226087481 case-ib-study-in-ectopic-pregnancy

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Introduction
A heart beat signifies life, from the day it starts to beat in the womb, till it stops,
and where death conquers us. The heart beats not only to one tune but it also responds
to the tune of emotions and physical stress. As some of us may have also experience
moments of joy or sorrow and the heart may feel pain or pleasure.
In medicine, an acute disease is a disease with a rapid onset or a short course.
The term “Acute” may often be confused by the general public to mean “severe”,
however, this has a different meaning. Coronary, may refer to as “the heart” or “relating
1

to the heart”. While syndrome is defined as a set of signs and symptoms that tend to
occur together and which reflect the presence of a particular disease or an increased
chance of developing a particular disease.
Acute Coronary Syndrome is defined as a spectrum of conditions involving chest
discomfort or other symptoms caused by lack of oxygen to the heart muscle (the
myocardium). The unification of these manifestations of coronary artery disease under a
single term reflects the understanding that these are caused by a similar
pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or
rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary
arteries and impaired blood supply to the heart muscle.
According to the morbidity rate, taken from the records of the Department of
Health for region X, the occurrence of cardiovascular diseases per 100,000 populations
is 3,356. This data is taken from the 2001-2005, a 5 years average record. While the
occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373
per 100,000 populations.
2

OBJECTIVES OF THE STUDY
The study aims to explore the concepts about the condition and the quality of
nursing care being rendered to our client Mrs. F that was diagnosed with Acute
Coronary Syndrome.
In order to learn more about the health condition of the patient, the study wants
to fathom about the predisposing and precipitating factors, anatomy and physiology and
the pathophysiology of the condition experienced by the client. Basically the main goal
of this study in relation to knowledge is to identify the nursing interventions after the
condition of patient Mrs. F.
The study aims to critically analyze the qualitative and quantitative data gathered
in order to establish connection between the different manifestations experienced by the
patient with that of the disease process. To be able to improve skills, the students also
endeavors to come up with nursing care plans that will alleviate Mrs. F.’s condition. The
presentors also intend to compare and contrast the ideal management for Acute
Coronary Syndrome with that of the actual management. In addition, the study seeks to
disseminate essential information to everybody for awareness.
Furthermore, by this study, the provider will be able to exercise that attitude of
determination and in order to come up with a successful study.
3

SCOPE AND LIMITATIONS OF THE STUDY
This case study tackles about Acute Coronary Sydrome specifically on the case
of patient Mrs. F. It includes essential concepts in relation to the said condition such as
the patient’s profile and health history, nursing assessment and clinical manifestations,
drug study and diagnostic exams done. The anatomy and physiology is also included as
well as the pathophysiology of Acute Coronary Syndrome with its associated factors.
The Medical and Nursing Management along with the discharge plans with its referrals
are also being covered. The prognosis is also given.
The scope of the plan encompasses during the Recovery Phase which was on
February 12, 13, 14, 15, 16, 18 and 19 of year 2008 wherein the assigned students who
have assessed the client with cumulative interaction and good rapport to the patient and
significant others. Nursing Management covers the above mentioned dates which
encompasses the client’s Recovery Phase. Data gathering about the Laboratory results
covers from February 05 to February 16, 2008.
The areas of concerns are limited to the discussions of Acute Coronary
Syndrome and the quality of Nursing Care to the patient. The quantity and quality of the
information are limited to the data gathered from the client, significant others and his
medical records.
Immediate family background is limited because the patient has difficulty in
recalling necessary information that would aid in the data gathering. Data gathering was
limited in the confines of Maria Reyna Hospital, Cagayan de Oro City and Aluba,
Cagayan de Oro. Generally, the content of the report is limited to the elaboration of the
diagnosis given to the patient and the corresponding Nursing Management.
4

PATIENT’S PROFILE
Name: Mrs. FMrs. F
Age: 81 years old81 years old
Sex: Female
Birthday: June 3, 1926June 3, 1926
Birth rank: 2nd
to the eldest
Number of siblings: 7
Religion: Roman Catholic
Civil Status: Married
Number of children: 13, with 10 living and 3 deceased
Nationality: Filipino
Height: 5 Ft.
Weight: 73 kg
Address: Baungon, Bukidnon
Occupation: House wife
Income: Php. 15,000/ mo.
Educational Attainment: 1st year H.S.
Date Admitted: February 05, 2008
Time Admitted: 12: 05 PM
Chief Compliant: Shortness of breath and chest pain
Date Discharged: February 16, 2008
Time Discharged: 4:15 PM
Final Diagnosis: Acute Coronary Syndrome, hypertension, Myocardial
Infarction
5

Significance of the study
The study is significant to the following people, the client, the client’s family, the
researchers, nursing student, and future researchers.
The study is significant to the client, because it enlightens the client’s queries and
doubts regarding her condition. Allowing her to understand the situation of her present
state, this would allow her to be more aware of the importance of following the
treatment regimen.
Client’s family must also be aware of the condition of the client. With the study,
the client’s family will be able to participate in the client’s treatment, and they will be
able realize the importance of the support system in participating in the client’s care.
The study is also important to the researchers, since it allows them to explore the
client’s condition, giving them first hand experience in observing the manifestations of
the disease condition and allowing them to apply theoretical knowledge regarding
nursing managements for the manifested signs and symptoms.
Nursing students and future researchers may use the study for reference or basis
purposes in planning an intervention or understanding a condition which could be
similar or related to the study presented.
6

Health History
Family History
History of hypertension was present to both paternal and maternal side, in
addition to the given data’s from the informant; there’s no history of CA on the clients
lineages. However, on her maternal side a history of diabetes mellitus and heart
problems was present.
Mrs. F.’s grandfather (father side) died due to liver abscess. It was known that
her grandfather was a chain tobacco smoker consuming 24 sticks or approximately
1pack of cigarette per day and drinks alcoholic beverages such as “tuba”. Additionally,
patient’s grandmother (father side) died due to normal aging with high blood pressure.
Patient’s maternal side history revealed that grandparents died due to aging.
Furthermore, patient’s father died due to normal aging with hypertension. It was
mentioned that her father was also a smoker, consuming 15-20 estimated sticks of
cigarette per day. He also drinks alcoholic beverages like “tuba”. Her mother died at her
88 years of age due to normal aging process.
On the siblings of the client’s father side, all had hypertension. Some of her
mother’s siblings had hypertension and one had CVA.
Personal Social history
Mrs. F. had her menarche at the age of 13 years old. At the age of 20 years old,
Mrs. F. met Mr. S. at Baungon, Bukidnon and got married. Mrs. F.’s reproductive profile
was G13, P13, T13, P0, A0, and L10. She has 13 children. Her first pregnancy was on
February 3, 1947 with their first child named Sohrab through Normal Spontaneous
Vaginal Hospital delivery. Sorab died on January 29, 1989 due to an accident. Second
delivery was a pregnancy uterine full term, normal Spontaneous delivery with a baby
7

boy named after his father, Santiago Jr. History divulges that the patient’s second child
died after birth. Third pregnancy was still a normal spontaneous vaginal delivery. The
baby was named Leopoldo, Leopoldo died due to measles at the age of 3months. Her
fourth pregnancy was still normal named her third child Elleonor with an educational
attainment of High School level who was born February 22, 1949. Mrs. F.’s 10
remaining pregnancies were all full term and were all delivered through normal
spontaneous vaginal delivery. The remaining 10 children were the following: Gemma
who was born on December 18 1950, married and with an educational attainment of
High School Grad, Rosalina born aug. 18, 1951 with an educational attainment of High
School graduate ,married (female), Efren born Sept. 18 1952 with an educational
attainment of High School level and is married (male), Salvacion born on Feb. 15, 1953
a High School level and is married (female), Marjorie born on Oct. 16, 1962 a High
School graduate and is married (female), Jose born on 0ct. 18, 1963 a High School
level and is single (male), Marites born on Dec. 10, 1964 a High School level and is
married (female), Nancy born on Aug. 22, 1966 a college graduate and is married
(female),Edgardo born on Nov. 2 1967 a High School Grad and is single(male).
Patient’s husband, Mr. S. was the Former vice Mayor of Baungon, Bukidnon. On
the year 1963- 1965.Being a wife of the vice mayor, she participated well in politics and
has a lot of programs and campaigns for her husband. She was also a member of the
Catholic Women’s League and has done a lot of outreach programs for the church.
Their family social status was at peak that time, but then a great downfall happened in
their lives. At the age of 39 years old, Mr. Santiago was stabbed due to political conflicts
which caused his death. She hardly accepted it because of the traumatic experience
they had.
After two years, Mrs. F. got married to Mr. V. He is a Cebuano who came to
Baungon, Bukidnon in search for work and found more than what he had expected. Mr.
V was afraid in marrying her because he has to face all of her children to ask for the
hands of their mother. Luckily, all of her children understood and accepted him and they
got married. Mr. V. and Mrs. F. were not blessed with children somehow blessed with
their adopted children who were Margie and Kristine.
8

They have their own house in Baungon, Bukidnon and took cared by her adopted
daughter Margie. When visiting in Cagayan de Oro wherein her sons and daughters are
residing in the same area, they stay in her daughter’s house Marites in Aluba, Coca-
cola compound where they are warmly welcomed. Our client’s source of income is only
P15,000 pesos a month from her pension pay.
Past medical History
On 1965, the year of Mr. S.’s death, Mrs. F. had traumatic experience that
caused her psychological and physical stress. It was claimed by the informant that at
the year 1984, patient was admitted to City Hospital due to her first stroke attack. That
admission lasts for a week and she was diagnosed to have Cerebro Vascular Accident
or CVA. Her, second attack was on year 1991 at Madonna Hospital Intensive Care Unit
(ICU). After a couple of years from her 2nd admission, patient suffered from persistent
chest pain thus gave way to her third admission at Maria Reyna Hospital the year 2006.
After that admission, patient was given home medications to be maintained which are:
Telmisartan (pritor) 40mg 1 tab/day, Clopidogrel (Plavix) 75mg 1 tab OD, Metroprolol
50mg ½ tab BID, Amniodarone (Cordarone) 200mg 1 tab TID, ASA 80mg 1 tab OD,
Atorvastatin (Lipitor) 80mg 1 TAB OD @ hs, SMN (imdur) 60mg 1 TAB BID.
One year after her third admission patient underwent surgery on her left eye. An
Extra Capsular Cataract Lens Extraction (ECCLE) was done on the year 2007.
History of Present Illness
One week prior to admission patient experienced blurring of vision and headache
which continue until the day of admission. She didn’t do anything because she thought
that it’s just a symptom of her cataract. 3days prior to adm. Client took Isodril for her
moderate chest pains radiating from the left shoulder to her back but wasn’t relieved.
Informant stated that, 1 day prior to admission, patient had shortness of breath with
9

inability to lie flat on bed and the night of the same date (February 4, 2008), patient
noted and complained for moderate chest pain radiating to her left shoulder and back.
On the 5th
day of February 2008, Severe Chest pain suffered by the patient persisted
with difficulty in breathing and shortness of breath which prompt her admission at Maria
Reyna Hospital and was initially diagnosed with Hypertensive Cardiovascular disease.
The client was ruled with the final diagnosis of Acute Coronary Syndrome and was
under the observation and medical treatment of Dr. Alenton.
Chief Complaint
Shortness of breath
10

Developmental Data
GROWTH AND DEVELOPMENT
Patient: Mrs. F
Gender: Female
Age: 81 years old
Psychosocial Theory – Erik Erikson
Erik Erikson’s theory of psychosocial development is one of the best-known
theories of personality in psychology. His theory describes the impact of social
experience across the whole lifespan. In each stage, Erikson believed people
experience a conflict that serves as a turning point in development. In Erikson’s view,
these conflicts are centered on either developing a psychological quality or failing to
develop that quality. During these times, the potential for personal growth is high, but so
is the potential for failure.
In this theory, the patient has the task of Integrity vs. Despair which is the final
task of psychosocial theory which ranges at 65 years old until death. This phase occurs
during old age and is focused on reflecting back on life. Those who are unsuccessful
during this phase will feel that their life has been wasted and will experience many
regrets. The individual will be left with feelings of bitterness and despair. Those who feel
proud of their accomplishments will feel a sense of integrity. Successfully completing
this phase means looking back with few regrets and a general feeling of satisfaction.
These individuals will attain wisdom, even when confronting death.
The patient has developed a feeling of despair. She’s destructed by her worries
for things that might worsen her condition and for things that might happen to her
offspring. Patient was even afraid of facing death because she felt that she hasn’t done
11

her best yet for the future of her grown children for the reason that some of her children
didn’t have a stable job and others were unemployed. Another reason of despair was
that the client wasn’t able to prepare for the current health condition she is experiencing
brought by aging. For instance, the client wasn’t able to prepare by saving or by making
investments that could have had supported her health needs and maintenance.
Normally, it is usually anticipated by any person during younger years when she/he is
still able and strong. She verbalized that these emotions triggered her to have the
disease condition.
Developmental Task theory – Robert Havighurst
Havighurst (1972) defines a developmental task as one that arises at a certain
period in our lives. The successful achievement of which leads to happiness and
success with later tasks while, failure leads to unhappiness, social disapproval, and
difficulty with later tasks. These tasks provide a framework that a nurse can use to
evaluate a person’s general accomplishments. Robert Havighurst believed that learning
is basic to life and that people continue to learn throughout life. He believed that in each
stage in a person’s life, a person has different tasks to be learned.
In later maturity (61+) where the patient belongs, there are six (6) tasks to be learned,
as follows;
1. Adjusting to decreasing physical strength and health.
2. Adjusting to retirement and reduced income.
3. Adjusting to death of a spouse.
4. Adopting and adapting social roles in a flexible way.
5. Establishing satisfactory physical living arrangements.
6. Establishing an explicit affiliation with one’s age group.
These tasks are arranged in chronological order;
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(1) Adjusting to death of a spouse. At an early age of 39, she became a widow and
left with 11 children. This was not an easy situation after the tragic death of her husband
especially raising the kids. Presently, patient is happily married with her second
husband Mr. V.
(2) Adopting and adapting social roles in a flexible way. She used to be the wife of a
vice mayor in their place. She attended most of the social functions her husband was
connected and interact very well to the constituents in the community. She remarried at
age 41 and she didn’t have a child with her present spouse. She was able to adopt her
second marriage for her husband loves her children as his and was also very
supportive.
(3) Adjusted to reduced income. Patient had stopped working at the age of 58. That
was the time when she was admitted in the hospital due to CVD. She used to work in an
eatery but due to her age and physical condition, her children advised her to stay at
home as they were grown up and would support her.
(4) Establishing physical living arrangements with her family. At present, the couple
is no longer working and is supported by the children. They are happily living together in
their house at Baungon, Bukidnon.
(5) Adjusting to decreasing physical strength and health due to her present health
condition and her old age.
(6) Establishing an explicit affiliation with one’s age group. Until now the patient has
casual communication with her age level. She still could recognize some of her friends
during her younger years and at present. Much as she wanted to be with them always
but her health and age condition would not allow anymore.
Interpersonal Theory – Harry Stack Sullivan
Harry Stack Sullivan was an American psychiatrist who extended theory of
personality development to include the significance of interpersonal relationships. He
13

thought that inadequate or nonsatisfying relationships produced anxiety, which he saw
as the basis for all emotional problems.
Sullivan saw interpersonal development as taking place over seven stages, from
infancy to mature adulthood. Personality changes can take place at any time but are
more likely to occur during transitions between stages.
In this theory, the patient falls under the final stage which is the adulthood stage
which starts from 23 years of age. This is the time when a person establishes a stable
relationship with a significant other person and develops a consistent pattern of viewing
the world. The struggles of adulthood include financial security, career, and family. With
success during previous stages, adult relationships and much needed socialization
become easier to attain. Without a solid background, interpersonal conflicts that result
in anxiety become more commonplace.
The patient has developed well according to this theory. In fact, two years after
the death of her first husband, she was able to find herself again, started a new life and
got married with her second husband. She was able to get over her first husbands
death in just 2 years.
The patient can also be considered as having a good coping mechanism
because she was able to adjust to possible crises in life. For instance, though they were
not living a lavish life, but they were able to adopt well a life that suits their resources.
As a couple, they were able to meet their basic needs in life.
14

Medical Management
Doctors Orders
DATE ORDERS RATIONALE
February
05, 2008
2:30 pm
 Pls. admit under the service of Dr.
Alenton.
 To render proper
medical management
 Secure consent to care.  For legal purposes which
pertains to medical
treatment and
procedures.
 Temperature Pulse Respirations q 4
hrs.
 To obtain baseline data.
 Nothing Per Orem temporary  To prevent the risk for
aspiration.
 Start venoclysis with D5W 500cc at
10cc/hr.
 For saline lock;
emergency IVTT drugs
used.
 Labs.
 Complete Blood Count  To check for any
hematologic
unusualities.
 Sodium  To check for serum
sodium content in the
body.
 Potassium  To check for potassium
content in the body.
15

 Creatinine  To check for any tissue
damage.
 Serum Glutamic Pyrovic
Transimenase
 To check for liver
functioning.
 Trop T (quantitative)  To detect and diagnose
Myocardial infarction.
 Creatinine Kinase-MB-stat!  To immediately check for
the degree of infarction
 Electrocardiogram 12 Leads  To monitor cardiac
functioning.
 Chest X-ray –Antero
posterior (portable)
 To detect mediastinal
abnormalities
 Fasting Blood Sugar
=Lipid Profile
 To check for blood sugar
level.
 Med’s.
 Nitroglycerin (Transderm)
patches 5mg now x 12 OD.
 Treatment of Angina
 Aspirin 80mg 4 tabs now then
1 tab OD after(pc) lunch
 Treatment and
prophylaxis of
Myocardial infarction
16

 Clopidrogrel (Plavix)
75g 4 tabs now then
once a day(OD)
 Treatment of patients with acute
coronary syndrome and
myocardial infarction
 Captopril 25g ½ tab
now then three times
a day (BID)
 Treatment for Hypertension
 Fondaparinux
(Arixtra) 2.5mg
Subcutaneous (SQ)
now then OD
 Prevents the formation of
thrombus
 Tramadol (Dolcet) 1
cap now then three
times a day (TID)
 Prophylaxis for pain
 Tramadol (Dolcet) 1
cap now then three
times a day (TID)
 Prophylaxis for pain
 Metoprolol (Neobloc)
80mg 1 tab now then
twice a day (BID)
 Prevention of reinfarction in
 Oxygen inhalation at 2
liters/ minute via nasal
cannula.
 To provide supplemental
oxygen.
 Moderate high back rest  To promote lung expansion
 Complete Bed Rest without
toilet privilege
 To prevent increase workload of
the heart.
 Intake and Output every
shift.
 To determine fluid retention and
dehydration.
17

 Monitor vital signs every
hour and record
 To check for any unusualities
 Will inform Attending
Physician
 For proper management and
care.
 Refer accordingly  To aid for further medical
intervention
5:13pm  Add’s meds.
 Atorvastatin (lipitor)
80mg 1 tab now then
OD at
 Treatment of elevated Low
density lipoprotein
 Lactulose 20cc OD
at hs.
 Prevent Constipation
 Decrease Captopril to
25g ¼ tab now then every
8hour.
 Reduce the risk of hypotension
 Decrease Metoprolol to
50g ½ tab then BID
 Reduce the risk of hypotension
 Start Isoket drip: D5W
90cc +1 amp Isoket at
10cc/hr.
 Treatment for left ventricular
failure secondary to acute
 Repeat ECG 12 Leads
in morning
 For comparison purposes and to
check for the effectivity of drugs
 Increase Aspirin to
80mg 2 tabs OD PC lunch
 To attain drug efficacy level.
 Remove transderm
patch.
 Chest pain subsides; not
needed for treatment.
18

 Attached to cardiac
monitor.
 To monitor cardiac functioning
7:03pm  Ranitidine(Ulcin) 150g 2
tab BID PO
 Treatment for sour stomach in
adults
 May have soft, low salt.
Low fat diet.
 To meet nutritional needs
intended for MI patient
 Shift ranitidine PO to
50mg IVTT q 8hrs.
 For fast drug absorption.
8:07pm  Soft diet  To meet nutritional needs
intended for MI patient.
 12 lead ECG with long
lead 2
 To assess cardiac status
 FBS lipid profile, uric
acid, SGPT in am
 Aid to diagnosed for
hyperglycemia, hyperuricemia
and M.I
 Kalium durule 1 tab
TIDx6 doses.
 Treatment for hypokalemia
10:45pm  Increased Isoket to15cc/hr  To attain drug efficacy level
 Give Tramadol 50mg
IVTT now
 Treatment for moderate to
severe pain
10:50pm  Increased Isoket
to20cc/hr
19

 Increased Isoket
to25cc/hr
11:00pm  Increased Isoket
to30cc/hr
 Give morphine 4mg IVTT
now.
 Relief of moderate to severe
acute pain
11:30pm  Shift ranitidine PO to
50mg IVTT q 8hrs.
 For fast drug absorption
February 06,
2008
6:05 am
 Pls. Follow-up repeat
ECG with long lead 3
care of heart station.
 For continuous monitoring.
 To follow Isoket drip: D5
water 90cc. plus 1 amp.
Isokit at 30cc. / min.
 Left ventricular failure
secondary to acute Myocardial
infarction
 Metformin (Imax)
500mg. 1 tab BID
 Oral treatment for type 2
diabetes
 Isoket drip to consume  To obtain effectivity of
medication
 Imdur 60mg. 1 Tab BID  Prophylaxis and treatment
for angina pectoris.
4:30 pm  IV follow-up with D5
Water 500cc.10cc/hour
 For saline lock; emergency
IVTT drugs used.
 Add 1 banana per meal.  Aid to increase serum
potassium level.
20

February
07,2008
6:05pm
 Limit visitors  To promote rest and
decrease fatigue.
 Facilitate ECG with
long lead 2 in a.m
 For continuous monitoring.
February
08,2008
7:15 am
Summary of meds:
 Isosorbide
Mononitrate
(Imdur) 60mg 1
tab OD
 Left ventricular failure
secondary to acute Myocardial
infarction
 Isosorbide
Dinitrate (Isordil)
5mg 1 tab 5L
PRN for chest
pain
 Treatment and prophylaxis of
 Aspirin 80mg 2
tabs OD PC
lunch
 Treatment of patients with
acute coronary syndrome and
 Clopidrogrel
(Plavix) 750mg 1
tab OD
 Captopril 25mg
¼ tab q 8hrs
 Treatment for hypertension
 Fondaparinux
(Arixtra) 2.5mg
OD SQ
 Prophylaxis of Deep Vein
thrombosis
21

 Metoprolol 50mg
½ tab BID PO
 Prevention of reinfarction in
 Atorvastatin
(lipitor) 80mg 1
tab OD at HS.
 Treatment of elevated Low
density lipoprotein
 Lactulose 20cc
at HS hold for
BM >/= 2x/day
 Prevent constipation
 Metformin
500mg (Imax) 1
tab BID PO
 Oral treatment for Type II
diabetes mellitus
 Ranitidine
Hydrochloride
(Zantac) 150mg
1 tab BID PO
 Prophylaxis for GI irritation
 Increase
Imdur to 60mg 1tab
BID
 To attain drug efficacy level
 Vastaril
MR 1 tab BID
 Prophylaxis and treatment
for Angina pectoris.
 Now give
Isordil q 5 mins for 3
doses of chest pain if
not relieved by first
dose.
 Treatment and prevention of
angina pectoris
2:00pm  IVF to
follow with PNSS 500c
at 10cc/hr.
 For saline lock; emergency
IVTT drugs used.
22

February 9,
2008
1:08am
 Metoclopramide (plazil)
10mg IVTT now
 Prevention of nausea and
vomiting
 Aluminum Magnesium
Hydroxide (maalox)
10ml now then TID
 Treatment for hyperacidity
5:40am  IVF to ff: PNSS 500cc
@ 10cc/hr
 Saline lock; for emergency
IVTT drugs used
8:40am  Repeat ECG today  For comparison purposes
and to check for the
effectiveness of the drug
 Increase Maalox 10ml
to QID before meals
and HS
 Inform IMROD for any
recurrence of chest pain
and SOB
 For further medical
management
4:00pm  Off O2 – may have 02
PRN for dyspnea
 To aid patient during SOB
 200mg Cordarone 1 tab
TID
 Treatment of ventricular
arrhythmias
February
11,2008
 May sit on bed with
dangle legs.
 To determine pt. ability to sit
upright in her own
23

February
12,2008
 Summary of meds
 Aspirin 80mg 2 tabs OD
PC lunch PO
 Treatment and prophylaxis of
 Clopidogrel (Plavix)
75mg 1 tab OD PO
 Captopril 25mg ¼ tab q
8h
 Prophylaxis and treatment for
hypertension
 Fondaparinux (Arixtra)
2.5mg OD SL– Day 7
last dose at 6pm
 Prophylaxis of Deep Vein
thrombosis
 Tramadol(dolcet) 1 tab
TID prn for pain
 Moderate to severe pain
 Metoprolol 50mg ½ tab
BID
 Hypertension , Angina
Pectoris, Prevention of
reinfarction in Myocardial
Infarction
 Atorvastatin (Lipitor)
80mg 1tab OD @ HS
 Treatment of Low density
Lipoproteins
 Lactulose 20cc OD, hold
for BM > 2x/day
 Prevent constipation
 Metformin (I-max)
500mg 1tab BID
 Oral treatment for Type II
diabetes
 Ranitidine (Zantac)
150mg 1tab BID
 Prophylaxis for GI irritation
24

 Isosorbide Mononitrite
(Imdur) 60mg 1tab BID
 Relieve and prevent angina
 Aluminum Magnesium
Hydroxide (Maalox)
10ml QID
 Neutralizes gastric acidity
 Amniodarone
(cordarone) 200mg 1tab
tid
arrhythmias
10:20am  Repeat ECG 12 leads
now
 For comparison purposes
 DIET: decreased fat,
decreased Na,
hypertensive diet
 To prevent hypertension( a
precipitating factor)
 May sit on bedside chair  Ready for ambulation and
slow assumption of activity daily
living.
 May walk @ bedside
with assistance.
 To promote exercise and
prevent sudden orthostatic
hypotension.
7:55pm  ECG 12 lead now  To assess cardiac status
 Give
metoclopramide(Plazil)
10mg IVTT now
vomiting
 Refer for recurrent of
vomiting and save
vomitus care of IMROD
 For ocular inspection.
 May decrease Aspirin
80mg 1 tab OD pc lunch
 To prevent the risk of
bleeding.
25

 Hold Ranitidine  Shift to new drug ordered
Pantoprazole
26

Feb. 13, 2008  Start Pantoprazole
(Pantoloc) 20mg 1 tab
now then O.D P.O
 Prophylaxis for epigastric
hyperacidity
12:55p.m  May walk inside the
ward.
 To promote exercise, and
improved blood circulation
 B/P and Cardiac rate
after walking.
 To monitor cardiac changes
when doing certain activities.
Feb. 14, 2008
8:10p.m
 Discontinue Maalox  Epigastric hyperacidity
subsides.
 May walk to the
bathroom with
assistance
 Enhances self care and
prevent from sudden orthostatic
hypotension
 Give Domperidone
(Motilium) 1 tab am then
BID.
 Treatment for flatulence
Feb.15, 2008
8:00am
 I.V.F to consume then
discontinue
 Patient’s fluid status is stable,
and in preparation for patients
may go home.
 May walk inside the
ward
 To promote exercise and
blood circulation.
 B/P and Cardiac rate
after walking and record
 To monitor cardiac changes
when doing certain activities.
27

12:30pm  Metoclopramide (plazil)
10mg. IVTT every 8
hours prn
vomiting
Feb. 16,2008
11:02 am
 MGH  Patient may continue
treatment at home
 Home medications  For treatment compliance
regimen.
 Telmisartan
(Priton)40mg 1
tab O.D
 Treatment of essential
Hypertension
 Clopidogrel
(Plavix) 75mg 1
tab O.D
 Treatment of patients
with acute coronary syndrome
and Myocardial infarction
 Metoprolol 50mg
½ tab BID
o Treatment for
hypertension
 Atorvastatin
(Lipitor) 80mg 1
tab OD @ H.S
for hyperlipidemia
 ISMN (Imdur)
60mg 1 tab BID
for Angina pectoris
 Amniodarone
(Cordarone)
200mg 1 tab TID
arrhythmias
 Aspirin 80mg 1
tab OD pc lunch
 Prophylaxis for MI
 Metformin (Imax)  Treatment for Type II
28

500mg 1 tab BID diabetes mellitus
 Day Feb.20, 2008 at
MRH clinic follow-up
check-up.
 To evaluate for the
effectiveness of medical and
nursing care.
 Photocopy all labs.
Results (2copies)
 For legal and
documentation purposes.
Blood Chemistry
02-05-08
Test Normal Range Results Implications
Creatinine .7 - 1.2 1.3 mg/dl Myocardial Infarction
Na 137 – 145 132 mmol/L Hyponatremia
K 3.5 – 5.1 3.4 mmol/L Hypokalemia
ALT 9 – 52 3.0 u/L liver functioning
decrease r/t drugs
adverse effect and
gerontologic
consideration
CK-MB 0 – 18 7 u/L
29

Differential Count
02-05-08
Segmenters 55 – 65 % 46 Suggest anemia
Lymphocytes 25 – 35 % 53 Anemia
Eosinophils 1 – 3 % 01 Reduced in Stress
Hematology
02-05-08
HCT 35 – 50 % 29.4 Iron Deficiency
Anemia
HGB 11 – 16.5 g/dl 9.8 Iron Deficiency
Anemia
RBC 3.8 – 5.80 10/mm
WBC 5 – 10 10/mm 9,100
Platelet Count 140,000 – 440,000 333,000
30

Chest x-ray Report
02-05-08
Examination Desired: CCXR Port
 Haziness seen in the left base
 Heart I magnified
 Aorta is calcified
 Spurs seen at the margins of the thoracic spine.
Impression:
 Probable left basal Pneumonia
 Atherosclerotic Aorta
 Thoracic Spondylosis
31

Fasting Blood Sugar Lipid Profile
02-06-08
Glucose 74 – 106 132 mg/dL Hyperglycemia
Uric Acid 2.5 – 6.2 8.4 mg/dL Hyperuricemia,
Cholesterol 0 – 200 187 mg/dL Hypercholesterolemia
Triglycerides 0 – 150 60 mg/dL Atherosclerosis
Direct HGL 40 – 60 38 mg/dL
LDL 60 – 180 137 mg/dL
VDRL 25 – 50 12 mg/dL
ALT 8 - 52 27 U/L
Troponin T (Quantitative)
 2.0 ng/ml
02-06-08
Interpretation of Results Rationale
1. < 0.03 ng/ml Low Cardiac Risk
2. Between 0.03 ng/ml &0.1 ng/ml Medium Cardiac Risk (Possible
Myocardial damage)
3. Between 0.1 ng/ml & 3.0 ng/ml High Risk (Myocardial damage
detected)
4. > 2.0 ng/ml Massive Myocardial damage has
been detected
32

HGT (Hemoglucotest)
02-08-08
 94 mg/dL (N)
IVF Sheet
02-05-08
Bottle # Types of Solution Running hours
gtts/min
Time Started Rationale
1 D5W 500cc 10 cc/hr 2:45 PM Isotonic solution
2 D5W 90cc + 1 amp
Isoket
10 cc/hr + 1 amp 3:25 PM Isotonic solution
3 PNSS 500cc 10 cc/hr Isotonic solution
4 PNSS 500cc 10 cc/hr 2:45 PM Isotonic solution
5 PNSS 500cc 10 cc/hr Isotonic solution
33

Electrocardiograph tracing
ECG findings
Rhythm Sinus Axis +39
Rate: Atrial 93bpm Ventricular 93bpm Position
P.R. 0.20sec Q.R.S 0.10sec Q.T. 0.44sec Q.T. Ratio
ECG Diagnosis
- sinus rhythm
- inferolateral and anterior wall ischemia
34

ECG findings
Rhythm sinus Axis +10
Rate: Atrial 93bpm Ventricular 93bpm Position
P.R. 0.20 sec Q.R.S. 0.08 sec Q.T. 0.44 sec
ECG Diagnosis
- sinus rhythm
- anterolateral wall ischemia
- left ventricular hypertrophy by voltage criteria
35

Pathophysiology with Anatomy and Physiology
A. Review of Anatomy and Physiology of the Organs Involved
Cardiovascular System
Heart
For all its might, the cone-shaped heart is a relatively small, roughly the same
size as a closed fist—about 12 cm (5 in) long, 9 cm (3.5 in) wide at its broadest point,
and 6 cm (2.5 in) thick. Its mass averages 250 g (8 oz) in adult females and 300 g (10
oz) in adult males. The heart rests on the diaphragm, near the midline of the thoracic
cavity. It lies in the mediastinum, a mass of tissue that extends from the sternum to the
vertebral column between the lungs. About two-thirds of the mass of the heart lies to the
left of the body’s midline. Visualize the heart as a cone lying on its side. The pointed
end of the heart is the apex, which is directed anteriorly, inferiorly, and to the left. The
broad portion of the heart opposite the apex is the base, which is directed posteriorly,
superiorly, and to the right.
In addition to the apex and the base, the heart has several surfaces and borders
9margins). The anterior surface is deep to the sternum and ribs. The inferior surface is
the part of the heart between the apex and the right border and rests mostly on the
diaphragm. The right border faces the right lung and extends from the inferior surface to
the base. The left border, also called the pulmonary border, faces the left lung and
extends from the base to the apex.
36

Layers and Coverings of the Heart
The heart is located between the lungs in the thoracic cavity and is surrounded
and protected by the pericardium (peri- _ around). The pericardium consists of an outer,
tough fibrous pericardium and an inner, delicate serous pericardium. The fibrous
pericardium attaches to the diaphragm and also to the great vessels of the heart. Like
all serous membranes, the serous pericardium is a double membrane composed of an
outer parietal layer and an inner visceral layer. Between these two layers is the
pericardial cavity filled with serous fluid. The wall of the heart has three layers: the outer
epicardium (epi- _ on, upon; cardia _ heart), the middle myocardium (myo muscle), and
the inner endocardium (endo- _ within, inward). The epicardium is the visceral layer of
the pericardium. The majority of the heart is myocardium or cardiac muscle tissue. The
endocardium is a thin layer of endothelium deep to the myocardium that lines the
chambers of the heart and the valves.
Surface Structures of the Heart
The human heart has four chambers and is divided into right and left sides. Each
side has an upper chamber called an atrium and a lower chamber called a ventricle.
The two atria form the base of the heart and the tip of the left ventricle forms the apex.
Auricles (auricle _ little ear) are pouch-like extensions of the atria with wrinkled edges.
Shallow grooves called sulci (sulcus, singular) externally mark the boundaries between
37

the four heart chambers. Although a considerable amount of external adipose tissue is
present on the heart surface for cushioning, most heart models do not show this.
Cardiac muscle tissue that composes the heart walls has its own blood supply and
circulation, the coronary (corona_ crown) circulation. Coronary blood vessels
encompass the heart similar to a crown and are found in sulci. On the anterior surface
of the heart, the right and left coronary arteries branch off the base of the ascending
aorta just superior to the aortic semilunar valve, and travel in the sulcus separating the
atria and ventricles. These small arteries are supplied with blood when the ventricles
are resting. When the ventricles contract, the cusps of the aortic valve open to cover the
openings to the coronary arteries.
A clinically important branch of the left coronary artery is the anterior interventricular
branch, also known as the left anterior descending (LAD) branch that lies between the
right and left ventricles and supplies both ventricles with oxygen-rich blood. This
coronary artery is commonly occluded which can result in a myocardial infarct and, at
times, death.
Great Vessels of the Heart
The great veins of the heart return blood to the atria and the great arteries carry
blood away from the ventricles. The superior vena cava, inferior vena cava, and
coronary sinus return oxygen-poor blood to the right atrium. The superior vena cava
returns blood from the head, neck, and arms; the inferior vena cava returns blood from
the body inferior to the heart. The coronary sinus is a smaller vein that returns blood
from the coronary circulation. Blood leaves the right atrium to enter the right ventricle.
From here, oxygen-poor blood passes out the pulmonary trunk, the only vessel that
removes blood from the right ventricle. This large artery divides into the right and left
pulmonary arteries that carry blood to the lungs where it is oxygenated. Oxygen-rich
blood returns to the left atrium through two right and two left pulmonary veins. The blood
then passes into the left ventricle that pumps blood into the large aorta. The aorta
distributes blood to the systemic circulation. The aorta begins as a short ascending
aorta, curves to the left to form the aortic arch, descends posteriorly and continues as
the descending aorta.
38

Internal Structures of the Heart
The heart has four valves that control the one-way flow of blood: two
atrioventricular (AV) valves and two semilunar valves (semi- _ half; lunar _ moon).
Blood passing between the right atrium and the right ventricle goes through the right AV
valve, the tricuspid valve (tri _ three; cusp _ flap). The left AV valve, the bicuspid valve,
is between the left atrium and the left ventricle. This valve clinically is called the mitral
valve (miter _ tall, liturgical headdress) because the open valve resembles a bishop’s
headdress. String-like cords called chordae tendineae (tendinous strands) attach and
secure the cusps of the AV valves to enlarged papillary muscles that project from the
ventricular walls. Chordae tendinae allow the AV valves to close during ventricular
contraction, but prevent their cusps from getting pushed up into the atria. The two
semilunar valves allow blood to flow from the ventricles to great arteries and exit the
heart. Blood in the right ventricle goes through the pulmonary (semilunar) valve to enter
the pulmonary trunk, a large artery. The aortic (semilunar) valve is located between the
left ventricle and the aorta. These two semilunar valves are identical, with each having
three pockets that fill with blood, preventing blood from flowing back into the ventricles.
The two ventricles have a thick wall between them called the interventricular septum.
Between the two atria is a thinner interatrial septum.
Coronary Circulation
There are two major coronary arteries: the right and the left. These two arteries
branch out of the aorta immediately after the aortic valve. The right coronary artery
splits into the marginal branch, which feeds blood into the right ventricle, and the
posterior interventricular branch, which supplies the left ventricle. The left coronary
artery is notably larger than the right coronary artery because it feeds the left heart,
which, as a result of it's more powerful contractions, requires a more vigorous blood
flow. The left coronary artery splits into the anterior interventricular branch and a
circumflex branch. The anterior interventricular branch runs towards the apex of the
39

heart, providing blood for both of the ventricles and the ventricular septum. The
circumflex branch, on the other hand, follows the groove between the left atrium and the
left ventricle, providing blood supply to both of these chambers until it reaches and joins
with the right coronary artery in the posterior of the heart.
The coronary arteries are especially subject to blockage and narrowing which
can cause a depletion of blood to certain parts of the heart, possibly causing a heart
attack.
Blood Flow through the Heart
The function of the right side of the heart is to collect de-oxygenated blood, in the
right atrium, from the body and pump it, via the right ventricle, into the lungs (pulmonary
circulation) so that carbon dioxide can be dropped off and oxygen picked up (gas
exchange). This happens through the passive process of diffusion. The left side (see left
heart) collects oxygenated blood from the lungs into the left atrium. From the left atrium
the blood moves to the left ventricle which pumps it out to the body. On both sides, the
lower ventricles are thicker and stronger than the upper atria. The muscle wall
surrounding the left ventricle is thicker than the wall surrounding the right ventricle due
to the higher force needed to pump the blood through the systemic circulation.
Starting in the right atrium, the blood flows through the tricuspid valve to the right
ventricle. Here it is pumped out the pulmonary semilunar valve and travels through the
pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein
to the left atrium. It then travels through the mitral valve to the left ventricle, from where
it is pumped through the aortic semilunar valve to the aorta. The aorta forks, and the
blood is divided between major arteries which supply the upper and lower body. The
blood travels in the arteries to the smaller arterioles, then finally to the tiny capillaries
which feed each cell. The (relatively) deoxygenated blood then travels to the venules,
which coalesce into veins, then to the inferior and superior venae cavae and finally back
to the right atrium where the process began.
40

Blood Vessels
Blood circulates inside the blood vessels, which form a closed transport system,
the so-called vascular system. Like a system of roads, the vascular system has its
freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the
large arteries leaving the heart. It then moves successively smaller and smaller arteries
and then into the arterioles, which feed the capillary beds in the tissues. Capillary beds
are drained by venules, which in turn empty into the great veins (venae cavae) entering
the heart. Thus arteries, which carry blood away from the heart, and veins, which drain
the tissues and return the blood to the heart, are simply conducting vessels. Only the
tiny hair-like capillaries, which extend and branch through the tissue and connect the
smallest arteries (arterioles) to the smallest veins (venules), directly serve the needs of
the body cells. The capillaries are the side streets or alleys that intimately intertwine
among the body cells. It is only through their walls that exchanges between the tissue
cells and the blood can occur. (Marieb, 2006)
41

Layers of Blood Vessel Walls
The walls of blood vessels have three coats, or tunics. The tunica intima which
lines the lumen or interior of the blood vessels, is a thin layer of endothelium (squamous
epithelial cells) resting on a basement membrane. Its cells fit closely together and form
a slick surface that decreases friction as blood flows through the vessel lumen. (Marieb,
2006)
The tunica media is the bulky middle coat. It is mostly smooth muscle and elastic
tissue. The smooth muscle, which is controlled by the sympathetic nervous system, is
active in changing the diameter of the vessels. As the vessel constrict or dilate, blood
pressure increases or decreases, respectively. Marieb, 2006)
The tunica externa is the outermost tunic; it is composed largely of fibrous
connective tissue. Its function is basically to support and protect the vessels. (Marieb,
2006)
42

The Microcirculation
The microcirculation is that portion of the circulatory system for exchange of
water, gases, nutrients, and waste material. As such, it is the most important part of the
cardiovascular system because it is where the exchange with tissues takes place.
Although the microcirculation is considered as a closed system, its walls are much more
permeable than any other part of the circulation.
Factors Affecting Flow of Blood
The flow of a fluid through a vessel is determined by the pressure difference
between the two ends of the vessel and also the resistance to flow.
• Pressure Difference. For any fluid to flow along a vessel there must be a
pressure difference otherwise the fluid will not move. In the cardiovascular
system, the “pressure head” or force is generated by the pumping of the heart
and there is a continuous drop in pressure from the left ventricle to the tissue and
also from the tissue back to the right atrium. (Hinchliff, 2000)
• Resistance to Flow. Resistance is a measure of the ease with which a fluid
flows through a tube: the easier it is the less resistance to flow, and vice versa. In
the circulatory system, the resistance is usually described as vascular resistance,
43

or also known as peripheral resistance. Resistance is essentially a measure of
the friction between the molecules of the fluid, and between the tube wall and the
fluid. The resistance depends on the viscosity of the fluid and the radius and
length of the tube. (Hinchliff, 2000)
• Radius of the Tube. The smaller the radius of a vessel, the greater is the
resistance to the movement of particles. Small alterations in the size of the radius
of the blood vessels, particularly of the more peripheral vessels, can greatly
influence the flow of blood. Atheromatous changes in the walls of large and
medium-sized arteries cause narrowing of the lumen of the vessels and result in
an increased vascular resistance. (Hinchliff, 2000)
• Length of the Tube. The longer the tube, the greater the resistance to the flow
of liquid through it. A longer vessel will require a greater pressure to force a given
volume of liquid through it than will a shorter vessel. (Hinchliff, 2000)
• Viscosity of the Fluid. Viscosity is a measure of the intermolecular or internal
friction within a fluid or in other words, of the tendency of the fluid to resist flows.
The greater the viscosity of the fluid, the greater is the force required to move
that liquid. (Hinchliff, 2000)
Blood
Blood is a specialized bodily fluid (technically a tissue) that is composed of a
liquid called blood plasma and blood cells suspended within the plasma. The blood cells
present in blood are red blood cells (also called RBCs or erythrocytes), white blood cells
(including both leukocytes and lymphocytes) and platelets (also called thrombocytes).
Plasma is predominantly water containing dissolved proteins, salts and many other
substances; and makes up about 55% of blood by volume. Mammals have red blood,
which is bright red when oxygenated, due to hemoglobin. Some animals, such as the
horseshoe crab use hemocyanin to carry oxygen, instead of hemoglobin.
44

By far the most abundant cells in blood are red blood cells. These contain hemoglobin,
an iron-containing protein, which facilitates transportation of oxygen by reversibly
binding to this respiratory gas and greatly increasing its solubility in blood. In contrast,
carbon dioxide is almost entirely transported extracellularly dissolved in plasma as
bicarbonate ion. White blood cells help to resist infections and parasites, and platelets
are important in the clotting of blood.
Blood is circulated around the body through blood vessels by the pumping action of the
heart. Arterial blood carries oxygen from inhaled air to the tissues of the body, and
venous blood carries carbon dioxide, a waste product of metabolism produced by cells,
from the tissues to the lungs to be exhaled.
Medical terms related to blood often begin with hemo- or hemato- (BE: haemo- and
haemato-) from the Greek word "α μαἷ " for "blood." Anatomically and histologically, blood
is considered a specialized form of connective tissue, given its origin in the bones and
the presence of potential molecular fibers in the form of fibrinogen.
Constituents of human blood
Blood accounts for 7% of the human body weight, with an average density of
approximately 1060 kg/m³, very close to pure water's density of 1000 kg/m3
. The
average adult has a blood volume of roughly 5 litres, composed of plasma and several
kinds of cells (occasionally called corpuscles); these formed elements of the blood are
erythrocytes (red blood cells), leukocytes (white blood cells) and thrombocytes
(platelets). By volume the red blood cells constitute about 45% of whole blood, the
plasma constitutes about 55%, and white cells constitute a minute volume.
Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics; its flow
properties are adapted to flow effectively through tiny capillary blood vessels with less
resistance than plasma by itself. In addition, if all human haemoglobin was free in the
plasma rather than being contained in RBCs, the circulatory fluid would be too viscous
for the cardiovascular system to function effectvely.
45

Cells
4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In
mammals, mature red blood cells lack a nucleus and organelles. They contain the
blood's hemoglobin and distribute oxygen. The red blood cells (together with endothelial
vessel cells and other cells) are also marked by glycoproteins that define the different
blood types. The proportion of blood occupied by red blood cells is referred to as the
hematocrit, and is normally about 45%. The combined surface area of all the red cells in
the human body would be roughly 2,000 times as great as the body's exterior surface.
4,000-11,000 leukocytes: White blood cells are part of the immune system;
they destroy and remove old or aberrant cells and cellular debris, as well as attack
infectious agents (pathogens) and foreign substances. The cancer of leukocytes is
called leukemia.
200,000-500,000 thrombocytes: Platelets are responsible for blood clotting
(coagulation). They change fibrinogen into fibrin. This fibrin creates a mesh onto which
red blood cells collect and clot, which then stops more blood from leaving the body and
also helps to prevent bacteria from entering the body.
Plasma
About 55% of whole blood is blood plasma, a fluid that is the blood's liquid
medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.7-
3.0 litres in an average human. It is essentially an aqueous solution containing 92%
water, 8% blood plasma proteins, and trace amounts of other materials. Plasma
circulates dissolved nutrients, such as, glucose, amino acids and fatty acids (dissolved
in the blood or bound to plasma proteins), and removes waste products, such as,
carbon dioxide, urea and lactirc acid.
Other important components include:
46

• Serum albumin
• Blood clotting factors (to facilitate coagulation)
• Immunoglobulins (antibodies)
• Various other proteins
• Various electrolytes (mainly sodium and chloride)
The term serum refers to plasma from which the clotting proteins have been removed.
Most of the proteins remaining are albumin and immunoglobulins.
The normal pH of human arterial blood is approximately 7.40 (normal range is 7.35-
7.45), a weak alkaline solution. Blood that has a pH below 7.35 is too acidic, while blood
pH above 7.45 is too alkaline. Blood pH, arterial oxygen tension (PaO2), arterial carbon
dioxide tension (PaCO2) and HCO3 are carefully regulated by complex systems of
homeostasis, which influence the respiratory system and the urinary system in the
control the acid-base balance and respiration. Plasma also circulates hormones
transmitting their messages to various tissues.
Color
Hemoglobin
Hemoglobin is the principal determinant of the color of blood in vertebrates. Each
molecule has four heme groups, and their interaction with various molecules alters the
exact color. In vertebrates and other hemoglobin-using creatures, arterial blood and
capillary blood are bright red as oxygen impacts a strong red color to the heme group.
Deoxygenated blood is a darker shade of red with a bluish hue; this is present in veins,
and can be seen during blood donation and when venous blood samples are taken.
Blood in carbon monoxide poisoning is bright red, because carbon monoxide causes
the formation of carboxyhemoglobin. In cyanide poisoning, the body cannot utilize
oxygen, so the venous blood remains oxygenated, increasing the redness. While
hemoglobin containing blood is never blue, there are several conditions and diseases
where the color of the heme groups make the skin appear blue. If the heme is oxidized,
47

methemoglobin, which is more brownish and cannot transport oxygen, is formed. In the
rare condition sulfhemoglobinemia, arterial hemoglobin is partially oxygenated, and
appears dark-red with a bluish hue (cyanosis), but not quite as blueish as venous blood.
Veins in the skin appear blue for a variety of reasons only weakly dependent on the
color of the blood. Light scattering in the skin, and the visual processing of color play
roles as well.
Skinks in the genus Prasinohaema have green blood due to a buildup of the waste
product biliverdin.
Hemocyanin
The blood of most molluscs, including cephalopods and gastropods, as well as
some arthropods such as horseshoe crabs contains the copper-containing protein
hemocyanin at concentrations of about 50 grams per litre. Hemocyanin is colourless
when deoxygenated and dark blue when oxygenated. The blood in the circulation of
these creatures, which generally live in cold environments with low oxygen tensions, is
grey-white to pale yellow, and it turns dark blue when exposed to the oxygen in the air,
as seen when they bleed. This is due to change in color of hemocyanin when is it
oxidized. Hemocyanin carries oxygen in extracellular fluid, which is in contrast to the
intracellular oxygen transport in mammals by hemoglobin in RBCs.
Pancreatic Islets
The pancreas, located close to the stomach in the abdominal cavity is a mixed
gland. Probably the best-hidden endocrine glands in the body are the pancreatic islets,
formerly called the islets of Langerhans. These little masses of hormone-producing
tissue are scattered among the enzyme-producing acinar tissue of the pancreas. Two
important hormones produced by the islet cells are insulin and glucagons. (Marieb,
2006)
48

High levels of glucose in the blood stimulate the release of insulin from the beta
cells of the islets. Insulin acts on just about all body cells and increases their ability to
transport glucose across their plasma membranes. Once inside the cells, glucose is
oxidized for energy or converted to glycogen or fat for storage. These activities are also
speeded up by insulin. Since insulin sweeps the glucose out of the blood, its effect is
said to be hypoglycemic. As blood glucose levels fall, the stimulus for insulin release
ends (negative feedback control). Insulin is the only hormone that decreases blood
glucose levels. Insulin is absolutely necessary for the use of glucose by the body cells.
Without it, essentially no glucose can get into the cells to be used. (Marieb, 2006)
Glucagons act as an antagonist of insulin; that is, it helps to regulate blood
glucose levels but is a way opposite to that of insulin. Its release by the alpha cells of
the islets is stimulated by low blood levels of glucose. Its action is basically
hyperglycemic. Its primary target organ is the liver, which stimulates to break down
stored glycogen to glucose and to release glucose into the blood. (Marieb, 2006)
Insulin
The main function of the insulin is to participate in maintaining homeostasis of
blood glucose level and to promote other metabolic activities that are anabolic. When
absorbed nutrients, especially glucose, are in excess of immediate needs insulin
promotes storage. It reduces high blood nutrients by:
49

Acting on cell membranes and stimulating uptake and utilization of glucose by muscles
and connective tissue cells;
Increasing conversion of glucose to glycogen, especially in the liver and skeletal
muscles;
Accelerating uptake of amino acids by cells, and the synthesis of proteins;
Promoting synthesis of fatty acids and storage of fat in adipose tissue, and; Preventing
the breakdown of protein and fat and gluconeogenesis.
Glucagon
The effect of glucagon is increasing blood glucose levels by stimulating:
Conversion of glycogen to glucose (in the liver and skeletal muscle);
Gluconeogenesis, the manufacture of glucose by the body from noncarbohydrate
materials. (Burke, 1995)
Somatostatin
The effect of somatostatin (also produced by hypothalamus) is to inhibit the
secretion of both insulin and glucagons. It delays intestinal absorption of glucose.
(Smeltzer, 2007)
Metabolism
Metabolism is a broad term referring to all chemical reactions that are necessary
to maintain life. In involves catabolism, in which substances are broken down to simpler
substances, and anabolism, in which larger molecules or structures are built from
smaller ones. During catabolism, energy is released and captured to make ATP, the
energy-rich molecule used to energize all cellular activities, including catabolic
reactions. (Marieb, 2006)
50

Just as an oil furnace uses oil (its fuel) to produce heat, the cells of the body use
carbohydrates as their preferred fuel to produce cellular energy (ATP). Glucose, also
known as blood sugar, is the major breakdown product of carbohydrate digestion.
Glucose is also the major fuel used for making ATP in most body cells. Basically, the
carbon atoms released leave the cells as carbon dioxide, and the hydrogen atoms
removed (which contain energy-rich electrons) are eventually combined with oxygen to
form water. These oxygen-using events are referred to collectively as cellular
respiration. (Marieb, 2006) The overall reaction is summed up simply as:
C6H12O6 + 6 O2 => 6 CO2 + 6 H20 + ATP (energy).
51

Nursing Assessment (System Review and Nursing
Assessment II)
57

Nursing Management
Ideal Nursing Management
Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular
resistance, vasoconstriction
Actions/Interventions Rationale
Independent
Provide calm, restful surroundings,
minimize environmental activity/noise.
Limit the number of visitors and length
of stay.
Help reduce sympathetic stimulation;
promotes relaxation.
Maintain activity restrictions, e.g.
bedrest/chair rest; schedule periods of
uninterrupted rest; assist client with
self-care activities as needed.
Reduces physical stress and tension
that affect blood pressure and the
course of hypertension.
Provide comfort measures, e.g. back
and neck massage, elevation of head.
Decreases discomfort and may reduce
sympathetic stimulation.
Instruct in relaxation techniques,
guided imagery, distractions.
Can reduce stressful stimuli, promotes
relaxation.
Maintain activity restrictions, e.g.
bedrest/chair rest; schedule periods of
uninterrupted rest; assist client with
self-care activities as needed.
Reduces physical stress and tension
that affect blood pressure and the
course of hypertension
Provide comfort measures, e.g. back
and neck massage, elevation of head.
Decreases discomfort and may reduce
sympathetic stimulation.
Instruct in relaxation techniques,
guided imagery, distractions
Can reduce stressful stimuli, produce
calming effect, thereby reducing BP
Dependent
58

Administer medications as indicated;
Thiazide diuretics, e.g. chlorothiazide
(Diuril); hydrochlorothiazide
(Esidrix/HydroDIURIL);
bendroflumethiazide (naturetin);
indapamide (Lozol); metolazone
(Diulol); quenthinazone (Hydromox)
Diuretics are considered first-line
medications for uncomplicated stage I
or II hypertension and may be used
alone or in association with other drugs
(such as β-blockers) to reduce BP in
clients with relatively normal renal
function. These diuretics potentiate the
effects of other antihypertensive agents
as well, by limiting fluid retention, and
may reduce the incidence of strokes
and heart failure
Nursing Diagnosis: Activity intolerance related to generalized weakness
Independent
Instruct client in energy- conserving
techniques e.g., suing chair when
showering, sitting to brush teethe or
comb hair, carrying out activates at a
slower pace
Energy-saving techniques reduce the
energy expenditure thereby assisting in
equalization of oxygen supply and
demand
Encourage progressive activity/self-
0care when tolerated. Provide
assistance as needed.
Gradual activity progression prevents a
sudden increase in cardiac workload.
Providing assistance only as needed
encourages independence in
performing activities
Nursing Diagnoses: Risk for impaired Gas Exchange related to alveolar-capillary
membrane changes, e.g. fluid collection/shifts into interstitial space/alveoli
Independent
Encourage frequent position changes Helps prevent atelectasis and
pneumonia
Maintain chair/bed rest, with head of
bed elevated 20-30 degrees, semi-
Reduce oxygen consumption/demands
59

fowler’s position. Support arms with
pillows
and promotes maximal lung inflation.
Dependent
Administer supplemental oxygen as
indicated
INcre4ases alveolar oxygen
concentration, which may
correct/reduce tissue hypoxemia.
Nursing Diagnosis: Knowledge deficit related to Lack of information/misunderstanding of
medical condition/therapy needs.
Independent
be alert to signs of avoidance, e.g.,
changing subject away from
information being presented or
extremes of behavior
Natural defenses mechanisms, such as
anger or denial of significance of
situation, can block learning, affecting
patient’s responses and ability to
assimilate information.
Encourage identification/reduction of
individual risk factors, e.g.,
smoking/alcohol consumption, obesity.
these behaviors/chemicals have direct
adverse effect on cardiovascular
function and may impede recovery,
increase risk for complications
Educate client regarding gradual
resumption of activities (walking, work,
recreational activity.
Gradual increase in activity increases
strength and prevents overexertion,
may enhance, collateral circulation, and
allows return to normal lifestyle.
Emphasizes importance of contacting
physician if chest pain, change in
anginal pattern or other symptoms
recur.
Timely evaluation/intervention may
prevent complications.
Stress importance of reporting
development of fever in association
w3ith diffuse/atypical chest pain and
joint pain
post MI-complication of pericardial
inflammation requires further medical
evaluation/intervention.
60

Nursing diagnosis: Ineffective coping related to situational crisis
Actions/Intervention Rationale
Independent
Encourage patient to talk about what is
happening at this time and what has
occurred to precipitate feelings of
helplessness and anxiety.
Provides clues to assist patient to
develop coping and regain equilibrium.
Allow patient to be dependent in the
beginning, with gradual resumption of
independence in ADLs. Self-care and
other activities. Make opportunities for
patient to make simple decisions about
care/other activities when possible,
accepting choice not to do so.
Promotes feelings of security (patient
will know nurse will provide safety). As
control is regained, patient has the
opportunity to develop adaptive
coping/problem-solving skills.
Accept verbal expressions or anger,
setting limits on maladaptive behavior
Verbalizing angry feelings in important
process for resolution of grief and loss.
However, preventing destructive
actions (such as striking out at others)
preserves patient’s self-esteem.
Discuss feelings of inability to find
meaning in life/reason for living,
feelings of futility or alienation from
God.
Crisis situation may evoke, questioning
of spiritual beliefs, affecting ability to
cope with current situation and plan for
the future.
Promote safe and hopeful environment,
as needed. Identify positive aspects of
this experience and assist patient to
view it as a learning opportunity.
May be helpful while patient regains
inner control. The ability to learn from
the current situation can provide skills
for moving forward
Provide support for patient to problem-
solve solutions for current situation.
Provide information and reinforce
reality as patient begins to ask
questions; look at what is happening.
Helping/SO to brainstorm possible
solutions (giving consideration to the
pros and cons of each) promotes
feelings of self-control/esteem.
61

Provide for gradual implementation and
continuation of necessary behavior and
lifestly changes. Reinforce positive
adaptation/ new coping behaviors
Reduces anxiety of sudden change and
allows for developing new and creative
solutions
Dependent
Refer to other resources as necessary
(eg. Clergy, psychiatric clinical nurse
specialist/psychiatrist, family/ marital
therapist, addiction support groups).
Additional assistance may be needed
to help patient resolve problems or
make decisions.
Nursing Diagnosis: Family Coping, ineffective: risk for compromised related to
prolonged disease/disability progression that exhausts the supportive capacity of family
members.
Independent
Evaluate pre-illness/current behaviors
that may be interfering with the
care/recovery of client
Information about family problems
(e.g., divorce/ separation, financial
limitations, substance use) will be
helpful in determining options and
developing an appropriate plan of care.
Discuss underlying reasons for patient
behaviors with family.
When family members know why
patient is behaving in different ways, it
helps them understand and accept/deal
with situation
Assist family/patient to understand
“who owns the problem” and who is
responsible for resolution. Avoid
balance blame or guilt.
When these boundaries are defined,
each individual can begin to take care
of own self and stop taking care of
others in inappropriate ways.
Involve family in information giving,
problem solving and care of patient as
feasible. Identify other ways of
demonstrating support while
maintaining patient’s independence
Information can reduce feelings of
helplessness. Involvement in care
enhances feelings of control and self
worth
Dependent
62

Refer to appropriate resources for
assistance as indicated (e.g.
counseling, psychotherapy, financial,
spiritual).
May need additional assistance in
resolving family issues.
Nursing Diagnosis: Therapeutic Regimen: risk for ineffective management related to
perceived barriers; economic difficulties, side effects of therapy, mistrust of regimen
and/or healthcare personnel; complexity of healthcare system.
Action/Intervention Rationale
Independent
Review patients/SO’s knowledge and
understanding of the need for
treatment/medication, as well as
consequences of the need for
treatment/medication, as well as
consequences of actions and choices.
Not ability to comprehend information,
including literacy, level of education,
primary language.
Provides opportunities to clarify
viewpoints/misconceptions. Verifies
that patient/SO has accurate/ factual
information with which to make
informed choices.
Be aware of developmental and
chronological age.
Impacts ability to understand own
needs/incorporate into treatment
regimen.
Determine cultural, spiritual, and health
beliefs and ethical concerns
.
Provide insight into thoughts/factors
related to individual situation. Beliefs
will affect patient’s perception of
situation and participation in treatment
regimen. Treatment may be
incongruent with patient’s
social/cultural lifestyle and perceived
role/responsibilities
63

Nursing Diagnosis: Pain related to an imbalance in oxygen supply and demand
Action/Interventions Rationale
 Position patient in bed in semi-
fowler’s position
>this allows for rest and adequate
chest excursion, to increase available
oxygen and to decrease cardiac work.
 Administer oxygen by way of
nasal cannula at 4L/min.
maintain oxygen saturation at
92% or above.
>to increase oxygen supply. May
decrease pain and PVCs
 Administer nitroglycerin and
morphine based on vital signs
and pain relief.
> both medications will help alleviate
pain by decreasing venous return to the
heart, thereby decreasing cardiac work.
Morphine will also help to decrease the
patients sensation of pain.
 Monitor BP closely by way of
non-invasive BP monitor.
>both medications may decrease BP
because both will decrease venous
return. Intra-arterial blood pressure
monitoring may be used if condition
warrants.
 Attach electrodes for continuous
bedside cardiac monitor. Monitor
heart rate and rhythm frequently.
>increased rate may indicate heart
block; dysrhythmias are common
initially, increased frequency suggests
ischemia.
 Administer and monitor
thrombolytic therapy
>may help to relieve the coronary
occlusion.
 Monitor signs of bleeding; avoid
unnecessary venous or arterial
punctures.
>thrombolytics cause clot lysis may
cause bleeding.
64

Nursing Diagnosis: decreased cardiac output related to decreased cardiac contractility
and dysrrhythmias.
 Actions/ Interventions Rationales
 Administer I.V fluids as ordered >I.V fluid may be necessary to
compensate for the decreased venous
return caused by nitrates and
morphine.
 Monitor closely for signs of
developing left ventricular failure
(e.g auscultate lung sounds for
crackles and heart sounds for
s3).
>left ventricular failure may develop as
a result of the decreased myocardial
contractility and/ or the administration
of excess fluids.
 Monitor urine output hourly >Monitor urine output hourly
 Monitor mental status >a change in mental status may
indicate a decrease in cardiac output.
 Interpret rhythm strip at least
every 4 hours, more frequently
as condition warrants.
Administer antiarrythmics, if
indicated.
>dysrythmias such as PVCs result in a
decreased stroke volume and less
coronary artery filling time. Frequent
monitoring, especially during the first
few hours of an acute MI and during
thrombolytic therapy administration, is
necessary to prevent and treat lethal
dysrhythmias
 Administer vasopressors; titrate
to BP response.
>administration of vasopressors with
aqcute MI is controversial in that they
may cause an increase in systemic
vascular resistance, which increases
cardiac work.
 Employ hemodynamic
monitoring: central venous
pressure CVP and pulmonary
artery catheter and pulmonary
artery pressure.
>these parameters will help to guide
fluid volume administration, vasoactive
drug administration and assess cardiac
performance.
65

Nursing Diagnosis: Anxiety related to fear of death
Interventions/ Actions Rationales
 Explain equipment,
procedures, and need for
frequent assessment to the
patient and family. Discuss
visiting hours and the need to
allow for rest
>helps conserve energy.
 Observe for autonomic signs
and symptoms for anxiety (eg
increase heart rate, BP and
respiratory rate)
>anxiety is associated with an increase
in sympathetic activity, which increases
cardiac work.
 Administer diazepam
(valium) or morphine
>may aid in limiting patient’s anxiety
 Offer back massage >touch and massage may promote
relaxation.
 Maintain continuity of care >consistency of routine and staff
promotes trust and confidence.
66

Nursing Diagnosis: activity intolerance related to imbalance between myocardial oxygen
supply and demand.
 Document heart rate and
rhythm and BP changes
before, during, and after
activity as indicated.
Correlate with reports of
chest pain/shortness of
breath.
>trends determine patients response to
activity and may indicate myocardial
oxygen deprivation that may require
decrease in activity level/ return to
bedrest, changes in medication
regimen or use of supplemental
oxygen.
 Encourage rest (bed/chair)
initially. Thereafter, limit
activity on basis of pain/
adverse cardiac response.
Provide nonstress
diversional activities
>reduces myocardial workload/ oxygen
consumption, reducing risk of
complications (e.g extension of MI).
 Instruct patient to avoid
increasing abdominal
pressure . e.g straining
during defecation
>activities that require holding of breath
and bearing down can result in
bradycardia (temporarily reduced
cardiac output) and rebound
tachycardia with elevated BP.
 Explain pattern of graded
increase increases of activity
level e.g, getting up to
commode or sitting in a chair
>progressive activity provides
controlled demand on the heart,
increasing strength and preventing over
exertion.
 Review signs and symptoms
reflecting intolerance of
present activity level.
>palpitations, pulse irregularities,
development of chest pain, or dyspnea
may indicate changes in exercise
regimen or medication.
67

Nursing Diagnosis: Ineffective tissue perfusion related to interruption of blood flow.
ACTIONS/INTERVENTIONS RATIONALE
 Investigate sudden changes
or continued alterations in
mentation e.g, anxiety,
confusion, lethargy, stupor.
>cerebral perfusion is directly related to
cardiac output and is also influenced by
electrolyte/ acid-base variations,
hypoxia, and systemic emboli.
 Inspect pallor, cyanosis,
mottling, cool/clammy skin.
Note strength of peripheral
pulse.
>systemic vasoconstriction resulting
from diminished cardiac output may be
evidenced by decreased skin perfusion
and diminished pulses.
 Monitor respirations, note
work of breathing
>cardiac pump failure and/ or ischemic
pain may precipitate respiratory
distress; however, sudden/ continued
dyspnea may indicate thromboembolic
pulmonary complications.
 Monitor intake. Note
changes in urine output.
Record urine specific gravity
as indicated.
>decreased intake/ persistent nausea
may relut in reduced circulating
volume, which negatively affects
perfusion and organ function. Specific
gravity measurements reflect hydration
status and renal function.
 Administer medications as
indicated auch as clopidogrel
(plavix)
>reduces mortality in MI patients, and
is taken daily.
 Assessing GI function, noting
anorexia, decreased/absent
bowel sounds,
nausea/vomiting, abdominal,
distention, constipation
>reduced blood flow to mesentery can
produce GI dysfunction. E.g, loss of
peristalsis. Problems may be
potentiate/ aggravated by use by use of
analgesics, decreased activity and
dietary changes.
68

SOAPIE
S “Dali ra ko kapuyon kung ipabakod ug ipalakaw-lakaw” as verbalized by the client.
O
Heart rate of 52 beats per minute
Generalized weakness
Cold, clammy skin (Temp-36.8C)
A Decreased cardiac output related to underlying physiological condition
P
SHORT TERM: at the end of 1 hour, the client will be able to verbalize feelings to cooperate
LONG TERM; at the end of 2 days, the client will be able to participate in daily activities
I
a. monitored pulse rate
every four hours
To better detect arrhythmias which indicate cardiac arrest or
other complications.
b. monitored skin
temperature every four
hours
Cold, clammy skin may indicate decreased cardiac output
c. instructed patient to
report chest pain
immediately
This may be a signal of myocardial hypoxia or injury
d. instructed patient to
avoid overexertion
( e.g., straining during
bowel movements
Overexertion increases myocardial oxygen demand which may
cause bradycardia and decreased cardiac output
e. administered
antiarrythmic drugs,
such as cordarone, as
prescribed by the
doctor
Antiarryythmic drugs acts on peripheral smooth muscle to
decrease peripheral resistancce
E At the end of 1 hour, the client verbalized cooperation
69

S No verbal cues
O
Moist, cool clammy skin (T-36.8C)
Non palpable dorsalis pedis both left and right
Poor capillary refill- 5 seconds
Pale extremities
Diaphoresis
Pulse rate of 52 beats per minute
A Ineffective peripheral tissue perfusion related to decreased cardiac output
P
SHORT TERM: at the end of 1 hour, the client will be able to have an improvement on
peripheral tissue perfusion
LONG TERM; at the end of 1 week, the patient will maintain improved peripheral tissue
perfusion
I
A. Assisted the client to
ambulate but within her
tolerance
To prevent thrombus formation, thus, improving blood circulation
B. Monitored and
recorded intake and
output
May be a sign of decreased renal perfusion
C. Provided a diet is low
in fat and sodium
Foods high in fat and sodium contributes to the plaque formation
that leads to decreased blood flow.
D. Instructed the
significant others not to
let the client wear tight
clothing
To prevent impairment of blood flow.
E. Administered
anticoagulants such as
clopidogrel as
prescribed by the doctor
To dilute and enhance further blood flow to periphery
E At the end of 1 hour, the client was able to have an improvement on peripheral tissue perfusion
70

S “ kinahanglan pa ko agakon para makabakod” as verbalized by the client
O
Heart rate of 52beats per minute
Generalized weakness
Unable to prompt up by herself
A Activity intolerance related to generalized body weakness.
P
SHORT TERM: at the end of 1 hour, the client will be able to participate in carrying out
activities while on bed with assistance
LONG TERM: at the end of 2 days, the client will be able to continue in performing activities of
daily living.
I
A. Taken and recorded vital signs before
and after the activities
This is to provide baseline data
B. Performed passive range of motion
To asses the degree of motion
C. Encouraged client to have frequent
rests during activities To prevent the patient from fatigue
D. Provided relief through comfort
measures To enhance ability to participate in activities
E. Reminded the significant others in
assisting the patient
To improve the mobility of the patient
E
At the end of 1 hour, the client was able to participate in carrying out activities while on bed
with assistance.
“Dili man kayo ko gakaon ” as verbalized by the client
71

O
Decreased consumption of her daily meal- ate 3 tbsp. of her share
Decreased weight (Present weight of 71 kilograms from her Past weight- 73 kilograms)
A Imbalanced nutrition: less than body requirements related to loss of appetite
P
SHORT TERM: at the end of 30 minutes, the patient will increase consumption of daily meal.
LONG TERM: at the end of 1 day, the client will be able to demonstrate behaviors and lifestyle
changes to maintain appropriate weight.
I
A. Presented meal in an attractive
manner
To entice the client’s appetite
B. Provided small frequent feeding
To encourage the client to eat
C. Provided a well-ventilated area,
conducive for eating
To improve the client’s appetite
D. reminded the client the importance of
eating
To determine weight loss and weight gain
E. regulated and monitored IV fluids as
ordered by the doctor
To provide nutritional supplements
E
At the end of 30 minutes, the patient was able to increase consumption of daily meal (8 tbsp
per meal).
72

S
‘dili ko kaklaro” as verbalized by the client
O
Cloudiness of the right eye
Presence of senile ring around the patient’s left eye
History of cataract surgery
A Risk for injury related to cloudiness of the eye secondary to aging
P
SHORT TERM: at the end of 1 hour, the client will be able to reduce risk factors and protect
self from injury.
LONG TERM: at the end of 3 days, the client will be able to verbalized feeling of safety,
comfort and security.
I
A. Instructed the significant others to
never to leave the client
To prevent any accidents that may happen to
the client
B. Placed pillow at the sides of the client
This is to promote safety
C. Raised side rails.
To prevent patient from falling off the bed
D. Anticipated with the patient’s needs. To avoid accidents that may cause injury to
the client
E. Provided information regarding
condition that may result increased
risk of injury
To reduce the risk of possible occurrence of
injuries
E At the end of 1 hour, the client was able to reduce risk factors and protect self from injury.
73

S “daku man kayo mi ug bayrunon diri, kanusa man ko makauli?” as verbalized by the client
O
Stares blankly for about a minute
Restlessness (consistent in changing side lying position from one side to the other)
Financial resources with a Family income of - 15,000 pesos/ month
Facial Grimace
A Anxiety related to present status secondary to hospital confinement
P
SHORT TERM: at the end of 45 minutes, the client will be able to adapt to the situational crisis
and have a positive outlook with her condition.
LONG TERM: at the end of 2 days, the patient will be able to cope with the present situation
I
A. Encouraged client
to express feelings
One way of releasing tension and assessing the level of anxiety.
B. Listened attentively
concerning client’s
feelings
To identify client’s problem regarding the situation
C. Diverted client’s
attention through
listening to a
soothing music
This will help client divert her attention for the time being
D. Provided a less
stressful
environment
To prevent client from an environment that could trigger stress.
E. Instructed
significant others to
schedule visiting
others
To promote restful environment.
E At the end of 45 minutes, the client was able to have a sense of control over the current crisis
74

S
“di nako ganahan mubalik sa doctor, pareha raman gihapon, nana man akong karaan na
record sa ECG, pwede nato” as verbalized by the client
O
• Restlessness
• Information misinterpretation
• Inadequate follow through of instructions
A Knowledge deficit related to disease condition
P
SHORT TERM: at the end of 1 hour, the client will participate in learning process regarding her
current condition
LONG TERM: at the end of 2 days, the client will understand the importance of her treatment.
I
A. Encouraged client to verbalize
feelings
To know client’s current problem
B. Discussed possible options to the
family regarding her present
treatment
Giving information to the family members and
client’s knowledge regarding disease
condition helps client cope with present
condition
C. Provided information for client to refer
to.
To facilitate learning regarding her treatment
D. Provided information about additional
learning resources
To promote wellness
E. Emphasized the importance of follow
up check-up
To have a better understanding of her
condition.
E At the end of 1 hour, the client was able participate in the learning process.
S “di ko ganahan muinom sa akong mga tambal kay daghan kaayo.” As verbalized by the client
75

O Non compliance with medication
A Risk for ineffective therapeutic regimen
P
SHORT TERM: at the end of 45 minutes, the client will be able to comply with the medications.
LONG TERM: at the end 2 days, the client will be able to properly comply with the medications
I
A. Encouraged client to verbalize
feelings
To express client’s concerns
B. Listened attentively to client
By actively listening, this helps in determining
client’s problems and feel comfortable
C. Discussed to verbalize options
regarding treatment of condition
To provide alternatives and choices regarding
the course of treatment
D. Refrained family members from
verbalizing negative expectations with
the presence of the client
To not show inacceptance of the situation
E. Referred patient’s concern to the
attending physician
To help patient understand the importance of
proper compliance
E At the end of 1 hour, the family was able to verbalized feelings of control over their plight.
76

Progress Notes
Date: February 12, 2008
Day 1
Specific Objectives:
At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able
to:
1. Be acquainted with the management and staff of Saint Joseph’s Ward 5.
2. Ask permission from the family and from Mrs. F. to be the subject of the case
study.
3. Have the formal/ written consent signed, and receive the management’s
approval.
4. Inform the family and Mrs. F about the purposes and objectives of the visit.
5. Establish a contract that notes the Nurse – Client Responsibilities.
6. Conduct an interview about Mrs. F’s family history.
7. Conduct an assessment about Mrs. F’s past and present health conditions.
8. Identify problems related to Mrs. F’s present health condition.
9. Set goals for care.
10.Inform Mrs. F about follow – up visits of the group.
77

Problems identified:
• Blurred vision at the right eye
• Epigastric pain
• Nausea and vomiting
• Pallor
• Diaphoresis
• Weak pulses (radial, femoral, popliteal, posterior tibial)
• Absence of pulse beats at the Dorsalis Pedis site
• Weakness of lower extremities
• Restless
Evaluation:
After 2 hours, the group was able to meet the objectives for the day. The group
was able to meet Mrs. F and the family; explained the purpose of the meeting,
established individual roles, identified problems, and set – up parameters of succeeding
meetings.
78

Day 2
At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able
to:
1. Ask consent from the family and Mrs. F for further interview and assessment.
2. Conduct further interview about Mrs. F’s family history.
3. Conduct an assessment about Mrs. F’s past and present health condition.
4. Identify problems related to Mrs. F’s health condition.
5. Apply nursing interventions for the problems identified.
6. Provide health teachings for the improvement of Mrs. F’s health condition.
7. Evaluate progress after providing nursing care.
8. Remind Mrs. Fabout follow – up visits of the group.
• Blurred vision at the right eye
• Pallor
• Diaphoresis
• Weak pulses (radial, femoral, popliteal, posterior tibial)
• Absence of pulse beats at the Dorsalis Pedis site
79

• Restless
Evaluation:
After 8 hours, the day’s objectives were met. The group was able to conduct
further assessment; applied nursing interventions for the problems identified, noted new
problems and complaints, and reminded Mrs. F about the next visits.
80

Day 3
At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able
to:
3. Conduct further assessment about Mrs. F’s past and present health condition
4. Identify problems regarding Mrs. F’s health condition.
5. Render nursing interventions for the problems identified.
8. Copy data from Mrs. F’s chart.
9. Remind Mrs. F about follow – up visits of the group.
• Blurred vision
• Abdominal fullness
• Diaphoresis
• Pallor
• Weak Pulse (femoral, popliteal, posterior tibial)
• Absence of pulse beats at the dorsalis pedis site
81

Evaluation:
After 2 hours, the objectives of the group were met. With the family and Mrs. F’s
consent, the group was able to conduct further assessment about Mrs. F’s past and
present health conditions and was able to apply nursing interventions in relation to the
problems identified by the group and copied data from Mrs. F’s chart and reminded Mrs.
F about succeeding visits of the group.
82

Day 4
At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able
to:
3. Conduct further assessment about Mrs. F’s past and present health condition.
4. Identify problems regarding Mrs. F’s health condition.
5. Render nursing interventions for the problems identified.
8. Copy data from Mrs. F’s chart.
9. Remind Mrs. F about follow – up visits of the group.
• Blurred vision
• Diaphoresis
• Weak pulse (popliteal, posterior tibial)
• Absence of pulse beats at the dorsalis pedis site
• Weakness of the lower extremities
Evaluation:
After 2 hours, the group was able to meet the day’s objectives. The group was
able to assess Mrs. F and identified new problems, gave health teachings and reminded
Mrs. F about the group’s following visits.
83

Day 5
At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be
able to:
1. Visit Mrs. F at Coca – Cola Compound, Aluba, Cagayan de Oro City.
4. Conduct further assessment about Mrs. F’s condition after discharge.
6. Remind Mrs. F about the ending of the group’s correlation.
Evaluation:
After 2 hours, the group was able to meet the objectives. The group was able to visit
and examine Mrs. F after being discharged from the hospital. The group was able to
impart health teachings such as to return to Maria Reyna Hospital for follow – up check
– up, to maintain prescribed home medications until advised by physician to discontinue
and to do exercise regularly. The group also reminded Mrs. F that February 19, 2008
will be the group’s last visit.
84

Day 6
At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be
able to:
1. Visit Mrs. F at Coca – Cola Compound, Aluba, Cagayan de Oro City.
2. Ask consent from the family and Mrs. F for the completion of the interview and
assessment.
3. Provide additional health teachings for the improvement of Mrs. F’s health
condition.
4. Thank the family and Mrs. F for the approval and cooperation with the group.
5. End the group’s correlation with the family and Mrs. F.
Evaluation:
After 2 hours, the group was able to meet the objectives for the day. The group
was able to complete the interview and assessment of the needed data for the case
study and gave a token as a sign of appreciation for the family and for Mrs. F’s approval
and cooperation.
85

Discharge Plan and Referrals
Medications
Last February 16, 2008 Mrs. F was discharged and advised to have her follow-up
check-up on February 20, 2008 with the following home medication by instructions:
• Telmizartan (Priton) 40 mg 1tab. O.D (Angiotensin II
receptor blocker).
• Clopidogrel (Plavix) 75 mg 1 tab O.D (Anti-coagulant).
• Metoproplol(Neobloc) 50mg ½ tab O.D (Beta Blocker/Anti-Hypertensive).
• Atorvastatin (Lipitor) 80 mg 1 tab O.D q hs. (Anti-Hyperlipidemic).
• ISMN (Imdur) 60 mg 1 tab O.D (Anti-anginal/Nitrate/Vasodilator).
• Trimetazidine (Vastarel) 1 tab BID (Anti-anginal drugs).
• Amiodarone (Cordarone) 200 mg 1 tab BID (Class III/Anti-arrythmic).
• Aspirin (Acet) 80 mg 1 tab O.D p.c lunch (Anti-coagulant).
• Metformin HCL (I-max) 500 mg 1 tab BID (Anti-diabetic).
• Encouraged the patient and instructed the significant others to follow
prescribed home medications and give drugs on time.
• Instructed the significant others to give drugs with food when indicated.
Activity
• Encouraged the patient and instructed the significant others to control
activities of daily living.
• Encouraged the patient and instructed the significant others to
participate in passive active range of motion as tolerated.
• Instructed the significant others to provide safety precautions to the
patient, especially when ambulating or using the bathroom.
• Instructed the client’s significant others to minimize prolonged
exposure to sunlight.
Diet
• Encouraged the patient and instructed the significant others to prepare
foods that are:
86

 Low calorie - Calorie restriction in individuals with
hypertension is recommended. Otherwise normal individuals need the daily-
recommended calorie according to the age, sex and physical activity.
 Low fat - It is advisable to reduce the fat consumption since
hypertension has greater risk of arteriosclerosis. It is better to avoid high
intake of animal fat or hydrogenated oils, which contain saturated fatty
acids. The cholesterol rich foods such as liver, meat, organ meat, egg yolk,
lobster, crab and prawns should be minimized in the diet. The dietary fats
should consist of vegetable oil like corn oil, olive oil and sunflower oil.
 High fiber- Not only does a high fiber diet aid in healthy
bowel movements but also research has shown that it also lowers
cholesterol. There are even types of fiber that will help reduce the risk of
colon cancer.
 High protein – Most high protein foods are extremely low in
carbohydrates and extremely low in saturated fat. Therefore, by eating a
high protein diet loaded with high protein foods, at the same time you'd end
up eating low carbohydrates foods and low saturated fat foods. And, if you
didn't already know, in order to lose weight and lose fat, eating low
carbohydrates and eating little or no saturated fat is a must. Chicken, lean
meats, beef and fish and egg whites.
 Low sodium and high potassium diet- Help to lower high
blood pressure. Moderate sodium restriction 2- 3 gm per day decreases
diastolic blood pressure 6- 10 mmHg and enhances the blood pressure
lowering effect of diuretic therapy. Potassium intake should be increased.
Food sources of potassium should be increased to patients who are on
diuretics. For example apricots, tomato, watermelon, banana, leafy
vegetables, and potato should be included in the daily diet since they
contain low sodium and high potassium. Hypertensive patients with kidney
disease should avoid a high intake of potassium as it puts an excessive load
on the kidney.
87

Oatmeal Banana
Raw
Carrots
Apple
Broccoli Raw
Tomatoes
Cereals
• Instructed the significant others to avoid gastric irritant foods, such as
spicy products this is to minimize gastrointestinal disorder, such as
nausea and vomiting, abdominal pain, CNS disorder like dizziness,
headache.
88

Treatment
• Encouraged patient to verbalize feelings and needs when presence of
chest pain, weakness, and prolonged headache, this is to lessen the
burden of the patient and for immediate action as well as to minimize
entertaining negative thoughts.
• Encouraged patient and instruct the significant others to monitor weight
and blood pressure daily.
89

Prognosis
Hypertension:
There is no cure for hypertension, but it can be controlled by changes in one’s
lifestyle and the use of prescribed medications. The major goal of nursing care for
hypertensive patients focuses on lowering and controlling the blood pressure without
adverse effects and value cost. The patient needs to understand the disease process
and how life’s changes and medications can control hypertension; the nurse needs to
emphasize the concept of controlling HPN rather than curing it.
` Hypertension is more common in men than women and in people over the age of
65 than in younger persons. Hypertension is serious because people with the condition
have a higher risk for heart disease and other medical problems than people with
normal blood pressure. Getting regular blood pressure checks and treating hypertension
as soon as it is diagnosed can avoid serious complications.
If left untreated, hypertension can lead to the following medical conditions:
• Arteriosclerosis, also called atherosclerosis
• Heart attack
• Stroke
• Enlarged heart
• Kidney damage
Risk factors for hypertension include:
• Age over 60
• Male sex
• Weight
• 25Heredity
Diabetes Mellitus:
In most patients diabetes can be controlled by diet, exercise and insulin
injections. If the condition is not treated, however, some serious complications may
result.
For example, uncontrolled diabetes is the leading cause of blindness, kidney
disease and amputations of arms and legs. It also doubles a person’s risk for heart
90

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