A care for client with Acute Coronary Syndrome In partial fulfillment of Related Learning Experience (R.L.E) Submitted By: Roderos, Mitch Angela BSN 4C GROUP II S.Y 2011-2012 Clinical Instructor Ms. Virginia Lorda 1
INTRODUCTION Coronary artery disease (CAD) is an umbrella term used to cover any group of clinicalsymptoms compatible with acute myocardial ischemia. Acute myocardial ischemia is chest paindue to insufficient blood supply to the heart muscle that results from coronary artery disease(also called coronary heart disease). also called coronary heart disease (CHD), a single largestkiller of American men and women in all cultural groups (American Heart Association [AHA2003). According to the AHA, CHD caused more than 1 out of every 5 deaths in the UnitedStates in 2000. From 1990 to 2000, the death rate from CAD declined 25%. Multiple factors canbe identified as contributing to the declined in CAD. These factor include more effective medicaltreatment and an increase awareness and emphasis on reducing the major modifiablecardiovascular risk factor (e.g., high blood pressure [BP], smoking, high cholesterol, obesity,diabetes). (Principles of Medical Surgical Nursing Lemone, Burke Vol. 2 4the Edition 2007 page974-975) In Acute coronary syndrome, it is believed that the atherosclerotic plaque in the coronaryartery ruptures, resulting in platelet aggregation (―clumping‖), thrombus (clot) formation, andvasoconstriction. The amount of disruption of atherosclerotic plaque determines the degree ofobstruction of the coronary artery and the specific disease process (unstable angina ormyocardial infarction [MI]. Between 10% and 30 % of the client with unstable angina progressto having an MI in 1 year and 29% die of MI in 5 years (AHA, 2003). Acute coronary syndrome (ACS) is a condition of unstable cardiac ischemia. ACsincludes unstable angina and acute myocardial ischemia with or without significant injury of themyocardial tissue. As estimated 1.4 million Americans are admitted to the hospital annually withACS (Kasper et. al.., 2005).Fast Facts: Acute coronary syndrome (severe cardiac ischemia), a common cause of hospital admission, includes unstable angina and acute myocardial infarction. Unstable angina is characterized by injury to myocardial cells; with prompt restoration of blood flow, muscle tissue recovers. Myocardial infarction is characterized by necrosis and death of myocardial cells; scar tissue forms and functional muscle is lost. ACS is the most common identified cause of sudden cardiac death (American Heart Association [AHA], 2005). 2
A. DEMOGRAPHIC DATA 1. Client‘s name : Patient D.V 2. Gender: Male 3. Age, Birth date and Birth place: 59 years old, April 24,1952 at Tarlac 4. Marital Status: Single 5. Nationality: Filipino 6. Religion: Romasn Catholic 7. Address: 15 Natividad St. Bangkal Quezon City 8. Educational Background: College Undergraduate 9. Occupation: The client manages his own karinderya 10. Usual Source of Medical Care: Ospital ng MakatiB. SOURCE AND RELIABLITY OF INFORMATION Patient‘s Chart Patient HimselfC. REASON FOR SEEKING CARE “Naninikip ang dibsdib” As verbalized by the patientD. HISTORY OF PRESENT ILLNESS November 20,2011 2 hours prtor to admission – Patient was watching television (FPJ movie) when patient complained of chest pain radiating to the left sshoulder. No medication takeb few hour persistence Upon Admission - Patient‘s vital signs was taken and recorded of blood pressure of 130/70, PR: 84, RR: 26, Temp: 36.4 with general survey of Levigne‘s sign, Facial Grimace and DyspneaE. PAST MEDICAL HISTORY Pediatric/Childhood/ Adult Illness: Mumps (7 y/o); Chiken Pox (17 y/o) Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0) Serious/ Chronic Illnesses: The client has Hypertension X4, HBP of 200/100 UBP 150/80 Hospitalizations: There was no recorded previous hospitalization for the past year 2010 Operations: No known operations Immunizations: The client verbalized of having complete immunization of DPT, OPV, BCG and Measles vaccine.Allergies: No known AllergiesMedications prior to confinement: The client took Norvasc 10 g/tabLast Examination Date: November 20, 2011 3
F. FAMILY HISTORY Father Mother (+) HPN (+) HPN (+) DM (+) Asthma ( 65 y/o 63 y/o 59 y/o 58 y/o (+) Asthma 27 y/o (+) Asthma LEGEND Male Female Client Deceased1.) Heredo-Family Illness: Maternal – Patient B‘s mother is known to have High blood pressre and Asthma. Currently, his older sister next to him has asthma and so as his only daughter started when she was 2 years old. Father- Patient’t B‘s father has no known family illness running in their blood.G. SOCIO-ECONOMIC The client consists of a nuclear family and lives together with his aged mother, wife and his daughter. The client states that he contributes for the family financial expenses by the help of their Karinderya and his working daughter. Financial Resources are adequate enough to provide for them for the expenses of their everyday living. 4
DEVELOPMENTAL HISTORY Erik Erickson Age Task Patient’s Description Psychosocial Theory Generativity 30-65 years Eriksons analysis of this stage The client is presently Vs. old middle was strongly oriented towards enjoying himself at his senior Stagnation age parenting. Generatively years. The client states that potentially extends beyond he enjoys managing their ones own children, and also to karinderya to spend time and all future generations, which to contribute in generating gives the model ultimately a income. The client is well very modern globally established from raising his responsible perspective. daughter well. Having children is not a prerequisite for Generativity, The client stated the he had just as being a parent is no lived his life productively. guarantee that Generativity The client exhibits will be achieved. Caring for generativity from Erickson‘s children is the common psychosocial development. Generativity scenario, but The client stated that he had success at this stage actually worked hard on his younger depends on giving and caring - years to have a stable life. putting something back into He stated that he doesn‘t life, to the best of ones have anything to ask for, capabilities. except to have longer life to spend his golden years with Stagnation is an extension of his beloved family. intimacy which turns inward in the form of self-interest and self-absorption. Its the disposition that represents feelings of selfishness, self- indulgence, greed, lack of interest in young people and future generations, and the wider world. Adults need to create or nurture things that will outlast them, often by having children 5
or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world H. REVIEW OF SYSTEMS 1. Regional Examinations (December 1, 2011 9:30 am) Vital Signs: Temp : 37.51°c RR: 26 cpm PR: 86 cpm BP: 100/70mmHg General Assessment: Patient is seen conscious and coherent; garbed in hospital gown,sitting on bed without difficulty. Skin is clean and smooth with normal skin turgor. Nails are long but not dirty and with normal capillary refill. Patient is with ongoing oxygen therapy via Nasal Cannula regulated at 4 Liters per minute, and hooked with D5W 500 cc X 10 cc/hr Infusing well at his left matacarpal vein. Date of System Normal Findings Actual Findings AssessmentDecember 1,2011 Integumentary Smooth and good skin I: turgor, no lesions or Brown color, no lesion, no swelling any discoloration, no and edema. clubbing, no breaks Normal looking &abnormal curvature. Visible veins on both arms Has a temperature of 37.51°c. In nails: Long and clean nails and round nails. Pink Nail bed P: 6
Warm, soft, smooth, and has a good skin turgor. In nails: Hard, immobile, and smooth.December 1,2011 Hair and Head No lesion, no I: tenderness, no pain on -His hair color is black, hair is evenly palpation, no masses, distributed, no lumps, no nodules or depression, -Has thick hair. symmetrical -No presence of parasite and dandruff. -In scalp: Symmetrical and round and no lesion. P: -Hair texture is smooth and soft. -In head the texture is smooth and firm.December 1,2011 Eyes Eyelid intact, no I: redness, swelling, -Lid margins moist and light pink, discharge or lesions. lashes short, evenly spaced and curled Eyeballs are moist & outward. glossy, conjunctiva numerous small blood -Bulbar conjunctiva is clear with tiny vessels. Sclera white. vessels visible, palpebral conjunctiva Good eye contact. is light pink with no discharge, white sclera. - In PERRLA: *Cornea is transparent and the shape of the iris and pupil is round and equal. *The left and right eye has a good reaction to light (constrict and dilate) -In extra ocular movements: *Both eyes coordinated well in all directions. 7
December 1,2011 Ears Ears are symmetrical I: with 10 degrees angle. -Equal size and similar appearance. Color is same in facial with no tenderness or -No lesions, brown in color same with any nodule and his complexion. without any presence P: of discharge. -Warm, smooth, no nodules and no tenderness in auricle and tragus.December 1,2011 Mouth and 32 adult teeth are I & P: Throat present with moist and -Lips and surrounding tissue relatively pink mucous symmetrical.No lesions, swelling and membrane without any drooping. lesions or swelling. -Lip is light pink; moist, smooth and with no lesions. -Buccal mucosa is light pink, moist and without lesions.-Gums are light pink, and moist. -In tongue: *Moist, some papillae present, symmetrical appearance, midline fissures present and the color is pink and color white at the center and no lesions as well as the sides of the tongue. *Hard palate: slightly pink. *Soft palate: pink, -Has 32 teeth and stained with a hint of yellow color.December 1,2011 Neck No tenderness on I: palpation, no pain, -Neck is symmetric with head symmetrically align, centered and without bulging masses. no enlarged lymph nodes, no tracheal P: lateral deviation. -Smooth skin, firm, and none tender and none enlarged nodules. 8
December 1,2011 Breast and No palpable nodules I: Axillae and lesions. Breast is -Nipples have no discharges and not firm and round. cracked.December 1,2011 Respiratory Intercostals spaces are I: even and relaxed; -The color of his chest is similar to his chest symmetry is complexion. equal, no pain or tenderness, and no -With Chest in drawing abnormal breath -Chest symmetry is equal sound. -Thorax: is straight. -The RR of the patient is 26cpm. -Dyspneic, with Nasal Flaring -Chest X-Ray impression of pulmonary congestion P: No pain or tenderness. A: Lung is clear to auscultation on inspiration and expiration.December 1,2011 Cardiovascular No fatigue on simple PR : 86 bpm activities, no BP: 100/70 mmHg arrhythmias and heart murmurs. PR=60- I:-Neck veins are not distended. 100bpm. P: -No vibrations or palpitation in aortic, pulmonic, or tricuspid area. A:-No murmur sound heard. Chest X-Ray reveals atheromatous aortaDecember 1,2011 Abdominal No pain, No palpable I: masses and tenderness, -Flat abdomen Flat and round. P: -No tenderness, lesions and masses 9
December 1,2011 Musculoskeletal Have good range of -Does not need assistance to stand and motion and no toes point straight ahead. Able to limitation of shrug shoulders against resistance. movements.December 1,2011 Neurologic Have no tremors -No presence of tremors, oriented, no paralysis. Oriented, no history of seizures, mental dysfunction history of seizures, or hallucinations. mental dysfunction or hallucinations.December 1,2011 Lympathic Has no bleeding No swollen lymph nodes. tendencies, normal lymph nodes. 2. Laboratory Studies/Diagnostics 11/20/11 Clinical Chemistry Section Test Name S.I Unit Range Conversion Unit Result Interpretation Result ResultCreatinine 157 Umol/L 53-115 1.78 mg/dL 0.60- Above Normal 1.30AST 40 u/L 15-37 40 u/L 15 – 37 Above NormalSGPT 39 u/L 30-65 39 u/L 30 - 65 NormalNa 136 mmol/L 136-145 136 mmol/L 136-145 NormalK 3.6 mmol/L 3.5-5.1 3.6 mmol/L 3.5-5.1 NormalChloride 102 mmol/L 98 - 107 102 mmol/L 98 - 107 Normal 11/24/11 Clinical Chemistry Section Test Name S.I Unit Range Conversion Unit Result Interpretation Result ResultBUN 17.4 mmol/L 2.5-6.4 48.74 mg/dl 7.0-18.0 Above NormalCreatinine 154 Umol/L 53-115 1.74 mg/dl 0.60-1.30 Above Normal 10
11/27/11 Clinical Chemistry Section Test Name S.I Unit Range Conversion Unit Result Interpretation Result ResultGlucose (fasting) 2.10 mmol/L 4.1-5.1 30-45 mg/dl 73-99 Below NormalUric Acid 371 Ummol/L 165-428 6.22 mg/dl 2.6 – 7.2 NormalCholesterol Total 2.69 mmol/L 1.3-5.2 103.46 mg/dl 50-200 NormalTriglycerides 0.60 mmol/L 0.17-1.70 53.33 mg/dl 15-150 NormalHDL 0.66 mmol/L 1.04 - 25.38 mg/dl 40-60 Normal 1.55LDL 1.64 mmol 1.89-3.09 63.08 mg/dl 72.69- Below Normal 118.85AST (SGOT) 66 u/L 15-37 66 u/L 15-37 Above NormalALT (SGPT) 66 u/L 30- 65 66 u/L 30-55 Above Normal 11/28/11 Glycohemoglobin Test Test Name Result Reference Range InterpretationGlycohemoglobin Test 2.10 4.1-5.1 Below Normal 11/21/11 Test Name S.I Unit Range Conversion Unit Result Interpretation Result ResultCK-MB 110 u/L 7-25 110 u/L 7-25 Above Normal Damage to cardiac cells, indication of myocardial infarction 11/27/11 Test Name Result InterpretationTroponin I Positive Indicates myocardial infarction 11/28/11 Test Name Result InterpretationTroponin I Negative Does not indicate myocardial injury 11
11/20/11 Hematology Laboratory (Date) Normal Value Result Interpretation/Significance11/20/11 M - 14-18 g/dl 15 NormalHemoglobin F – 12 -16 g/dlHematocrit M – 0.40 – 0.54 0.55 Normal F – 0.37 – 0.37White Blod Cells 4.0 – 11.0 15.5 Above NormalRed Blood Cells M – 5.0 -6.4 6.3 Below Normal. DIFFERENTIAL COUNTSegmenters 0.5 – 0.7 0.96 Above NormalLymphocytes 0.2 – 0.4 0.3 Above NormalMonocytes 0.02 – 0.05 0.01 Above NormalPlatelet 150- 300 195 Normal 11/21/11 Blood Coagulation Test Reference Results Interpretation Protrombin Time 10.4 – 14 13.9 Normal % Activity 73-127% 72.6% Normal INR 0.88 – 1. 21 1.21 Normal Activated PTT 36.4 – 41.25 sec 46.1 sec Above Normal 12
3. Other Assessment Toolss Procedure Indication Results Nursing intervention11/26/11 The acid-fast stain is Microscopic Pre an especially Examination : Advise patient to drink a lot of fluids important test for the the night before the test. It makes theAcid Fast Stain genus Mycobacteriu test more accurate if its done firstSpecimen m, to rule out Negative thing in the morning. pulmonary Advised patient not to take tuberculosis. antibiotics and some sulfonamides because it may interfere with test results, causing the results to be falsely negative. Prior to breakfast, the patient will be asked to provide a 5-10 mL specimen of sputum delivered into a sterile cup with a screw top lid. Intra Asked patient to cough deeply and spit the substance that comes up from the lungs (sputum) into a container. Patient may be asked to inhale a mist of salty steam in order to cough more deeply and produce sputum. Post Place it in a sterile container, label appripiately and immdiately forward in the laboratory. 13
Procedure Indication Results Nursing intervention11/19/11 CT scanning or There are fluffy Pre sometimes called infiltrates noted Remove all Metal objects including CAT scanning is a with accentuation jewelry, eyeglasses, dentures andX-ray noninvasive medical of the pulmonary hairpins. Patient may also be asked test that helps vasculature to remove hearing aids and physicians diagnose removable dental work. and treat medical Instruct not to eat or drink anything conditions. The heart is not for several hours beforehand, enlarged CT scanning especially if a contrast material will combines special x- be used in exam. ray equipment with The aorta shows sophisticated Intra some calcifications computers to produce A chest ct scan takes about 30 along it‘s walls multiple images or mins., which includes preparation pictures of the inside time of the body. These Diaphragm and Patient mat lie on a narrow table cross-sectional sinuses are intake that moves through the hole images of the area While inside the scanner, an x-ray being studied can tube moves around your body. You then be examined on Impression: will wear soft buzzing, clicking or a computer monitor, whirring noises as the scanner takes Pulmonary printed or transferred pictures congestion and to a CD. The technician will ask you to lie edema R/O still and hold your breath for short pneumonia periods. these measures help make athermanous aorta the picture as clear as possible the scan itself Post CT exams are generally painless, fast and easy. After a CT exam, you can return to your normal activities. 14
Procedure Indication Results Nursing intervention11/21/11 5:00 am Electrocardiogram Abnormal ECG PreElectrocardiogram (ECG) provides 12 Lateral Explain the procedure to the vector views of the Infarction patient. heart‘s electrical Anteroseptal Instruct patient to wear activity as reflected by Infarction comfortable, loose-fitting clothing electrical potential Marked right Instruct to remove all Metal differences between axis deviation objects including jewelry, positive and negative With runs of eyeglasses, dentures and hairpins. electrodes placed in PVC Patient may also be asked to the limbs and chest remove hearing aids and wall. ECG is crucial removable dental work. for establishing many In some instances, men may cardiac diagnoses, require the shaving of a small especially arrhythmias amount of chest hair to obtain and myocardial optimal contact between the leads ischemia. and the skin Acute11/21/11 12:00 pm anteroseptal IntraElectrocardiogram infarction EKG leads are attached to the Lateral body while the patient lies flat on Infarction a bed or table. Leads are attached Ventricular to each extremity (four total) and Premature to six pre-defined positions on the Contraction front of the chest. A small amount of gel is applied to the skin, which allows the electrical impulses of the heart to be more easily11/21/11 11:00 pm Prior to streptokinase Lateral transmitted to the EKG leads.Electrocardiogram therapy Infarction Instruct that the test takes about Anteroseptal five minutes and is painless. Infaction Poor right progression11/21/11 8:00 pm Acute anteriorElectrocardiogram infarction Abnormal Q Ventricular premature contraction 15
I. FUNCTIONAL ASSESSMENTHEALTH PERCEPTION-HEALTH MANAGEMENT Prior to admission, patient sees health being able to do everyday things well according to the manner he wants it. The client stated he doesn‘t easilly get sick and when he does, he just let it subside not until if his condition worsens, that‘s the time when he would visit the hospital. The client does not use any vitamins and medications. Client has not experienced colds in the past month. The client stated that he would eat lots of nutritious foods and keeping himself physically fit is his way to keep himself healthySELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN Before the patient was admitted, he sees himself being able to do things according tothe manner he wants it. He does not mind his health not until the manifestation of discomfortbrought from his disease. Presently, the client verbalized difficulty of being sick; he statedthat he will find it hard to adjust from it. That client claims that he acquired his disease due toover fatigue and abusing his body by work when he was young back then. The clientverbalizes a decrease in self-perception due to aging and performing strenuous activities dueto presence of exertional dyspnea.ACTIVITY/EXERCISE PATTERN Prior to confinement, the client claims his activities as sort of exercise by means ofmanaging their mini Karinderya for the whole day. Presently, the patient is confined in theprimary holding unit. The client assumes full self care on himself. The client is on bed restand does minimal activities. Feeding 0 Grooming 0 Bathing 0 Gen. Mobility 0 Toiling 0 House 0 maintenance Bed mobility 0 Dressing 0 Legends: Level 0 – Self Care Level I – Use of equipments Level II– Assistance from another person Level III –Requires assistance from another person or device Level IV – Dependent and does not participate 16
SLEEP/REST PATTERN Before the client was admitted, the client stated that he is usually sleeps late because oftheir Karinderya. The client states that he has 7 hours of sleep everyday without the any use ofsleeping aids. He stated that the client would take a nap at noon for about 2 hours. Presently, The client has no difficulty of sleeping except from some external factors suchas the noise of other patients that he shares the ward with. The client does not use any sleepingpills but prefers to play music in his radio to induce sleep. The client verbalizes of having siestaafter taking his lunchNUTRITIONAL-METABOLIC PATTERN The client eats three times a day with low salt and low fat diet. The client has good appetiteand has no known food allergies. Wound heals normally. He recalled that his last meal wasnoodles and bread and half of one serving. The client has no known allergies and drinks 450 mlof water noted on our 6- 2 morning shift last December 1, 2011. The client has no dentalproblems, no foul odors and excess perspiration.ELIMINATION PATTERN The client states that he defecates once a day usually in the morning in soft brown stoolwithout difficulty and use of laxatives. The client urinates 3x day or more varying in his fluidintake; he verbalizes no difficulty in voiding.SEXUALITY/REPRODUCTIVE The patient is not sexually active and was circumcised at the age of 12. The client is marriedwith his wife for almost 40 years. The client displays intimate close relationship to his wife. Theclient states that he depends most on her wife for taking care of him and in giving himmedication and her attention at him, since he tends to be forgetful. The patient‘s wife is notaround during the interview. INTERPERSONALRELATIONSHIPS/RESOURCES The client is the youngest son among his 3 siblings. The client is married to his wife for 40years and is a father to his only daughter. He stated that there are no family quarrels so far. Theclient is a humorous person, that made gave them openness and good bonds. The client statedthat he decides on the facing family‘s major decisions with the help of his wife. The client statedthat he muses with his present lifeCOPING & STRESS MANAGEMENT/ TOLERANCE PATTERN The client states the he has no stressful situation encountered presently. Since he statedthat he is feeling a lot better than his admission. The client states that whenever he encounters a 17
difficult situation, he would think about it several times prior to decision making. The clientverbalized that he can control his emotions.VALUES/ BELIEFS The Client is a Roman Catholic.. The client stated that he barely attends the churchbecause of several preoccupations. he believes that he got his illness as God ‗warning towardshis way of living. He stated that he will stop from over abusing his body and he would adhere tohealthy lifestyle.PERSONAL/SOCIAL HISTORYHabits: The client is known to be a hard-working man. Patient D.V stated that he cannottolerate not to do anything during his free time. He make sure that his goals are achieved at theend of the dayVices: The client stated does not consume alcoholic beverages and does not smoke.Lifestyle: The client was known to live in a stressful lifestyle. The client states that he is skillfulClient’s usual daily life: The client‘s typical day is working as chef in his mini Karinderya thatrun every day but closes half-day during Sundays. Patient D.V states that he prefers to be withhis family watching television or taking siesta during his free time.Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings.Travel: The client has no previous local and intonation travel for the past 4 months. J. ENVIRONMENTAL HISTORY The client lives together with his family composed of 4 house hold members. A bungalow type of house with 209 square meters is owned by the patient residing near the highway. The client narrated that it is a cemented house with 2 bedrooms and 1 bath room. The house is fully ventilated and well lit of 12 windows. Their doors for about the size of 180X1 meter. The client stated that their surroundings are well-sanitized. Their electricity supply comes from Meralco and their water supply are from Deep well. They order Mineral water for drinking. The client‘s residence is advantageous, since it is near the public market, transportation, at school and Hospital. 18
K. PEDIATRIC HISTORY L. MATERNAL AND BIRTH HISTORY Birth date: April 24,1952 Hospital: Not assessed Birth weight: Unrecalled Type of delivery: Normal Spontaneous Delivery Condition after birth: In fine stable condition Mother: Complications of delivery: None Anesthesia drug guring labor: Unrecalled Exposure to Teratogenic Agents during Pregnancy: None 19
I. PATHOPHYSIOLOGY CLIENT-BASED Predisposing Factor Precipitating Factor Age (75 years old) Diet (Cholesterol Gender (Male) rich foods) Stressful Lifestyle Plaque Formation Atherosclerotic plaque ruptures or erodes Thrombin is generated and Fibrin is deposited Platelet Aggregation Clots are being formed Thickening and narrowing of arterial vessels Obstruction in Blood Flow Cells become ischemic Myocardial cell contract less effectively Lactic acid is Decrease O2 supply to secreted myocardium Decrease Cardiac Output Stimulate pain Receptor Decrease O2 supply to the different part of Chest Pain the bodyD.O.B. Pallor Body Weakness 20
II. CONCEPT MAPPING 1. Ineffective Airway Clearance related to increased tracheobronchial secretions as evidenced by productive cough T/C Acute Coronary Syndrome Probably MI,5. Risk for decreased cardiac Has CVD, Heart dysrhytmia not in failureoutput related to degeneration 2. Ineffective tissue perfusion:of cardiac muscle Patient B.R; 25 y/o Male. cardiopulmonary related to Temp.: 37.5°c RR: 19cpm PR: 86 cpm BP: 100/70mmHg. reduced coronary blood flow as evidenced by chest pain Dyspnea Productive cough in whitish sputum Chest X-Ray result of Pulmonary Congestion and Edema Weak looking Facial Grimace Presence of arrhytmias Positive Troponin I Elevated Ck-MB With Verbal Reports of Weaknhess With Exertional dypnea With verbal expression of worry 4. Anxiety related to fear of 3. Activity Intolerance related death, change in health status to imbalance in oxygen supply and demand as evidenced by fatigue
III. PROBLEM LIST Actual Problem Number Problem Remarks Ineffective Airway Clearance The client presently exhibits 1 related to increased dyspnea and productive cough in tracheobronchial secretions as whittish secretions. Moreover, evidenced by productive cough Pulmonary congestion is noted upon chest X-ray. 2 Ineffective tissue perfusion: Presence of a Positive Troponin I cardiopulmonary related to indicates myocardial injusry, thus reduced coronary blood flow as a presence of a decrease in oxygen evidenced by chest pain supple results in the failure to nourish the tissues at capillary level 3 Activity Intolerance related to Due to imbalance ratio of oxygen imbalance in oxygen supply and of supply and demand and demand as evidenced by verbal presence of productive cough has reports of weakness led the patientInsufficient physiological or psychological energy to complete required or desired daily activities 4 Anxiety related to fear of death Patient D.V verbalized a and change in health status as generalized, unidentified feeling of evidenced by verbal expression discomfort due to his experience of worry of Chest Pain
PotentialProblem Number Problem Remarks 1 Risk for decreased cardiac The client is at reisk for decreased output related to degeneration cardiac due to history of a positive of cardiac muscle troponin I and elevated CK-MB indicating a myocardial injury. Therefore, it is possibible that there may be presence of inadequate blood pumped by the heart to meet the metabolic demands of the body due to degeneration of cardiac muscle.
IV. NURSING CARE PLAN Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Ineffective After 9 hour of Monitor Respirations and breath sounds, Indication of respiratory distress After 9 hours noting rate and sounds and/or accumulation of―Matatagalan pa Airway nursing of nursing secretionsbago bumalik ang Clearance intervention, the intervention,kulay ko‖ as related to client will be able the client Elevated head of bed, changed position To decrease pressure on theverbalized by the increased to demonstrate every 2 hours PRN diaghraphm was able topatient tracheobronch behaviors to demonstrate Kept area patient‘s sorrounding clean To prevent aggravation of ial secretions maintain clear and free from draughts by means of condition behaviors to instructing to reduce things and placeObjective: as evidenced airway maintain only valuable things in his bed, and Dyspnea by productive fixed the patien‘t bed linen clear airway Productive cough cough in whitish Instruct patient to do deep breathing by To maximize effort on sputum asking tha patient to inhale deeply and expectorating secretions. Chest X-Ray exhale slowly. and coughing exercises result of Pulmonary Encourage the patient to increase fluid Hydration can liquefy viscous Congestion and intake for at least 2000 ml/day. Within secretions and improve secretion Edema cardiac tolerance clearance. Weak looking Facial Grimace Asisted client with postural drainage To loosen viscous and percussion if not contraindicated by condition Auscultate breath sounds and assess air To determine progress movement
Administered bronchodilators as To provide pharmacologicalprescribed by the physician. treatment and for fast recoveryInstruct home regimen interventions To provide cost reducing wayssuch as boiling water and instruc the in improving expotoratingpatient to inhale the steam to serve as an secretions.alternative to nebulaizationReferred to respiratory therapist for To determine effectiveness ofadjunct treatment modalities. drug theraphy
Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Ineffective After 8 hours of Intially Assess, document and reposrt These data assist in After 8 hours“Ang Sikip ng tissue Nursing the physician about the following: determining the cause and of Nursingdibdib ko‖ as perfusion: intervention, the effect of the chest discomfort intervention,verbalized by the cardiopulmon client will be and provide a baseline with the clientpatient ary related to free from chest which post-therapy symptoms remained reduced pain/discomfort can be compared. free fromObjective: coronary chest Presence of blood flow as a.) The patient‘s description of chest These data assist in pain/discomf arrhytmias evidenced by discomfort,including location, determining the cause and ort Positive Troponin I chest pain intensity,radiation, duration, and effect of the chest discomfort Elevated Ck- factors that and provide a baseline with MB Chest Pain affect it. Other symptoms such which post-therapy symptoms as nausea, diaphoresis, or complaints can be compared. of unusual fatigue. b.) The effect of chest discomfort on MI decreases myocardial cardiovascular contractility and ventricular perfusion—to the heart compliance and may produce (eg, change in blood pressure, heart dysrhythmias. Cardiac output sounds), to the brain (eg, changes in
LOC), to the kidneys (eg, decrease in is reduced, resulting in urine output), and to the skin (eg, reduced blood pressure color, temperature). and decreased organ perfusion.The heart rate may increase as a ompensatory mechanism to maintain cardiac output. Obtain a 12-lead ECG recording during An ECG during symptoms symptomatic event, as prescribed, to may be useful in the determine extension of infarction. diagnosis of an extension of MI. Administer oxygen as prescribed Oxygen therapy may increase the oxygen supply to the myocardium if actual oxygen saturation is less than normal.
Adminiser medications as prescribed Medication therapy is the first line of defense in preserving myocardial tissue. The side effects of these medications can be hazardous and the patient‘s status must be assessed Ensure physical rest: use of the Physical rest reduces myocardial bedsidecommode with assistance; oxygen consumption. Fear and backrest elevated to promote comfort; anxiety precipitate the stress diet as tolerated; arms supported during response; this results in upper extremity activity; use of stool increased softener to prevent straining at stool. levels of endogenous Provide a restful environment, and allay catecholamines,which increase fears and anxiety by being supportive, myocardial oxygen calm, and competent. Individualized consumption. visitation is based on patient response. Also, with increased epinephrine, the pain threshold is decreased, and pain increases myocardial oxygen consumption
Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Activity After 8 hours of Determine factors The client marks to have After 8 hours―Mabilis akong Intolerance nursing intervention, contributing to fatigue pulmonary congestion and under of nursinghingalin kahit sa pag related to the client will observation to have acute intervention,gawa ng mga simpleng imbalance in participate willingly coronary syndrome the clientbagay‖ as verbalized by oxygen supply in necessary and participatedthe patient and demand as desired activities. Evaluate client‘s percieved To provide comparative baseline willingly in evidenced by limitations by asking past data and to provide information necessary verbal reports activities and present about needed intervention and desiredObjective: of weakness activities activities. With Verbal Reports Assess cardiopulmonary Manifestations results The client of Weaknhess response to physical activity, intolerance of activity verbalized of With Exertional including vital signs before, incorporating dypnea during and after activity such Facial grimace exercises and Provide and monitor To provide an increase in exposure to response to supplemental oxygen supply sunlight in exygen his daily living
Assist client wit activities To protect the client from injurywhen walking to the washroom, getting up in bed andlying back to bedProvide intervals of rest To minimize occurrences ofbetween activities fatigueEncourage and acknowledge Helps to minimize frustrationthe difficulty of the situatio and rechannel energyof the clientEncouraged patient to expose Sunlight is rich in Vitamin D andhimself in sun light around 7- will help the client to increase8 am vitalityAssist and provide passive To maintain and enhance muscleand active ROM tone of client
Cues/Needs Nursing Diagnosis Planning Implementation Rationale EvaluationSubjective: Anxiety related to After 8 hours Assess, document, and report to These data provide information After 8 hours―Mamamatay na fear of death and of nursing the physician the patient‘s and about the psychological well- of nursingata ko‖ as change in health intervention family‘s level being and a baseline. Causes of interventionverbalized by the status as evidenced the client will of anxiety and coping anxiety are variable and the clientpatient by verbal manifest mechanisms. individual, and may include acute manifest expression of worry reduction of illness, pain, disruption of ADL reduction ofObjective: anxiety and anxious family members anxiety With verbal can transmit anxiety to the expression of patient.the nurse must also It was worry identify strategies to reduce the observed an Decreased family‘s fear and anxiety. increase of mental social concentration Assess the need for spiritual If a patient finds support in a interaction to counseling religion, religious relatives and and refer as appropriate. Counseling other people. Allow patient and family to Unresolved anxiety serves as the express anxiety and fear: stress response that increases a. By showing genuine interest myocardial oxygen consumption. and concern b. By facilitating
communication (listening,reflecting, guiding)c. By answering questions The presence of supportive familyEncourage the presence of the members may reduce bothfamily relative to assist patient‘s andin reducing the patient‘s level of family‘s anxiety.anxietyEncourage active participationin a cardiac rehabilitation Prescribed cardiac rehabilitationprogram by educating the uses may help to eliminate fear ofof his medications, the need for death, reduce anxiety, anddiet modification and exercise enhance feelings of wellbeing.Teach stress reductiontechniques. Such as a.) Deep Breathing Stress reduction may help to b.) Pursed Lip Breathing reduce myocardial c.) Music Therapy by oxygen consumption and may means of listening to enhance feelings of well-being. music available in his resources
Cues/Needs Nursing Diagnosis Planning Implementation Rationale EvaluationSubjective: Risk for decreased At the end of 1 Keep client on bed or chair rest Decreased oxygen consumption At the end of―Sa awa ng Diyos cardiac output week of in position of comfort. and risk for decompensation. 2 weeks ofe gumaan na kahit related to nursing nursingpapano ang degeneration of intervention, Administer high-flow oxygen To increase oxygen available for intervention,pakiramdam ko‖ cardiac muscle the client will via mask as indicated cardiac function/tissue perfusion the client willas verbalized by display displayedthe patient hemodynamic Decrease Stimuli, provide quiet To promote adequate rest hemodynamic stability. environment. stabilityObjective: Presence of Elevate legs when in sitting To enhance venous return arrhytmias position. Provide fluids/electrolytes as To minimize dehydration and indicated dysrhtmias. Encourage changing positions To reduce risk for orthostatic slowly, dangling legs before hypotension standing Early detection in changing in Monitor vital signs, watch out these parameters promotes timely for circulatory failure. intervention.
MEDICAL-SURGICAL MANAGEMENT i. Pharmacotherapeutics DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING ACTIONGeneric Name: Binds to opiate Moderate to severe CNS: dizziness, headache, Assess type, location, duration Instruct patient on how and when to ask for receptors in the pain. Also sedation, confusion, and intensity of pain pain medication.Morphine Sulfate CNS. Alters the provides: dysphoria, euphoria, floating Assess blood pressure, pulse, May cause drowsiness or dizziness. Advice perceptions of the Analgesia during feeling, hallucinations, and respiration before and patient to call for assistance when response to painful labor, sedation EENT: blurred vision, periodically during ambulating and to avoid activities requiringBrand Name: stimuli while before surgery, diplopia, miosis (high doses) administration. If respiratory alertness until response to the medication is producing supplement to . RESP: respiratory rate is <10/min, assess level of known. generalize CNS balance analgesia. depression. orthostatic sedation. Physical stimulation Caution patient to change positions slowlyClassification: depression. hypotension, palpitations, may be sufficient to prevent to minimize orthostatic hypotension. patients. GI: dry mouth, nausea, significant hypoventilation. Advice patient that frequent mouth rinses,Narcotic vomiting, constipation, ileus. Assess previous analgesic good oral hygiene, and sugarless gum orAnalgesic urinary urgency. clammy history. It may induce candy may decrease dry mouth. feeling, sweating. physical withdrawal symptoms Encourage patient to turn, cough, andDosage: dependence, psychological breathe deeply every 2 hr to preventTIV prn for Chest dependence, tolerance, atelectasis.Pain Advise patient to avoid concurrent use of alcohol or other CNS depressant
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHINGS ACTIONGeneric Name: Inhibits platelet Treatment of CNS: Headache, dizziness, Assess for symptoms of stroke, Instruct to Avoid taking OTC medications aggregation by patients at risk for weakness, syncope, flushing MI during treatment containing aspirin or NSAIDs withoutClopidogrel blocking ADP ischemic events— CV: Hypertension, edema Monitor liver function studies: consulting health care professional. receptors on history of MI, Dermatologic: Rash, AST, ALT, bilirubin, Instruct patient to take medication asBrand Name: platelets, ischemic stroke, pruritus creatinine if patient is on long- ordered preventing peripheral artery GI: Nausea, GI distress, term therapy Advise patient to notify health carePlavix clumping of disease constipation, diarrhea, GI Monitor blood studies: professional promptly if fever ,chills ,sore platelets Treatment of bleed CBC,Hgb, Hct, protime, throat or unusual bleeding occursClassification: patients with acute Other: Increased bleeding cholesterol if the patient is on coronary risk long-term therapy;Platelet syndrome thrombocytopenia andAggregation neutropenia may occur.Inhibitors Assess for symptoms ofDosage: stroke,peripheral vascular disease or MI75 g/ tab Precautions: Bleeding disorders, recent surgery, hepatic impairment, pregnancy
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING ACTIONGeneric Name: Acts on blood vessels, It used for the Orthostatic hypotension; Assess respiratory status Avoid hazardous activities and requiring GI, respiratory system symptomatic relief of palpitations; bradycardia; Monitor CBC during long activities with alertnessDiphenhydramine by antagonizing the allergic conditions tachycardia; reflex term therapy Avoid alcohol, other depressants effects of histamine including urticaria tachycardia; Assess movement disorder Inform patient that drug may cause dry H1- receptor site; and angio edema, extrasystoles; faintness. Assess nausea and mouthBrand Name: decreases allergic rhinitis, and Drowsiness; sedation; vomiting response by blocking conjunctivitis, and in dizziness, disturbed Assess for allergicBenadryl histamine; causes pruritic skin coordination. Nasal reaction (skin itching, increase heart rate, disorders. It is used stuffiness; dry mouth; rash, inflammation )Classification: vasodilation, for its anti- emetic nose and throat; sore Avoid alcohol secretions; significant properties in the throat.Antihistamine CNS depressant treatment of nausea and vomiting,Dosage:1 tab
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING ACTIONGeneric Name: Convert Acute CNS: Intracranial Assess patient carefully for bleeding every 15 min during Explain purpose of plasminogen to Coronary Hemorrhage, epistaxis, the 1st hr of therapy, every 15-30 min during the next 8hr, medication and the needStreptokinase plasmin, which is Thrombosis, gingival bleeding, and at least every 4hr for the duration of therapy. for close monitoring to then able to degrade Massive periorbital edema, GI Inquire about previous reaction to anistreplase or patient and family. fibrin present in Pulmonary bleeding, streptokinase therapy. Assess patient for hypersensitivity Instruct the patient toBrand Name: clots. Lysis of Emboli, bronchospasms, reaction (rash,dyspnea, fever, changes in facial color, report hypersensitivity throbi in coronary AcuteIschemic hemoptysis, allergic swelling around the eyes, wheezing). If these occur, reactions and bleeding or arteries, with Stroke, reactions, ecchymoses, inform physician promptly. Keep epinephrine, an bruisingClassification: preservation of Occluded flushing antihistamine, and resuscitation equipment close by in the Explain the need for bed ventricular Central venous event of an anaphylactic reaction. rest during therapy toDosage: function. Lysis of access Assess neurologic status throughout therapy. Altered avoid therapy. pulmonary emboli sensorium may be indicative of intracranial bleeding. Instruct patient to avoid1 tab or deep vein Assess intensity, character, location, and radiation of chest unnecessary procedures thrombosis pain. Note presence of associated symptoms (nausea, that is prone to bleeding vomiting diaphoresis.) or bruising such as Monitor heart sounds all breath frequently. Inform shaving and vigorous physician if sign of CHF occur (rales/crackles,dyspnea, S, tooth brushing heart sounds jugular venous distension, relived CVP). Monitor ECG continuously. Notify physician if significant arrhythmias occur.
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING ACTIONGeneric Name: It increases neuronal General CNS: Transient, mild Discuss risk of fetal abnormalities with Avoid hazardous activities membrane Indications drowsiness initially; sedation, patients desiring to become pregnant. and requiring activities withDiazepam permeability to - Short-term depression, lethargy, apathy, Assess for hypersensitivity. alertness chloride ions by management of fatigue, disorientation, Reduce dose of opioid analgesics with IV Avoid alcohol, other binding to anxiety restlessness, confusion, diazepam; dose should be reduced by at depressantsBrand Name: stereospecific - Insomnia delirium, headache, slurred least one-third or eliminated. Inform patient that drug benzodiazepine associated with speech, dysarthria, stupor, Instruct not to stop taking the drug without may cause dry mouthValium receptors on the anxiety rigidity, tremor, mild consulting the health care provider. Instruct about side effects of postsynaptic GABA - Sleepwalking paradoxical excitatory Observe the 15 rights of drug drug: Drowsiness, dizziness,Classification: neuron within the - Night terrors reactions, extrapyramidal administration. GI upset, dreams, difficulty CNS and enhancing - Premedication symptoms, visual and auditory Do not administer intrarterially; may concentrating, fatigue,Antiepileptic, the GABA before disturbances produce arteriospasm, gangrene. nervousness, cryingAnxiolytic, inhibitory effects anaesthesia CV: Bradycardia, tachycardia, Carefully monitor P. BP, respiration during Instruct to take drug exactlySkeletal muscle resulting in - Adjunct in the CV collapse, hypertension and IV administration. as prescribed.relaxant hyperpolarisation management of hypotension, edema Change from IV therapy to oral therapy as and stabilization seizures Dependence: Drug dependence soon as possible.Dosage: - Muscle with withdrawal syndrome Do not use small veins for IV injection. spasms5g TIV
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING ACTIONGeneric Name: Potentiate inhibitory Prevention of CNS: Dizziness, Assess for signs of bleeding and Advise patient to report any effect of antithrombin ischemic headache, Insomnia hemorrhage (bleeding gums: nosebleed symptoms of unusualEnoxaparin on factor Xa and complications from CV: Edema GI: unusual bruising black tarry stools bleeding or bruising thrombn. Prevents unstable angina, Constipation,Nausea, hematuria fall in hematocrit or blood dizziness itching rash feverBrand Name: thrombus prevention treatment of deep reversible increase in pressure guaiac positive stools); bleeding swelling or difficulty vein thrombosis in liver enzymes GU: from surgical site notify physician if these breathing to health careLovenox patients at risk for urinary retention occur,. professional immediately. thromboembolism Derm: ecchymoses, Assess for evidence of additional or Instruct patient not to takeClassification: complications due to pruritus, rash,urticaria increased thrombosis symptoms depend on aspirin or NSAIDs without severly restricted Hemat: bleeding, area of involvement. Monitor neurogical consulting healt careAnticoagulant, mobility during acute anemia, status frequently for sign of neurological professional while onAntiThrombotic illness thrombocytopenia impairement may required urgent therapy. Misc: Fever statement.Dosage: Monitor for hypersensitivity reactions60 g SQ BID report signs of physician.
DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING ACTIONGeneric Name: Inhibits activity of Short-term treatment CNS:Headache , 1. Assessment Tell patient to swallow acid (proton) pump of active dizziness,asthenia, vertigo, History: tablets or capsules wholePantaprazole and binds to duodenal ulcer; insomnia, apathy, Hypersensitivity to omeprazole or and not to open, crush, or hydrogen-potassium First-line anxiety,paresthesias, any of chew them.Brand Name: adenosine therapy in treatment dream abnormalities its components; pregnancy, lactation Instruct patient to take drug triphosphatase at of Dermatologic: Physical: 30 minutes before meals.Protonix secretory surface of heartburn or Rash,inflammation, Skin lesions; reflexes, affect; Caution patient to avoid gastric parietal cells symptoms of urticaria, pruritus, urinary hazardous activities if heClassification: to block formation of gastroesophageal alopecia, dry skin output, abdominal exam; respiratory gets dizzy.Proton Pump gastric acid.. reflux GI: auscultation Instruct to avoid beveragesInhibitors, Gastric disease (GERD); Diarrhea, Interventions rich in nicotine, caffeine andAcid suppressor Short-term abdominal pain, 2. Administer before meals. Caution patient alcohol which stimulate treatment of active nausea, vomiting, to swallow capsules whole,not to open, stomach acid or delay ulcerDosage: benign constipation, dry chew, or crush them. healing. gastric ulcer; GERD, mouth, tongue atrophy Dosage adjustments may be necessary in severe Asians and patients with hepatic erosive esophagitis, impairment. poorly Administer antacids with omeprazole, if responsive needed symptomatic GERD;
DISCHARGE HEALTH TEACHING Content StrategyM-medication To adhere in prescribed Instruct patient to take the prescribed therepautic regimen for medications as ordered by the physician. health maintainance and Instruct patient to avoid taking OTC drugs resistance. unless given with medical advice Encourage patient to include atleast 30 minutes To promote a healthyE-exercise of walking or jogging or perfrom tolerated and lifestyle, maximizing the preferred activities as a means of exercise level of health and increase the body‘s immunity. Educate client by adhering maintainanceT-treatment Attending the follow up theraphy, appropriate diet and having exercise check up. will reduce likelihood of occurances and aggravation of disease.H-health Health teaching about the Instruct the patient about home-madeteaching disease, exercise and diet. interventions in reducing blood pressure such as: a.) Pineapple or Calamansi juice to reduce blood pressure b.) Chewing of raw or fried garlic after meals c.) Refrain from consumption of caffeineted beverages, such as coffee and chocolateO-OPD Instruct that they need to Emphasize the importance of adhering to have a health check up. medications and attending follow-up check up. Encourage patient to adhere to weekly blood pressure monitoring
D-diet Maintain and ensure Instruct patient to avoid consumption of salty adequate intake for and fatty foods. noursihment, Instructed patient to limit consumption of high caloric foods such as rice to reduce occurences of high blood pressure and increase in blood sugar.S-signs and If any signs of symptoms are Advise patient to refer to health caresymptoms present go to the nearest professional for sudden onset of blurry vision, hospital for check up. intense head ache, chest pain unrelieved with rest and medications V. ONGOING APPRAISAL Patient D.V, a 59 year old male, has been admitted to Ospital ng Makati last November 20, 2011 with the chief complaint of chest pain. Upon assessment, it was observed that the patient is conscious, with general survey of Levigne‘s sign, Facial Grimace and Dyspnea . The client is admitted in Emergency Room and inserted of D5W 500cc X 10cc/hr at left metacarpal vein with laboratory tests rendered such as CBC, PTT, BUN, Creatinine, Serum Na, K, Trop I, CK-MB, ECG, and CBG. Chest X-Ray was ordered and for oxygen therapy at 4 liters per minute. Patient D.V was initially treated with morphine TIV for his chest pain, ISDN 80 cc D5W + 20 g, Clopidgogrel 75 g/Tab,. The patient is ordered for streptokinase therapy 1-5 MIV in 90 ml D5W. Prior to therapy, the given Diphenhydramine 50 g TIV, Hydrocholine 100g IV, Diazepam 5g TIV for anxiety, Pantaprazole 10 g TIV OD and Enoxaparin 60 g SQ BID . Presently, the patient‘s condition is stable. Negative of Troponin I, Normal Cholesterol Therapy due to streptokinase therapy and for 2-D echocardiogram with heplock inserted and latest vital signs of Temp.: 37.5°c RR: 19cpm PR: 86 cpm BP: 100/70mmHg.