acute coronary syndrome, stemi, anterior wall, killips - 1, dm type ii - uncontrolled

A Case Study on Acute Coronary Syndrome, ST Elevation Myocardial Infarction, Anterior Wall, Killips – 1, Diabetes Mellitus Type II - Uncontrolled

I. INTRODUCTION

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. It encompasses a range of

thrombotic coronary artery diseases, including unstable angina and both ST-segment

elevation and non–ST-segment elevation myocardial infarction. Diagnosis requires an

electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. In

acute coronary syndrome, common electrocardiographic abnormalities include T-wave

tenting or inversion, ST-segment elevation or depression (including J-point elevation in

multiple leads), and pathologic Q waves. If prompt actions are not done complications

such as Myocardial Infarction may take place. (http://www.mayoclinic.com/health/acute-

coronary-syndrome/DS01061/DSECTION=symptoms)

The risk factors for acute coronary syndrome are similar to those for other types

of heart disease. It includes Older age (older than 45 for men and older than 55 for

women), high blood pressure, high blood cholesterol, cigarette smoking, lack of physical

activity, type 2 diabetes, family history of chest pain, heart disease or stroke. Signs and

symptoms include Chest pain (angina) that feels like burning, pressure or tightness and

lasts several minutes or longer, Pain elsewhere in the body, such as the left upper arm

or jaw (referred pain), nausea, vomiting, shortness of breath (dyspnea), and sudden,

heavy sweating (diaphoresis) (http://www.mayoclinic.com/health/acute-coronary

syndrome/DS01061/DSECTION=symptoms)

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 year-average record. While the

occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373

per 100,000 populations.(http://www.dh.gov.uk/en/index.htm http://www.dh.gov.uk/en

/index.htm)

On the other hand, Diabetes Mellitus is a condition in which the pancreas no

longer produces enough insulin or cells stop responding to the insulin that is produced,

so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms

include frequent urination, lethargy, excessive thirst, and hunger. The treatment

includes changes in diet, oral medications, and in some cases, daily injections of insulin.

1

http://www.dh.gov.uk/en%20/index.htm

http://www.dh.gov.uk/en%20/index.htm

http://www.dh.gov.uk/en/index.htm

http://www.mayoclinic.com/health/acute-coronary%20syndrome/DS01061/DSECTION=symptoms


http://www.mayoclinic.com/health/acute-coronary-syndrome/DS01061/DSECTION=symptoms

http://www.mayoclinic.com/health/acute-coronary-syndrome/DS01061/DSECTION=symptoms


The most common form of diabetes is Type II, It is sometimes called age-onset

or adult-onset diabetes, and this form of diabetes occurs most often in people who are

overweight and who do not exercise. Type II is considered a milder form of diabetes

because of its slow onset (sometimes developing over the course of several years) and

because it usually can be controlled with diet and oral medication. The consequences of

uncontrolled and untreated Type II diabetes, however, are the just as serious as those

for Type I. This form is also called noninsulin-dependent diabetes, a term that is

somewhat misleading. Many people with Type II diabetes can control the condition with

diet and oral medications, however, insulin injections are sometimes necessary if

treatment with diet and oral medication is not working. Diabetes is the third leading

cause of death in the United States after heart disease and cancer.

(http://www.medicinenet.com/diabetes_mellitus/page4.htm#tocf)

2

http://www.medicinenet.com/diabetes_mellitus/page4.htm#tocf

http://www.medicinenet.com/script/main/art.asp?articlekey=13931


II. SCOPE AND LIMITATIONS OF THE STUDY

This case study tackles about Acute Coronary Syndrome specifically on the case

of patient JB. 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 and other relevant

data are also being covered.

The scope of the plan encompasses during the course of duty last June 29, 30

and July 1 of year 2011 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 June

29 to 30, 2011

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

Syndrome with uncontrolled diabetes type II 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.

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 that was diagnosed with Acute Coronary

Syndrome and uncontrolled diabetes type II.

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.

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 patient’s condition. The

presentors also intend to compare and contrast the ideal management for Acute

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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

SIGNIFICANCE OF THE STUDY

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

nursing students

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

doubts regarding her condition. Allowing him to understand the situation of his

present state, this would allow him 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 nursing students, since it allows them to

explore the client’s condition, giving them firsthand 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.

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III. CLIENT’S PROFILE

A. Socio-demographic Date

Patient JB is a 54-year old male, Protestant, married to his 50-year old

wife and is currently residing at Opol, Misamis Oriental was admitted last June

29, 2011 due to chest pain at Northern Mindanao Medical Center – Intensive

Coronary Care Unit.

B. Vital Signs

Upon assessment, the patient’s vital signs were: BP: 110/80 mmHg,

Temperature: 36.2 degree Celsius, PR: 58 beats per minute (bradycardia), and

RR: 25 cycles per minute (tachypnea) and 27 cycles per minute (tachypnea)

upon exertion. The patient weighs 62 kilograms and is 160 centimeters tall

C. Health Pattern Assessment

Aside from the current condition, patient also complained of non-productive

cough and prostate enlargement. Generally, he looks normal and able to

ambulate and change positions as well. There was no history of tobacco and

illicit drug use as well as alcohol consumption yet he’s taking a cupful of coffee

everyday for almost 30years. No allergies were reported.

Past Medical History

Client JB has been previously hospitalized twice. First was last July

2009 at Cagayan de Oro Medical Center with the diagnosis of Myocardial

Infarction and the second admission was in Northern Mindanao Medical

Center last November 2009 due to left cerebrovascular disease. He also

has the family history of Diabetes Mellitus on both maternal and paternal

side and taking metformin 500mg to control increase blood glucose level

taken BID. He was also diagnosed to have Benign Prostate Hypertrophy

(BPH) and was given tamsulosin hydrochloride 400mg OD taken every

morning.

History of Present Illness

Client JB was climbing the stairs upon reaching the second plight of

it, he felt intense pain on his left chest that radiated to his left shoulder

associated with shortness of breathing. He was then brought to the

Emergency Room subsequently, thus caused him to be admitted last June

29, 2011. His diagnosis was Acute Coronary Syndrome, ST Elevation,

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Myocardial Infarction (STEMI) Anterior Wall, Killips-1, Diabetes Mellitus

Type II - Uncontrolled.

Physical Assessment

Client JB has an oxygen inhalation @ 2 LPM via nasal cannula and

an intravenous fluid of PNSS1L regulated at 10 cc per hour infusing well at

the right arm. Capillary Blood Glucose Monitoring was also done to the

patient: on the first day, he has blood glucose of 172mg/dl then the next

day it became normal with a value of100mg/dl.

HEENT:

Head, hair and scalp Normocephalic with fine hair and clean scalp.

Eyes: sclera, pupils Sclerae are anicteric, pupils are equal in size and

reaction to light. Periorbital region is not sunken

or edematous. Cornea and lens are not opaque

and conjunctiva is pale.

Ears and tympanic membrane Equal in size with no discharges and has equal

auditory function. Intact tympanic membrane.

Nose No nasal flaring noted. Septum is medial. Mucosa

is pink in color. Gross smell is normal and

symmetrical.

Mouth, lips, tongue, teeth and

oral mucosa

Lips are pink but oral mucosa is pale. No lesions

noted in the mouth. Tongue is midline. Teeth are

complete with plaques noted. Gums are pinkish.

Throat and neck Trachea and uvula are midline. Thyroids are non

palpable. Tonsils are not inflamed.

Facial movements Symmetrical.

Cognitive/ Neurological Assessment

Level of consciousness Conscious, coherent and responsive

Orientation Oriented to time, place and person

Emotional state Calm, but upon exertion he feels dizzy and

answers questions inappropriately.

Primary language Visayan

Educational attainment College graduate of Criminology at Ateneo de

Davao University

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Nutritional and Metabolic Pattern

At home, Client JB usually eats three times a day with red meat

and rice, but after he was diagnosed with stroke and myocardial infarction

he was consuming fish, vegetables, and rice with good appetite yet still

cannot resist fatty foods and sweets too. He drinks water and other fluids

at most 10 glasses a day. He takes no vitamins or mineral supplement at

all.

Upon hospital stay, his diet was on low salt low fat, full diabetic diet

with no nausea and vomiting reported.

Elimination Pattern

Patient JB usually follows a pattern in defecating, he used to

defecate once every morning; his stool appears soft in consistency, yellow

to brown in color and in minimal amount with no discomforts upon

defecating.

He urinates at about 6-8 times a day with amber to yellow colored

urine and in moderate amount and with no difficulty. He has an enlarged

prostate and had difficulty urinating before but it subsided after taking due

medications.

Abdominal configuration Symmetrical, no superficial veins, with no lesions

and scars

Bowel sounds Normoactive upon auscultation

Percussion Tympanic and dullness noted on right upper

quadrant

Activity-Exercise Pattern

He used to be very active before but after the diagnosis of

myocardial infarction, his activities and exercises were restricted but he

could still walk for no more than one kilometer and can perform tolerable

exercises. Upon overexertion, pain is felt radiating to the left shoulders

with a pain scale of 6/10 sometimes felt at night which takes for a minute.

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His leisure activities include watching TV and socializing with his children

and friends.

CARDIOVASCULAR STATUS

Chest pain, radiation Positive chest pain at the left side that radiates to the

left shoulder, palpitations noted at some times

Point of maximal impulse,

Precordial area

5th intercostal space, midclavicular line

Flat

Heart sounds Distinct and regular, no murmurs noted

Peripheral pulses Regular and symmetrical

Capillary refill time 2 seconds, no clubbing noted

RESPIRATORY STATUS

Breathing pattern Irregular (tachypnea)

Lung expansion Symmetrical

Vocal/tactile fremitus Symmetrical

Percussion Resonant

Breath sounds Rales crackles at inspiration

Cough Non - productive with colorless sputum, minimal in

amount and viscous in consistency

Sleep and Rest Pattern

Client JB usually sleeps about 6-8hours a day with naps during day

time. He said this number of hours is adequate enough for his activities

the following day. He does not have any history of sleep disturbances but

he prays and meditates before sleeping to promote a good and sound

sleep.

Role and Relationship Pattern

Client JB is married to his 50- year old healthy wife and a father to

two healthy kids. The eldest is 20 years old and has graduated Computer

Science Studies and the second age 14 who is currently a fourth year high

school student. He lives with his family. Client JB reported to have a

Diabetes Mellitus in both maternal and paternal side but confused why he

has developed Myocardial Infarction.

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Value and Belief Pattern

Client X is a Protestant; in fact he is a community facilitator of their

church. He strongly believes that without God he will be nothing. He gets

his strength in facing his condition from his faith that gives him hope. He

believes his hospitalization interferes with his religious rites but he finds

ways to communicate with God through prayers as an alternative.

Moreover, he considers his church mates as his support group and they

visited him quite often.

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REVIEW OF SYSTEMS

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Chest pain of 6/10

Pale conjunctiva

Pale oral mucosa

Copious non-productive

cough

Prostate Enlargement

Abnormal decrease of heart rate of

58 bpm (bradycardia)

Abnormal increase of RR of 25 cpm (at

rest) and 27cpm (upon exertion)

Pain radiating to shoulders

CBG shows abnormal increase of blood

glucose of 172mg/dl (first day) and normal

blood glucose of 100mg/dl (second

day)


IV. ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The body’s

primary energy source is glucose, a simple sugar resulting from the digestion of foods

containing carbohydrates (sugars and starches). Glucose from the digested food

circulates in the blood as a ready energy source for any cells that need it. Insulin is a

hormone or chemical produced by cells in the pancreas, an organ located behind the

stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to

open a doorway into the cell through which glucose can enter. Some of the glucose can

be converted to concentrated energy sources like glycogen or fatty acids and saved for

later use. When there is not enough insulin produced or when the doorway no longer

recognizes the insulin key, glucose stays in the blood rather entering the cells.

Anatomy of the pancreas:

The pancreas is an elongated, tapered organ located across the back of the

abdomen, behind the stomach. The right side of the organ (called the head) is the

widest part of the organ and lies in the curve of the duodenum (the first section of the

small intestine). The tapered left side extends slightly upward (called the body of the

pancreas) and ends near the spleen (called the tail).

The pancreas is made up of two types of tissue:

Exocrine tissue

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o The exocrine tissue secretes digestive enzymes. These enzymes are

secreted into a network of ducts that join the main pancreatic duct, which

runs the length of the pancreas.

Endocrine tissue

o The endocrine tissue, which consists of the islets of Langerhans, secretes

hormones into the bloodstream.

Functions of the pancreas:

The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine tissue in the pancreas help break down

carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down

the pancreatic duct into the bile duct in an inactive form. When they enter the

duodenum, they are activated. The exocrine tissue also secretes bicarbonate to

neutralize stomach acid in the duodenum.

The hormones secreted by the endocrine tissue in the pancreas are insulin and

glucagon (which regulate the level of glucose in the blood), and somatostatin (which

prevents the release of the other two hormones.

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CARDIOVASCULAR SYSTEM

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The right and left coronary arteries most often arise independently from individual

ostia in association with the right and left aortic valve cusps.

The left anterior descending (LAD) and left circumflex (LCX) coronary arteries

arise at the left main coronary artery bifurcation; they supply the anterior LV, the bulk of

the interventricular septum (anterior two thirds), the apex, and the lateral and posterior

LV walls. The right coronary artery (RCA) generally supplies the right ventricle (RV), the

posterior third of the interventricular septum, the inferior wall (diaphragmatic surface) of

the left ventricle (LV), and a portion of the posterior wall of the LV (by means of the

posterior descending branch).

When the posterior descending coronary artery (PDA), which supplies the

posterior interventricular septum, arises from the LCX artery, the circulation is called left

dominant. Most often, the PDA arises from the RCA; this anatomy is called right-

dominant circulation.

In two thirds of patients, the first branch of the RCA is the conus artery, which

supplies the conus arteriosus (RV outflow tract); occasionally the conus arteriosus

arises from a separate orifice.

In 60% of patients, the sinus node artery arises from the proximal RCA, and in

40% of patients, it arises from the LCX artery. The anterior branches supply the free

wall of the RV, and the acute marginal branches supply the RV. When the RCA extends

to the crux (the origin of the PDA), it supplies the atrioventricular (AV) node (90%);

otherwise, the AV node is supplied by the LCX.

Therefore, obstruction of the RCA commonly affects the sinus node and the AV

node, resulting in bradycardia, with or without heart block. Not surprisingly, RCA

occlusion frequently manifests with sinus bradycardia, AV block, RV myocardial

infarction, and/or inferoposterior myocardial infarction (of the LV).Heart is a hollow

muscular organ that pumps blood through the body. The heart, blood, and blood

vessels make up the circulatory system, which is responsible for distributing oxygen and

nutrients to the body and carrying away carbon dioxide and other waste products. The

heart is the circulatory system's power supply. It must beat ceaselessly because the

body's tissues-especially the brain and the heart itself-depend on a constant supply of

oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood

for more than a few minutes, death will result.

The human heart is shaped like an upside-down pear and is located slightly to

the left of center inside the chest cavity. About the size of a closed fist, the heart is

made primarily of muscle tissue that contracts rhythmically to propel blood to all parts of

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the body. This rhythmic contraction begins in the developing embryo about three weeks

after conception and continues throughout an individual's life. The muscle rests only for

a fraction of a second between beats. Over a typical life span of 76 years, the heart will

beat nearly 2.8 billion times and move 169 million liters (179 million quarts) of blood.

STRUCTURE OF THE HEART

The human heart has four chambers. The upper two chambers, the right and left

atria, are receiving chambers for blood. The atria are sometimes known as auricles.

They collect blood that pours in from veins, blood vessels that return blood to the heart.

The heart's lower two chambers, the right and left ventricles, are the powerful pumping

chambers. The ventricles propel blood into arteries, blood vessels that carry blood away

from the heart.

A wall of tissue separates the right and left sides of the heart. Each side pumps

blood through a different circuit of blood vessels: The right side of the heart pumps

oxygen-poor blood to the lungs, while the left side of the heart pumps oxygen-rich blood

to the body. Blood returning from a trip around the body has given up most of its oxygen

and picked up carbon dioxide in the body's tissues. This oxygen-poor blood feeds into

two large veins, the superior vena cava and inferior vena cava, which empty into the

right atrium of the heart.

The right atrium conducts blood to the right ventricle, and the right ventricle

pumps blood into the pulmonary artery. The pulmonary artery carries the blood to the

lungs, where it picks up a fresh supply of oxygen and eliminates carbon dioxide. The

blood that is oxygen-rich returns to the heart through the pulmonary veins, which empty

into the left atrium. Blood passes from the left atrium into the left ventricle, from where it

is pumped out of the heart into the aorta, the body's largest artery. Smaller arteries that

branch off the aorta distribute blood to various parts of the body.

A. THE HEART VALVES

Four valves within the heart prevent blood from flowing backward in the heart. The

valves open easily in the direction of blood flow, but when blood pushes against the

valves in the opposite direction, the valves close. Two valves, known as atrioventricular

valves, are located between the atria and ventricles. The right atrioventricular valve is

formed from three flaps of tissue and is called the tricuspid valve. The left

atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other

two heart valves are located between the ventricles and arteries. They are called

semilunar valves because they each consist of three half-moon-shaped flaps of tissue.

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The right semilunar valve, between the right ventricle and pulmonary artery, is also

called the pulmonary valve. The left semilunar valve, between the left ventricle and

aorta, is also called the aortic valve.

B. THE MYOCARDIUM

Muscle tissue, known as myocardium or cardiac muscle, wraps around a scaffolding

of tough connective tissue to form the walls of the heart's chambers. The atria, the

receiving chambers of the heart, have relatively thin walls compared to the ventricles,

the pumping chambers. The left ventricle has the thickest walls-nearly 1 cm (0.5 in)

thick in an adult-because it must work the hardest to propel blood to the farthest

reaches of the body.

C. THE PERICARDIUM

A tough, double-layered sac known as the pericardium surrounds the heart. The

inner layer of the pericardium, known as the epicardium, rests directly on top of the

heart muscle. The outer layer of the pericardium attaches to the breastbone and other

structures in the chest cavity and helps hold the heart in place. Between the two layers

of the pericardium is a thin space filled with a watery fluid that helps prevent these

layers from rubbing against each other when the heart beats.

D. THE ENDOCARDIUM

The inner surfaces of the heart's chambers are lined with a thin sheet of shiny, white

tissue known as the endocardium. The same type of tissue, more broadly referred to as

endothelium, also lines the body's blood vessels, forming one continuous lining

throughout the circulatory system. This lining helps blood flow smoothly and prevents

blood clots from forming inside the circulatory system.

E. THE CORONARY ARTERIES

The heart is nourished not by the blood passing through its chambers but by a

specialized network of blood vessels. Known as the coronary arteries, these blood

vessels encircle the heart like a crown. About 5 percent of the blood pumped to the

body enters the coronary arteries, which branch from the aorta just above where it

emerges from the left ventricle. Three main coronary arteries-the right, the left

circumflex, and the left anterior descending-nourish different regions of the heart

muscle. From these three arteries arise smaller branches that enter the muscular walls

of the heart to provide a constant supply of oxygen and nutrients. Veins running through

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the heart muscle converge to form a large channel called the coronary sinus, which

returns blood to the right atrium.

FUNCTION OF THE HEART

The heart's duties are much broader than simply pumping blood continuously

throughout life. The heart must also respond to changes in the body's demand for

oxygen. The heart works very differently during sleep, for example, than in the middle of

a 5-km (3-mi) run. Moreover, the heart and the rest of the circulatory system can

respond almost instantaneously to shifting situations-when a person stands up or lies

down, for example, or when a person is faced with a potentially dangerous situation.

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LEGEND:

Predisposing Factors

Precipitating Factors

Disease Process

Management

Diagnostic Examination

Signs and symptoms

Compensatory Mechanism


V. PATHOPHYSIOLOGY

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Predisposing Factors:

Sedentary Lifestyle

Eating habits consuming organ meats and fatty foods

Age (54 years old)

Gender (male)

Family History of DM

Predisposing Factors:

Sedentary Lifestyle

Eating habits consuming organ meats and fatty foods

Age (54 years old)

Gender (male)

Family History of DM

Precipitating Factors:

Poor compliance to medication

Precipitating Factors:

Poor compliance to medication

Increase blood glucose level within the serum

Beta cells response poorly to hyperglycemia

Scanty amount of insulin being released Increase glucagon release

Increase breakdown of lipids

Continuous increase in serum blood glucose

Increased cell division causing further mutations

Activation of the k-ras oncogene

P53 mutations which prevent apoptosis

Prolong lifespan of affected cells

Continuous replication of affected cells

Increases number of malignant cells

Abnormal increase in

blood glucose level of 139mg/dl


blood glucose level of 139mg/dl

CBG shows blood glucose

level of `72mg/dL

CBG shows blood glucose

level of `72mg/dL

Administered metformin (Glucophage) 500mg 1

tab. OD BID

Administered metformin (Glucophage) 500mg 1

tab. OD BID

Administered atorvastatin

(Lipitor) 80mg, 1 tab,

PO, OD at HS

Administered atorvastatin

(Lipitor) 80mg, 1 tab,

PO, OD at HS


===========================>

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Increase blood concentration which leads to its viscosity

Clot formation and lipid deposition on the anterior coronary artery

Sluggish flow going to the heart

Plaque formation in the intimal lining of the anterior coronary artery

Increase hydrostatic pressure on the coronary artery

Anaerobic metabolism is initiated

Ischemia on the myocardium

Presence of surgical wound.

Presence of surgical wound.

Susceptible to infection

Ketosteril 1cap. PO BID

Ketosteril 1cap. PO BID

Abnormal

decrease in

lymphocytes 7.1 and 7.9

Abnormal

decrease in

lymphocytes 7.1 and 7.9

NPO stateNPO statePossible increase in acid production within the GI lining

Activation of pain

mediators

1. celecoxib 1.5gm IVTT every 6 hours

2. paracetamol 60mg IVTT every 6 hours

3. ketorolac 30mg IVTT every 8 hours

4. tramadol 500mg IVTT every 6 hours

1. celecoxib 1.5gm IVTT every 6 hours

2. paracetamol 60mg IVTT every 6 hours

3. ketorolac 30mg IVTT every 8 hours

4. tramadol 500mg IVTT every 6 hours

1.omeprazole 20mg PO every 6 hours

2. ranitidine 500mg IVTT every 8 hrs.

1.omeprazole 20mg PO every 6 hours

2. ranitidine 500mg IVTT every 8 hrs.

Partial blockage of the anterior coronary artery

The fibrous cap (plaque) protrude in the intimal lining

Chest pain radiating to

the shoulders

Pain scale of 6/10

Chest pain radiating to

the shoulders

Pain scale of 6/10

Collateral circulation is stimulated to help perfuse the myocardium

Increase respiratory rate of 25cpm (at rest) and 27cpm (upon exertion)

Provide oxygen inhalation at 2LPM via

nasal cannula

Provide oxygen inhalation at 2LPM via

nasal cannula

Lactic acid production

Still insufficient to supply blood to the heart

Intravenous PNSS at 10cc/hr

Intravenous PNSS at 10cc/hr

Patient JB climbed two flights of stairsPatient JB climbed two flights of stairs


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Platelet activation

Change in platelet shape ↑ Expression of Platelet GP IIb/IIIa

Platelet adhesion to subendothelial matrix

Platelet degranulation

Enhances platelet

aggregation

Converts fibrinogen to

fibrin

Formation of

thrombin

Plaque ruptures

Release of Thromboxane A2,

Serotonin and other platelet

aggregatory agent

Exposure of subendohelial matrix

Enhanced affinity to fibrinogen

Platelet aggregation

Plasma Coagulation

System activationStabilization of fibrin clot

Hardening of the coronary artery

Pale mucosa

Pale conjunctiva

Pale mucosa

Pale conjunctiva

Abnormal decrease of RBC (3.58), Hct (31.5) ,

and Hgb (11.1)

Abnormal decrease of RBC (3.58), Hct (31.5) ,

and Hgb (11.1)


VI. LABORATORY RESULTS

Hematology Report

(06/29/11)

TEST RESULTS REFERENCE VALUES INTERPRETATION

Hgb 11.1 13.7-16.7 g/dL A decrease in rbc may also decrease hemoglobin

since rbc carries oxygen to the blood. A Low

hemoglobin may also indicate anemia.

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Abnormal decrease

of blood pressure

of 58bpm

Abnormal decrease

of blood pressure

of 58bpm

1. Administered enoxaparin (Clexane) 0.4cc SC every 12 hours

2. clopidogrel (Plavix) 75 mg, 1 tab PO at HS

3. aspirin (Atria SR) 80mg, 1tab, PO, OD after PC

1. Administered enoxaparin (Clexane) 0.4cc SC every 12 hours

2. clopidogrel (Plavix) 75 mg, 1 tab PO at HS

3. aspirin (Atria SR) 80mg, 1tab, PO, OD after PC

Coronary occlusion Further deprivation of

oxygen supply to the

Infarction on the myocardium takes place

Impaired repolarization of the myocardium

Abnormal ST elevation

seen in the ECG

Abnormal ST elevation

seen in the ECG

Decrease cardiac contractility

Decrease ventricular function

Decrease cardiac output

Decrease perfusion to the system

O2 inhalation

O2 inhalation


Hct 31.5 37.0- 47.0 gm% A low hematocrit level indicates that a person does not

have a sufficient volume of red blood cells.

WBC 12, 300 5,000-10,000 cell/mm3 A high blood count indicates is not a specific disease

by itself but indicates infection, systemic illness,

inflammation, allergy, leukemia and tissue injury.

DIFFERENTIAL

COUNT:

Segmenters 55 45-70% Within Normal Range

Lymphocytes 40 18-45% Within Normal Range

Monocytes 5 4-8% Within Normal Range

Platelet count 329, 000 144,000-372,000 cell/mm3 Within the normal range which connotes the clotting

factor is good.

RBC 3.58 4.7-6.1 10^6/uL A decrease Red blood cell production may indicate

anemia and low oxygen levels due to poor heart or

lung function.

MCV 81.6 80.0-96.0 fL Within Normal Range

MCH 30 27.0-31.0 pg Within Normal Range

22


MCHC 25.2 32.0-36.0% A low MCHC number might indicate the presence of

anemia, but other factors will be measured as well

before making this diagnosis. The mean corpuscular

volume indicates the size of the red blood cells in a

person's body.

Hematology Report

(06/30/11)

TEST RESULTS REFERENCE VALUES INTERPRETATION

Hgb 14.0 13.7-16.7 g/dL Within the Normal Range.

Hct 39.6 37.0- 47.0 gm% Within Normal Range

23


WBC 11,000 5,000-10,000 cell/mm3 It is beyond normal range. Increase in the WBC count

may indicate infection.

DIFFERENTIAL

COUNT:

Segmenters 56 45-70% Within the Normal Range

Lymphocytes 20 18-45% Within the Normal Range

Monocytes 5.0 4-8% Within the normal range.

Platelet count 376, 000 144,000-372,000 cell/mm3 Within the normal range thus, the clotting factor is

good.

RBC 4.0 4.7-6.1 10^6/uL Within the normal Range

MCV 83.6 80.0-96.0 fL Within the Normal Range

MCH 28.0 27.0-31.0 pg Within the Normal Range

MCHC 36.0 32.0-36.0% Within the Normal Range

Others Laboratory Examinations

(06/29/11)

24


Diagnostic/Laboratory

Procedures/Tests

Purposes Result Analysis and Interpretation

1. ECG The electrocardiogram (ECG or

EKG) is a diagnostic tool that

measures and records the

electrical activity of the heart in

exquisite detail. Interpretation of

these details allows diagnosis of a

wide range of heart conditions.

These conditions can vary from

minor to life threatening.

ST segment elevation Myocardial injury causes the T wave to

become enlarged and symmetric. As the

area of injury becomes ischemic, myocardial

repolarization is altered and delayed,

causing T wave to invert. The injured

myocardial cells depolarize normally but

repolarize more rapidly than normal cells,

causing the ST segment to rise at least 1

mm above isoelectric line.

2. CK-MB CK-MB is a more sensitive marker

of myocardial injury than total CK

activity, because it has a lower

basal level and a much narrower

normal range. It is the most

specific index for the diagnosis of

acute MI.

2 ng/mL (Reference Value: 0-

3 ng/mL)

NORMAL

3. Creatinine The test is done to evaluate kidney

function. Creatinine is removed

1.9 mg/dL (Reference Value: Any condition that impairs the function of

the kidneys will probably raise the creatinine

25


from the body entirely by the

kidneys. If kidney function is

abnormal, creatinine levels will

increase in the blood (because

less creatinine is released through

your urine).

0.59-1.21) level in the blood. The most common

reasons for developing raised creatinine

levels will be when the filtration mechanism

becomes gradually damaged by long-term

raised blood pressure or diabetes.

4. Glucose The test is done to evaluate the

blood glucose within the

circulation.

139 mg/dL (Reference Value:

59.9 – 110.1)

The abnormal decrease of the blood

glucose level denotes the so-called

hyperglycemia where the concentration of

blood increases which results to its

viscosity.

VII. DRUG STUDY

26


DRUG ORDER

(Generic name, brand

name, classification,

dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS

CONTRAINDICATIONS ADVERSE EFFECTS

OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

atorvastatin

BRAND NAME:

Lipitor

CLASSIFICATION:

Lipid-lowering agents

HMG-CoA inhibitor

DOSAGE: 80mg 1 tab

ROUTE: PO

FREQUENCY:

ONCE A DAY

Inhibit an enzyme, 3-

hydroxy-

3methylglutaryl-

coenzyme A (HMG-

CoA) reductase, which

is responsible for

catalyzing an early step

in the synthesis of

cholesterol.

Secondary

prevention of

cardiovascular

disease (decrease

risk of MI, stroke,

revascularization

procedures,

angina, and

hospitalizations for

CHF) in patients

with clinically

evident CHD.

Patients hypersensitive

to atorvastatin and

active liver disease or

unexplained persistent

in aspartate

aminotransferase (AST)

or alanine

aminotransferase (ALT)

CNS: dizziness,

headache, insomnia,

weakness

EENT: rhinitis

CV: chest pain,

peripheral edema

Resp: bronchitis

GI: abdominal cramps,

constipation, diarrhea,

flatulence, heartburn,

elevated liver enzyme,

nausea

GU: erectile dysfunction

1. Confirm patient through

asking his name and

looking on his name

bracelet.

2. Obtain a dietary history,

especially with regard to fat

consumption.

3. Evaluate serum

cholesterol and triglyceride

levels before initiating,

during, and after the

therapy, if possible.

4. Explain to the patient

what the drug is for.

5. Administer drug before

27


TIMING : 8pm

patient goes to sleep.

28


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

clopidogrel bisulfate

BRAND NAME:

Plavix

CLASSIFICATION:

Antiplatelet agent

Platelet aggregation

inhibitor

DOSAGE: 75mg 1 tab

ROUTE: PO

FREQUENCY: Once a

Inhibits platelet

aggregation by

irreversibly inhibiting

the binding of ATP to

platelet receptors

thereby, decreases

occurrence of

atherosclerotic events.

Reduction of

atherosclerotic

events in patients

with MI.

1. Hypersensitivity to

clopidogrel bisulphate

2. Pathologic bleeding

(e.g. peptic ulcer,

intracranial hemorrhage

3. Severe liver

impairment

4. Patients with rare

galactose intolerance

CNS: depression,

dizziness, headache,

fatigue

EENT: epistaxis

CV: chest pain, edema,

hypertension

Resp: cough, dyspnea

GI: GI bleeding,

abdominal pain,

diarrhea, dyspepsia,

gastritis, constipation

Derm: rashes, purpura,

pruritus, bruising

Hematology: bleeding,

neutropenia

Metabolic:


asking his name and

looking on his name

bracelet.



3. Administer drug before

patient goes to sleep.

4. Monitor the vital signs

prior, during and after

therapy.

5. Ensure patient’s safety

through side rails up.

6. Keep patient’s skin intact

29


Day

TIMING: HS (8PM)

hypercholesterolemia

Muskuloskeletal:

arthralgia, back pain

Miscellaneous: fever,

hypersensitivity reaction

by positioning patient every

2 hrs.

30


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

aspirin

BRAND NAME:

Artria S.R.

CLASSIFICATION:

antipyretics, nonopioid

analgesics

salicylates

DOSAGE:80mg 1 tab

ROUTE: PO

FREQUENCY: Once a

Produce analgesia and

reduce inflammation

and fever by inhibiting

the production of

prostaglandins

Prophylaxis of

transient ischemic

attacks and MI,

fever, mild to

moderate pain


clopidogrel bisulphate

2. Pathologic bleeding

(e.g. peptic ulcer,

intracranial hemorrhage

3. Severe liver

impairment

4. Patients with rare

galactose intolerance

EENT: tinnitus,

GI: GI bleeding,

abdominal pain,

nausea, vomiting,

diarrhea, dyspepsia,

epigastric distress,

anorexia, hepatotoxicity

Hematology: increase

bleeding time,

anemia,hemolysis

Miscellaneous: allergic

reactions; anaphylaxis

and laryngeal edema


asking his name and

looking on his name

bracelet.



3. Assess pain: location,

type, and intensity before

and at the peak of drug

action after administration.

4. Administer drug after

lunch.

5. Monitor the vital signs,

especially temperature (for

31


Day

TIMING: after lunch

fever) prior, during and after

therapy.

32


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

enoxaparin sodium

BRAND NAME:

Clexane

CLASSIFICATION:

anticoagulants

antithrombotics

DOSAGE: 4000iu

(40mg) per 0.4 ml

ROUTE: subcutaneous

FREQUENCY:

Potentiate the inhibitory

effect of antithrombin

on factor Xa and

thrombin. Thus,

preventing thrombus

formation.

Treatment of acute

ST- segment-

elevation MI and

prevention of

venous

thromboembolism.

(VTE)


specific agents or pork

products


enoxaparin sodium

3. Active bleeding

4. History of heparin-

induced

thrombocytopenia

CNS: dizziness,

headache, insomnia

CV: edema

GI: vomiting,

constipation, nausea,

reversible increase in

liver enzymes

GU: urinary retention

Derm: ecchymosis,

pruritus, rash, urticaria

Hematology: bleeding,

anemia,

thrombocytopenia

Local: erythema at

injection site, irritation,

pain, hematoma


asking his name and

looking on his name

bracelet.



3. Assess for signs of

bleeding and hemorrhage

(bleeding gums, nosebleed,

black tarry stools,

hematuria). Notify physician

if such manifestations

occur.

4. Administer the drug in a

33


Q 12H

TIMING: 8am-8pm

slow manner,

subcutaneously.

5. Alternate injection site to

avoid hypertrophy

34


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

omeprazole

BRAND NAME:

Prisolec

CLASSIFICATION:

Antiulcer agent

Proton-pump inhibitor

DOSAGE: 40mg

ROUTE: IVTT

FREQUENCY: Q 24H

TIMING: 8pm

Binds to an enzyme on

gastric parietal cells in

the presence of acidic

gastric pH, preventing

the final transport of

hydrogen ions in the

gastric lumen.

Reduction of risk of

GI bleeding in

critically ill patients

and condition

where inhibition of

gastric acid

secretion may be

beneficial


omeprazole

2. Metabolic alkalosis

3. Hypocalcemia

CNS: dizziness,

headache, drowsiness,

fatigue, weakness

CV: chest pain

GI: abdominal pain,

acid regurgitation,

constipation, diarrhea,

flatulence, nausea,

vomiting

Derm: itching, rash

Miscellaneous: allergic

reaction


asking his name and

looking on his name

bracelet.

2. Obtain a skin test prior to

initial administration.



4. Inform the patient that

administration may cause

pain on IV site.

5. Administer the drug in a

slow manner, intravenously.

35


DRUG ORDER



dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

36


GENERIC NAME:

metoprolol

BRAND NAME:

Lopresor

CLASSIFICATION:

Antianginals,

antihypertensive agent

Beta blockers

DOSAGE: 50mg 1 tab

ROUTE: PO

FREQUENCY:

BID

TIMING: 8am-6pm

Unknown. A Selective

beta blocker that

selectively blocks beta-

adrenergic receptors;

decreases cardiac

output, peripheral

resistance, and cardiac

oxygen consumption;

and depresses rennin

secretion.

Early intervention in

acute MI


metoprolol

2. Uncompensated CHF

3. Pulmonary edema

4. Cardiogenic shock

5. Bradycardia or heart

block

CNS: fatigue, dizziness,

drowsiness, anxiety,

weakness nervousness,

nightmares, insomnia

EENT: blurred vision,

stuffy nose

Resp: bronchospasm,

wheezing

CV: hypotension,

peripheral

vasoconstriction,

bradycardia, CHF,

Pulmonary edema

GI: constipation,

diarrhea,

flatulence,gastric pain,

heartburn, dry mouth,

nausea, vomiting,

Derm: itching, rash

GU: erectile

dysfunction, urinay


asking his name and

looking on his name

bracelet.



3. Monitor vital signs before,

during, and after

administration. Take apical

pulse before administering.

If HR is <60bpm, inform

physician.

4. Monitor intake and output

accurately.

5. Monitor HGT as

prescribed.

6. Administer drug with or

after meals.

7. Assess for signs and

37


frequency

Derm: rashes

Endo: hyperglycemia,

hypoglycaemia

MS: arthralgia, back

pain

Miscellaneous: drug-

induced lupus

syndrome

symptoms of CHF

(dyspnea, rales/crackles,

peripheral edema, jugular

venous distention) and

prompt physician if these

occur.

38


DRUG ORDER

(Generic name,

brand name,

classification,

dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

lactulose

BRAND NAME:

Duphalac

CLASSIFICATION:

laxative

osmotics

DOSAGE: 3.3g/5ml

30 ml

ROUTE: PO

Increases water

content and softens

the stool, lowers pH of

the colon, which

inhibits diffusion of

ammonia from the

colon into the blood,

thereby reducing

blood ammonia.

Prophylaxis for

pending constipation

to avoid valsalva

maneuver causing

then more agitation to

the patient.


lactulose

2. Galactosemia

3. Bowel obstruction

GI: belching, cramps,

distention, flatulence,

diarrhea

Endo: hyperglycemia

1. Confirm patient

through asking his

name and looking on

his name bracelet.

2. Explain to the

patient what the drug

is for.

3. Assess for bowel

distention, presence of

bowel sounds, and

normal pattern of

bowel function.

3. Monitor vital signs

before, during, and

39


FREQUENCY:

HS

TIMING: 8pm

after administration.

4. Monitor HGT as

ordered.

5. Monitor intake and

output accurately.

Assess the color,

consistency, and

amount of stool

produced.

6. Administer drug

before sleeping hours.

7. Provide safety

measures; keep side

rails up at all times.

40


DRUG ORDER

(Generic name,

brand name,

classification,

dosage, route,

frequency)

MECHANISM OF

ACTIONINDICATIONS


OF THE DRUG

NURSING

RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME:

metformin HCl

BRAND NAME:

Glucophage

CLASSIFICATION:

Antidiabetics

biguanides

DOSAGE: 500mg 1

tab

ROUTE: PO

Decreases hepatic

glucose production,

decreases intestinal

glucose absorption

and increases

sensitivity to insulin.

Management of type 2

diabetes mellitus


metformin

2. Metabolic acidosis

3. Sepsis

4. Dehydration

5. Hypoxemia

6. Hepatic impairment

7. Renal dysfunction

GI: abdominal

bloating, diarrhea,

nausea, vomiting,

unpleasant metallic

taste.

Endo:

hypoglycaemia

F and E: lactic

acidosis

Misc: decreased

vitamin B12 levels

1. Confirm patient

through asking his

name and looking on

his name bracelet.

2. Explain to the

patient that metformin

only controls

hyperglycemia and

does not cure DM.

3. Assess for bowel

distention, presence of

bowel sounds, and

normal pattern of

41


FREQUENCY:

TID

TIMING: 8am-6pm

bowel function.

4. Monitor vital signs

before, during, and

after administration.

5. Administer

metformin with meals.

6. Monitor HGT as

ordered.

7. Monitor intake and

output accurately.

42


ASESSMENT DATA

(Subjective and Objective)

NURSING DIAGNOSIS

(Problem and Etiology)

GOAL AND OBJECTIVES NURSING INTERVENTIONS AND

RATIONALE

EVALUATION

“Murag naai plemas

nagpikit diri sa akong

tutunlan nga dili nako

magawas” as verbalized by

the patient.

Objective:

Abnormal increase of

RR of 25cpm

(tachypneic)

Non – productive

cough

Abnormal breath

sounds heard upon

auscultation (rales on

inspiration)

Ineffective Airway

clearance related to

retained copious

secretions in the

tracheobronchial tract.

Short-Term Goals:

Within 3-5 minutes of

thorough nursing

intervention the patient will

be able to:

a) Improve respiratory

status from 25cpm

(tachypneic) to

normal range of RR

(12 – 22cpm)

b) Expectorate

gradually secretions.

Long-Term Goals:

After 8 hours of the course

of duty, the client will be

able to:

INDEPENDENT:

1. Auscultate breath sounds.

R – This will serve as a baseline

data for the effectiveness of the

actions done.

2. Assist patient on moderate high

back rest.

R – To maximize lung expansion

promoting then proper exchange

of gases.

3. Demonstrate and instruct proper

and effective deep breathing and

coughing exercises.

R – To effectively expectorate

copious secretions lodge in the

Short- Term Goals:

Goals met. After 5 minutes of

thorough nursing intervention

the patient was able to

improve respiratory status

from 25cpm to a normal range

of RR (22cpm) and gradually

expectorated secretions.

Long-Term Goals:

Goals partially met. After 8

hours of thorough nursing

interventions the client was

able to maintain the

respiratory status within the

normal range (12 – 22cpm).

Although, there are clear

43


a) Maintain the

respiratory status

within the normal

range (12 – 22cpm)

b) Expectorate all

copious secretions

lodge within the

tracheobronchial tract

as manifested by

clear breath sounds.

airways.

4. Instruct patient to increase fluid

intake within the cardiac tolerance.

R – This will soften the copious

secretions for easy expectoration.

5. Do chest tapping at appropriate

intervals.

R – To dislodge secretions from

smaller airways to larger airways

for easy expectoration.

6. Turn the patient into sides every 2

hours and/or appropriate intervals.

R – This will prevent respiratory

complications and allows the

release of pressure on the back

especially on the sacral area and

other bone prominences that may

create ulceration.

breath sounds heard upon

auscultation, there are times

that patient coughs roughly

which may denote the

existence of secretions within

the tracheobronchial tract.

.

44


DEPENDENT:

1. Provide oxygen inhalation, as

ordered, at 2LPM via nasal cannula.

R - To adequately provide oxygen

unto the client preventing then

tachypnea.

45


ASESSMENT DATA


NURSING DIAGNOSIS



RATIONALE

EVALUATION

Subjective:

“Usahay kay naa

gapitik-pitik sa

akong dughan” as

verbalized by the

patient.

“Usahay pud kay

gahanguson ko..” as

verbalized by the

patient.

Objective:

Abnormal decrease of HR

of 58bpm (bradycardia)

Abnormal increase of RR

of 25cpm (tachypneic)

ST elevation on the ECG

Decreased Cardiac

Output related to

altered preload as in

decrease venous return

secondary to ST

Elevation Myocardial

Infarction (STEMI)

Short- Term Goals:

Within 5 – 10 minutes of

thorough nursing

intervention, the client will

be able to:

a) Improve heart rate

from 58bpm

(bradycardia) to

normal range of HR

(60 – 100bpm).

b) Improve respiratory

status of the client

from 25cpm

(tachypneic) to

normal range of RR

(12 – 22cpm).

INDEPENDENT:

1. Monitor Vital Signs frequently

especially HR and RR.

R – This will serve as a baseline

data for the effectiveness of the

actions done.

2. Assist client in moderate high

back rest.

R – To maximize lung expansion

promoting then proper exchange

of gases.

3. Provide quiet environment and

decrease stimuli.

R – To promote adequate rest and

to avoid agitation in the client

Short- Term Goals:

Goals met. After 10 minutes

of thorough nursing

intervention, the client was

able to improve heart rate

from 58bpm to normal range

of HR (67bpm), improve

respiratory status of the

client from 25cpm to normal

range of RR (22cpm).

Long- Term Goals:

Goals partially met. After 16

hours of duty, the patient

was able to maintain HR

within the normal range (60 –

46


of the client

Long- Term Goals:

At the end of 16 hours of

duty, the patient will be able

to:

a) Maintain HR within

the normal range (60

– 100bpm)

b) Maintain respiratory

status of the client

within the normal


c) See significant

progress unto the

client’s ECG of

normal PQRST

waves.

decreasing then oxygen demand.

4. Allow client to rest in appropriate

intervals.

R – This would decrease oxygen

consumption using it instead for

the myocardium for better cardiac

contractility to increase cardiac

output.

5. Assist client in elevating the legs

when sitting.

R – To promote effective venous

return, increasing then cardiac

output because of the ample

oxygenation of the myocardium.

6. Provide psychological support,

clarify and inform client about the

current condition and

misconceptions about the disease

too.

100bpm), maintain

respiratory status of the

client within the normal range

(12 – 22cpm) but we weren’t

able to see progress of the

ECG because there was no

follow-up order.

47


R – It helps client to overcome the

fear of unknown and lessens

anxiety because anxiety

increases agitation affecting then

our normal body physiology

causing then decrease cardiac

output.

DEPENDENT:

1. Administer enoxaparin 0.4cc, SC

every 12hours; aspirin 80g 1 tab,

OD p.c. lunch; and clopidogrel 75g 1

tab, OD at HS, as ordered.

R – prevention of thrombosis and

somehow preventing the

thickening of clot formation

within the coronary artery which

causes the blockage of the blood

vessels impeding then the

oxygenation to the myocardium,

decreasing the CO.

48


2. Administer lactulose 30cc OD at

HS, as ordered.

R – This will act as a prophylaxis

for the patient to prevent valsalva

maneuver during defecation

because in doing so, it will affect

cardiac rate and further agitate

the patient not to mention it

impedes blood flow causing then

cardiac anomalies and decreases

CO as well.

3. Provide oxygen inhalation at

2LPM via nasal cannula, as ordered.

R – This would help in providing

easy access of oxygen supply for

the body to avoid overexertion

during its compensatory action to

improve cardiac output.

49


COLLABORATIVE:

1. Refer to the dietician for low salt,

low fat diet.

R – To help client in the

management of STEMI and DM

Type II, improving then cardiac

functioning of the client.

50


ASESSMENT DATA


NURSING DIAGNOSIS



RATIONALE

EVALUATION

51


Subjective:

“Usahay paspas ang

pitik sah akong

dughan ug mura ko

ganerbioson” as

verbalized by the

patient.

Objcetive:

Abnormal decrease of

heart rate of 58bpm


respiratory rate of

25cpm


blood glucose level of

172mg/dl. (CBG)


blood glucose level of

139mg/dL (labs)

Ineffective tissue

perfusion

(cardiopulmonary)

related to sluggish

blood flow due to

increase viscosity of

blood circulation

secondary to Diabetes

Mellitus

Short-Term Goals:


thorough nursing


be able to:

a.) Establish and

maintain normal vital

signs of heart rate

60-100bpm from

58bpm.

b.) Establish and

maintain normal

respiratory rate of

12-22cpm from

25cpm.

Long-Term Goals:


thorough nursing


INDEPENDENT:

1. Elevate peripheries or extremities

R – To promote venous return to

the heart.

2. Demonstrate and assist patient in

active and passive range-of –motion.

R – To increase the blood flow by

improving circulation and prevent

formation of thrombus.

3. Turn patient at appropriate

intervals.

R – Bed mobility improves

circulation in the body.

4. Instruct patient to have a complete

bed rest without toilet privilege.

R – To prevent overexertion and

fatigue.

Short- Term Goals:

Goals Met. At the end of 8



able to established and

maintain normal vital signs of

HR (67bpm) and RR (22cpm).

Long – Term Goals:

Goals met. At the end of 16



establish and maintain normal

blood glucose within the

normal range (100mg/dL) from

172mg/dL (CBG) and

139mg/dL (labs) and

maintained heart rate (60 –

100bpm) and respiratory rate

(12 – 22cpm) within the

normal range.

52


be able to:

a.) Establish and

maintain normal

blood glucose within

the normal range

( 70 – 110mg/dL)

from 172mg/dL

(CBG) and

139mg/dL (labs)

b.) Maintain heart rate

(60 – 100bpm) and

respiratory rate (12

– 22cpm) within the

normal range.

DEPENDENT:

1. Administer metformin

(Glucophage) 50mg,p.o at TID as

ordered.

R – This anti-diabetic agent aids in

lowering down blood glucose

level.

COLLABORATIVE:

1. Refer to dietician for full diabetic

diet.

R – To avoid worsening of the

condition leading to its

complication, Diabetic

Ketoacidosis.

ASESSMENT DATA


NURSING DIAGNOSIS



RATIONALE

EVALUATION

53


Subjective:

“Gasakit usahay

akong dughan” as

verbalized by the

patient.

Objective:

Pain Scale :6/10

Restless

Guarding on the left

chest.

Acute pain (left chest)

related to partial

blockage of the

coronary artery

secondary to acute

coronary syndrome

Short-Term

Within 10 - 15 minutes of

nursing care and

interventions, the patent

will:

1. Report controlled

pain as evidenced

by a decreased pain

scale from 6/10 to

0/10.

2. Demonstrate use of

relaxation skills.

Long-Term

After 8 hours of thorough

nursing intervention, the

client will be able to report

relieved of pain.

INDEPENDENT:

1. Monitor V/S which is usually

altered when patient is in acute pain.

R - Changes in vital signs may

indicate acute pain and

discomfort.

2. Provide comfort measures to the

patient such as providing appropriate

ventilation.

R - To promote relaxation.

3. Assist patient to find position of

comfort.

R - Position affects the patient’s

ability to relax and rest/sleep

effectively.

4. Teach patient deep-breathing

exercise to help refocus attention and

enhance coping abilities.

R - This reduces muscle tension

Short- Term Goals:

Goals met

After 15 minutes of Nursing

interventions, the patient

reported pain was relieved as

evidenced by a pain scale of

0/10 and demonstrated

relaxation techniques such as

deep breathing exercise.

Long-Term Goals:

Goal partially met

After the 8-hour shift, the

patient reported relieved pain

with a pain scale of 0/10.

54


ASESSMENT DATA


NURSING DIAGNOSIS



RATIONALE

EVALUATION

Subjective:

“Dili na nako

mabuhat kayo akong

gabuhaton sa una

nga wa pako

nagsakit” as

verbalized by the

patient.

“Dali rako kapuyon

ug kung masobraan,

hanguson dayon ko”,

as verbalized by the

patient.

Objective:

Activity Intolerance

(Level 1) related to

imbalance between

oxygen supply and

demand secondary to

inability of the heart to

pump out adequate

amount of blood.

Short-Term Goals:

After 5 hours of nursing

interventions, the client will

be able to:

a.) Verbalize

acceptance the

need for activity

modification.

b.) Improve the

respiratory status of

the client from

27cpm (upon

exertion) to normal


c) Improve client’s

INDEPENDENT:

1. Allow rest in between activities

R – This will decrease oxygen

consumption and to avoid

overexertion.

2. Inform the client about the recent

medical condition.

R – This will clarify thought of the

client’s and gain cooperation

along the way.

3. Assist client in doing activity

modification. ( i.e. instead of

buying/cooking meals, he can

Short-Term Goals:

Goals met. After 5 hours of

nursing interventions, the

client will be able to verbalize

acceptance the need for

activity modification, improved

the respiratory status of the

client from 27cpm (upon

exertion) to normal range

(22cpm), improved client’s

responses from restless to

coherent by answering

questions appropriately and

perform activities within the

cardiac tolerance.

55


Pallor mucosa and

conjunctiva


RBC (3.58); Hgb

(11.1); and Hct (31.5).


RR of 27cpm upon

exertion (tachypnea)

Restless

responses from

restless to coherent

by answering

questions

appropriately.

d) Perform activities

within the cardiac

tolerance.

Long-Term Goals:


interventions, the client will

be able to:

a. Maintain RR within

the normal range

(12 – 22cpm)

b. Maintain client’s

responses upon

doing activities ( i.e.

don’t feel dizzy

easily)

prepare the utensils and plates)

R – This will encourage client in

his health management. In this

manner, it would gain client’s

compliance to activity

modification and this will be more

achievable rather than setting

your own activities.

4. Promote comfort measures and

provide relief of pain non-

pharmacologically.

R – To enhance ability to

participate in activities.

5. Increase exercise/activity levels

gradually. (i.e from the bed to sitting

position on the bed to chair and

assist in ambulation)

R – To conserve energy and

increase activity competency.

Long-Term Goals:

Goals met. After 16 hours of


client will be able to maintain

RR within the normal range

(12 – 22cpm), maintained

client’s responses upon doing

activities ( i.e. don’t feel dizzy

easily), continuously do

modified activities within the

cardiac tolerance, improved

client’s laboratory results of

RBC from 3.58 to normal

range ( 4.0); Hgb from 11.1 to

normal range (14.0); and Hct

from 31.5 to normal range

(39.6).

56


c. Continuously do

modified activities

within the cardiac

tolerance.

d. Improve client’s

laboratory results of

RBC from 3.58 to

normal range ( 4.2 –

5.4); Hgb from 11.1

to normal range

(12.0 – 16.0); and

Hct from 31.5 to

normal range (37.0

– 47.0)

6. Assist client in Active and Passive

Range of Motion.

R – To initiate gradual; activity to

the client.

DEPENDENT:

1. Provide oxygen inhalation at

2LPM via nasal cannula, as per

doctor’s order

R – To give adequate oxygen flow

especially during exertion.

57


ASESSMENT DATA


NURSING DIAGNOSIS



RATIONALE

EVALUATION

58


Risk factors:

Dietary Intake (still

consumes sweet, salty,

fatty and carbohydrate-

rich foods)

Stress

Sedentary lifestyle

(lack of exercise)

Risk for Unstable

Blood Glucose

Short term Goal:

After 30 minutes of nursing


will be able to:

Verbalize

understanding of the

factors that may

lead to unstable

glucose such as

eating sweet, salty,

fatty and

carbohydrate-rich

foods.

Long term Goal:



will be able to:

a.) Maintain a normal

glucose level; 70-

110 mg.

INDEPENDENT:

1. Ascertain client’s knowledge or

understanding of condition and

treatment needs.

R: To know what are the

information to be given

2. Provide information on balancing

food intake and anti-diabetic agents.

R: To enhance the efficacy of the

medication

3. Review client’s common situations

that contribute to glucose instability.

R: Multiple factors can play a role

at any time , such as missing

meals and infection

5. Encourage client to read labels

and choose foods described as

having a low glycemic index, higher

fiber, and low fat content.

Short- Term Goals:

Goal met. After 30 minutes of

nursing intervention, the

patient was able to verbalize

understanding of the factors

that may lead to unstable

glucose such as eating sweet,

salty, fatty and carbohydrate-

rich foods.

Long term Goal:

Goal met. After 16 hours of


patient was able to maintain a

Normal glucose level; (indicate

the CBG)

59


R: These foods produce a slower

rise in blood glucose

6. Discuss how client’s anti-diabetic

medications work.

R: Drugs and combinations of

drugs work in varying ways with

different blood glucose control

and side effects. Understanding

drug actions can help client avoid

or reduce risk of potential for

hypoglycemic reactions.

7. Encourage client to develop a

system for self-monitoring

R - To provide a sense of control

and enable client to follow own

progress.

Dependent:

1. Administer metformin 500 mg PO

tid as ordered.

R – This anti-diabetic agent aids in

lowering down blood glucose 60

IX. DISCHARGE PLANNING

MEDICATIONS

Discuss to the patient and family the dosage, frequency, and adverse effects of

the drugs. Explain that the drugs used for effective control of elevated BP will

likely produce adverse effect.

Explain to the patient and family members the importance of taking medicines.

The patient will able to take medications as what had been prescribed by the

physician religiously and be able to follow directions as instructed by the nurse.

In patients with self-administer insulin, demonstrate patient the appropriate

preparation and administration techniques.

ECONOMIC STATUS

Inform the patient to avail to some government programs such as philhealth.

Explain to significant others that the rehabilitation may be prolonged to be able to

for the family to prepare financial needs.

Have occupational therapist to help re-learn everyday activities or ADL.

TREATMENT

Emphasized the importance of regular follow-up check-ups and as instructed by

physician.

Advised patient and family members to seek medical advise if any unusuality

arises

Reinforced the importance of having blood sugar checked every day.

Admit patient in cardiac rehabilitation, this is a monitored exercise and education

program that can help the patient return to an active lifestyle.

HEALTH TEACHING

Encouraged client to do at least 30 minutes of walking a day as a form of

exercise.

Encouraged client to quit smoking and offered nicotine replacement. Cessation of

cigarette smoking reduces the progression of disease, as shown by lower rates

of amputation and lower incidences of rest ischemia in patients who quit, and it

reduces the risks of myocardial infarction and death from other vascular causes.

Instructed to monitor blood sugar regularly. Adjustments in diet, medication and

exercise can be made accordingly.

Encouraged to stick to the monitoring protocol prescribed by the doctor.

Generally, blood is monitored before meals and at bedtime.

Safety precaution should be maintained to prevent foot injury such as do not

wear open shoes or walk barefoot

Teach to the patient signs and symptoms of diabetic neuropathy and emphasize

the need for safety precautions because neuropathy decreased sensation can

hide sense injuries.

Adjust of activities to avoid over exertion and fatigue, allow rest periods

OUT-PATIENT

The patient could avail his medication from government hospitals that he could

get some benefits.

He will also avail the services offered by the barangay health center and at the

botikang bayan

Instruct patient to seek regular medical check-up

DIET

Eat a variety of foods as recommended in the Diabetes Food Pyramid to get a

balanced intake of the nutrients your body needs - carbohydrates, proteins, fats,

vitamins, and minerals.

Reduce the amount of fat you eat by choosing fewer high-fat foods and cooking

with less fat.

Eat more fiber by eating at least 5 servings of fruits and vegetables every day.

Eat fewer foods that are high in sugar like fruit juices, fruit-flavored drinks,

sodas, and tea or coffee sweetened with sugar.

Use less salt in cooking and at the table. Eat fewer foods that are high in salt,

like canned and packaged soups, pickles, and processed meats.

SPIRITUALITY

Encouraged patient and Family members to go to church every Sunday and to

continue to seek God’s guidance and enlightenment.

Emphasized the importance of prayers in healing

Encouraged to ask for divine assistance in everything and to

encouragecontinuing to pray to God.

Encouraged to continue to have a positive outlook in life.

Encouraged to keep faith in God and not to give up easily when hardtimes come

X. RELATED LEARNING EXPERIENCE

Taking up nursing course have entitled the group to become disciplined in

everything that we do. As much as we want to think that the nursing life is easy to

somehow lessen the stress and sometimes burden but it’s not working. This have made

us realize that it’s better to accept the idea that nothing is easy and hence, molding

ourselves to become disciplined is one way of passing this difficult road to success.

Our duty at the Intensive Care Unit of Northern Mindanao Medical Center is

probably the busiest duty we’ve ever had unlike in CUMC Intensive Care Unit its

opposite due to fewer patients admitted. But despite it, we have taken it as an

opportunity to take advantage of our duty time in improving our clinical skills and as well

as improving our knowledge. We’ve learned a lot in the clinical area and so it’s definitely

worth our exhaustion.

The entire process of making this case study may have not been easy for all of

us but fortunately, we’ve manage to deal with the problems properly and thus, we were

able to finish this case study in the best way we could. Whether the outcome of this

case study is good or bad, we must take it as a lesson and a parameter to continue

seeking knowledge and improving our skills.

This case study enabled the group to identify nursing intervention which are

appropriate to promote the well-being of the patient and as well as the medical

management for the case.

We would like to thank Mr. Hamed Fabre, for giving his best to teach us and to

mold us in becoming good and competent nurses in the future. Furthermore, this

rotation would have not been successful without the guidance of our almighty God!

XI. REFERENCE

BOOKS:

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C, (2002). Nursing Care

Plans Guidelines for Individualizing Patient Care, (6th ed.). Thailand

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C (2006). Nurse’s pocket

Guide; Diagnoses, Prioritized Interventions, and Rationales. (10thed.).

Philadelphia, Pennsylvania

Smeltzer, Suzanne C., RN, Edd, FAAN, & Bare, Brenda G., RN, MSN,(2004).

Textbook of Medical-Surgical Nursing, (10th ed.), Philadelphia

Karch, Amy M. ; 2006 Lippincott’s Nursing Drug Guide, 8th edition. Lippincott

Williams & Wilkins.

Nurses’ Pocket Guide, 10th edition F.A. Davis.

Nursing Care Plans, 7th edition F.A. Davis Doeuger, Moorhouse, Murr.

Patient’s Chart

Black, Joyce M. et. al, Medical-Surgical Nursing: Clinical Management for

Positive outcome. 7th edition. Philadelphia, W.B. Saunders. 2005

Malseed, Roger T. ; Springhouse Nurses’ Drug Guide 2004, 5th edition.

Davis drug handbook, 10th edition

Drug handbook by Saunders

Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th

edition By: Joyce Black and Jane Hokanson Hawks

Nursing Care of Infants and Children by Wong

INTERNET:

http://cpmcnet.columbia.edu/dept/gi/.html

http://www.drstandley.com/labvalues

http://www.google.com.ph/search?anatomy&meta=

http://www.merck.com/ l

http://www.wpro.who.int/countries/2009/phl/health_situation.htm

www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink

http://www.tuberculosistextbook.com/tb/tbchild.htm

(http://www.mayoclinic.com/health/acute-coronary

syndrome/DS01061/DSECTION=symptoms)

http://www.mayoclinic.com/health/acute-coronary

syndrome/DS01061/DSECTION=symptoms





http://www.tuberculosistextbook.com/tb/tbchild.htm

http://www.cureresearch.com/c/cerebral_palsy/stats-country.htm?ktrack=kcplink

http://www.wpro.who.int/countries/2009/phl/health_situation.htm

http://www.merck.com/mmhe/sec10/ch135/ch135e.html

http://www.drstandley.com/labvalues

acute coronary syndrome, stemi, anterior wall, killips - 1, dm type ii - uncontrolled

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