A care for client with Acute Coronary Syndrome

In partial fulfillment of Related Learning Experience (R.L.E)

Submitted By: Roderos, Mitch Angela

BSN 4C GROUP II S.Y 2011-2012

Clinical Instructor Ms. Virginia Lorda

INTRODUCTION Coronary artery disease (CAD) is an umbrella term used to cover any group of clinical symptoms compatible with acute myocardial ischemia. Acute myocardial ischemia is chest pain due to insufficient blood supply to the heart muscle that results from coronary artery disease (also called coronary heart disease). also called coronary heart disease (CHD), a single largest killer of American men and women in all cultural groups (American Heart Association [AHA 2003). According to the AHA, CHD caused more than 1 out of every 5 deaths in the United States in 2000. From 1990 to 2000, the death rate from CAD declined 25%. Multiple factors can be identified as contributing to the declined in CAD. These factor include more effective medical treatment and an increase awareness and emphasis on reducing the major modifiable cardiovascular risk factor (e.g., high blood pressure [BP], smoking, high cholesterol, obesity, diabetes). (Principles of Medical Surgical Nursing Lemone, Burke Vol. 2 4the Edition 2007 page 974-975) In Acute coronary syndrome, it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (clumping), thrombus (clot) formation, and vasoconstriction. The amount of disruption of atherosclerotic plaque determines the degree of obstruction of the coronary artery and the specific disease process (unstable angina or myocardial infarction [MI]. Between 10% and 30 % of the client with unstable angina progress to having an MI in 1 year and 29% die of MI in 5 years (AHA, 2003). Acute coronary syndrome (ACS) is a condition of unstable cardiac ischemia. ACs includes unstable angina and acute myocardial ischemia with or without significant injury of the myocardial tissue. As estimated 1.4 million Americans are admitted to the hospital annually with ACS (Kasper et. al.., 2005).

Fast Facts: Acute coronary syndrome (severe cardiac ischemia), a common cause of hospital admission, includes unstable angina and acute myocardial infarction. Unstable angina is characterized by injury to myocardial cells; with prompt restoration of blood flow, muscle tissue recovers. Myocardial infarction is characterized by necrosis and death of myocardial cells; scar tissue forms and functional muscle is lost. ACS is the most common identified cause of sudden cardiac death (American Heart Association [AHA], 2005).

A. DEMOGRAPHIC DATA 1. 2. 3. 4. 5. 6. 7. 8. 9. Clients name : Patient D.V Gender: Male Age, Birth date and Birth place: 59 years old, April 24,1952 at Tarlac Marital Status: Single Nationality: Filipino Religion: Romasn Catholic Address: 15 Natividad St. Bangkal Quezon City Educational Background: College Undergraduate Occupation: The client manages his own karinderya

10. Usual Source of Medical Care: Ospital ng Makati

B. SOURCE AND RELIABLITY OF INFORMATION Patients Chart Patient Himself

C. REASON FOR SEEKING CARE Naninikip ang dibsdib As verbalized by the patient

D. HISTORY OF PRESENT ILLNESS November 20,2011 2 hours prtor to admission Patient was watching television (FPJ movie) when patient complained of chest pain radiating to the left sshoulder. No medication takeb few hour persistence Upon Admission - Patients vital signs was taken and recorded of blood pressure of 130/70, PR: 84, RR: 26, Temp: 36.4 with general survey of Levignes sign, Facial Grimace and Dyspnea

E. PAST MEDICAL HISTORY Pediatric/Childhood/ Adult Illness: Mumps (7 y/o); Chiken Pox (17 y/o) Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0) Serious/ Chronic Illnesses: The client has Hypertension X4, HBP of 200/100 UBP 150/80 Hospitalizations: There was no recorded previous hospitalization for the past year 2010 Operations: No known operations Immunizations: The client verbalized of having complete immunization of DPT, OPV, BCG and Measles vaccine.

Allergies: No known Allergies Medications prior to confinement: The client took Norvasc 10 g/tab Last Examination Date: November 20, 2011
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F. FAMILY HISTORY

Father (+) HPN (+) DM ( 65 y/o 63 y/o

Mother

(+) HPN (+) Asthma

59 y/o

58 y/o

(+) Asthma

27 y/o

(+) Asthma

LEGEND

Male

Female

Client

Deceased

1.) Heredo-Family Illness: Maternal Patient Bs mother is known to have High blood pressre and Asthma. Currently, his older sister next to him has asthma and so as his only daughter started when she was 2 years old. FatherPatientt Bs father has no known family illness running in their blood.

G. SOCIO-ECONOMIC The client consists of a nuclear family and lives together with his aged mother, wife and his daughter. The client states that he contributes for the family financial expenses by the help of their Karinderya and his working daughter. Financial Resources are adequate enough to provide for them for the expenses of their everyday living.

DEVELOPMENTAL HISTORY

Erik Erickson Psychosocial Theory

Age

Task

Patients Description

Generativity Vs. Stagnation

30-65 years Erikson's analysis of this stage old middle age was strongly oriented towards parenting. Generatively potentially extends beyond one's own children, and also to all future generations, which gives the model ultimately a very modern globally responsible perspective. Having children is not a prerequisite for Generativity, just as being a parent is no guarantee that Generativity will be achieved. Caring for children is the common Generativity scenario, but success at this stage actually depends on giving and caring putting something back into life, to the best of one's capabilities.

The client is presently enjoying himself at his senior years. The client states that he enjoys managing their karinderya to spend time and to contribute in generating income. The client is well established from raising his daughter well.

The client stated the he had lived his life productively. The client exhibits generativity from Ericksons psychosocial development. The client stated that he had worked hard on his younger years to have a stable life. He stated that he doesnt have anything to ask for, except to have longer life to spend his golden years with

Stagnation is an extension of intimacy which turns inward in the form of self-interest and self-absorption. It's the disposition that represents feelings of selfishness, selfindulgence, greed, lack of interest in young people and future generations, and the wider world. Adults need to create or nurture things that will outlast them, often by having children

his beloved family.

or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world

H. REVIEW OF SYSTEMS 1. Regional Examinations (December 1, 2011 9:30 am)

Vital Signs:

Temp : 37.51c RR: 26 cpm PR: 86 cpm BP: 100/70mmHg

General Assessment: Patient is seen conscious and coherent; garbed in hospital gown,sitting on bed without difficulty. Skin is clean and smooth with normal skin turgor. Nails are long but not dirty and with normal capillary refill. Patient is with ongoing oxygen therapy via Nasal Cannula regulated at 4 Liters per minute, and hooked with D5W 500 cc X 10 cc/hr Infusing well at his left matacarpal vein.

Date of Assessment December 1,2011

System

Normal Findings

Actual Findings

Integumentary

Smooth and good skin turgor, no lesions or any discoloration, no clubbing, no breaks &abnormal curvature.

I: Brown color, no lesion, no swelling and edema. Normal looking Visible veins on both arms Has a temperature of 37.51c. In nails: Long and clean nails and round nails. Pink Nail bed P:

 Warm, soft, smooth, and has a good skin turgor. In nails: Hard, immobile, and smooth. December 1,2011 Hair and Head No lesion, no tenderness, no pain on palpation, no masses, no lumps, no nodules or depression, symmetrical I: -His hair color is black, hair is evenly distributed, -Has thick hair. -No presence of parasite and dandruff. -In scalp: Symmetrical and round and no lesion. P: -Hair texture is smooth and soft. -In head the texture is smooth and firm. December 1,2011 Eyes Eyelid intact, no redness, swelling, discharge or lesions. Eyeballs are moist & glossy, conjunctiva numerous small blood vessels. Sclera white. Good eye contact. I: -Lid margins moist and light pink, lashes short, evenly spaced and curled outward. -Bulbar conjunctiva is clear with tiny vessels visible, palpebral conjunctiva is light pink with no discharge, white sclera. - In PERRLA: *Cornea is transparent and the shape of the iris and pupil is round and equal. *The left and right eye has a good reaction to light (constrict and dilate) -In extra ocular movements: *Both eyes coordinated well in all directions.

December 1,2011

Ears

Ears are symmetrical with 10 degrees angle. Color is same in facial with no tenderness or any nodule and without any presence of discharge.

I: -Equal size and similar appearance. -No lesions, brown in color same with his complexion. P: -Warm, smooth, no nodules and no tenderness in auricle and tragus.

December 1,2011

Mouth and Throat

32 adult teeth are present with moist and pink mucous membrane without any lesions or swelling.

I & P: -Lips and surrounding tissue relatively symmetrical.No lesions, swelling and drooping. -Lip is light pink; moist, smooth and with no lesions. -Buccal mucosa is light pink, moist and without lesions.-Gums are light pink, and moist. -In tongue: *Moist, some papillae present, symmetrical appearance, midline fissures present and the color is pink and color white at the center and no lesions as well as the sides of the tongue. *Hard palate: slightly pink. *Soft palate: pink, -Has 32 teeth and stained with a hint of yellow color.

December 1,2011

Neck

No tenderness on palpation, no pain, symmetrically align, no enlarged lymph nodes, no tracheal lateral deviation.

I: -Neck is symmetric with head centered and without bulging masses. P: -Smooth skin, firm, and none tender and none enlarged nodules.

December 1,2011

Breast and Axillae

No palpable nodules and lesions. Breast is firm and round.

I: -Nipples have no discharges and not cracked. I: -The color of his chest is similar to his complexion. -With Chest in drawing -Chest symmetry is equal -Thorax: is straight. -The RR of the patient is 26cpm. -Dyspneic, with Nasal Flaring -Chest X-Ray impression of pulmonary congestion P: No pain or tenderness. A: Lung is clear to auscultation on inspiration and expiration.

December 1,2011

Respiratory

Intercostals spaces are even and relaxed; chest symmetry is equal, no pain or tenderness, and no abnormal breath sound.

December 1,2011

Cardiovascular

No fatigue on simple activities, no arrhythmias and heart murmurs. PR=60100bpm.

PR : 86 bpm BP: 100/70 mmHg I:-Neck veins are not distended. P: -No vibrations or palpitation in aortic, pulmonic, or tricuspid area. A:-No murmur sound heard. Chest X-Ray reveals atheromatous aorta

December 1,2011

Abdominal

No pain, No palpable masses and tenderness, Flat and round.

I: -Flat abdomen P: -No tenderness, lesions and masses

December 1,2011

Musculoskeletal Have good range of motion and no limitation of movements.

-Does not need assistance to stand and toes point straight ahead. Able to shrug shoulders against resistance.

December 1,2011

Neurologic

Have no tremors paralysis. Oriented, no history of seizures, mental dysfunction or hallucinations.

-No presence of tremors, oriented, no history of seizures, mental dysfunction or hallucinations.

December 1,2011

Lympathic

Has no bleeding tendencies, normal lymph nodes.

No swollen lymph nodes.

2. Laboratory Studies/Diagnostics 11/20/11 Clinical Chemistry Section

Test Name

S.I Result

Unit

Range

Conversion Result

Unit

Result

Interpretation

Creatinine

157

Umol/L

53-115

1.78

mg/dL

0.601.30 15 37 30 - 65

Above Normal

AST SGPT Na K

40 39 136 3.6

u/L u/L mmol/L mmol/L

15-37 30-65 136-145 3.5-5.1

40 39 136 3.6

u/L u/L

Above Normal Normal Normal Normal

mmol/L 136-145 mmol/L 3.5-5.1

Chloride

102

mmol/L

98 - 107

102

mmol/L 98 - 107

Normal

11/24/11 Clinical Chemistry Section

Test Name

S.I Result

Unit

Range

Conversion Result

Unit

Result

Interpretation

BUN Creatinine

17.4 154

mmol/L Umol/L

2.5-6.4 53-115

48.74 1.74

mg/dl mg/dl

7.0-18.0 0.60-1.30

Above Normal Above Normal

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11/27/11 Clinical Chemistry Section

Test Name

S.I Result

Unit

Range

Conversion Result

Unit

Result

Interpretation

Glucose (fasting) Uric Acid

2.10 371

mmol/L

4.1-5.1

30-45 6.22 103.46 53.33 25.38

mg/dl mg/dl mg/dl mg/dl mg/dl

73-99 2.6 7.2 50-200 15-150 40-60

Below Normal Normal Normal Normal Normal

Ummol/L 165-428 mmol/L mmol/L mmol/L 1.3-5.2 0.17-1.70 1.04 1.55

Cholesterol Total 2.69 Triglycerides HDL 0.60 0.66

LDL

1.64

mmol

1.89-3.09

63.08

mg/dl

72.69118.85

Below Normal

AST (SGOT) ALT (SGPT)

66 66

u/L u/L

15-37 30- 65

66 66

u/L u/L

15-37 30-55

Above Normal Above Normal

11/28/11 Glycohemoglobin Test

Test Name Glycohemoglobin Test

Result 2.10

Reference Range 4.1-5.1

Interpretation Below Normal

11/21/11

Test Name

S.I Result

Unit

Range

Conversion Result

Unit

Result

Interpretation

CK-MB

110

u/L

7-25

110

u/L

7-25

Above Normal Damage to cardiac cells, indication of myocardial infarction

11/27/11

Test Name Troponin I

Result Positive

Interpretation Indicates myocardial infarction

11/28/11

Test Name Troponin I

Result Negative

Interpretation Does not indicate myocardial injury

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11/20/11 Hematology

Laboratory (Date) 11/20/11

Normal Value

Result

Interpretation/Significance

M - 14-18 g/dl Hemoglobin F 12 -16 g/dl

15

Normal

Hematocrit

M 0.40 0.54 F 0.37 0.37

0.55

Normal

White Blod Cells Red Blood Cells

4.0 11.0 M 5.0 -6.4

15.5 6.3

Above Normal Below Normal.

DIFFERENTIAL COUNT Segmenters Lymphocytes Monocytes Platelet 0.5 0.7 0.2 0.4 0.02 0.05 150- 300 0.96 0.3 0.01 195 Above Normal Above Normal Above Normal Normal

11/21/11 Blood Coagulation Test Protrombin Time % Activity INR Activated PTT Reference 10.4 14 73-127% 0.88 1. 21 36.4 41.25 sec 13.9 72.6% 1.21 46.1 sec Results Interpretation Normal Normal Normal Above Normal

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3. Other Assessment Toolss Procedure 11/26/11 Indication The acid-fast stain is an especially important test for the Acid Fast Stain Specimen genus Mycobacteriu m, to rule out pulmonary tuberculosis. Negative Results Microscopic Examination : Pre Advise patient to drink a lot of fluids the night before the test. It makes the test more accurate if it's done first thing in the morning. Advised patient not to take antibiotics and some sulfonamides because it may interfere with test results, causing the results to be falsely negative. Prior to breakfast, the patient will be asked to provide a 5-10 mL specimen of sputum delivered into a sterile cup with a screw top lid. Intra Asked patient to cough deeply and spit the substance that comes up from the lungs (sputum) into a container. Patient may be asked to inhale a mist of salty steam in order to cough more deeply and produce sputum. Post Place it in a sterile container, label appripiately and immdiately forward in the laboratory. Nursing intervention

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Procedure 11/19/11

Indication CT scanning or sometimes called CAT scanning is a

Results There are fluffy infiltrates noted with accentuation of the pulmonary vasculature Pre

Nursing intervention

Remove all Metal objects including jewelry, eyeglasses, dentures and hairpins. Patient may also be asked to remove hearing aids and removable dental work.

X-ray

noninvasive medical test that helps physicians diagnose and treat medical conditions. CT scanning combines special xray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor, printed or transferred to a CD.

The heart is not enlarged

Instruct not to eat or drink anything for several hours beforehand, especially if a contrast material will be used in exam.

The aorta shows some calcifications along its walls Intra A chest ct scan takes about 30 mins., which includes preparation time Diaphragm and sinuses are intake Patient mat lie on a narrow table that moves through the hole While inside the scanner, an x-ray tube moves around your body. You Impression: Pulmonary congestion and edema R/O pneumonia athermanous aorta will wear soft buzzing, clicking or whirring noises as the scanner takes pictures The technician will ask you to lie still and hold your breath for short periods. these measures help make the picture as clear as possible the scan itself

Post CT exams are generally painless, fast and easy. After a CT exam, you can return to your normal activities.

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Procedure 11/21/11 5:00 am Electrocardiogram

Indication Electrocardiogram (ECG) provides 12 vector views of the hearts electrical activity as reflected by electrical potential differences between positive and negative electrodes placed in the limbs and chest wall. ECG is crucial for establishing many cardiac diagnoses, especially arrhythmias and myocardial ischemia.

Results Abnormal ECG Lateral Infarction Anteroseptal Infarction Marked right axis deviation With runs of PVC Pre

Nursing intervention

Explain the procedure to the patient. Instruct patient to wear comfortable, loose-fitting clothing Instruct to remove all Metal objects including jewelry, eyeglasses, dentures and hairpins. Patient may also be asked to remove hearing aids and removable dental work.

In some instances, men may require the shaving of a small amount of chest hair to obtain optimal contact between the leads and the skin

Acute 11/21/11 12:00 pm Electrocardiogram anteroseptal infarction Lateral Infarction Ventricular Premature Contraction Intra EKG leads are attached to the body while the patient lies flat on a bed or table. Leads are attached to each extremity (four total) and to six pre-defined positions on the front of the chest. A small amount of gel is applied to the skin, which allows the electrical impulses of the heart to be more easily 11/21/11 11:00 pm Electrocardiogram Prior to streptokinase therapy Lateral Infarction Anteroseptal Infaction Poor right progression transmitted to the EKG leads. Instruct that the test takes about five minutes and is painless.

11/21/11 8:00 pm Electrocardiogram

Acute anterior infarction Abnormal Q Ventricular premature contraction

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I. FUNCTIONAL ASSESSMENT HEALTH PERCEPTION-HEALTH MANAGEMENT

Prior to admission, patient sees health being able to do everyday things well according to the manner he wants it. The client stated he doesnt easilly get sick and when he does, he just let it subside not until if his condition worsens, thats the time when he would visit the hospital. The client does not use any vitamins and medications. Client has not experienced colds in the past month. The client stated that he would eat lots of nutritious foods and keeping himself physically fit is his way to keep himself healthy

SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN Before the patient was admitted, he sees himself being able to do things according to the manner he wants it. He does not mind his health not until the manifestation of discomfort brought from his disease. Presently, the client verbalized difficulty of being sick; he stated that he will find it hard to adjust from it. That client claims that he acquired his disease due to over fatigue and abusing his body by work when he was young back then. The client verbalizes a decrease in self-perception due to aging and performing strenuous activities due to presence of exertional dyspnea.

ACTIVITY/EXERCISE PATTERN Prior to confinement, the client claims his activities as sort of exercise by means of managing their mini Karinderya for the whole day. Presently, the patient is confined in the primary holding unit. The client assumes full self care on himself. The client is on bed rest and does minimal activities. Feeding Bathing Toiling 0 0 0 Grooming Gen. Mobility House maintenance Bed mobility Legends: Level 0 Self Care Level I Use of equipments Level II Assistance from another person Level III Requires assistance from another person or device Level IV Dependent and does not participate 0 Dressing 0 0 0 0

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SLEEP/REST PATTERN Before the client was admitted, the client stated that he is usually sleeps late because of their Karinderya. The client states that he has 7 hours of sleep everyday without the any use of sleeping aids. He stated that the client would take a nap at noon for about 2 hours. Presently, The client has no difficulty of sleeping except from some external factors such as the noise of other patients that he shares the ward with. The client does not use any sleeping pills but prefers to play music in his radio to induce sleep. The client verbalizes of having siesta after taking his lunch NUTRITIONAL-METABOLIC PATTERN The client eats three times a day with low salt and low fat diet. The client has good appetite and has no known food allergies. Wound heals normally. He recalled that his last meal was noodles and bread and half of one serving. The client has no known allergies and drinks 450 ml of water noted on our 6- 2 morning shift last December 1, 2011. The client has no dental problems, no foul odors and excess perspiration.

ELIMINATION PATTERN The client states that he defecates once a day usually in the morning in soft brown stool without difficulty and use of laxatives. The client urinates 3x day or more varying in his fluid intake; he verbalizes no difficulty in voiding. SEXUALITY/REPRODUCTIVE The patient is not sexually active and was circumcised at the age of 12. The client is married with his wife for almost 40 years. The client displays intimate close relationship to his wife. The client states that he depends most on her wife for taking care of him and in giving him medication and her attention at him, since he tends to be forgetful. The patients wife is not around during the interview.

INTERPERSONALRELATIONSHIPS/RESOURCES The client is the youngest son among his 3 siblings. The client is married to his wife for 40 years and is a father to his only daughter. He stated that there are no family quarrels so far. The client is a humorous person, that made gave them openness and good bonds. The client stated that he decides on the facing familys major decisions with the help of his wife. The client stated that he muses with his present life COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN The client states the he has no stressful situation encountered presently. Since he stated that he is feeling a lot better than his admission. The client states that whenever he encounters a

17

difficult situation, he would think about it several times prior to decision making. The client verbalized that he can control his emotions. VALUES/ BELIEFS The Client is a Roman Catholic.. The client stated that he barely attends the church because of several preoccupations. he believes that he got his illness as God warning towards his way of living. He stated that he will stop from over abusing his body and he would adhere to healthy lifestyle. PERSONAL/SOCIAL HISTORY Habits: The client is known to be a hard-working man. Patient D.V stated that he cannot tolerate not to do anything during his free time. He make sure that his goals are achieved at the end of the day Vices: The client stated does not consume alcoholic beverages and does not smoke. Lifestyle: The client was known to live in a stressful lifestyle. The client states that he is skillful Clients usual daily life: The clients typical day is working as chef in his mini Karinderya that run every day but closes half-day during Sundays. Patient D.V states that he prefers to be with his family watching television or taking siesta during his free time. Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings. Travel: The client has no previous local and intonation travel for the past 4 months. J. ENVIRONMENTAL HISTORY

The client lives together with his family composed of 4 house hold members. A bungalow type of house with 209 square meters is owned by the patient residing near the highway. The client narrated that it is a cemented house with 2 bedrooms and 1 bath room. The house is fully ventilated and well lit of 12 windows. Their doors for about the size of 180X1 meter. The client stated that their surroundings are well-sanitized. Their electricity supply comes from Meralco and their water supply are from Deep well. They order Mineral water for drinking. The clients residence is advantageous, since it is near the public market, transportation, at school and Hospital.

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K. PEDIATRIC HISTORY L. MATERNAL AND BIRTH HISTORY

Birth date: April 24,1952 Birth weight: Unrecalled Type of delivery: Normal Spontaneous Delivery Condition after birth: In fine stable condition

Hospital: Not assessed

Mother: Complications of delivery: None Anesthesia drug guring labor: Unrecalled Exposure to Teratogenic Agents during Pregnancy: None

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I.

PATHOPHYSIOLOGY CLIENT-BASED

Predisposing Factor Age (75 years old) Gender (Male)

Precipitating Factor Diet (Cholesterol rich foods) Stressful Lifestyle

Plaque Formation

Atherosclerotic plaque ruptures or erodes

Thrombin is generated and Fibrin is deposited

Platelet Aggregation

Clots are being formed

Thickening and narrowing of arterial vessels

Obstruction in Blood Flow

Cells become ischemic

Myocardial cell contract less effectively

Lactic acid is secreted

Decrease O2 supply to myocardium

Decrease Cardiac Output Stimulate pain Receptor Decrease O2 supply to the different part of the body Chest Pain

D.O.B.

Pallor

Body Weakness

20

II.

CONCEPT MAPPING 1. Ineffective Airway Clearance related to increased tracheobronchial secretions as evidenced by productive cough

5. Risk for decreased cardiac output related to degeneration of cardiac muscle

T/C Acute Coronary Syndrome Probably MI, Has CVD, Heart dysrhytmia not in failure
2. Ineffective tissue perfusion: Patient B.R; 25 y/o Male. Temp.: 37.5c RR: 19cpm PR: 86 cpm BP: 100/70mmHg. Dyspnea Productive cough in whitish sputum Chest X-Ray result of Pulmonary Congestion and Edema Weak looking Facial Grimace Presence of arrhytmias Positive Troponin I Elevated Ck-MB With Verbal Reports of Weaknhess With Exertional dypnea With verbal expression of worry cardiopulmonary related to reduced coronary blood flow as evidenced by chest pain

4. Anxiety related to fear of death, change in health status

3. Activity Intolerance related to imbalance in oxygen supply and demand as evidenced by fatigue

III.

PROBLEM LIST Actual Problem Number Problem Ineffective Airway Clearance 1 related to increased tracheobronchial secretions as evidenced by productive cough Remarks The client presently exhibits dyspnea and productive cough in whittish secretions. Moreover, Pulmonary congestion is noted upon chest X-ray.

Ineffective tissue perfusion: cardiopulmonary related to reduced coronary blood flow as evidenced by chest pain

Presence of a Positive Troponin I indicates myocardial injusry, thus a presence of a decrease in oxygen supple results in the failure to nourish the tissues at capillary level

Activity Intolerance related to imbalance in oxygen supply and demand as evidenced by verbal reports of weakness

Due to imbalance ratio of oxygen of supply and demand and presence of productive cough has led the patientInsufficient physiological or psychological energy to complete required or desired daily activities

Anxiety related to fear of death and change in health status as evidenced by verbal expression of worry

Patient D.V verbalized a generalized, unidentified feeling of discomfort due to his experience of Chest Pain

Potential Problem Number 1 Problem Risk for decreased cardiac output related to degeneration of cardiac muscle Remarks The client is at reisk for decreased cardiac due to history of a positive troponin I and elevated CK-MB indicating a myocardial injury. Therefore, it is possibible that there may be presence of inadequate blood pumped by the heart to meet the metabolic demands of the body due to degeneration of cardiac muscle.

IV. Cues/Needs

NURSING CARE PLAN Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Matatagalan pa bago bumalik ang kulay ko as verbalized by the patient

Ineffective Airway Clearance related to increased tracheobronch ial secretions

After 9 hour of nursing intervention, the client will be able to demonstrate behaviors to maintain clear airway

Monitor Respirations and breath sounds, noting rate and sounds

Indication of respiratory distress and/or accumulation of secretions

After 9 hours of nursing intervention,

Elevated head of bed, changed position every 2 hours PRN Kept area patients sorrounding clean and free from draughts by means of instructing to reduce things and place only valuable things in his bed, and fixed the patient bed linen Instruct patient to do deep breathing by asking tha patient to inhale deeply and exhale slowly. and coughing exercises Encourage the patient to increase fluid intake for at least 2000 ml/day. Within cardiac tolerance Asisted client with postural drainage and percussion if not contraindicated by condition Auscultate breath sounds and assess air movement

To decrease pressure on the diaghraphm To prevent aggravation of condition

the client was able to demonstrate behaviors to maintain clear airway

Objective:

as evidenced

Dyspnea by productive Productive cough cough in whitish sputum Chest X-Ray result of Pulmonary Congestion and Edema Weak looking Facial Grimace

To maximize effort on expectorating secretions.

Hydration can liquefy viscous secretions and improve secretion clearance. To loosen viscous

To determine progress

Administered bronchodilators as prescribed by the physician. Instruct home regimen interventions such as boiling water and instruc the patient to inhale the steam to serve as an alternative to nebulaization

To provide pharmacological treatment and for fast recovery To provide cost reducing ways in improving expotorating secretions.

Referred to respiratory therapist for adjunct treatment modalities.

To determine effectiveness of drug theraphy

Cues/Needs

Nursing Diagnosis

Planning

Implementation Intially Assess, document and reposrt the physician about the following:

Rationale These data assist in determining the cause and effect of the chest discomfort and provide a baseline with which post-therapy symptoms can be compared.

Evaluation

Subjective: Ang Sikip ng dibdib ko as verbalized by the patient

Ineffective tissue perfusion: cardiopulmon ary related to reduced

After 8 hours of Nursing intervention, the client will be free from chest pain/discomfort

After 8 hours of Nursing intervention, the client remained free from chest

Objective: Presence of arrhytmias Positive Troponin I Elevated CkMB Chest Pain

coronary blood flow as evidenced by chest pain a.) The patients description of chest discomfort,including location, intensity,radiation, duration, and factors that affect it. Other symptoms such These data assist in determining the cause and effect of the chest discomfort and provide a baseline with which post-therapy symptoms can be compared.

pain/discomf ort

as nausea, diaphoresis, or complaints of unusual fatigue.

b.) The effect of chest cardiovascular perfusionto the heart

discomfort on

MI decreases myocardial contractility and ventricular

(eg, change in blood pressure,

heart

compliance and may produce dysrhythmias. Cardiac output

sounds), to the brain (eg, changes in

LOC), to the kidneys (eg, decrease in urine output), and to the skin (eg, color, temperature).

is reduced, resulting in reduced blood pressure

and decreased organ perfusion.The heart rate may increase as a ompensatory mechanism to maintain cardiac output.

Obtain a 12-lead ECG recording during

symptomatic event, as prescribed, to determine extension of infarction.

An ECG during symptoms may be useful in the diagnosis of an extension of MI.

Administer oxygen as prescribed

Oxygen therapy may increase the oxygen supply to the myocardium if actual oxygen saturation is less than normal.

 Adminiser medications as prescribed

Medication therapy is the first line of defense in preserving myocardial tissue. The side effects of these medications can be hazardous and the patients status must be assessed

Ensure physical rest: use of the bedsidecommode with assistance; backrest elevated to promote comfort; diet as tolerated; arms supported during upper extremity activity; use of stool softener to prevent straining at stool.

Physical rest reduces myocardial oxygen consumption. Fear and anxiety precipitate the stress response; this results in increased levels of endogenous

Provide a restful environment, and allay catecholamines,which increase fears and anxiety by being supportive, calm, and competent. Individualized visitation is based on patient response. myocardial oxygen consumption. Also, with increased epinephrine, the pain threshold is decreased, and pain increases myocardial oxygen consumption

Cues/Needs

Nursing Diagnosis

Planning

Implementation Determine factors contributing to fatigue

Rationale

Evaluation

Subjective: Mabilis akong hingalin kahit sa pag gawa ng mga simpleng

Activity Intolerance related to imbalance in

After 8 hours of nursing intervention, the client will participate willingly in necessary and desired activities.

The client marks to have pulmonary congestion and under observation to have acute coronary syndrome

After 8 hours of nursing intervention, the client participated

bagay as verbalized by oxygen supply the patient and demand as evidenced by verbal reports Objective: With Verbal Reports of Weaknhess With Exertional dypnea Facial grimace of weakness

Evaluate clients percieved limitations by asking past activities and present activities Assess cardiopulmonary response to physical activity, including vital signs before, during and after activity Provide and monitor response to supplemental exygen

To provide comparative baseline data and to provide information about needed intervention

willingly in necessary and desired activities.

Manifestations results intolerance of activity

The client verbalized of incorporating such exercises and

To provide an increase in oxygen supply

exposure to sunlight in his daily living

 Assist client wit activities when walking to the wash room, getting up in bed and lying back to bed Provide intervals of rest between activities Encourage and acknowledge the difficulty of the situatio of the client Encouraged patient to expose

To protect the client from injury

To minimize occurrences of fatigue

Helps to minimize frustration and rechannel energy

Sunlight is rich in Vitamin D and

himself in sun light around 7- will help the client to increase vitality 8 am Assist and provide passive and active ROM To maintain and enhance muscle tone of client

Cues/Needs Subjective: Mamamatay na ata ko as verbalized by the patient

Nursing Diagnosis Anxiety related to fear of death and change in health status as evidenced by verbal

Planning After 8 hours of nursing intervention the client will manifest

Implementation Assess, document, and report to the physician the patients and familys level of anxiety and coping mechanisms.

Rationale These data provide information about the psychological wellbeing and a baseline. Causes of anxiety are variable and individual, and may include acute illness, pain, disruption of ADL and anxious family members can transmit anxiety to the patient.the nurse must also identify strategies to reduce the familys fear and anxiety.

Evaluation After 8 hours of nursing intervention the client manifest reduction of anxiety

expression of worry reduction of Objective: With verbal expression of worry Decreased mental concentration Assess the need for spiritual counseling and refer as appropriate. anxiety

It was observed an increase of social

If a patient finds support in a religion, religious Counseling

interaction to relatives and other people.

Allow patient and family to express anxiety and fear: a. By showing genuine interest and concern b. By facilitating

Unresolved anxiety serves as the stress response that increases myocardial oxygen consumption.

communication (listening, reflecting, guiding) c. By answering questions The presence of supportive family Encourage the presence of the family relative to assist members may reduce both patients and

in reducing the patients level of familys anxiety. anxiety Encourage active participation in a cardiac rehabilitation program by educating the uses of his medications, the need for diet modification and exercise Teach stress reduction techniques. Such as a.) Deep Breathing b.) Pursed Lip Breathing c.) Music Therapy by means of listening to music available in his resources Stress reduction may help to reduce myocardial oxygen consumption and may enhance feelings of well-being. Prescribed cardiac rehabilitation may help to eliminate fear of death, reduce anxiety, and enhance feelings of wellbeing.

Cues/Needs Subjective: Sa awa ng Diyos e gumaan na kahit papano ang pakiramdam ko as verbalized by the patient

Nursing Diagnosis Risk for decreased cardiac output related to degeneration of cardiac muscle

Planning At the end of 1 week of nursing intervention, the client will display hemodynamic stability.

Implementation Keep client on bed or chair rest in position of comfort.

Rationale Decreased oxygen consumption and risk for decompensation.

Evaluation At the end of 2 weeks of nursing

Administer high-flow oxygen via mask as indicated

To increase oxygen available for cardiac function/tissue perfusion

intervention, the client will displayed

Decrease Stimuli, provide quiet environment.

To promote adequate rest

hemodynamic stability

Objective: Presence of arrhytmias Elevate legs when in sitting position. To enhance venous return

Provide fluids/electrolytes as indicated

To minimize dehydration and dysrhtmias.

Encourage changing positions slowly, dangling legs before standing

To reduce risk for orthostatic hypotension

Early detection in changing in Monitor vital signs, watch out for circulatory failure. these parameters promotes timely intervention.

MEDICAL-SURGICAL MANAGEMENT i. DRUG NAME Pharmacotherapeutics MECHANISM OF ACTION Generic Name: Binds to opiate receptors in the Morphine Sulfate CNS. Alters the perceptions of the response to painful Brand Name: stimuli while producing generalize CNS Classification: depression. patients. Narcotic Analgesic Moderate to severe CNS: dizziness, headache, pain. Also provides: Analgesia during labor, sedation before surgery, supplement to balance analgesia. sedation, confusion, dysphoria, euphoria, floating feeling, hallucinations, EENT: blurred vision, diplopia, miosis (high doses) . RESP: respiratory depression. orthostatic hypotension, palpitations, GI: dry mouth, nausea, vomiting, constipation, ileus. urinary urgency. clammy feeling, sweating. physical Dosage: TIV prn for Chest Pain dependence, psychological dependence, tolerance, Assess type, location, duration and intensity of pain Assess blood pressure, pulse, and respiration before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Assess previous analgesic history. It may induce withdrawal symptoms Instruct patient on how and when to ask for pain medication. May cause drowsiness or dizziness. Advice patient to call for assistance when ambulating and to avoid activities requiring alertness until response to the medication is known. Caution patient to change positions slowly to minimize orthostatic hypotension. Advice patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may decrease dry mouth. Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis. Advise patient to avoid concurrent use of alcohol or other CNS depressant INDICATION SIDE EFFECTS NURSING IMPLICATION PATIENT TEACHING

DRUG NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATION Assess for symptoms of stroke, MI during treatment Monitor liver function studies: AST, ALT, bilirubin, creatinine if patient is on longterm therapy Monitor blood studies: CBC,Hgb, Hct, protime, cholesterol if the patient is on long-term therapy; thrombocytopenia and neutropenia may occur. Assess for symptoms of stroke,peripheral vascular disease or MI

PATIENT TEACHINGS

Generic Name:

Inhibits platelet aggregation by

Treatment of patients at risk for ischemic events history of MI, ischemic stroke, peripheral artery disease Treatment of patients with acute coronary

CNS: Headache, dizziness, weakness, syncope, flushing CV: Hypertension, edema Dermatologic: Rash, pruritus GI: Nausea, GI distress, constipation, diarrhea, GI bleed Other: Increased bleeding risk

Instruct to Avoid taking OTC medications containing aspirin or NSAIDs without consulting health care professional. Instruct patient to take medication as ordered Advise patient to notify health care professional promptly if fever ,chills ,sore throat or unusual bleeding occurs

Clopidogrel

blocking ADP receptors on

Brand Name:

platelets, preventing

Plavix

clumping of
platelets

Classification:

Platelet Aggregation Inhibitors Dosage:

syndrome

75 g/ tab

Precautions: Bleeding disorders, recent surgery, hepatic impairment, pregnancy

DRUG NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATION

PATIENT TEACHING

Generic Name:

Acts on blood vessels, It used for the

Orthostatic hypotension;

Assess respiratory status Monitor CBC during long term therapy

Avoid hazardous activities and requiring activities with alertness Avoid alcohol, other depressants Inform patient that drug may cause dry mouth

GI, respiratory system symptomatic relief of palpitations; bradycardia; Diphenhydramine by antagonizing the allergic conditions effects H1Brand Name: of histamine including urticaria receptor site; and angio edema, allergic rhinitis, and tachycardia; reflex tachycardia; extrasystoles; faintness. Drowsiness; sedation; dizziness, disturbed coordination. Nasal stuffiness; dry mouth; nose and throat; sore throat.

Assess movement disorder Assess nausea and vomiting Assess for allergic reaction (skin itching, rash, inflammation )

decreases

response by blocking conjunctivitis, and in Benadryl histamine; increase Classification: heart causes pruritic skin rate, disorders. It is used for its anti- emetic

vasodilation,

Avoid alcohol

secretions; significant properties in the Antihistamine CNS depressant treatment of nausea and vomiting, Dosage:

1 tab

DRUG NAME

MECHANISM OF INDICATION ACTION

SIDE EFFECTS

NURSING IMPLICATION

PATIENT TEACHING

Generic Name:

Convert plasminogen

Acute to Coronary

CNS: Intracranial Hemorrhage, epistaxis, gingival bleeding, periorbital edema, GI bleeding, bronchospasms, hemoptysis, allergic reactions, ecchymoses, flushing

Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every 15-30 min during the next 8hr, and at least every 4hr for the duration of therapy.

Explain purpose of medication and the need for close monitoring to patient and family.

Streptokinase

plasmin, which is Thrombosis, then able to degrade Massive fibrin present Lysis in Pulmonary of Emboli,

Inquire about previous reaction to anistreplase or streptokinase therapy. Assess patient for hypersensitivity reaction (rash,dyspnea, fever, changes in facial color, swelling around the eyes, wheezing). If these occur, inform physician promptly. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.

Instruct the patient to report hypersensitivity reactions and bleeding or bruising Explain the need for bed rest during therapy to avoid therapy.

Brand Name:

clots.

throbi in coronary AcuteIschemic arteries, Classification: preservation ventricular Dosage: with Stroke, of Occluded Central venous

function. Lysis of access pulmonary emboli

Assess neurologic status throughout therapy. Altered sensorium may be indicative of intracranial bleeding. Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting diaphoresis.)

Instruct patient to avoid unnecessary procedures that is prone to bleeding or bruising such as shaving and vigorous tooth brushing

1 tab

or

deep

vein

thrombosis

Monitor heart sounds all breath frequently. Inform physician if sign of CHF occur (rales/crackles,dyspnea, S, heart sounds jugular venous distension, relived CVP).

Monitor ECG continuously. Notify physician if significant arrhythmias occur.

DRUG NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATION

PATIENT TEACHING

Generic Name:

It increases neuronal membrane

General Indications - Short-term management of anxiety - Insomnia associated with anxiety - Sleepwalking - Night terrors - Premedication before anaesthesia - Adjunct in the management of seizures - Muscle spasms

CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, disorientation, restlessness, confusion, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, mild paradoxical excitatory reactions, extrapyramidal symptoms, visual and auditory disturbances CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, edema Dependence: Drug dependence with withdrawal syndrome

Discuss risk of fetal abnormalities with patients desiring to become pregnant. Assess for hypersensitivity. Reduce dose of opioid analgesics with IV diazepam; dose should be reduced by at least one-third or eliminated.

Avoid hazardous activities and requiring activities with alertness

Diazepam

permeability to chloride ions by binding to

Avoid alcohol, other depressants Inform patient that drug may cause dry mouth Instruct about side effects of drug: Drowsiness, dizziness, GI upset, dreams, difficulty concentrating, fatigue, nervousness, crying

Brand Name:

stereospecific benzodiazepine

Instruct not to stop taking the drug without consulting the health care provider. Observe the 15 rights of drug administration. Do not administer intrarterially; may produce arteriospasm, gangrene. Carefully monitor P. BP, respiration during IV administration. Change from IV therapy to oral therapy as soon as possible. Do not use small veins for IV injection.

Valium

receptors on the postsynaptic GABA

Classification:

neuron within the CNS and enhancing

Antiepileptic, Anxiolytic, Skeletal muscle relaxant

the GABA inhibitory effects resulting in hyperpolarisation and stabilization

Instruct to take drug exactly as prescribed.

Dosage:

5g TIV

DRUG NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATION Assess for signs of bleeding and hemorrhage (bleeding gums: nosebleed unusual bruising black tarry stools hematuria fall in hematocrit or blood pressure guaiac positive stools); bleeding from surgical site notify physician if these occur,. Assess for evidence of additional or increased thrombosis symptoms depend on area of involvement. Monitor neurogical status frequently for sign of neurological impairement may required urgent statement. Monitor for hypersensitivity reactions report signs of physician.

PATIENT TEACHING Advise patient to report any symptoms of unusual bleeding or bruising dizziness itching rash fever swelling or difficulty breathing to health care professional immediately. Instruct patient not to take aspirin or NSAIDs without consulting healt care professional while on therapy.

Generic Name:

Potentiate

inhibitory Prevention of

CNS: Dizziness, headache, Insomnia CV: Edema GI: Constipation,Nausea, reversible increase in liver enzymes GU: urinary retention Derm: ecchymoses, pruritus, rash,urticaria Hemat: bleeding, anemia, thrombocytopenia Misc: Fever

effect of antithrombin ischemic Enoxaparin on factor Xa and complications from

thrombn. Brand Name:

Prevents unstable angina, treatment of deep vein thrombosis in

thrombus prevention

Lovenox

patients at risk for thromboembolism

Classification:

complications due to severly restricted

Anticoagulant, AntiThrombotic

mobility during acute illness

Dosage: 60 g SQ BID

DRUG NAME

MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

NURSING IMPLICATION

PATIENT TEACHING

Generic Name:

Inhibits activity of acid (proton) pump

Short-term treatment of active duodenal ulcer; First-line therapy in treatment of heartburn or symptoms of gastroesophageal reflux disease (GERD); Short-term treatment of active

CNS:Headache , dizziness,asthenia, vertigo, insomnia, apathy, anxiety,paresthesias, dream abnormalities Dermatologic: Rash,inflammation, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry

1. Assessment History: Hypersensitivity to omeprazole or any of its components; pregnancy, lactation Physical: Skin lesions; reflexes, affect; urinary output, abdominal exam; respiratory auscultation Interventions 2. Administer before meals. Caution patient to swallow capsules whole,not to open, chew, or crush them. Dosage adjustments may be necessary in Asians and patients with hepatic impairment. Administer antacids with omeprazole, if needed

Tell patient to swallow tablets or capsules whole and not to open, crush, or chew them.

Pantaprazole

and binds to hydrogen-potassium

Brand Name:

adenosine triphosphatase at

Instruct patient to take drug 30 minutes before meals. Caution patient to avoid hazardous activities if he gets dizzy.

Protonix

secretory surface of gastric parietal cells

Classification: Proton Pump Inhibitors, Gastric Acid suppressor

to block formation of gastric acid..

Instruct to avoid beverages rich in nicotine, caffeine and alcohol which stimulate stomach acid or delay ulcer healing.

Dosage:

benign

gastric ulcer; GERD, mouth, tongue atrophy severe erosive esophagitis, poorly responsive symptomatic GERD;

DISCHARGE HEALTH TEACHING Content M-medication To adhere in prescribed therepautic regimen for health maintainance and resistance. Instruct patient Strategy to take the prescribed

medications as ordered by the physician. Instruct patient to avoid taking OTC drugs unless given with medical advice Encourage patient to include atleast 30 minutes of walking or jogging or perfrom tolerated and preferred activities as a means of exercise

E-exercise

To promote a healthy lifestyle, maximizing the level of health and increase the bodys immunity.

Educate T-treatment Attending the follow up check up.

client

by

adhering

maintainance

theraphy, appropriate diet and having exercise will reduce likelihood of occurances and aggravation of disease.

H-health teaching

Health teaching about the disease, exercise and diet.

Instruct

the

patient

about

home-made

interventions in reducing blood pressure such as: a.) Pineapple or Calamansi juice to reduce blood pressure b.) Chewing of raw or fried garlic after meals c.) Refrain from consumption of caffeineted beverages, such as coffee and chocolate

O-OPD

Instruct that they need to have a health check up.

Emphasize the importance of adhering to medications and attending follow-up check up. Encourage patient to adhere to weekly blood pressure monitoring

D-diet

Maintain and ensure adequate intake for noursihment,

Instruct patient to avoid consumption of salty and fatty foods. Instructed patient to limit consumption of high caloric foods such as rice to reduce occurences of high blood pressure and increase in blood sugar. Advise

S-signs symptoms

and If any signs of symptoms are present go to the nearest hospital for check up.

patient

to

refer

to

health

care

professional for sudden onset of blurry vision, intense head ache, chest pain unrelieved with rest and medications

V.

ONGOING APPRAISAL

Patient D.V, a 59 year old male, has been admitted to Ospital ng Makati last November 20, 2011 with the chief complaint of chest pain. Upon assessment, it was observed that the patient is conscious, with general survey of Levignes sign, Facial Grimace and Dyspnea . The client is admitted in Emergency Room and inserted of D5W 500cc X 10cc/hr at left metacarpal vein with laboratory tests rendered such as CBC, PTT, BUN, Creatinine, Serum Na, K, Trop I, CK-MB, ECG, and CBG. Chest X-Ray was ordered and for oxygen therapy at 4 liters per minute. Patient D.V was initially treated with morphine TIV for his chest pain, ISDN 80 cc D5W + 20 g, Clopidgogrel 75 g/Tab,. The patient is ordered for streptokinase therapy 1-5 MIV in 90 ml D5W. Prior to therapy, the given Diphenhydramine 50 g TIV, Hydrocholine 100g IV, Diazepam 5g TIV for anxiety, Pantaprazole 10 g TIV OD and Enoxaparin 60 g SQ BID . Presently, the patients condition is stable. Negative of Troponin I, Normal Cholesterol Therapy due to streptokinase therapy and for 2-D echocardiogram with heplock inserted and latest vital signs of Temp.: 37.5c RR: 19cpm PR: 86 cpm BP: 100/70mmHg.