I. INTRODUCTION
A.) OVERVIEW OF THE STUDY
Acute myocardial infarction (MI) is defined as death or necrosis of
myocardial cells. It is a diagnosis at the end of the spectrum of myocardial
ischemia or acute coronary syndromes. Myocardial infarction occurs when
myocardial ischemia exceeds a critical threshold and overwhelms myocardial
cellular repair mechanisms that are designed to maintain normal operating
function and hemostasis. Ischemia at this critical threshold level for an extended
time period results in irreversible myocardial cell damage or death.
Critical myocardial ischemia may occur as a result of increased
myocardial metabolic demand and/or decreased delivery of oxygen and
nutrients to the myocardium via the coronary circulation. An interruption in the
supply of myocardial oxygen and nutrients occurs when a thrombus is
superimposed on an ulcerated or unstable atherosclerotic plaque and results in
coronary occlusion. A high-grade (> 75%) fixed coronary artery stenosis due to
atherosclerosis or a dynamic stenosis associated with coronary vasospasm can
also limit the supply of oxygen and nutrients and precipitate an MI. Conditions
associated with increased myocardial metabolic demand include extremes of
physical exertion, severe hypertension (including forms of hypertrophic
obstructive cardiomyopathy), and severe aortic valve stenosis. Other cardiac
valvular pathologies and low cardiac output states associated with a
decreased aortic diastolic pressure, which is the prime component of coronary
perfusion pressure, can also precipitate MI
Myocardial infarction can be subcategorized on the basis of anatomic,
morphologic, and diagnostic clinical information. From an anatomic or
morphologic standpoint, the two types of MI are transmural and nontransmural. A
transmural MI is characterized by ischemic necrosis of the full thickness of the
2
affected muscle segment(s), extending from the endocardium through the
myocardium to the epicardium. A nontransmural MI is defined as an area of
ischemic necrosis that does not extend through the full thickness of myocardial
wall segment(s). In a nontransmural MI, the area of ischemic necrosis is limited
to either the endocardium or the endocardium and myocardium. It is the
endocardial and subendocardial zones of the myocardial wall segment that are
the least perfused regions of the heart and are most vulnerable to conditions of
ischemia. An older subclassification of MI, based on clinical diagnostic criteria, is
determined by the presence or absence of Q waves on an electrocardiogram
(ECG). However, the presence or absence of Q waves does not distinguish a
transmural from a non-transmural MI as determined by pathology
A more common clinical diagnostic classification scheme is also based on
ECG findings as a means of distinguishing between two types of MIone that is
marked by ST elevation and one that is not. The distinction between an STelevation MI and a non-ST-elevation MI also does not distinguish a transmural
from a non-transmural MI. The presence of Q waves or ST segment elevation is
associated with higher early mortality and morbidity; however, the absence of
these two findings does not confer better long-term mortality and morbidity.
The most common etiology of MI is a thrombus superimposed on a
ruptured or unstable atherosclerotic plaque.
.
Myocardial infarction is the leading cause of death in the United States
(US) as well as in most industrialized nations throughout the world.
Approximately 800,000 people in the US are affected and in spite of a better
awareness of presenting symptoms, 250,000 die prior to presentation to a
hospital.4 The survival rate for US patients hospitalized with MI is approximately
90% to 95%. This represents a significant improvement in survival and is related
to improvements in emergency medical response and treatment strategies.
In general, MI can occur at any age, but its incidence rises with age. The
actual
incidence
is
dependent
upon
predisposing
risk
factors
for
B.)
The main reason and purpose student nurses conduct care study and
exposure in the clinical area is for them to identify problems encountered by the
clients; this is one of their tools of learning knowledgeably and skillfully.
We, as health care providers, it is indeed our vocation to adjoined hands
w/ the health team for the promotion of wellness of our clients. Our main
objectives for this study are the following:
To determine the family and personal health history of our patient that
may affect present health condition
To identify the cause and effect of the main problem through a correct
analysis of the pathophysiology of the case.
To evaluate the effectiveness of the actual nursing care plan that was
established.
To give referrals and follow-up for the health promotion of the client.
In general, this study aims to enhance the skills and knowledge of the
students in providing holistic care to the patient. Students logically search further
knowledge in order to attain the desired goal and intervention for the wellness of
the patient.
C.)
Prior to the day of duty, the group has already chosen a patient for care
study. They performed a physical assessment to the patient to properly identify
the nursing problems, which require necessary and direct interventions and
medical regimen. The study on medications and doctors order were limited to
our chosen patient
The preventive care and anticipatory guidance are integral to nursing
practice. Thus, this care study focuses on the particular case of the patient. Since
the patients diagnosis is more on cardiovascular disease, the group has focused
on acute myocardial infarction as one of his admitting diagnosis. However, the
group did not just limit the interventions on monitoring cardiac activity of the
patient. Any symptoms and unusualties were kept watch and monitored. Any
Referrals and follow-up, so as with the nursing management were fully granted
and analyzed for the said case.
Supposedly, this case study should be focused on Gynecology concept
but due to the unavailability and presence of gyne patient in Cagayan de Oro
Polymeric General Hospital, the concept is focused on medical from Station 7.
5
The care for our chosen patient is only limited for 2 days of duty excluding the
physical assessment done prior to the day of duty.
II.
HEALTH HISTORY
Sex:
Male
Age:
64 years old
Religion:
Roman Catholic
Civil Status:
Married
Occupation:
Income:
P 6,000/ month
Nationality:
Filipino
Date Admission:
Time:
09:40 pm
36.6 C
Pulse Rate:
54 bpm
Respiratory rate:
18 cpm
Blood Pressure:
130/100 mmHg
Height:
53
Weight:
55.5 kgs
Chief complaints:
epigastric pain
Admitting Diagnosis:
Acute
myocardial
Hypertensive
infarction;
cardiovascular disease;
Dr. Alenton
7
C.)
On the 29th of June, Mr. ? has experienced chest pain with complaints of
acute epigastric pain, growing in character and on and off. The patient was
anorexic and hypertensive (180/ 60 mm Hg). With the help of his family he went
to the hospital for check-up, they thought that it was just an ulcer, but the doctor
came out to have a diagnosis of
cardiovascular disease; ruled out PUD; diabetic neprhopathy, and due to the
severity of pain he was prompted for admission in the Polymedic General
Hospital.
III.
DEVELOPMENTAL STATUS
ROBERT HAVIGHURSTS DEVELOPMENTAL TASK THEORY
Later Maturity (60 y.o- )
The fact that man learns his way through life is made radically clear by
consideration of the learning tasks of older people. They still have new
experiences ahead of them, and new situations to meet. At age sixty-five when a
man often retires from his occupation, his changes are better than even of living
another ten years. During this time the man or his wife very likely will experience
several of the following things: decreased income, moving to a smaller house,
loss of spouse by death, a crippling illness or accident, a turn in the business
cycle with a consequent change of the cost of living. After any of these events the
situation may be so changed that the old person must learn new ways of living.
The developmental tasks of later maturity differ in only one fundamental respect
from those of other ages. They involve more of a defensive strategy--of holding
on the life rather than of seizing more of it. In the physical, mental and economic
spheres the limitations become especially evident; the older person must work
8
hard to hold onto what he already has. In the social sphere there is a fair chance
of offsetting the narrowing of certain social contacts and interests by the
broadening of others. In the spiritual sphere there is perhaps no necessary
shrinking of the boundaries, and perhaps there is even a widening of them.
Our patient Agustin Sarmiento is already at the later maturity stage. At
his age he will be adjusting in decreasing physical strength and health, adjusting
to retirement and reduced income, adjusting to death of spouse, establishing an
explicit affiliation with one's age group, meeting social and civic obligations,
establishing satisfactory physical living arrangements: The principal values that
older people look for in housing, according to studies of this matter, are: quiet,
privacy, independence of action, nearness to relatives and friends, residence
among own cultural group, closeness to transportation lines and communal
institutions like libraries, shops, movies, churches, etc.
9
Our patient Agustin Sarmiento belongs to the older adult stage. His
central task is Ego Integrity versus Despair. Ego integrity is the ego's
accumulated assurance of its capacity for order and meaning. Despair is signified
by a fear of one's own death, as well as the loss of self-sufficiency, and of loved
partners and friends. He must learn to accept the life that he has led (good and
bad) to have a life in facing death. As he learns to live with his choices and the
certainty of death, he fined a inner-strength to go on with integrity. Some despair
is inevitable, a he mourn his own deaths. When he recognizes all that he have
been, are and will be, then we show his wisdom.
10
and on self- chosen ethical and abstract principles that are universal,
comprehensive and consistent.
IV.
MEDICAL MANAGEMENT
A.)
DATE
DOCTORS ORDER
DOCTORS ORDER
RATIONALE
Secure consent to
care
To have consent in
rendering medical
treatment to patient
TPR qh
Diabetic diet
Diet prescribed in
treatment of type 2
Diabetes mellitus
Lab. CBC,
crea,K,Hgt stat.
FBS, lipid profile,
ECG
IVF PNSS1L @
10gtts/min
Meds.
ISMO 60g
Isordil 5g SL PRN
Antianginals; to
prevent situations that
may cause anginal
attacks of the patient
Antiulcer drug; to
11
q8h
Please refer
accordingly
Troponine T now
To measure levels of
cardiac troponins
To determine blood
type of the patient &
the presence of ABO
and Rh factor
Transfuse 2U PRBC
Repeat ECG in AM
For continued
surveillance of the
hearts electrical
activity
Relieve of moderate to
severe pain
Pantoprazole
(Ulcepraz) 40g IVT
OD,start now
To lower down BP of
the patient
To determine the
effectivity of the
medication (captopril)
Tramadol 50mg IV
now then PRN
Relieve of moderate to
severe pain
Anticoagulant drug; to
maintain arterial
patency
11:07pm
June 30,2007
11:00am
2:55pm
BP:180/100mmHg
8:00pm
12
Plavix 75mg 4 tabs
now then 1tab OD
To reduce the
thrombotic events in
patient with
atherosclerosis
O2 inhalation 2L/min
Increases myocardial
oxygen supply &
relieves pain
Repeat ECG in AM
For continued
surveillance of the
hearts electrical
activity
To monitor the health
status of the patient &
have baseline data in
giving medications
VS qh & record
Adjunct to diet to
reduce LDL
cholesterol, total
cholesterol, and to
increase HDL
cholesterol of the
patient
Antihypertensive drug;
to lower the BP of the
patient
Antihypertensive drug;
to lower the BP of the
patient
IVF PNSS1L @
10gtts/min
July 1. 2007
July 2, 2007
12:20am
BP: 190/90mmHg
10:25am
BP: 160/80mmHg
HR: 88bpm
13
BP: 200/80mmHg
HR: 94bpm
IVT drugs
Give captopril 25mg
tab SL now
Bepridil (Vascor) 10
mg. 1 tab now then
OD P.O.
O2 inhalation 2l/min
July 3, 2007
BP: 200/110mmHg
12:50pm
Antihypertensive drug;
to lower the BP of the
patient
For hypertension; For
chronic stable angina,
used alone or in
combination
Bblockers nitrates
Increases myocardial
oxygen supply &
relieves pain
Antianginal; to reduce
cardiac oxygen
demand by
decreasing preload
and afterload.
Increase O2
inhalation to 4L/min
Increases myocardial
oxygen supply &
relieves pain
Antihypertensive drug;
to lower the BP of the
patient
Antianginal; to reduce
cardiac oxygen
demand by
decreasing preload
and afterload
Repeat ECG in AM
For continued
surveillance of the
hearts electrical
activity
Antihypertensive drug;
to lower the BP of the
patient
5:30pm
Therabloc 50mg 1tab
now then OD
IVF PNSS1L @
10gtts/min
14
B.)
IVT drugs
LABORATORY AND DIAGNOSTIC EXAMINATIONS
RESULTS
IMPLICATIONS
Cross- matiching
Patients blood type
Donors blood type
Not done
Packed red blood cell
Compatible
Dia- med microsystem
1.) HEMATOLOGY
Date: June 30, 2007
Time: 3: 46 pm
RESULTS
REFERENCE
VALUES
IMPLICATIONS
221.64 mgs/dl
<200.00
28.39 mgs/dl
30.00 85.00
166.01 mgs/dl
<150.00
Increased- Risk
of atherosclerotic
occlusive
coronary
diseases
and
peripheral
vascular disease
Decreased- HDL
cholesterol
is
lower in patients
with
increased
risk for coronary
heart disease
Increasedhigher in patients
1.) BLOOD
CHEMISTRY
Date: June 30,
2007
Time: 5:00 am
Lipid Profile
Triglycerides
HDL
LDL
15
44.33 mgs/dl
VLDL
0.00- 40.00
.
106.18 mgs/dl
70.00- 99.00
Fasting blood
sugar
3.)
HEMATOLOGY
Date: June 30,
2007
Time: 1:02 am
Increased
with
increased
risk for coronary
heart disease
Increased- Risk
of
nephrotic
syndrome
Increased- risk
for
diabetes
mellitus
and
chronic
renal
insufficiency
Troponin levels
rise rapidly and
are
detectable
within 1 hour of
myocardial cell
injury and renal
diseases
Troponin- T
ABO + Rh
Blood Rh (D) positive
Blood group
4.) CHEMISTRY
Date: June 29,
2007
Time: 11:43 pm
6.17 mgs/ dl
Creatinine
5.)
HEMATOLOGY
Date: June 29,
2007
Time: 11:43 pm
0.90 1.50
Increased- risk
of
nephritis;
chronic
renal
insufficiency;
diabetic
nephropathy;
reduced
renal
blood flow
16
Complete blood
count
Total RBC
2.57x 10^9/L
g/dl
5.0- 10.0
13.70- 16.70
Hgb
28.0
40.00- 49.70
108.9
70.00- 97.00
28.2
32.0- 35.0
70.9
54.0- 67.0
3.69- 5.90
11.1 g/dl
13.70- 16.70
32.5
40.0- 49.70
66.0
54.0- 62.0
Hct
MCV
MCHC
Differential
count
Neutrophils
Decreased- risk
of renal failure
and
dietary
deficiency
Decreased- risk
of kidney disease
and
dietary
deficiency
Decreased- risk
of
nutritional
deficiency
Increased- RBC
is
macrocytic;
risk of foilc acid
deficiency
Decreased- risk
of iron deficiency
anemia
Increased- acute
bacterial
infection,
physical
or
emotional stress
6.)
HEMATOLOGY
Date: July 1, 2007
Time: 6: 36 pm
Complete Blood
Count
Total RBC
Hgb
Hct
Differential
count
Neutrophils
Decreased- risk
of renal failure;
dietary deficiency
Decreased- risk
of
dietary
deficiency
and
kidney disease
Decreased- risk
of
nutritional
deficiency
Increased- acute
bacterial
infection;
physical
or
17
Lymphocytes
Monocytes
15.4
20.0- 40.0
13.1
4.0- 10.0
emotional stress
Increased- viral
infection
Increased- viral
infection; other
chronic disease
18
SARMIENTO, AGUSTIN M.
Date
Classification
Ordered
Dose/
Frequency
Route
Mechanism of
Action
Isosorbide
dinitrale
(Isordil)
7-2-07
Antianginals
5 mg tab
SL for 3
doses every 5
minutes if
chest pain is
not relieved
Thought
to
reduce cardiac
oxygen
demand
by
decreasing
preload
&
afterload: also,
may increase
blood
flow
through
the
collateral
coronary
vessels
Bepridil
(Vascor)
7-2-07
Calcium
Channel Blocker
Antianginal
Antihypertensiv
e
10 mg. 1 tab
now then OD
P.O.
Inhibits calcium
ion
influx
across
cell
membrane
during cardiac
depolarization,
produces,
relaxation
of
coronary
vascular
muscle
diseases
coronary
vascular
arteries,
myocardial 02
delivery in pts
vasospastic
angina SA/AV
node
conduction
inhibits
fast
Specific
Indication
(why drug is
ordered)
Acute anginal
attacks
Contraindication
Side Effects/
Toxic Effects
Nursing
Precaution
Contraindicated
potentials
hypersensitivity
or idiosyncrasy
to nitrates & in
those severe
hypolension
To prevent
tolerance a
nitrate-free
interval of 8 to
12 hours per
day is
recommended.
Hypertension
For chronic
stable angina,
used alone or
in combination
B-blockers
nitrates
Pts. history of
angineurotic
edema & other
allergic
reactions due to
ACE inhibitors:
pregnancy
lactation
Flushing,
vascular
headache,
cerebral
ischemia
associated
postural
hypotension,
N/V
weakness,
restless,
pallor,
persipiration &
collapse
Rarely:
fatigue,
dizziness, hotflush,
diarrhea,
nausea,
vomiting
Discomfort in
the throat,
nonproductive
cough,
palpitation
headache &
rash
CHF,
hypotension,
hepatic injury,
pregnancy C,
lactation, renal
disease,
concomitant Bblocker
therapy
19
sodium current.
DRUG STUDY
Name of Patient:
SARMIENTO, AGUSTIN M.
Name of Drug
Generic
(Brand)
Date
Ordered
Classification
Dose/
Frequency
Route
Mechanism of
Action
Ranitidine
Hydrochloride
(Zantac)
6-29-07
9:45 pm
Anti-ulcer drug
50 mg IV q
8H
6-2-10
Completely
inhibits action
of histamine on
the
H2
at
receptors sites
of parietal cells,
decreasing
gastric
acid
secretion
Olmesartain
Medoxomil
(Olmetec)
6-29-07
ACE inhibitors
antihypertensive
20 g/mL
1 tab OD
Selectively
blocks
the
binding
of
angiotensin to
specific
issue
receptors found
in the vascular
smooth muscle
& adrenal gland
this
action
blocks
the
vasoconstrictio
n effect of the
rennin.
Angiotensin
system as well
as the release
of aldosterone
to decrease BP.
Specific
Indication
(why drug is
ordered)
NSAIDassociated
peptic ulceration
Contraindication
Side Effects/
Toxic Effects
Nursing
Precaution
Contraindicated
in patients
hypersensitive
to drug and
those acute
porphyria acute
dosage in pt.
impaired renal
function
For
hypertension,
alone or in
combination
other
antihypertensive
Contraindicated
hypersensitivity
to any
component of
the drug,
pregnancies
lactation
Occasionally,
reversible
hepatitis. Rarely
agranulocytosis,
acute
pancreatic,
hypersensitivity,
reversible
mental
confusion, skin
rash; headache
CNS: headache
CU:
hypertension
SKIN: rash, dry
GI: diarrhea,
abdominal pain
nausea,
constipation
Use caution
renal
dysfunction
Respiratory
URL,
symptoms,
bronchitis,
cough,
angioedema,
flue like
symptoms
Administers
regard to
meals
Monitor pt.
closely in any
situation that
may lead to a
decrease BP
20 to
seduction in
fluid volume
20
DRUG STUDY
Name of Patient:
Name of Drug
Generic
(Brand)
SARMIENTO, AGUSTIN M.
Date
Classification
Ordered
Dose/
Frequency
Route
Mechanism of
Action
tramadol HCI
(Dolmal)
6-30-07
Opioid
Analgesics
50 mg IV now
then PRN for
moderate to
severe pain
A
centrally
acting
synthetic
analgesic
compound not
chemically
related
to
opioid.
Thought
to
bind to opioid
receptors & of
norepinephrine
& serotonin
pantoprazole
sodium
(ulcepraz)
6-30-07
Antiulcer
drugs
40 mg IV OD
(-6)
Inhibits proton
pump activity
by finding to
hydrogen
potassium
oderosine
triphosphatase,
located
at
secretory
surface
of
gastric parietal
cells,
to
suppress
Specific
Indication
(why drug is
ordered)
For moderate
to severe pain
Contraindication
Side Effects/
Toxic Effects
Nursing
Precaution
Contraindicated
in patients
hypersensitive
to drug or other
opioids, in
breast feeding
women and in
those acute
intoxication
from alcohol
use cautiously
in pts. at risk for
renal or hepatic
impairment
Respiratory
depression,
palpitations,
chills, chest
pain, decrease
in BP,
arrhythmia,
vomiting,
nausea, GI
distention,
borborygymi,
urticaria,
excessive
bronchial
secretions
Doudenal &
gastric ulcer in
combination
2 appropriate
antibiotics for
the reduction
of H Pylon in
pts. peptic
ulcer of the
objective of
reducing the
recurrence of
Contraindicated
in pts.
hypersensitive
to any
component of
the formulation
safety &
efficacy of using
the IV for
mutation to
start, therapy
for GERD are
Headache,
diarrhea, rarely,
nausea, upper
abdominal
pain,
flatulence, skin
rash, pruritus
or dizziness,
edema, fever,
onset of
depression &
disturbance in
vision
Releases pts
level of pain at
least 30 min.
after
administration.
Monitor CV
and respiratory
status w/hold
dose & notify
prescribe if RR
is below 12
cm. Monitor
bowel &
bladder
function
anticipate
need for
laxative for
better
analgesic
effect give
drug before
onset of pain.
Stop treatment
IV
pantoprazole
when P.O. form
is warranted
drug cant be
given regard to
meals
symptomatic
response to
therapy doesnt
preclude the
presence of
21
gastric
secretion
acid
duodemal are
unknown
unknown.
Specific
Indication
(why drug is
ordered)
Hypertension
diabetic
nephropathy
Contraindication
Side Effects/
Toxic Effects
Contraindicated
in pts.
hypersensitive
to drug or ACE
inhibitors use
cautiously in
pts. impaired
renal function
CNS:
dizziness
fatigue; rash,
pruritus,
flushing,
angioedema,
loss of taste
perception;
stomatitis, GI
irritation &
abdominal
pain;
leucopenia;
cough
gastric
malignancy.
DRUG STUDY
Name of Patient:
Name of Drug
Generic
(Brand)
captopril
(Capoten)
SARMIENTO, AGUSTIN M.
Date
Ordered
Classification
7-2-07
Antihypertensiv
e
Dose/
Frequency
Route
Mechanism of
Action
1. 25 mg Tab
SL now
12:10 pm
Inhibits ACE,
preventing
conversion of
Angiotensin II,
a
potent
vasoconstrictor
less
angiotensin II
decreasing
aldosterone
secretion,
which reduces
sodium
&
water retention
& lowers blood
pressure.
2. 25 mg
tab
SL now
Nursing
Precaution
Monitor
patients blood
pressure &
pulse rate
frequently
elderly pts
may be moir
sensitive to
drugs
hypotensive
effects in
patients
impaired renal
function or
collagen
vascular
disease,
monitor WBC
and differential
counts before
starting
treatment,
every 2 wks
for the first 3
months of
therapy and
periodically
thereafter.
22
DRUG STUDY
Name of Patient:
SARMIENTO, AGUSTIN M.
Name of Drug
Generic
(Brand)
Date
Ordered
Classification
Dose/
Frequency
Route
Mechanism of
Action
atenol
(Therabloc)
7-3-07)
Antihypertensive
s
50 mg 1 tab
now then OD
(-6-)
A beta-blocker
that
selectively
blocks betaadrenergic
receptors,
decreases
cardiac output
and
cardiac
oxygen
consumption
and
depresses
rennin
secretion
Specific
Indication
(why drug is
ordered)
Hypertension
Angina
Pectoris,
Acute MI
Contraindication
Side Effects/
Toxic Effects
Nursing
Precaution
Contraindicated
in patients
sinus
bradycardia,
heart blocker
greater than
first degree
overt cardiac
failure, or
cardiogenic
shock use
cautiously in pts
at risk for heart
failure diabetes
& impaired
renal function
CNS: fatigue
dizziness
CV: hypotension
heart failure
GI: nausea,
diarrhea
Musculoskeletal:
leg pain
Respiratory
bronchospasm
Skin: rash
Check apical
pulse before
giving drug if
slower than
60 beats /min.
withhold drug
& call
prescriber.
Monitor pts
blood
pressure drug
may mask
signs &
symptoms of
hypoxemia in
diabetic pts
drug may
cause
changes in
exercise
tolerance &
ECG
23
DRUG STUDY
Name of Patient:
Generic name
of Ordered
Drug
SARMIENTO, AGUSTIN M.
Brand
Name
Date Ordered
Classification
Dose/
Frequency/
Route
Senna
Senokot
7-3-07
Laxatives
2 tabs
tonight -9
pm
fondaparimux
sodium
Arixtra
6-30-07
Anticoagulants
2.5 mgs SC
now then
OD 9 pm-8
am
clopidogrel
bisulfate
Plavix
6-30-07
Antiplatelet
agents
45 mgs, 4
tabs now,
then 1 tab
OD P.O. 106
Mechanism
Of
Action
Specific
Indication
ContraIndication
Stimulant laxative
that increases
peristalsis,
probably by
relaxing the effect
on smooth
muscle of the
intestine. Drug
also promotes
fluids
accumulation in
colon and small
intestine.
Binds to
antithrombin III
(at-III) and
potentates the
neutralization of
factor Xa by III
which interrupts
coagulation and
inhibits formation
of thrombin and
blood clots.
Acute
constipation
preparation, for
bowel
elimination
Contraindicated
in pts.
ulceration bowel
lesions, fecal
infaction, S/sx of
appendicitis,
acute surgical
abdomen, N/V
abdominal pain
To prevent
deep-vein
thrombosis
(VDT) w/c may
lead to acute
pulmonary
embolism
Contraindicated
in pts with
creatirine
clearance less
than 30 mL/min.
and in those
who are
hypertensive to
the drug or
weigh less than
50 kgs.
Inhibits the
binding of
adenosine
diphosphale to its
platelet, receptors
infecting ADPmediated
activation and
subsequent
platelet
aggregation
clopedogiel
To reduce
thrombotic
events with
acute coronary
syndrome,
atherosderosis
documented by
recent MI, or
established
peripheral
artenal
Contraindicated
in patients
hypersensitive
to drug or its
components and
in those with
pathologic
bleeding (such
as peptic ulcer)
use cautiously in
patients at risk
for increased
Side
Effects/
Toxic
Effects
GI: nausea,
abdominal
cramps
GU: red-pink
discoloration in
alkaline urine,
yellow brown
discoloration in
acid urine
CNS: fever,
dizziness,
confusion
CU:
hypotension,
edema
GI: nausea
GU: UTI, urine
retention
Hematologic:
hemorrhage,
thrombocylopeni
a
GI Bleeding
purpora,
bruising,
hematoma,
epistaxis,
hematutia,
ocular
hemorrhage
intracranial
bleeding,
abdominal pain,
dyspepsia
Nursing
Precaution
Before giving
drug for
constipation
determine
whether pt. has
adequate fluid
intake exercise
& diet
Limit diet to
clear liquids
after X-prep
liquid is taken.
Give by S.C.
injection only
never I.M.
Dont mix
other injections
or infusions to
avoid loss of
drug dont
expel air
bubble from
the syringe
Platelet
aggregation
wont return
normal for at
least 5 days
after drug has
been stopped
Dont confuse
plavix with
Paxil
24
irreversibly
modifies the
platelet ADP
receptor
disease.
bleeding from
trauma or other
pathologic
conditions
gastritis &
constipation,
rash, pruritus
25
DRUG STUDY
Name of Patient:
SARMIENTO, AGUSTIN M.
Generic
Brand
Date
Classification
name of
Name
Ordered
Ordered
Drug
isosorbide
Imdur
6-30-07
Anti-anginal
mononitate
atorvastatin
Lipitor
6-30-07
Antilipemics
Dose/
Frequency/
Route
Mechanism
Of
Action
Specific
Indication
ContraIndication
60 mgs 1 Tab
OD P.O.
-660 mgs tab
OD P.O.
-6-
Thought to
reduce
cardiac
oxygen
demand by
decreasing
preload and
afterload..
drug also
may blood
through
collateral
coronary
vessels
Acute anginal
attacks, post-MI
angina; to
prevent situations
that may cause
anginal attacks
Contraindicat
ed in pts.
hypersensitiv
e or
idiosyncratic
to nitrates &
in those
severe
hypotension
or acute MI
low left
ventricular
filling
pressure.
80 mgs 1 tab
OD tonight
Inhibits HMGCOA
reductase, an
early (and
rale-limiting)
step in
cholesterol
biosynsthesis
Reduction of
elevated total L
LDL cholesterol,
apolipoprotein B
& triglycerides &
increase HDL
cholesterol in pts.
primary
hypercholesterole
mia
Withhold or
stop drug in
pts. at risk for
renal failure
caused by
rhabdomyoly
sis resulting
from trauma,
in serious
acute
conditions
like myopathy
Side
Effects/
Toxic
Effects
CNS:
headache
CV:
orthostatic
hypotensio
n,
tachycardia
,
palitations,
edema
nausea
GI
disturbances
, headache,
myalgia
asthenia,
insomnia
muscle
cramps,
bronchitis,
rash
infection, flu
like
syndrome
allergic
reactions
Nursing
Precaution
To prevent
tolerance a nitrate
free interval of 8 to
12 hours per day is
recommended.
The regimen for
isosobide
mononitrate (1
tab.) on awakening
with the second
dose in 4 hrs. or 1
extended release
tab. Daily is
intended to
minimize nitrate to
tolerance by
providing a
substantial nitrate
free interval
Monitor BP and
intensely and
duration of drug
response
Use only after diet &
other condition
therapy prove
infective Pt should
follow a standard low
cholesterol diet
before & during
therapy.
Before starting
treatment assess pt
for underlying
causes for
hypercholesterolemi
a.
26
27
IV.
28
The path of blood flow in a human, then, is as follows:
1. The superior (a) and inferior (b) vena cava are the main veins that receive
blood from the body. The superior vena cava drains the head and arms, and the
inferior vena cava drains the lower body.
2. The right atrium receives blood from the body via the vena cavae. The atria are
on the top in the heart.
3. The blood then passes through the right atrioventricular valve, which is forced
shut when the ventricles contract, preventing blood from reentering the atrium.
4. The blood goes into the right ventricle (note that it has a thinner wall; it only
pumps to lungs). The ventricles are on the bottom of the heart.
5. The right semilunar valve marks the beginning of the artery. Again, it is
supposed to close to prevent blood from flowing back into the ventricle.
29
6. The pulmonary artery or pulmonary trunk is the main artery taking
deoxygenated blood to the lungs.
7. Blood goes to the right and left lungs, where capillaries are in close contact with
the thin-walled alveoli so the blood can release CO 2 and pick up O2.
8. From the lungs, the pulmonary vein carries oxygenated blood back into the
heart.
11. The blood enters the left ventricle. Note the thickened wall; the left ventricle
must pump blood throughout the whole body.
12. The blood passes through the left semilunar valve at the beginning of the aorta.
13. The aorta is the main artery to the body. One of the first arteries to branch off is
the coronary artery, which supplies blood to the heart muscle itself so it can
pump. The coronary artery goes around the heart like a crown. A blockage of the
coronary artery or one of its branches is very serious because this can cause
portions of the heart to die if they dont get nutrients and oxygen. This is a
coronary heart attack. From the capillaries in the heart muscle, the blood flows
back through the coronary vein, which lies on top of the artery.
14. The aorta divides into arteries to distribute blood to the body.
30
15. Small arteries are called arterioles.
17. These join again to form venules, the smallest of the veins.
These, in turn, join to form the larger veins, which carry the blood back to the superior
and inferior vena cava.
PHYSIOLOGY OF THE HEART
The work of the heart is to pump blood to the lungs through pulmonary
circulation and to the rest of the body through systemic circulation. This is
accomplished by systematic contraction and relaxation of the cardiac muscle in the
myocardium.
Conduction System
An effective cycle for productive pumping of blood requires that the heart be
synchronized accurately. Both atria need to contract simultaneously, followed by
contraction of both ventricles. Specialized cardiac muscle cells that make up the
conduction system of the heart coordinate contraction of the chambers.
Cardiac Cycle
The cardiac cycle refers to the alternating contraction and relaxation of the
myocardium in the walls of the heart chambers, coordinated by the conduction system,
during one heartbeat. Systole is the contraction phase of the cardiac cycle, and
diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8
second.
31
Heart Sounds
The sounds associated with the heartbeat are due to vibrations in the tissues
and blood caused by closure of the valves. Abnormal heart sounds are called
murmurs.
Heart Rate
The sinoatrial node, acting alone, produces a constant rhythmic heart rate.
Regulating factors are reliant on the atrioventricular node to increase or decrease the
heart rate to adjust cardiac output to meet the changing needs of the body. Most
changes in the heart rate are mediated through the cardiac center in the medulla
oblongata of the brain. The center has both sympathetic and parasympathetic
components that adjust the heart rate to meet the changing needs of the body.
Peripheral factors such as emotions, ion concentrations, and body temperature may
affect heart rate. These are usually mediated through the cardiac center.
32
PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTION
Predisposing factors
Age- 64 y.o
Hypertension
High HDL; Low LDL
Diabetes Mellitus
Myocardial ischemia
Cardiac output
Arterial Pressure
Precipitating Factors:
Coronary atherosclerotic heart
disease
Coronary thrombosis/ embolism
Decreased blood flow
Myocardial Conractility
Stimulation of
Baroreceptors
Stimulation of
Sympathetic Receptors
Peripheral vasoconstriction
Myocardial Contractility
Cellular Hypoxia
Afterload
Heart rate
Diastolic Filling
Decreased
Myocardial Tissue Per.
Increased myocardial
oxygen demand
S/Sx:- chest pain, oliguria, ECG changes, Elevated CK-M, Troponin T, LDH, AST
Myocardial
Oxygen Demand
33
Mechanisms of Occlusion
Most MIs are caused by a disruption in the vascular endothelium
associated with an unstable atherosclerotic plaque that stimulates the formation
of an intracoronary thrombus, which results in coronary artery blood flow
occlusion. If such an occlusion persists long enough (20 to 40 min), irreversible
myocardial cell damage and cell death will occur.5
The development of atherosclerotic plaque occurs over a period of years
to decades. The initial vascular lesion leading to the development of
atherosclerotic
plaque
is
not
known
with
certainty. The
two
primary
34
myocardium at risk of necrosis. The larger the MI, the greater is the chance of
death due to a mechanical complication or pump failure. The longer the time
period of vessel occlusion, the greater the chances of irreversible myocardial
damage distal to the occlusion.
The death of myocardial cells first occurs in the area of myocardium that
most distal to the arterial blood supplythat is, the endocardium. As the duration
of the occlusion increases, the area of myocardial cell death enlarges, extending
from the endocardium to the myocardium and ultimately to the epicardium. The
area of myocardial cell death then spreads laterally to areas of watershed or
collateral perfusion. Generally, after a 6- to 8-hour period of coronary occlusion,
most of the distal myocardium has died. The extent of myocardial cell death
defines the magnitude of the MI. If blood flow can be restored to at-risk
myocardium, more heart muscle can be saved from irreversible damage or
death.
35
Nursing Diagnosis:
Acute pain may be related to tissue ischemia secondary to coronary artery
occlusion
Possibly evidenced by
Reports of pain with our without radiation
Facial grimacing
Restlessness, changes in level of consciousness
Changes in pulse, BP
Desired outcomes
Patient will verbalize relief control of pain
Demonstrate use of relaxation techniques
Display reduced tension, relaxed manner, ease of movement
INTERVENTIONS
Independent
1. Obtain full description of pain from
patient including location, intensity (010), duration; quality (dull/crushing);
and radiation
2. Instruct patient
immediately
to
report
Assist/
instruct
in
RATIONALE
36
techniques, e.g, deep/ slow breathing, response to pain. Provides a sense of
distraction behaviors, visualization, having some control over the situation,
guided imagery
increase in positive attitude.
Collaborative
5. Administer supplemental oxygen by Increases amount of oxygen available
means of nasal cannula
for myocardial uptake and thereby may
relieve discomfort associated with
tissue ischemia
Administer medications as
indicated, e.g.:
Beta-blockers, e.g.,
pindolol, propanolol
Analgesics,
e.g.,
sulfate (Demerol)
Nursing diagnosis
Possibly evidenced by
37
RATIONALE
Decreased cardiac output results in
diminished weak/ thready pulses.
Irregularities suggest dysrhythmias,
which may require further evaluation.
Monitoring.
S3 is usually associated with HF, but it
may also be noted with mitral
insufficiency (regurgitation) and left
ventricular
overload
that
can
accompany severe infarction.
S4 may be associated with myocardial
ischemia, ventricular stiffening and
pulmonary or systemic hypertension
Collaborative
5. Administer antidysrhythmics drugs
and ACE inhibitors as indicated
Nursing diagnosis
38
Possibly evidence by
Presence of signs and symptoms establishes an actual diagnosis
Desired outcome
Patient will demonstrate adequate tissue perfusion as individually
appropriate, e.g. skin warm and dry, peripheral pulses
present/strong, vital signs within patients normal range, patient
alert/ oriented, balanced intake/ output,absence of edema, free of
pain/ discomfort.
INTERVENTIONS
RATIONALE
Independent
1. Inspect
for
pallor,
cyanosis, Systemic vasoconstriction resulting
mottling, cool/ clammy skin. Note from diminished cardiac output may be
strength of peripheral pulses
evidenced by decreased skin perfusion
and diminished pulses.
2. Encourage active/ passive leg Enhances venous return, reduces
exercises, avoidance of isometric venous stasis, and decreases risk of
exercises
thrombophlebitis; however, isometric
exercises can adversely affect cardiac
output by increasing myocardial work
and oxygen consumption.
3. Monitor respirations, note work of Cardiac pump failure may precipitate
breathing
respiratory distress, sudden/ continued
dyspnea may indicate thromboembolic
pulmonary complications
4. Monitor intake, note changes in Decreased intake/ persistent nausea
urine output. Record urine specific may result in reduced circulating
gravity
volume, which negatively affects
perfusion and organ function. Specific
gravity measurements reflect hydration
status and renal function.
Collaborative
5. Administer medications, e.g.:
39
Ranitidine
antacids
Nursing diagnosis
Activity intolerance may be related to imbalance between
myocardial oxygen supply and demand; presence of
ischemia/necrotic myocardial tissues; cardiac depressant effects of
certain drugs (Beta- blockers, antidysrythmics)
Possibly evidenced by
Alterations in heart rate and BP with activity
Development of dysrythmias
Changes in skin color/ moisture
Exertional angina
Generalized weakness
Desired outcomes
Patient will demonstrate measurable/ progressive increase in
tolerance for activity with heart rate/ rhythm and BP within patients
normal limits and skin warm, pink, dry.
Report pain absent/ controlled within time frame for administered
medications
INTERVENTIONS
RATIONALE
Independent
1. Promote rest (bed/ chair) initially. Reduces myocardial workload. Oxygen
Limit activity on basis of pain/ consumption,
reducing
risk
of
hemodynamic response. Provide complications (e.g., extension of MI)
nonstress diversional activities.
2. Instruct patient to avoid increasing Activities that require holding the breath
abdominal pressure, e.g., straining and bearing down (Valsalva maneuver)
during defecation
can result in bradycardia, temporarily
reduced cardiac output, and rebound
tachycardia with elevated BP.
Progressive
activity
provides
a
3. Explain pattern of graded increase controlled demand on the heart,
40
of activity level, e.g., getting up in increasing strength and preventing
chair when there is no pain, overexertion
progressive ambulation, and resting
for 1 hour after meals
Lengthy/ involved conversations can be
4. Limit visitors and or/ visit by patient, very taxing for the patient; however,
initially
periods of quiet visitation can be
therapeutic
Collaborative
5. Refer to
program
cardiac
Nursing diagnosis
Anxiety may be related to threat to or change in health and
socioeconomic status; threat of loss/ death; unconscious conflict
about essential values, beliefs, and goals of life
Possibly evidenced by
Fearful attitude
Apprehension, increased tension, restlessness, facial tension
Uncertainty, feelings of inadequacy
Somatic complaints/ sympathetic stimulation
Focus on self, expressions of concern about current and future
events
Fight or flight behavior
Desired outcomes
Patient will recognize feelings; identify causes, contributing factors;
verbalize reduction of anxiety/ fear; demonstrate positive problemsolving skills; identify/ use resources appropriately
INTERVENTIONS
RATIONALE
Independent
1. Maintain confident manner (without Patient and SO can be affected by the
false reassurance)
anxiety/uneasiness displayed by health
team members. Honest explanations
can alleviate anxiety.
2. Accept but do not reinforce use of Denial can be beneficial in decreasing
denial. Avoid confrontations.
anxiety but can postpone dealing with
41
the reality of the current situation.
Confrontation can promote anger and
increase use of denial, reducing
cooperation and possibly impeding
recovery.
3. Encourage
patient/
SO
to Sharing information elicits support.
communicate with one another, Comfort and can relieve tension of
sharing questions and concerns
unexpressed worries
4. Provide rest periods/ uninterrupted Conserves energy
sleep time, quiet surroundings, with coping abilities
patient controlling type, amount of
external stimuli
and
enhances
Collaborative
5. administer antianxiety/ hypnotics as Promotes relaxation/ rest and reduces
indicated, e.g., diazepam (Valium), feelings of anxiety
lorazepam
(Ativan),
flurazepam
(Dalmane)
B.)
Ah! Dili jud makatarong ug tulog. Maka mata-mata man jud labi
A
P
42
Rationale:
This Provides atmosphere conducive to sleep
3. Encouraged position of comfort, assist in turning
Rationale:
Repositioning alters areas of pressure and promotes rest
4. Provided nursing aids (e.g. back rub, bedtime care, pain relief,
comfortable position [semi- fowlers], relaxation techniques)
Rationale:
To promote rest, relaxation; to induce sleep
5. Attempted to allow for sleep cycles for at least 90 minutes
Rationale:
Experimental studies have indicated that 60- 90 minutes are
needed to complete one sleep cycle and the completion of an
entire cycle is necessary to benefit from sleep.
At the end of 4 hours, the patient was able to have sleep and
verbalized of feeling rested.
43
44
Isosorbide
mononitrate
(Imdur)
60
mg
tab
OD P.O
Rationale: to reduce cardiac oxygen demand by decreasing
preload and afterload. Increases blood flow through the
collateral coronary vessels.
45
weakness
Patients report of pain
Changes in v/s
At the end of 2 hours, patient will verbalize a relief from pain and
discomfort.
At the end 2 hours, patient verbalizes the relief from discomfort around
46
the chest.
1.) Monitored BP using proper equipment with cuff bladder that is twothirds diameter.
Rationale:
To detect
changes
from
baseline
that
indicate
changes
in
cardiovascular status
47
Caffeine stimulates sympathetic nervous system
4.) Maintained physical and emotional rest.
Rationale:
Sedatives
can
be
used
to
reduce
stress
and
associated
VIII.
Medication
Exercise
(Health teaching)
Advised patient to take prescribed medication at
regular basis;
Atenolol( therabloc) 50 mg.tab once a day P.O
Clopidogiel ( plavix) 75 mg. tab once a day P.O
ISMN ( Imdur) 60 mg tab once a day P.O
Atorvastatin calcium ( lipitor) once a day P.O
At the hospital, patient is advised to initiate gradual
exercise such as;
a) Lying or sitting exercises ( arms, legs, trunk)
b.) Exercise progress to standing and slow walking in
the hall.
c.) Exercise must be done twice a day for about 20
minutes
d.) Exercises (Deep, pursed lip or deep breathing
exercises)
48
Treatment
Out patient
Diet
Recommendations
Advised the patient for followed up check up from his assigned physician.
Advised patient peer for frequent monitoring of his vital sign to avoid any risk
and possible complication
Explain the purpose and preparation for diagnostic test to have clear
understanding of procedures and what is happening increase feeling of
control and lessens anxiety.
49
Provide positive reinforcement for gains/ improvement and participation in self
care/treatment program. This encourages continuation of healthy behavior.
Advice patient to take his medication at home as prescribed by the physician
for continues medication treatment.
Suggest engaging in relaxing, non strenuous activity to avoid any risk due to
over stress
Teach client on coping mechanisms with recurring pain and other clinical
manifestations
Encourage patient to eat nutritious food like vegetable fruits, foods the high
fiber contain like cereal and foods rich in protein.
X.
DOCUMENTATION
50
Upon assessment last July 3, 2007, patient X was received with a diagnosis
of Acute myocardial infarction; Hypertensive cardiovascular disease; ruled out
PUD; diabetic nephropathy. Pt. was sitting on bed and complaint on pain on
chest area upon coughing was noted. Instructed to do deep, breathing exercises
everytime chest pain is recurring. Pertinent data about the patients family and
personal health history were gathered.
The next day on the groups duty, pt. has oxygen inhalation regulated at
3l/min via nasal cannula and vital signs were monitored every 4 hours with
special consideration to the clients blood pressure. Due medication were
properly given and kept patient in moderate, high back rest and kept comfortably
on bed, keeping back dry. Pt. was observed for any unsualties during the shift.
No further complaints were noted from the patient.
On the 2nd day of duty the doctor ordered that client may go home the next
day if stable. So, the group imparted health teachings important for the client to
follow as his home care management. We helped the client in discharged
planning and reminded them the health teachings that we had discussed.
This study also tests our abilities and skills on how to find answers to the
patients problem, what action to be done in order to solve it and how to properly
and correctly use our initiative for the success and for the good outcome of our
care study. This is one of our tasks as a student or future nurses and it serves as
our training ground backed up with strict training in order for us to become
equipped, productive, efficient, and world-class nurses in the future.
B I B L I O G R A P H Y
51
Wilson, Billie Ann Nurses Drug Guide (vol. 1 & 2) Pearson Education
Inc.,Copyright 2000
HTML1Rollins Gina. "With smoking cessation drugs, dosing is key", ACPASIM Observer, 22(4); 1,16-17.
W E B L I O G R A P H Y
http://biology.clc.uc.edu/courses/bio105/circulat.htm
wwwmedlib.med.utah.edu\webpath\TUTORIAL\MYOCARD\MYOCARD