freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the
large arteries leaving the heart. It then moves successively smaller and smaller arteries
and then into the arterioles, which feed the capillary beds in the tissues. Capillary beds
are drained by venules, which in turn empty into the great veins (venae cavae) entering
the heart. Thus arteries, which carry blood away from the heart, and veins, which drain
the tissues and return the blood to the heart, are simply conducting vessels. Only the
tiny hair-like capillaries, which extend and branch through the tissue and connect the
smallest arteries (arterioles) to the smallest veins (venules), directly serve the needs of
the body cells. The capillaries are the side streets or alleys that intimately intertwine
among the body cells. It is only through their walls that exchanges between the tissue
cells and the blood can occur. (Marieb, 2006)

39
 Layers of Blood Vessel Walls

The walls of blood vessels have three coats, or tunics. The tunica intima which
lines the lumen or interior of the blood vessels, is a thin layer of endothelium (squamous
epithelial cells) resting on a basement membrane. Its cells fit closely together and form
a slick surface that decreases friction as blood flows through the vessel lumen. (Marieb,
2006)

The tunica media is the bulky middle coat. It is mostly smooth muscle and elastic
tissue. The smooth muscle, which is controlled by the sympathetic nervous system, is
active in changing the diameter of the vessels. As the vessel constrict or dilate, blood
pressure increases or decreases, respectively. Marieb, 2006)

The tunica externa is the outermost tunic; it is composed largely of fibrous

connective tissue. Its function is basically to support and protect the vessels. (Marieb,
2006)

40
 The Microcirculation

The microcirculation is that portion of the circulatory system for exchange of

water, gases, nutrients, and waste material. As such, it is the most important part of the
cardiovascular system because it is where the exchange with tissues takes place.
Although the microcirculation is considered as a closed system, its walls are much more
permeable than any other part of the circulation.

Factors Affecting Flow of Blood

The flow of a fluid through a vessel is determined by the pressure difference

between the two ends of the vessel and also the resistance to flow.

• Pressure Difference. For any fluid to flow along a vessel there must be a
pressure difference otherwise the fluid will not move. In the cardiovascular
system, the “pressure head” or force is generated by the pumping of the heart
and there is a continuous drop in pressure from the left ventricle to the tissue and
also from the tissue back to the right atrium. (Hinchliff, 2000)
• Resistance to Flow. Resistance is a measure of the ease with which a fluid
flows through a tube: the easier it is the less resistance to flow, and vice versa. In
the circulatory system, the resistance is usually described as vascular resistance,

41
 or also known as peripheral resistance. Resistance is essentially a measure of
the friction between the molecules of the fluid, and between the tube wall and the
fluid. The resistance depends on the viscosity of the fluid and the radius and
length of the tube. (Hinchliff, 2000)
• Radius of the Tube. The smaller the radius of a vessel, the greater is the
resistance to the movement of particles. Small alterations in the size of the radius
of the blood vessels, particularly of the more peripheral vessels, can greatly
influence the flow of blood. Atheromatous changes in the walls of large and
medium-sized arteries cause narrowing of the lumen of the vessels and result in
an increased vascular resistance. (Hinchliff, 2000)
• Length of the Tube. The longer the tube, the greater the resistance to the flow of
liquid through it. A longer vessel will require a greater pressure to force a given
volume of liquid through it than will a shorter vessel. (Hinchliff, 2000)
• Viscosity of the Fluid. Viscosity is a measure of the intermolecular or internal
friction within a fluid or in other words, of the tendency of the fluid to resist flows.
The greater the viscosity of the fluid, the greater is the force required to move
that liquid. (Hinchliff, 2000)

Blood

Blood is a specialized bodily fluid (technically a tissue) that is composed of a

liquid called blood plasma and blood cells suspended within the plasma. The blood cells
present in blood are red blood cells (also called RBCs or erythrocytes), white blood cells
(including both leukocytes and lymphocytes) and platelets (also called thrombocytes).
Plasma is predominantly water containing dissolved proteins, salts and many other
substances; and makes up about 55% of blood by volume. Mammals have red blood,
which is bright red when oxygenated, due to hemoglobin. Some animals, such as the
horseshoe crab use hemocyanin to carry oxygen, instead of hemoglobin.

42
By far the most abundant cells in blood are red blood cells. These contain hemoglobin,
an iron-containing protein, which facilitates transportation of oxygen by reversibly
binding to this respiratory gas and greatly increasing its solubility in blood. In contrast,
carbon dioxide is almost entirely transported extracellularly dissolved in plasma as
bicarbonate ion. White blood cells help to resist infections and parasites, and platelets
are important in the clotting of blood.

Blood is circulated around the body through blood vessels by the pumping action of the
heart. Arterial blood carries oxygen from inhaled air to the tissues of the body, and
venous blood carries carbon dioxide, a waste product of metabolism produced by cells,
from the tissues to the lungs to be exhaled.

Medical terms related to blood often begin with hemo- or hemato- (BE: haemo- and
haemato-) from the Greek word "αἷμα" for "blood." Anatomically and histologically, blood
is considered a specialized form of connective tissue, given its origin in the bones and
the presence of potential molecular fibers in the form of fibrinogen.

Constituents of human blood

Blood accounts for 7% of the human body weight, with an average density of
approximately 1060 kg/m³, very close to pure water's density of 1000 kg/m3. The
average adult has a blood volume of roughly 5 litres, composed of plasma and several
kinds of cells (occasionally called corpuscles); these formed elements of the blood are
erythrocytes (red blood cells), leukocytes (white blood cells) and thrombocytes
(platelets). By volume the red blood cells constitute about 45% of whole blood, the
plasma constitutes about 55%, and white cells constitute a minute volume.

Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics; its flow
properties are adapted to flow effectively through tiny capillary blood vessels with less
resistance than plasma by itself. In addition, if all human haemoglobin was free in the
plasma rather than being contained in RBCs, the circulatory fluid would be too viscous
for the cardiovascular system to function effectvely.

43
 Cells

4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In

mammals, mature red blood cells lack a nucleus and organelles. They contain the
blood's hemoglobin and distribute oxygen. The red blood cells (together with endothelial
vessel cells and other cells) are also marked by glycoproteins that define the different
blood types. The proportion of blood occupied by red blood cells is referred to as the
hematocrit, and is normally about 45%. The combined surface area of all the red cells in
the human body would be roughly 2,000 times as great as the body's exterior surface.

4,000-11,000 leukocytes: White blood cells are part of the immune system; they
destroy and remove old or aberrant cells and cellular debris, as well as attack infectious
agents (pathogens) and foreign substances. The cancer of leukocytes is called
leukemia.

200,000-500,000 thrombocytes: Platelets are responsible for blood clotting

(coagulation). They change fibrinogen into fibrin. This fibrin creates a mesh onto which
red blood cells collect and clot, which then stops more blood from leaving the body and
also helps to prevent bacteria from entering the body.

Plasma

About 55% of whole blood is blood plasma, a fluid that is the blood's liquid
medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.7-
3.0 litres in an average human. It is essentially an aqueous solution containing 92%
water, 8% blood plasma proteins, and trace amounts of other materials. Plasma
circulates dissolved nutrients, such as, glucose, amino acids and fatty acids (dissolved
in the blood or bound to plasma proteins), and removes waste products, such as,
carbon dioxide, urea and lactirc acid.

Other important components include:

44
 • Serum albumin
• Blood clotting factors (to facilitate coagulation)
• Immunoglobulins (antibodies)
• Various other proteins
• Various electrolytes (mainly sodium and chloride)
The term serum refers to plasma from which the clotting proteins have been removed.
Most of the proteins remaining are albumin and immunoglobulins.

The normal pH of human arterial blood is approximately 7.40 (normal range is 7.35-
7.45), a weak alkaline solution. Blood that has a pH below 7.35 is too acidic, while blood
pH above 7.45 is too alkaline. Blood pH, arterial oxygen tension (PaO2), arterial carbon
dioxide tension (PaCO2) and HCO3 are carefully regulated by complex systems of
homeostasis, which influence the respiratory system and the urinary system in the
control the acid-base balance and respiration. Plasma also circulates hormones
transmitting their messages to various tissues.

Color

Hemoglobin

Hemoglobin is the principal determinant of the color of blood in vertebrates. Each

molecule has four heme groups, and their interaction with various molecules alters the
exact color. In vertebrates and other hemoglobin-using creatures, arterial blood and
capillary blood are bright red as oxygen impacts a strong red color to the heme group.
Deoxygenated blood is a darker shade of red with a bluish hue; this is present in veins,
and can be seen during blood donation and when venous blood samples are taken.
Blood in carbon monoxide poisoning is bright red, because carbon monoxide causes
the formation of carboxyhemoglobin. In cyanide poisoning, the body cannot utilize
oxygen, so the venous blood remains oxygenated, increasing the redness. While
hemoglobin containing blood is never blue, there are several conditions and diseases
where the color of the heme groups make the skin appear blue. If the heme is oxidized,

45
methemoglobin, which is more brownish and cannot transport oxygen, is formed. In the
rare condition sulfhemoglobinemia, arterial hemoglobin is partially oxygenated, and
appears dark-red with a bluish hue (cyanosis), but not quite as blueish as venous blood.

Veins in the skin appear blue for a variety of reasons only weakly dependent on the
color of the blood. Light scattering in the skin, and the visual processing of color play
roles as well.

Skinks in the genus Prasinohaema have green blood due to a buildup of the waste
product biliverdin.

Hemocyanin

The blood of most molluscs, including cephalopods and gastropods, as well as

some arthropods such as horseshoe crabs contains the copper-containing protein
hemocyanin at concentrations of about 50 grams per litre. Hemocyanin is colourless
when deoxygenated and dark blue when oxygenated. The blood in the circulation of
these creatures, which generally live in cold environments with low oxygen tensions, is
grey-white to pale yellow, and it turns dark blue when exposed to the oxygen in the air,
as seen when they bleed. This is due to change in color of hemocyanin when is it
oxidized. Hemocyanin carries oxygen in extracellular fluid, which is in contrast to the
intracellular oxygen transport in mammals by hemoglobin in RBCs.

Pancreatic Islets

The pancreas, located close to the stomach in the abdominal cavity is a mixed
gland. Probably the best-hidden endocrine glands in the body are the pancreatic islets,
formerly called the islets of Langerhans. These little masses of hormone-producing
tissue are scattered among the enzyme-producing acinar tissue of the pancreas. Two
important hormones produced by the islet cells are insulin and glucagons. (Marieb,
2006)

46
 High levels of glucose in the blood stimulate the release of insulin from the beta
cells of the islets. Insulin acts on just about all body cells and increases their ability to
transport glucose across their plasma membranes. Once inside the cells, glucose is
oxidized for energy or converted to glycogen or fat for storage. These activities are also
speeded up by insulin. Since insulin sweeps the glucose out of the blood, its effect is
said to be hypoglycemic. As blood glucose levels fall, the stimulus for insulin release
ends (negative feedback control). Insulin is the only hormone that decreases blood
glucose levels. Insulin is absolutely necessary for the use of glucose by the body cells.
Without it, essentially no glucose can get into the cells to be used. (Marieb, 2006)

Glucagons act as an antagonist of insulin; that is, it helps to regulate blood

glucose levels but is a way opposite to that of insulin. Its release by the alpha cells of
the islets is stimulated by low blood levels of glucose. Its action is basically
hyperglycemic. Its primary target organ is the liver, which stimulates to break down
stored glycogen to glucose and to release glucose into the blood. (Marieb, 2006)

Insulin

The main function of the insulin is to participate in maintaining homeostasis of

blood glucose level and to promote other metabolic activities that are anabolic. When
absorbed nutrients, especially glucose, are in excess of immediate needs insulin
promotes storage. It reduces high blood nutrients by:

47
Acting on cell membranes and stimulating uptake and utilization of glucose by muscles
and connective tissue cells;

Increasing conversion of glucose to glycogen, especially in the liver and skeletal

muscles;

Accelerating uptake of amino acids by cells, and the synthesis of proteins;

Promoting synthesis of fatty acids and storage of fat in adipose tissue, and; Preventing
the breakdown of protein and fat and gluconeogenesis.

Glucagon

The effect of glucagon is increasing blood glucose levels by stimulating:

Conversion of glycogen to glucose (in the liver and skeletal muscle);

Gluconeogenesis, the manufacture of glucose by the body from noncarbohydrate

materials. (Burke, 1995)

Somatostatin

The effect of somatostatin (also produced by hypothalamus) is to inhibit the

secretion of both insulin and glucagons. It delays intestinal absorption of glucose.
(Smeltzer, 2007)

Metabolism

Metabolism is a broad term referring to all chemical reactions that are necessary
to maintain life. In involves catabolism, in which substances are broken down to simpler
substances, and anabolism, in which larger molecules or structures are built from
smaller ones. During catabolism, energy is released and captured to make ATP, the
energy-rich molecule used to energize all cellular activities, including catabolic
reactions. (Marieb, 2006)

48
 Just as an oil furnace uses oil (its fuel) to produce heat, the cells of the body use
carbohydrates as their preferred fuel to produce cellular energy (ATP). Glucose, also
known as blood sugar, is the major breakdown product of carbohydrate digestion.
Glucose is also the major fuel used for making ATP in most body cells. Basically, the
carbon atoms released leave the cells as carbon dioxide, and the hydrogen atoms
removed (which contain energy-rich electrons) are eventually combined with oxygen to
form water. These oxygen-using events are referred to collectively as cellular
respiration. (Marieb, 2006) The overall reaction is summed up simply as:

C6H12O6 + 6 O2 => 6 CO2 + 6 H20 + ATP (energy).

49
Pathophysiology

50
51
52
53
54
Nursing Assessment (System Review and Nursing
Assessment II)

55
 Nursing Management

Ideal Nursing Management

Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular
resistance, vasoconstriction

Actions/Interventions Rationale

Independent

Provide calm, restful surroundings, Help reduce sympathetic stimulation;

minimize environmental activity/noise. promotes relaxation.
Limit the number of visitors and length
of stay.
Maintain activity restrictions, e.g. Reduces physical stress and tension
bedrest/chair rest; schedule periods of that affect blood pressure and the
uninterrupted rest; assist client with course of hypertension.
self-care activities as needed.
Provide comfort measures, e.g. back Decreases discomfort and may reduce
and neck massage, elevation of head. sympathetic stimulation.
Instruct in relaxation techniques, Can reduce stressful stimuli, promotes
guided imagery, distractions. relaxation.
Maintain activity restrictions, e.g. Reduces physical stress and tension
bedrest/chair rest; schedule periods of that affect blood pressure and the
uninterrupted rest; assist client with course of hypertension
self-care activities as needed.
Provide comfort measures, e.g. back Decreases discomfort and may reduce
and neck massage, elevation of head. sympathetic stimulation.
Instruct in relaxation techniques, Can reduce stressful stimuli, produce
guided imagery, distractions calming effect, thereby reducing BP

Dependent

56
Administer medications as indicated; Diuretics are considered first-line
medications for uncomplicated stage I
Thiazide diuretics, e.g. chlorothiazide or II hypertension and may be used
(Diuril); hydrochlorothiazide alone or in association with other drugs
(Esidrix/HydroDIURIL); (such as β-blockers) to reduce BP in
bendroflumethiazide (naturetin); clients with relatively normal renal
indapamide (Lozol); metolazone function. These diuretics potentiate the
(Diulol); quenthinazone (Hydromox) effects of other antihypertensive agents
as well, by limiting fluid retention, and
may reduce the incidence of strokes
and heart failure

Nursing Diagnosis: Activity intolerance related to generalized weakness

Actions/Interventions Rationale

Independent

Instruct client in energy- conserving Energy-saving techniques reduce the

techniques e.g., suing chair when energy expenditure thereby assisting in
showering, sitting to brush teethe or equalization of oxygen supply and
comb hair, carrying out activates at a demand
slower pace
Encourage progressive activity/self- Gradual activity progression prevents a
0care when tolerated. Provide sudden increase in cardiac workload.
assistance as needed. Providing assistance only as needed
encourages independence in
performing activities

Nursing Diagnoses: Risk for impaired Gas Exchange related to alveolar-capillary

membrane changes, e.g. fluid collection/shifts into interstitial space/alveoli

Actions/Interventions Rationale

Independent

Encourage frequent position changes Helps prevent atelectasis and

pneumonia
Maintain chair/bed rest, with head of Reduce oxygen consumption/demands
bed elevated 20-30 degrees, semi-

57
fowler’s position. Support arms with and promotes maximal lung inflation.
pillows

Dependent

Administer supplemental oxygen as INcre4ases alveolar oxygen

indicated concentration, which may
correct/reduce tissue hypoxemia.

Nursing Diagnosis: Knowledge deficit related to Lack of information/misunderstanding of

medical condition/therapy needs.

Actions/Interventions Rationale

Independent

be alert to signs of avoidance, e.g., Natural defenses mechanisms, such as

changing subject away from anger or denial of significance of
information being presented or situation, can block learning, affecting
extremes of behavior patient’s responses and ability to
assimilate information.
Encourage identification/reduction of these behaviors/chemicals have direct
individual risk factors, e.g.,
smoking/alcohol consumption, obesity. adverse effect on cardiovascular
function and may impede recovery,
increase risk for complications
Educate client regarding gradual Gradual increase in activity increases
resumption of activities (walking, work, strength and prevents overexertion,
recreational activity. may enhance, collateral circulation, and
allows return to normal lifestyle.
Emphasizes importance of contacting Timely evaluation/intervention may
physician if chest pain, change in prevent complications.
anginal pattern or other symptoms
recur.
Stress importance of reporting post MI-complication of pericardial
development of fever in association inflammation requires further medical
w3ith diffuse/atypical chest pain and evaluation/intervention.
joint pain

58
Nursing diagnosis: Ineffective coping related to situational crisis

Actions/Intervention Rationale

Independent

Encourage patient to talk about what is Provides clues to assist patient to

happening at this time and what has develop coping and regain equilibrium.
occurred to precipitate feelings of
helplessness and anxiety.
Allow patient to be dependent in the Promotes feelings of security (patient
beginning, with gradual resumption of will know nurse will provide safety). As
independence in ADLs. Self-care and control is regained, patient has the
other activities. Make opportunities for opportunity to develop adaptive
patient to make simple decisions about coping/problem-solving skills.
care/other activities when possible,
accepting choice not to do so.
Accept verbal expressions or anger, Verbalizing angry feelings in important
setting limits on maladaptive behavior process for resolution of grief and loss.
However, preventing destructive
actions (such as striking out at others)
preserves patient’s self-esteem.
Discuss feelings of inability to find Crisis situation may evoke, questioning
meaning in life/reason for living, of spiritual beliefs, affecting ability to
feelings of futility or alienation from cope with current situation and plan for
God. the future.
Promote safe and hopeful environment, May be helpful while patient regains
as needed. Identify positive aspects of inner control. The ability to learn from
this experience and assist patient to the current situation can provide skills
view it as a learning opportunity. for moving forward
Provide support for patient to problem- Helping/SO to brainstorm possible
solve solutions for current situation. solutions (giving consideration to the
Provide information and reinforce pros and cons of each) promotes
reality as patient begins to ask feelings of self-control/esteem.
questions; look at what is happening.

59
Provide for gradual implementation and Reduces anxiety of sudden change and
continuation of necessary behavior and allows for developing new and creative
lifestly changes. Reinforce positive solutions
adaptation/ new coping behaviors

Dependent

Refer to other resources as necessary Additional assistance may be needed

(eg. Clergy, psychiatric clinical nurse to help patient resolve problems or
specialist/psychiatrist, family/ marital make decisions.
therapist, addiction support groups).

Nursing Diagnosis: Family Coping, ineffective: risk for compromised related to

prolonged disease/disability progression that exhausts the supportive capacity of family
members.

Actions/Interventions Rationale

Independent

Evaluate pre-illness/current behaviors Information about family problems

that may be interfering with the (e.g., divorce/ separation, financial
care/recovery of client limitations, substance use) will be
helpful in determining options and
developing an appropriate plan of care.
Discuss underlying reasons for patient When family members know why
behaviors with family. patient is behaving in different ways, it
helps them understand and accept/deal
with situation
Assist family/patient to understand When these boundaries are defined,
“who owns the problem” and who is each individual can begin to take care
responsible for resolution. Avoid of own self and stop taking care of
balance blame or guilt. others in inappropriate ways.
Involve family in information giving, Information can reduce feelings of
problem solving and care of patient as helplessness. Involvement in care
feasible. Identify other ways of enhances feelings of control and self
demonstrating support while worth
maintaining patient’s independence

Dependent

60
Refer to appropriate resources for May need additional assistance in
assistance as indicated (e.g. resolving family issues.
counseling, psychotherapy, financial,
spiritual).

Nursing Diagnosis: Therapeutic Regimen: risk for ineffective management related to

perceived barriers; economic difficulties, side effects of therapy, mistrust of regimen
and/or healthcare personnel; complexity of healthcare system.

Action/Intervention Rationale

Independent

Review patients/SO’s knowledge and Provides opportunities to clarify

understanding of the need for viewpoints/misconceptions. Verifies
treatment/medication, as well as that patient/SO has accurate/ factual
consequences of the need for information with which to make
treatment/medication, as well as informed choices.
consequences of actions and choices.
Not ability to comprehend information,
including literacy, level of education,
primary language.

Be aware of developmental and Impacts ability to understand own

chronological age. needs/incorporate into treatment
regimen.

Determine cultural, spiritual, and health Provide insight into thoughts/factors

beliefs and ethical concerns related to individual situation. Beliefs
will affect patient’s perception of
. situation and participation in treatment
regimen. Treatment may be
incongruent with patient’s
social/cultural lifestyle and perceived
role/responsibilities

61
Nursing Diagnosis: Pain related to an imbalance in oxygen supply and demand

Action/Interventions Rationale

 Position patient in bed in semi- >this allows for rest and adequate
fowler’s position chest excursion, to increase available
oxygen and to decrease cardiac work.

 Administer oxygen by way of >to increase oxygen supply. May

nasal cannula at 4L/min.
maintain oxygen saturation at
92% or above.
 Administer nitroglycerin and
morphine based on vital signs
and pain relief.
decrease pain and PVCs
> both medications will help alleviate
pain by decreasing venous return to the
heart, thereby decreasing cardiac work.
Morphine will also help to decrease the
patients sensation of pain.

 Monitor BP closely by way of >both medications may decrease BP

non-invasive BP monitor. because both will decrease venous
return. Intra-arterial blood pressure
monitoring may be used if condition
warrants.

 Attach electrodes for continuous >increased rate may indicate heart

bedside cardiac monitor. Monitor block; dysrhythmias are common
heart rate and rhythm frequently. initially, increased frequency suggests
ischemia.

 Administer and monitor >may help to relieve the coronary

thrombolytic therapy occlusion.

 Monitor signs of bleeding; avoid >thrombolytics cause clot lysis may

unnecessary venous or arterial cause bleeding.
punctures.

62
Nursing Diagnosis: decreased cardiac output related to decreased cardiac contractility
and dysrrhythmias.
 Actions/ Interventions
 Administer I.V fluids as ordered
 Monitor closely for signs of
developing left ventricular failure
(e.g auscultate lung sounds for
crackles and heart sounds for
s3).
 Monitor urine output hourly
 Monitor mental status
 Interpret rhythm strip at least
every 4 hours, more frequently
as condition warrants.
Administer antiarrythmics, if
indicated.
 Administer vasopressors; titrate
to BP response.
 Employ hemodynamic
monitoring: central venous
pressure CVP and pulmonary
artery catheter and pulmonary
artery pressure.
Rationales
>I.V fluid may be necessary to
compensate for the decreased venous
return caused by nitrates and
morphine.
>left ventricular failure may develop as
a result of the decreased myocardial
contractility and/ or the administration
of excess fluids.
>Monitor urine output hourly
>a change in mental status may
indicate a decrease in cardiac output.
>dysrythmias such as PVCs result in a
decreased stroke volume and less
coronary artery filling time. Frequent
monitoring, especially during the first
few hours of an acute MI and during
thrombolytic therapy administration, is
necessary to prevent and treat lethal
dysrhythmias
>administration of vasopressors with
aqcute MI is controversial in that they
may cause an increase in systemic
vascular resistance, which increases
cardiac work.
>these parameters will help to guide
fluid volume administration, vasoactive
drug administration and assess cardiac
performance.
63
Nursing Diagnosis: Anxiety related to fear of death

Interventions/ Actions Rationales

 Explain equipment, procedures, >helps conserve energy.

and need for frequent
assessment to the patient and
family. Discuss visiting hours
and the need to allow for rest

 Observe for autonomic signs >anxiety is associated with an increase

and symptoms for anxiety (eg in sympathetic activity, which increases
increase heart rate, BP and cardiac work.
respiratory rate)

 Administer diazepam (valium) or >may aid in limiting patient’s anxiety

morphine

 Offer back massage >touch and massage may promote

relaxation.

 Maintain continuity of care >consistency of routine and staff

promotes trust and confidence.

64
Nursing Diagnosis: activity intolerance related to imbalance between myocardial oxygen
supply and demand.

Actions/Interventions Rationale

 Document heart rate and >trends determine patients response to

rhythm and BP changes activity and may indicate myocardial
before, during, and after oxygen deprivation that may require
activity as indicated. decrease in activity level/ return to
Correlate with reports of
bedrest, changes in medication
chest pain/shortness of
breath. regimen or use of supplemental
oxygen.

 Encourage rest (bed/chair) >reduces myocardial workload/ oxygen

initially. Thereafter, limit consumption, reducing risk of
activity on basis of pain/ complications (e.g extension of MI).
adverse cardiac response.
Provide nonstress
diversional activities

 Instruct patient to avoid >activities that require holding of breath

increasing abdominal and bearing down can result in
pressure . e.g straining bradycardia (temporarily reduced
during defecation cardiac output) and rebound
tachycardia with elevated BP.

 Explain pattern of graded >progressive activity provides

increase increases of activity controlled demand on the heart,
level e.g, getting up to increasing strength and preventing over
commode or sitting in a chair exertion.

 Review signs and symptoms >palpitations, pulse irregularities,

reflecting intolerance of development of chest pain, or dyspnea
present activity level. may indicate changes in exercise
regimen or medication.

65
Nursing Diagnosis: Ineffective tissue perfusion related to interruption of blood flow.
ACTIONS/INTERVENTIONS
 Investigate sudden changes
or continued alterations in
mentation e.g, anxiety,
confusion, lethargy, stupor.
 Inspect pallor, cyanosis,
mottling, cool/clammy skin.
Note strength of peripheral
pulse.
 Monitor respirations, note
work of breathing
 Monitor intake. Note
changes in urine output.
Record urine specific gravity
as indicated.
 Administer medications as
indicated auch as clopidogrel is taken daily.
(plavix)
 Assessing GI function, noting
anorexia, decreased/absent
bowel sounds,
nausea/vomiting, abdominal,
distention, constipation
RATIONALE
>cerebral perfusion is directly related to
cardiac output and is also influenced by
electrolyte/ acid-base variations,
hypoxia, and systemic emboli.
>systemic vasoconstriction resulting
from diminished cardiac output may be
evidenced by decreased skin perfusion
and diminished pulses.
>cardiac pump failure and/ or ischemic
pain may precipitate respiratory
distress; however, sudden/ continued
dyspnea may indicate thromboembolic
pulmonary complications.
>decreased intake/ persistent nausea
may relut in reduced circulating
volume, which negatively affects
perfusion and organ function. Specific
gravity measurements reflect hydration
status and renal function.
>reduces mortality in MI patients, and
>reduced blood flow to mesentery can
produce GI dysfunction. E.g, loss of
peristalsis. Problems may be
potentiate/ aggravated by use by use of
analgesics, decreased activity and
dietary changes.
66
 SOAPIE

S “Dali ra ko kapuyon kung ipabakod ug ipalakaw-lakaw” as verbalized by the client.

Heart rate of 52 beats per minute

O Generalized weakness

Cold, clammy skin (Temp-36.8C)

A Decreased cardiac output related to underlying physiological condition

SHORT TERM: at the end of 1 hour, the client will be able to verbalize feelings to cooperate
P
LONG TERM; at the end of 2 days, the client will be able to participate in daily activities

a. monitored pulse rate To better detect arrhythmias which indicate cardiac arrest or
every four hours other complications.

b. monitored skin
temperature every four Cold, clammy skin may indicate decreased cardiac output
hours

c. instructed patient to
report chest pain This may be a signal of myocardial hypoxia or injury
immediately

d. instructed patient to
avoid overexertion Overexertion increases myocardial oxygen demand which may
( e.g., straining during cause bradycardia and decreased cardiac output
bowel movements

e. administered
antiarrythmic drugs,
I Antiarryythmic drugs acts on peripheral smooth muscle to
such as cordarone, as
decrease peripheral resistancce
prescribed by the
doctor

E At the end of 1 hour, the client verbalized cooperation

67
S No verbal cues

Moist, cool clammy skin (T-36.8C)

Non palpable dorsalis pedis both left and right

Poor capillary refill- 5 seconds

O
Pale extremities

Diaphoresis

Pulse rate of 52 beats per minute

A Ineffective peripheral tissue perfusion related to decreased cardiac output

SHORT TERM: at the end of 1 hour, the client will be able to have an improvement on
peripheral tissue perfusion
P
LONG TERM; at the end of 1 week, the patient will maintain improved peripheral tissue
perfusion

A. Assisted the client to

ambulate but within her To prevent thrombus formation, thus, improving blood circulation
tolerance

B. Monitored and
recorded intake and May be a sign of decreased renal perfusion
output

C. Provided a diet is low Foods high in fat and sodium contributes to the plaque formation
I in fat and sodium that leads to decreased blood flow.

D. Instructed the
significant others To prevent impairment of blood flow.
not to let the client
wear tight clothing
E. Administered
anticoagulants such as
To dilute and enhance further blood flow to periphery
clopidogrel as
prescribed by the doctor

E At the end of 1 hour, the client was able to have an improvement on peripheral tissue perfusion

68
S “ kinahanglan pa ko agakon para makabakod” as verbalized by the client

Heart rate of 52beats per minute

O Generalized weakness

Unable to prompt up by herself

A Activity intolerance related to generalized body weakness.

SHORT TERM: at the end of 1 hour, the client will be able to participate in carrying out
activities while on bed with assistance
P
LONG TERM: at the end of 2 days, the client will be able to continue in performing activities of
daily living.

A. Taken and recorded vital signs before This is to provide baseline data
and after the activities
B. Performed passive range of motion
To asses the degree of motion

C. Encouraged client to have frequent

rests during activities To prevent the patient from fatigue
I

D. Provided relief through comfort

measures To enhance ability to participate in activities

E. Reminded the significant others in To improve the mobility of the patient

assisting the patient

At the end of 1 hour, the client was able to participate in carrying out activities while on bed
E
with assistance.

“Dili man kayo ko gakaon ” as verbalized by the client

69
 Decreased consumption of her daily meal- ate 3 tbsp. of her share
O
Decreased weight (Present weight of 71 kilograms from her Past weight- 73 kilograms)

A Imbalanced nutrition: less than body requirements related to loss of appetite

SHORT TERM: at the end of 30 minutes, the patient will increase consumption of daily meal.
P

LONG TERM: at the end of 1 day, the client will be able to demonstrate behaviors and lifestyle
changes to maintain appropriate weight.

A. Presented meal in an attractive To entice the client’s appetite

manner
To encourage the client to eat
B. Provided small frequent feeding
I C. Provided a well-ventilated area, To improve the client’s appetite
conducive for eating
D. reminded the client the importance of To determine weight loss and weight gain
eating
E. regulated and monitored IV fluids as To provide nutritional supplements
ordered by the doctor

E
At the end of 30 minutes, the patient was able to increase consumption of daily meal (8 tbsp
per meal).

70
 ‘dili ko kaklaro” as verbalized by the client
S

Cloudiness of the right eye

O
Presence of senile ring around the patient’s left eye

History of cataract surgery

A Risk for injury related to cloudiness of the eye secondary to aging

SHORT TERM: at the end of 1 hour, the client will be able to reduce risk factors and protect
self from injury.

P
LONG TERM: at the end of 3 days, the client will be able to verbalized feeling of safety, comfort
and security.

To prevent any accidents that may happen to

A. Instructed the significant others to
never to leave the client the client

This is to promote safety

B. Placed pillow at the sides of the client

To prevent patient from falling off the bed

I C. Raised side rails.

D. Anticipated with the patient’s needs. To avoid accidents that may cause injury to
the client

E. Provided information regarding

To reduce the risk of possible occurrence of
condition that may result increased
injuries
risk of injury

E At the end of 1 hour, the client was able to reduce risk factors and protect self from injury.

71
S “daku man kayo mi ug bayrunon diri, kanusa man ko makauli?” as verbalized by the client

Stares blankly for about a minute

Restlessness (consistent in changing side lying position from one side to the other)
O
Financial resources with a Family income of - 15,000 pesos/ month

Facial Grimace

A Anxiety related to present status secondary to hospital confinement

SHORT TERM: at the end of 45 minutes, the client will be able to adapt to the situational crisis
and have a positive outlook with her condition.
P
LONG TERM: at the end of 2 days, the patient will be able to cope with the present situation

A. Encouraged client One way of releasing tension and assessing the level of anxiety.
to express feelings
B. Listened attentively
To identify client’s problem regarding the situation
concerning client’s
feelings
C. Diverted client’s
attention through This will help client divert her attention for the time being
listening to a
I
soothing music
D. Provided a less
To prevent client from an environment that could trigger stress.
stressful
environment
E. Instructed
significant others to
schedule visiting To promote restful environment.
others

E At the end of 45 minutes, the client was able to have a sense of control over the current crisis

72
 “di nako ganahan mubalik sa doctor, pareha raman gihapon, nana man akong karaan na
S
record sa ECG, pwede nato” as verbalized by the client

• Restlessness

O • Information misinterpretation

• Inadequate follow through of instructions

A Knowledge deficit related to disease condition

SHORT TERM: at the end of 1 hour, the client will participate in learning process regarding her
current condition
P
LONG TERM: at the end of 2 days, the client will understand the importance of her treatment.

A. Encouraged client to verbalize To know client’s current problem

feelings
Giving information to the family members and
B. Discussed possible options to the client’s knowledge regarding disease
family regarding her present condition helps client cope with present
treatment condition
I
C. Provided information for client to refer To facilitate learning regarding her treatment
to.
D. Provided information about additional To promote wellness
learning resources
To have a better understanding of her
E. Emphasized the importance of follow
up check-up condition.

E At the end of 1 hour, the client was able participate in the learning process.

S “di ko ganahan muinom sa akong mga tambal kay daghan kaayo.” As verbalized by the client

73
O Non compliance with medication

A Risk for ineffective therapeutic regimen

SHORT TERM: at the end of 45 minutes, the client will be able to comply with the medications.
P
LONG TERM: at the end 2 days, the client will be able to properly comply with the medications

A. Encouraged client to verbalize To express client’s concerns

feelings
By actively listening, this helps in determining
B. Listened attentively to client client’s problems and feel comfortable

To provide alternatives and choices regarding

C. Discussed to verbalize options
I the course of treatment
regarding treatment of condition
D. Refrained family members from
To not show inacceptance of the situation
verbalizing negative expectations with
the presence of the client
To help patient understand the importance of
E. Referred patient’s concern to the
attending physician proper compliance

E At the end of 1 hour, the family was able to verbalized feelings of control over their plight.

74
 Progress Notes

Date: February 12, 2008

Day 1

Specific Objectives:

At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able
to:

1. Be acquainted with the management and staff of Saint Joseph’s Ward 5.

2. Ask permission from the family and from Mrs. F. to be the subject of the case
study.

3. Have the formal/ written consent signed, and receive the management’s
approval.

4. Inform the family and Mrs. F about the purposes and objectives of the visit.

5. Establish a contract that notes the Nurse – Client Responsibilities.

6. Conduct an interview about Mrs. F’s family history.

7. Conduct an assessment about Mrs. F’s past and present health conditions.

8. Identify problems related to Mrs. F’s present health condition.

9. Set goals for care.

10. Inform Mrs. F about follow – up visits of the group.

75
Problems identified:

• Blurred vision at the right eye

• Epigastric pain

• Nausea and vomiting

• Pallor

• Diaphoresis

• Weak pulses (radial, femoral, popliteal, posterior tibial)

• Absence of pulse beats at the Dorsalis Pedis site

• Weakness of lower extremities

• Restless

Evaluation:

After 2 hours, the group was able to meet the objectives for the day. The group
was able to meet Mrs. F and the family; explained the purpose of the meeting,
established individual roles, identified problems, and set – up parameters of succeeding
meetings.

76
Date: February 13, 2008

Day 2

Specific Objectives:

At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able
to:

1. Ask consent from the family and Mrs. F for further interview and assessment.

2. Conduct further interview about Mrs. F’s family history.

3. Conduct an assessment about Mrs. F’s past and present health condition.

4. Identify problems related to Mrs. F’s health condition.

5. Apply nursing interventions for the problems identified.

6. Provide health teachings for the improvement of Mrs. F’s health condition.
7. Evaluate progress after providing nursing care.

8. Remind Mrs. Fabout follow – up visits of the group.

Problems identified:

• Blurred vision at the right eye

• Pallor

• Diaphoresis

• Weak pulses (radial, femoral, popliteal, posterior tibial)

• Absence of pulse beats at the Dorsalis Pedis site

• Weakness of lower extremities

77
 • Restless

Evaluation:

After 8 hours, the day’s objectives were met. The group was able to conduct
further assessment; applied nursing interventions for the problems identified, noted new
problems and complaints, and reminded Mrs. F about the next visits.

78
Date: February 14, 2008

Day 3

Specific Objectives:

At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able
to:

1. Ask consent from the family and Mrs. F for further interview and assessment.
2. Conduct further interview about Mrs. F’s family history.
3. Conduct further assessment about Mrs. F’s past and present health condition
4. Identify problems regarding Mrs. F’s health condition.
5. Render nursing interventions for the problems identified.
6. Evaluate progress after providing nursing care.
7. Provide health teachings for the improvement of Mrs. F’s health condition.
8. Copy data from Mrs. F’s chart.
9. Remind Mrs. F about follow – up visits of the group.

Problems identified:

• Blurred vision

• Abdominal fullness

• Diaphoresis

• Pallor

• Weak Pulse (femoral, popliteal, posterior tibial)

• Absence of pulse beats at the dorsalis pedis site

• Weakness of lower extremities

79
Evaluation:

After 2 hours, the objectives of the group were met. With the family and Mrs. F’s
consent, the group was able to conduct further assessment about Mrs. F’s past and
present health conditions and was able to apply nursing interventions in relation to the
problems identified by the group and copied data from Mrs. F’s chart and reminded Mrs.
F about succeeding visits of the group.

80
Date: February 15, 2008

Day 4

Specific Objectives:

At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able
to:

1. Ask consent from the family and Mrs. F for further interview and assessment.
2. Conduct further interview about Mrs. F’s family history.
3. Conduct further assessment about Mrs. F’s past and present health condition.
4. Identify problems regarding Mrs. F’s health condition.
5. Render nursing interventions for the problems identified.
6. Evaluate progress after providing nursing care.
7. Provide health teachings for the improvement of Mrs. F’s health condition.
8. Copy data from Mrs. F’s chart.
9. Remind Mrs. F about follow – up visits of the group.

Problems identified:

• Blurred vision

• Diaphoresis

• Weak pulse (popliteal, posterior tibial)

• Absence of pulse beats at the dorsalis pedis site

• Weakness of the lower extremities

Evaluation:

After 2 hours, the group was able to meet the day’s objectives. The group was
able to assess Mrs. F and identified new problems, gave health teachings and reminded
Mrs. F about the group’s following visits.

81
Date: February 18, 2008

Day 5

Specific Objectives:

At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be
able to:

1. Visit Mrs. F at Coca – Cola Compound, Aluba, Cagayan de Oro City.

2. Ask consent from the family and Mrs. F for further interview and assessment.
3. Conduct further interview about Mrs. F’s family history.
4. Conduct further assessment about Mrs. F’s condition after discharge.
5. Provide health teachings for the improvement of Mrs. F’s health condition.
6. Remind Mrs. F about the ending of the group’s correlation.

Evaluation:

After 2 hours, the group was able to meet the objectives. The group was able to visit
and examine Mrs. F after being discharged from the hospital. The group was able to
impart health teachings such as to return to Maria Reyna Hospital for follow – up check
– up, to maintain prescribed home medications until advised by physician to discontinue
and to do exercise regularly. The group also reminded Mrs. F that February 19, 2008
will be the group’s last visit.

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Date: February 19, 2008

Day 6

Specific Objectives:

At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be
able to:

1. Visit Mrs. F at Coca – Cola Compound, Aluba, Cagayan de Oro City.

2. Ask consent from the family and Mrs. F for the completion of the interview and
assessment.
3. Provide additional health teachings for the improvement of Mrs. F’s health
condition.
4. Thank the family and Mrs. F for the approval and cooperation with the group.
5. End the group’s correlation with the family and Mrs. F.

Evaluation:

After 2 hours, the group was able to meet the objectives for the day. The group
was able to complete the interview and assessment of the needed data for the case
study and gave a token as a sign of appreciation for the family and for Mrs. F’s approval
and cooperation.

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 Discharge Plan and Referrals

Medications

Last February 16, 2008 Mrs. F was discharged and advised to have her follow-up
check-up on February 20, 2008 with the following home medication by instructions:

• Telmizartan (Priton) 40 mg 1tab. O.D (Angiotensin II receptor blocker).

• Clopidogrel (Plavix) 75 mg 1 tab O.D (Anti-coagulant).
• Metoproplol(Neobloc) 50mg ½ tab O.D (Beta Blocker/Anti-Hypertensive).
• Atorvastatin (Lipitor) 80 mg 1 tab O.D q hs. (Anti-Hyperlipidemic).
• ISMN (Imdur) 60 mg 1 tab O.D (Anti-anginal/Nitrate/Vasodilator).
• Trimetazidine (Vastarel) 1 tab BID (Anti-anginal drugs).
• Amiodarone (Cordarone) 200 mg 1 tab BID (Class III/Anti-arrythmic).
• Aspirin (Acet) 80 mg 1 tab O.D p.c lunch (Anti-coagulant).
• Metformin HCL (I-max) 500 mg 1 tab BID (Anti-diabetic).

• Encouraged the patient and instructed the significant others to follow prescribed
home medications and give drugs on time.
• Instructed the significant others to give drugs with food when indicated.

Activity

• Encouraged the patient and instructed the significant others to control activities of
daily living.
• Encouraged the patient and instructed the significant others to participate in
passive active range of motion as tolerated.
• Instructed the significant others to provide safety precautions to the patient,
especially when ambulating or using the bathroom.
• Instructed the client’s significant others to minimize prolonged exposure to
sunlight.

Diet

• Encouraged the patient and instructed the significant others to prepare foods that
are:

 Low calorie - Calorie restriction in individuals with hypertension is

recommended. Otherwise normal individuals need the daily-recommended
calorie according to the age, sex and physical activity.

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 Low fat - It is advisable to reduce the fat consumption since hypertension has
greater risk of arteriosclerosis. It is better to avoid high intake of animal fat or
hydrogenated oils, which contain saturated fatty acids. The cholesterol rich
foods such as liver, meat, organ meat, egg yolk, lobster, crab and prawns
should be minimized in the diet. The dietary fats should consist of vegetable
oil like corn oil, olive oil and sunflower oil.

 High fiber- Not only does a high fiber diet aid in healthy bowel movements
but also research has shown that it also lowers cholesterol. There are even
types of fiber that will help reduce the risk of colon cancer.

 High protein – Most high protein foods are extremely low in carbohydrates
and extremely low in saturated fat. Therefore, by eating a high protein diet
loaded with high protein foods, at the same time you'd end up eating low
carbohydrates foods and low saturated fat foods. And, if you didn't already
know, in order to lose weight and lose fat, eating low carbohydrates and
eating little or no saturated fat is a must. Chicken, lean meats, beef and fish
and egg whites.

 Low sodium and high potassium diet- Help to lower high blood pressure.
Moderate sodium restriction 2- 3 gm per day decreases diastolic blood
pressure 6- 10 mmHg and enhances the blood pressure lowering effect of
diuretic therapy. Potassium intake should be increased. Food sources of
potassium should be increased to patients who are on diuretics. For example
apricots, tomato, watermelon, banana, leafy vegetables, and potato should be
included in the daily diet since they contain low sodium and high potassium.
Hypertensive patients with kidney disease should avoid a high intake of
potassium as it puts an excessive load on the kidney.

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Oatmeal Banana

Raw Apple
Carrots

Broccoli Raw
Tomatoes

Cereals

• Instructed the significant others to avoid gastric irritant foods, such as

spicy products this is to minimize gastrointestinal disorder, such as nausea
and vomiting, abdominal pain, CNS disorder like dizziness, headache.

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Treatment

• Encouraged patient to verbalize feelings and needs when presence of

chest pain, weakness, and prolonged headache, this is to lessen the
burden of the patient and for immediate action as well as to minimize
entertaining negative thoughts.
• Encouraged patient and instruct the significant others to monitor weight
and blood pressure daily.

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 Prognosis

Hypertension:

There is no cure for hypertension, but it can be controlled by changes in one’s

lifestyle and the use of prescribed medications. The major goal of nursing care for
hypertensive patients focuses on lowering and controlling the blood pressure without
adverse effects and value cost. The patient needs to understand the disease process
and how life’s changes and medications can control hypertension; the nurse needs to
emphasize the concept of controlling HPN rather than curing it.

` Hypertension is more common in men than women and in people over the age of
65 than in younger persons. Hypertension is serious because people with the condition
have a higher risk for heart disease and other medical problems than people with
normal blood pressure. Getting regular blood pressure checks and treating hypertension
as soon as it is diagnosed can avoid serious complications.

If left untreated, hypertension can lead to the following medical conditions:

• Arteriosclerosis, also called atherosclerosis

• Heart attack
• Stroke
• Enlarged heart
• Kidney damage

Risk factors for hypertension include:

• Age over 60
• Male sex
• Weight
• 25Heredity

Diabetes Mellitus:

In most patients diabetes can be controlled by diet, exercise and insulin

injections. If the condition is not treated, however, some serious complications may
result.

For example, uncontrolled diabetes is the leading cause of blindness, kidney

disease and amputations of arms and legs. It also doubles a person’s risk for heart
disease and increases the risk of stroke. Eye problems also occur more commonly
among diabetes than in general population.

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 Diabetes Mellitus (DM) is a common metabolic disorder in aging populations with
increased morbidity, disability and premature death. The prevalence of diabetes is about
20% in persons over 65 years of age and about 40% in persons over 85 years. A recent
communication from Kolkata (NSR Medical college) as per patients attending OPD
service, the prevalence was 11% in persons aged between 65-69 years. In another
study at Bhubaneshwar (Orissa), prevalence of diabetes was found as high as 20% in
the age group of 65 and above. The vast majority of patients with DM in the elderly are
type 2 (NIDDM) diabetics. Very rarely autoimmune destruction of Beta cells leading to
Type 1 (IDDM) DM can occur in the elderly. Some cases could be secondary to
associated diseases or drugs.

Myocardial Infarction

The incidence and prevalence of acute myocardial infarction (MI), increases

progressively with age. Based on the official survey of the Department of Health (DOH)
Region 10, the rate of Myocardial Infarction morbidity cases was 3,356. The rate was
97.3%. In addition, mortality rates following Acute Myocardial Infarction (ACS) increases
exponentially with age. In particular, elderly patients are less likely to report chest pain
than younger patients. Confusion or altered mental status may be the presenting
manifestation of Acute Myocardial Infarction in up to 20% of patients over 85 years of
age. Older patients are more likely to have “SILENT” or unrecognized MI’s as well as
MI”s without ST-segment elevation.

As compared with younger patients who experience heart failure, atrial fibrillation,
and cardiac rupture and shock. All of which are associated with increase mortality. Other
factors contributing to the poor prognosis following Acute Myocardial Infarction in elderly
individuals include:

• Marked decline in cardiovascular reserve in elderly

• Increase prevalence of morbid conditions
• Underutilization of evidence – based theories
• Women have high mortality rate after Acute Myocardial Infarction
compared with men. The extent to which their increased risk varies in
treatment is not well understood.

From the information stated above, therefore the patient has poor prognosis
attributed to age, sex, presence of other diseases as well as financial constraint may a
hindrance of her treatment. According to Dr. Cristina Cabral-Pauig, cardiologist from the
University of the Philippines-Philippine General Hospital said that both hypertension and
diabetes are "robust independent risk factors to the development and progression of

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cardiovascular disease and nephropathy." In addition, hypertension and diabetes
together raise CVD risk, even worsen prognosis.

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 Evaluation

The mainstay of nursing and medical treatment with the patient having with these
conditions is to help the patient to cope, alleviate distress, prevent further complications
and help the patient to recover as well as to encourage the patient and the significant
others to participate in the therapy. From the initiation of nursing and medical
interventions the client showed some signs of recuperation and gradually showed signs
of progress. This was evidence form the complete bed rest up to the condition she was
given the chance to ambulate gradually as tolerated.

On the last day of visitation the patient has returned to her normal daily activity
but with controlled environment and efforts in carrying tasks. Upon interview the client
showed orientation in time, place and person and was aware of her condition and
knows the prohibition in order to prevent complications and aggravations of her
condition. Her significant other, were also supportive and showed concern for the
patient.

From this, our goal was achieved as evidenced by the desire of the patient to go
back to her normal daily routine and from the progress of the patient.

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