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I. INTRODUCTION
A.) OVERVIEW OF THE STUDY
Acute myocardial infarction (MI) is defined as death or necrosis of
myocardial cells. It is a diagnosis at the end of the spectrum of myocardial
ischemia or acute coronary syndromes. Myocardial infarction occurs when
myocardial ischemia exceeds a critical threshold and overwhelms myocardial
cellular repair mechanisms that are designed to maintain normal operating
function and hemostasis. Ischemia at this critical threshold level for an extended
time period results in irreversible myocardial cell damage or death.
Critical myocardial ischemia may occur as a result of increased
myocardial metabolic demand and/or decreased delivery of oxygen and
nutrients to the myocardium via the coronary circulation. An interruption in the
supply of myocardial oxygen and nutrients occurs when a thrombus is
superimposed on an ulcerated or unstable atherosclerotic plaque and results in
coronary occlusion. A high-grade (> 75%) fixed coronary artery stenosis due to
atherosclerosis or a dynamic stenosis associated with coronary vasospasm can
also limit the supply of oxygen and nutrients and precipitate an MI. Conditions
associated with increased myocardial metabolic demand include extremes of
physical exertion, severe hypertension (including forms of hypertrophic
obstructive cardiomyopathy), and severe aortic valve stenosis. Other cardiac
valvular pathologies and low cardiac output states associated with a
decreased aortic diastolic pressure, which is the prime component of coronary
perfusion pressure, can also precipitate MI
Myocardial infarction can be subcategorized on the basis of anatomic,
morphologic, and diagnostic clinical information. From an anatomic or
morphologic standpoint, the two types of MI are transmural and nontransmural. A
transmural MI is characterized by ischemic necrosis of the full thickness of the

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affected muscle segment(s), extending from the endocardium through the
myocardium to the epicardium. A nontransmural MI is defined as an area of
ischemic necrosis that does not extend through the full thickness of myocardial
wall segment(s). In a nontransmural MI, the area of ischemic necrosis is limited
to either the endocardium or the endocardium and myocardium. It is the
endocardial and subendocardial zones of the myocardial wall segment that are
the least perfused regions of the heart and are most vulnerable to conditions of
ischemia. An older subclassification of MI, based on clinical diagnostic criteria, is
determined by the presence or absence of Q waves on an electrocardiogram
(ECG). However, the presence or absence of Q waves does not distinguish a
transmural from a non-transmural MI as determined by pathology
A more common clinical diagnostic classification scheme is also based on
ECG findings as a means of distinguishing between two types of 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

atherosclerosis, which are discussed below. Approximately 50% of all MI's in


the US occur in people younger than 65 years of age. However, in the future,
as demographics shift and the mean age of the population increases, a
larger percentage of patients presenting with MI will be older than 65 years

B.)

OBJECTIVES OF THE STUDY

The main reason and purpose student nurses conduct care study and
exposure in the clinical area is for them to identify problems encountered by the
clients; this is one of their tools of learning knowledgeably and skillfully.
We, as health care providers, it is indeed our vocation to adjoined hands
w/ the health team for the promotion of wellness of our clients. Our main
objectives for this study are the following:

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


that we can give specific nursing interventions.

To determine the family and personal health history of our patient that
may affect present health condition

To identify the cause and effect of the main problem through a correct
analysis of the pathophysiology of the case.

To determine the medical management given through identifying the


significant implication of the laboratory and diagnostic examinations
ordered as well as the medical orders and its rationale.

To make a nursing care plan for the different health problems


encountered by the client.

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


the client.

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

To impart health teachings to the client giving emphasis on his


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

To give referrals and follow-up for the health promotion of the client.
In general, this study aims to enhance the skills and knowledge of the
students in providing holistic care to the patient. Students logically search further
knowledge in order to attain the desired goal and intervention for the wellness of
the patient.
C.)

SCOPE AND LIMITATION

Prior to the day of duty, the group has already chosen a patient for care
study. They performed a physical assessment to the patient to properly identify
the nursing problems, which require necessary and direct interventions and
medical regimen. The study on medications and 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.

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The care for our chosen patient is only limited for 2 days of duty excluding the
physical assessment done prior to the day of duty.

II.

HEALTH HISTORY

A.) PATIENTS PROFILE


Name of Patient:

Sex:

Male

Age:

64 years old

Religion:

Roman Catholic

Civil Status:

Married

Occupation:

Income:

P 6,000/ month

Nationality:

Filipino

Date Admission:

June 29, 2007

Time:

09:40 pm

BASELINE VITAL SIGNS


Temperature:

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;

ruled out PUD; diabetic neprhopathy


Attending Physician:

Dr. Alenton

B.) FAMILY AND PERSONAL HEALTH HISTORY

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


that he was an alcohol drinker during his adolescence and late adulthood and
confessed that he only drinks 2-6 glasses even more on occasional basis;
however, he has no history of cigarette smoking. At fist, he experienced
hypertension in the year 1998 when he was still 55 years old. On the year 2006,
because of over workload and emotional stress, Mr. Agustin has experienced
severe chest pain and that same year he was diagnosed of having Diabetes
Nephropathy and Chronic Renal Insufficiency and was admitted at Northern
Mindanao Medical Center. During his admission last 2006, Mr. Sarmiento has
been transfused with 5 bags of Packed Red Blood Cell and there were no reports
of allergic reaction. At that time, he was advised by the doctor to have his
monthly check-up for his health problems.

According to the patients wife, there is no history of health problems from


their family. Nobody aside from Mr. Agustin Sarmiento has been admitted for
chronic illness. His children were neither non-smoker nor alcoholic but they do
drink alcohol occasionally Although there were presence of minor illnesses
before like cough, colds, LBM but they were able to catch on the treatment
regimen as a home care management.

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C.)

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

On the 29th of June, Mr. ? has experienced chest pain with complaints of
acute epigastric pain, growing in character and on and off. The patient was
anorexic and hypertensive (180/ 60 mm Hg). With the help of his family he went
to the hospital for check-up, they thought that it was just an ulcer, but the doctor
came out to have a diagnosis of

Acute myocardial infarction; Hypertensive

cardiovascular disease; ruled out PUD; diabetic neprhopathy, and due to the
severity of pain he was prompted for admission in the Polymedic General
Hospital.

III.

DEVELOPMENTAL STATUS
ROBERT 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.

ERIK ERICKSONS PSYCHOSOCIAL STAGES OF DEVELOPMENT


Ego Integrity vs Despair (65-)
Erik Erikson adapted and expanded Freuds theory of development to
include the entire life span, believing that people continue to develop throughout
life. He describes eight stages of development. Erikson envisions life as a
sequence of levels of achievement. Each stage signals a task that must be
achieve. The resolution of the task can be complete, partial or unsuccessful.
Erikson believes that the greater the task achievement, the healthier the
personality of the person; failure to achieve the task influences the persons
ability to achieve the new task. This developmental task can be viewed as a
series of crisis and successful resolution of this crisis and successful resolution of
these crisis is supportive to the persons ego failure to resole the crisis is
damaging to the ego.

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Our patient Agustin Sarmiento belongs to the older adult stage. His
central task is Ego Integrity versus Despair. Ego integrity is the ego's
accumulated assurance of its capacity for order and meaning. Despair is signified
by a fear of one's own death, as well as the loss of self-sufficiency, and of loved
partners and friends. He must learn to accept the life that he has led (good and
bad) to have a life in facing death. As he learns to live with his choices and the
certainty of death, he fined a inner-strength to go on with integrity. Some despair
is inevitable, a he mourn his own deaths. When he recognizes all that he have
been, are and will be, then we show his wisdom.

KOHLBERGS STAGES OF MORAL DEVELOPMENT


Post conventional (Universal Ethical and Principle Orientation
Lawrence Kohlbergs theory specifically addresses moral development in
children and adults. The morality of an individuals decision was not Kohlbergs
concern; rather he focused on the reasons of an individual makes a decision.
According to Kohlberg, moral development progress to three levels and six
stages. At Kohlberg first level, called the premolar or preconventional level,
children are responsive to cultural rules and labels of good and bad, right and
wrong. However, children interpret these terms of the physical consequence of
their action, that is, punishments or reward. At the second level, the conventional
level, the individual is concerned about maintaining the expectation of the family,
group or nation and sees this is right. The emphasis at third level is conformity
and loyalty to ones own expectation as well as societys. level three is called the
post conventional, autonomous or principal level. At this level people make an
effort to define valid values and principles without regard to outside authority or to
the expectation of others.
Our patient Agustin Sarmiento belongs to the Post Conventional level
and on the Universal Ethical principle orientation stage. His decisions and
behaviors re based on internalized rules, on conscience rather than social laws,

10
and on self- chosen ethical and abstract principles that are universal,
comprehensive and consistent.

IV.

MEDICAL MANAGEMENT
A.)
DATE

June 29, 2007


9:50pm
Hgt:188mgs/dL
BP: 180/60mmHg
HR:92bpm

DOCTORS ORDER

DOCTORS ORDER

RATIONALE

Please admit under


the serviceof Dr.
Alenton

For proper monitoring


of the patients
condition

Secure consent to
care

To have consent in
rendering medical
treatment to patient

TPR qh

To have baseline data


and monitor patients
condition

Diabetic diet

Diet prescribed in
treatment of type 2
Diabetes mellitus

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

To have baseline data


in planning of giving
treatment and care to
the patient

IVF PNSS1L @
10gtts/min

To keep vein open; to


have patent line in
cases of administering
IVT drugs

Meds.
ISMO 60g
Isordil 5g SL PRN

Zantac IVT now then

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

11
q8h

reduce gastric acid


secretions

Please refer
accordingly
Troponine T now

To measure levels of
cardiac troponins

Blood typing now


Cross-matching now

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

Transfuse 2U PRBC

For blood replacement

Repeat ECG in AM

For continued
surveillance of the
hearts electrical
activity

Tramadol 50mg IVT


now

Relieve of moderate to
severe pain

Pantoprazole
(Ulcepraz) 40g IVT
OD,start now

Inhibits proton pump


activity thus
suppresses gastric
acid secretion

Please give captopril


25mg tab SL now

To lower down BP of
the patient

Get BP & HR after 15


minutes

To determine the
effectivity of the
medication (captopril)

Tramadol 50mg IV
now then PRN

Relieve of moderate to
severe pain

Arixtra 25mg SC now


then OD

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

Lipitor 1 tab OD start


tonight

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

CBC after 2U PRBC

To determine the level


of the blood
components of the
patient after
transfusion

Give captopril 25mg


tab SL now, T.O. Dr.
Taboclaon

Antihypertensive drug;
to lower the BP of the
patient

Give captopril 25mg


SL now, T.O.
Dr. Espina

Antihypertensive drug;
to lower the BP of the
patient

IVF PNSS1L @
10gtts/min

To keep vein open; to


have patent line in
cases of administering

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

Give Isordil 5mg tab


SL for 3 doses q 5
minutes if chest pain
is not relieved

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

Increase O2
inhalation to 4L/min

Increases myocardial
oxygen supply &
relieves pain

Give captopril 25mg


tab SL now

Antihypertensive drug;
to lower the BP of the
patient

Give Isordil 5mg SL


now

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

To keep vein open; to


have patent line in
cases of administering

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B.)

IVT drugs
LABORATORY AND DIAGNOSTIC EXAMINATIONS
RESULTS

IMPLICATIONS

Cross- matiching
Patients blood type
Donors blood type

Blood Rh (D) positive


Blood Rh (D) positive

RBCs have antigen- can


initiate antibodies reaction

Bag serial # (s)


35147 segment
36353022
35260 segment
36352489
Re-screening
Blood component
Remarks
Method

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

3.49 x10^ 9/L

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

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C.) DRUG STUDY


Name of Patient:
Name of Drug
Generic
(Brand)

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

Assess pt. for


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

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.

ANATOMY AND PHYSIOLOGY

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


our heart plus our arteries and veins. In a persons heart, the atria (plural of atrium)
receive blood from the veins and the ventricles send blood to the arteries. As the
arteries become more finely divided, they are called arterioles. The finest divisions of
our vascular system are called capillaries. As the vessels get larger again, the smallest
are called venules which join and enlarge to form veins. Note that the distinction
between arteries and veins is by direction of blood flow, not oxygen content. Veins
carry blood toward the heart and arteries carry it away from the heart. Because of this,
not all arteries carry oxygenated blood. The two major exceptions, in which arteries are
carrying deoxygenated blood are the pulmonary artery which carries deoxygenated
blood from the heart to the lungs (to pick up oxygen there) and the umbilical arteries
which carry deoxygenated blood away from the babys body to the placenta (to pick up
oxygen there). We have double circulation: we have a separate pulmonary circuit to
the lungs and a systemic circuit to the body.

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.

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

10. The blood passes through the left atrioventricular valve.

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

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

13. The aorta is the main artery to the body. One of the first arteries to branch off is
the coronary artery, which supplies blood to the heart muscle itself so it can
pump. The coronary artery goes around the heart like a crown. A blockage of the
coronary artery or one of its branches is very serious because this can cause
portions of the heart to die if they 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.

16. The smallest vessels are the capillaries.

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

These, in turn, join to form the larger veins, which carry the blood back to the superior
and inferior vena cava.
PHYSIOLOGY OF THE HEART
The work of the heart is to pump blood to the lungs through pulmonary
circulation and to the rest of the body through systemic circulation. This is
accomplished by systematic contraction and relaxation of the cardiac muscle in the
myocardium.
Conduction System
An effective cycle for productive pumping of blood requires that the heart be
synchronized accurately. Both atria need to contract simultaneously, followed by
contraction of both ventricles. Specialized cardiac muscle cells that make up the
conduction system of the heart coordinate contraction of the chambers.
Cardiac Cycle
The cardiac cycle refers to the alternating contraction and relaxation of the
myocardium in the walls of the heart chambers, coordinated by the conduction system,
during one heartbeat. Systole is the contraction phase of the cardiac cycle, and
diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8
second.

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 Oxygen supply

Myocardial Conractility

Stimulation of
Baroreceptors

Altered Cell Membrane Int.

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

characteristics of the clinically symptomatic atherosclerotic plaque are a


fibromuscular cap and an underlying lipid-rich core. Plaque erosion may occur
due to the actions of metalloproteases and the release of other collagenases and
proteases in the plaque, which result in thinning of the overlying fibromuscular
cap. The action of proteases, in addition to hemodynamic forces applied to the
arterial segment, can lead to a disruption of the endothelium and fissuring or
rupture of the fibromuscular cap. The degree of disruption of the overlying
endothelium can range from minor erosion to extensive fissuring that results in
an ulceration of the plaque. The loss of structural stability of a plaque often
occurs at the juncture of the fibromuscular cap and the vessel walla site
otherwise known as the plaque's "shoulder region." Any amount of disruption of
the endothelial surface can cause the formation of thrombus via plateletmediated activation of the coagulation cascade. If a thrombus is large enough to
completely occlude coronary blood flow for a sufficient time period, MI can result.

Mechanisms of Myocardial Damage

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


occlusion in the coronary artery, the length of time of the occlusion, and the
presence or absence of collateral circulation. Generally speaking, the more
proximal the coronary occlusion, the more extensive is the amount of

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

VII. NURSING MANAGEMENT


A.) IDEAL NURSING CARE PLAN

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

Pain is a subjective experience and


must be described by the patient.
Assist patient to quantify pain by
comparing it to other experiences.

pain Delay in reporting pain hinders pain


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

3. Provide quiet environment, calm


activities, and comfort measures (e.g.,
dry/ wrinklefree linens, backrub).
Approach the patient calmly and
confidently
4.

RATIONALE

Decreases external stimuli, which may


aggravate anxiety and cardiac strain
and
limit
coping
abilities
and
adjustment to current situation.

relaxation Helpful in decreasing perception of/

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.:

Antianginals, e.g nitroglycerin Nitrates are useful for pain control by


coronary vasodilating effects, which
(Nitro-Bid, Nitro-stat, Nitro-Dur)
may increase coronary blood flow and
myocardial
perfusion.
Peripheral
vasodilation effects reduce the volume
of blood returning to the heart
(preload),
thereby
decreasing
myocardial work and oxygen demand.

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

Analgesics,
e.g.,
sulfate (Demerol)

Nursing diagnosis

atenolol, Important second-lineagents for pain


control through effect of blocking
sympathetic
stimulation,
thereby
reducing heart rate, systolic BP, and
myocardial oxygen demand.
morphine Although IV morphine is the usual drug
of choice, other injectable narcotics
may be used in acute phase/ recurrent
chest pain unrelieved by nitroglycerin to
reduce severe pain, provide sedation,
and decrease myocardial workload.

Risk for decreased cardiac output may include changes in rate,


rhythm, electrical conduction, reduced preload/ increased SVR,
infracted/dyskinetic muscle

Possibly evidenced by

Presence of signs and symptoms establishes actual diagnosis


Desired outcomes

37

Patient will demonstrate hemodynamic instability, e.g., BP, cardiac


output within normal range, adequate urinary output, decreased/
absent dysrhythmias,
Report decreased episodes of dyspnea,angina
Demonstrate an increase in activity tolerance
INTERVENTIONS
Independent
1. Evaluate quality and equality of
pulses, as indicated

2. Auscultate heart sound


Note development of S3,S4

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

3. Monitor heart rate and rhythm.


Document dysrhythmias via
telemetry

Heart rate and rhythm respond to


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

4. Provide small/ easily digested


meals. Restrict caffeine intake, e.g.,
coffee, chocolate, cola

Large meals may increase myocardial


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

Collaborative
5. Administer antidysrhythmics drugs
and ACE inhibitors as indicated

Nursing diagnosis

Dysrhythmias are usually treated


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

38

Tissue perfusion, altered, risk factors may include reduction/


interruption of blood flow, e.g., vasoconstriction, hypovolemia/
shunting and thromboembolic formation

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

(Zantac), Reduces or neutralizes gastric acid,


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

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

Provides continued support/ additional


rehabilitation supervision
and
participation
in
recovery and wellness process

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

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.)

ACTUAL NURSING MANAGEMENT


(SOAPIE FORM)

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

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


patient

A
P

verbalizations of interrupted sleep


complaints of not feeling rested
yawning
pain/ discomfort

Sleep pattern disturbance related to internal factors such as


illness, psychologic stress and external factors such as facility
routines
At the end of 2 days, the patient will be able to report improvement
of sleep/ rest pattern and verbalize increased sense of well- being
and feeling rested.

42

At the end of 4 hours, the patient will be able to get enough


uninterrupted sleep/ rest.
1. provided comfortable bedding and some of own possession,
e.g., pillows
Rationale:
Increases comfort for sleep as well as physiologic and psychologic
support
2. Maintained environment conducive to sleep/ rest (e.g. quiet
comfortable temperature, ventilation and closed door)

Rationale:
This Provides atmosphere conducive to sleep
3. Encouraged position of comfort, assist in turning
Rationale:
Repositioning alters areas of pressure and promotes rest
4. Provided nursing aids (e.g. back rub, bedtime care, pain relief,
comfortable position [semi- 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.

At the end of 2 days, the patient was able to verbalize a fair


improvement of his sleep/ rest pattern in between his medication/
treatment regimen.

43

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


sakit akong heart as verbalized by the patient

patient report chest pain with radiation to epigastrium


pain scale of 6
facial grimaces
changes in vital signs, baseline: HR=54 bpm, BP=140/90
mmHg

-Acute pain related to tissue ischemia of myocardial tissue


secondary to myocardial infarction.

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


pain, display reduced tension, relaxed manner and ease of
movement

1.) Obtained full description of pain from patient including


location, intensity (0-10), duration, quality and radiation.
Rationale:
Pain is a subjective experience and must be described by the pt.
Assist pt. to quantify pain by comparing it to other experiences.
2.) Maintained bed rest at least during periods of pain.
Rationale:

To reduce workload of the heart


3.) Positioned patient comfortably, in moderate high back rest
Rationale:
This allows for lung expansion by lowering the diaphragm

44

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


breathing
Rationale:
Helpful in decreasing perception of/ response to pain. Provides a
sense of having some control over the situation, increase in
positive attitude.
COLLABORATIVE
5.) Administered supplemental oxygen by means of nasal cannula
@ 3L/min.
Rationale:
Increases amount of oxygen available for myocardial uptake and
thereby may relieve discomfort associated with tissue ischemia
Administered medications as indicated such as:

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


5 minutes if chest pain is not relieved

Isosorbide

mononitrate

(Imdur)

60

mg

tab

OD P.O
Rationale: to reduce cardiac oxygen demand by decreasing
preload and afterload. Increases blood flow through the
collateral coronary vessels.

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


relief of chest pain and demonstrated the use of relaxation
techniques.

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


the patient.

45

weakness
Patients report of pain
Changes in v/s

Ineffective cardiopulmonary tissue perfusion related to reduced


coronary blood flow.

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

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


Patients description of chest discomfort, including location, intensity,
radiation, duration and factors that affect it. Other symptoms such as
nausea, diaphoresis complains of universal fatigue.

2.) Monitored respiration and note work of breathing.


3.) Assess GI functions and monitor fluid intake and urine output.
4.) Obtained a 12- lead ECG recording during the symptomatic event
as prescribed to determine extension of infarction
COLLABORATIVE:
5.) Administered oxygen @ 3L/min via nasal cannula.
Rationale:
Increases amount of oxygen available for myocardial uptake and
thereby may relieve discomfort associated with tissue ischemia

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

46
the chest.

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


verbalized by the patient.
Elevated BP=140/90 mmHg

Increased creatinine= 6.17 mgs/dl


Urine output of less than 30 ml/hr

Decreased cardiac output related to diminished blood flow caused by


increased vascular resistance.

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


within acceptable range.

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

2.) Maintained fluid and dietary sodium restrictions.


Rationale:
To reduce fluid restriction which contributes to hypertension
3.) Discouraged intake of coffee, tea, cola and chocolate which are
high in caffeine.
Rationale:

47
Caffeine stimulates sympathetic nervous system
4.) Maintained physical and emotional rest.
Rationale:
Sedatives

can

be

used

to

reduce

stress

and

associated

vasoconstriction; to reduce cardiac workload


5.) Administered antihypertensive as prescribed:
atenol (Therabloc) 50 mg 1 tab now then OD
Rationale:
A beta-blocker that selectively blocks beta-adrenergic receptors,
decreases cardiac output and cardiac oxygen consumption and
depresses rennin secretion

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


acceptable range.

VIII.

REFERRALS AND FOLLOW UP

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

In the hospital, patient is provided with the following


treatment ;
a.)Supplemental oxygen by nasal cannula @ 2-4
L/min.
b.)Cardiac monitoring for continued surveillance of
hearts activity.
c.)Frequent monitoring of vital signs including
temperature , pulse rate ( apical/ radial) and blood
pressure and intake and output
d.)Pharmacologic management to stabilize client
condition.
When the patient will be discharge, out patient
program consist of supervised , oven ECG monitored
, exercised training based on the results of exercised
stress test .support and guidance related to the
treatment of the disease and education and
counseling related to lifestyle modification .
Client is advised to
follow the prescribed
recommended diet ;
a) Diabetic diet: eat complex CHO foods with high
fiber content avoid added sugar and concentrated
sweets and all other CHO foods and eat regularly.
b) Eat foods low in calorie, saturated fats and
cholesterol; restriction of sodium; avoidance of
spicy foods soft fiber food and take small frequent
feedings

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.

IX. EVALUATION & IMPLICATION (PROGNOSIS)


This case study was done successfully although we experienced some
difficulties analyzing the health status of the client and understanding the medical
orders given. Using our critical thinking, we were able to carefully identify the
problem of our patient who needs direct interventions for the wellness of his
health. Moreover, the group was able to discuss some health teachings as stated
above for the improvement of the clients health and fast recovery.
The patient was able to understand the imparted health teachings and
verbalized to consistently follow his treatment regimen in home care
management. Although patients blood pressure did not lower down to his normal
range of blood pressure, other clinical manifestations such as severe chest pain
was not subjectively verbalized by the patient and labored breathing was not
evident. Still, patient has unproductive, dry cough. Mr. Sarmiento is progressing
well in his health condition and is for discharge any soon. Patient may have an
uncomplicated episode of myocardial infarction and may return to normal
activities and lifestyle with moderation and modification to some of those.

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

Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10 th edition)


Lippincott-Raven Publisher.Copyright 1996

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

Mosbys Pocket Dictionary of Medicine, Nursing and Allied Health (4 th


edition) Elsevier(Singapore) PTE LTD> Copyright 2002

Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing


Patient Care(6th edition) F.A Davis Company. Copyright 2000

Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition).


Addison esley Longman Inc. 1998.

MacMahon, S. Blood pressure and the risk of cardiovascular disease. N


Engl J Med 2000; 342:50

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

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