Professional Documents
Culture Documents
I. INTRODUCTION
In general, MI can occur at any age, but its incidence rises with age. The
actual incidence is dependent upon predisposing risk factors for
atherosclerosis, which are discussed below. Approximately 50% of all MI's in
the US occur in people younger than 65 years of age. However, in the future,
as demographics shift and the mean age of the population increases, a
larger percentage of patients presenting with MI will be older than 65 years
The main reason and purpose student nurses conduct care study and
exposure in the clinical area is for them to identify problems encountered by the
clients; this is one of their tools of learning knowledgeably and skillfully.
We, as health care providers, it is indeed our vocation to adjoined hands
w/ the health team for the promotion of wellness of our clients. Our main
objectives for this study are the following:
• To evaluate the effectiveness of the actual nursing care plan that was
established.
• To impart health teachings to the client giving emphasis on his
medications, exercises, treatment, out- patient follow- up and diet
• To give referrals and follow-up for the health promotion of the client.
In general, this study aims to enhance the skills and knowledge of the
students in providing holistic care to the patient. Students logically search further
knowledge in order to attain the desired goal and intervention for the wellness of
the patient.
Prior to the day of duty, the group has already chosen a patient for care
study. They performed a physical assessment to the patient to properly identify
the nursing problems, which require necessary and direct interventions and
medical regimen. The study on medications and doctor’s order were limited to
our chosen patient
The care for our chosen patient is only limited for 2 days of duty excluding the
physical assessment done prior to the day of duty.
Name of Patient: ?
Sex: Male
Age: 64 years old
Religion: Roman Catholic
Civil Status: Married
Occupation: ?
Income: P 6,000/ month
Nationality: Filipino
Date Admission: June 29, 2007
Time: 09:40 pm
that he was an alcohol drinker during his adolescence and late adulthood and
confessed that he only drinks 2-6 glasses even more on occasional basis;
hypertension in the year 1998 when he was still 55 years old. On the year 2006,
because of over workload and emotional stress, Mr. Agustin has experienced
severe chest pain and that same year he was diagnosed of having Diabetes
Mindanao Medical Center. During his admission last 2006, Mr. Sarmiento has
been transfused with 5 bags of Packed Red Blood Cell and there were no reports
of allergic reaction. At that time, he was advised by the doctor to have his
their family. Nobody aside from Mr. Agustin Sarmiento has been admitted for
chronic illness. His children were neither non-smoker nor alcoholic but they do
before like cough, colds, LBM but they were able to catch on the treatment
On the 29th of June, Mr. ? has experienced chest pain with complaints of
acute epigastric pain, growing in character and on and off. The patient was
anorexic and hypertensive (180/ 60 mm Hg). With the help of his family he went
to the hospital for check-up, they thought that it was just an ulcer, but the doctor
cardiovascular disease; ruled out PUD; diabetic neprhopathy, and due to the
Hospital.
DEVELOPMENTAL STATUS
The fact that man learns his way through life is made radically clear by
consideration of the learning tasks of older people. They still have new
experiences ahead of them, and new situations to meet. At age sixty-five when a
man often retires from his occupation, his changes are better than even of living
another ten years. During this time the man or his wife very likely will experience
several of the following things: decreased income, moving to a smaller house,
loss of spouse by death, a crippling illness or accident, a turn in the business
cycle with a consequent change of the cost of living. After any of these events
the situation may be so changed that the old person must learn new ways of
living.
The developmental tasks of later maturity differ in only one fundamental respect
from those of other ages. They involve more of a defensive strategy--of holding
on the life rather than of seizing more of it. In the physical, mental and economic
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spheres the limitations become especially evident; the older person must work
hard to hold onto what he already has. In the social sphere there is a fair chance
of offsetting the narrowing of certain social contacts and interests by the
broadening of others. In the spiritual sphere there is perhaps no necessary
shrinking of the boundaries, and perhaps there is even a widening of them.
Our patient Agustin Sarmiento belongs to the older adult stage. His
central task is Ego Integrity versus Despair. Ego integrity is the ego's
accumulated assurance of its capacity for order and meaning. Despair is signified
by a fear of one's own death, as well as the loss of self-sufficiency, and of loved
partners and friends. He must learn to accept the life that he has led (good and
bad) to have a life in facing death. As he learns to live with his choices and the
certainty of death, he fined a inner-strength to go on with integrity. Some despair
is inevitable, a he mourn his own deaths. When he recognizes all that he have
been, are and will be, then we show his wisdom.
11:07pm
To reduce the
Plavix 75mg 4 tabs thrombotic events in
now then 1tab OD patient with
atherosclerosis
Increases myocardial
O2 inhalation 2L/min oxygen supply &
relieves pain
For continued
Repeat ECG in AM surveillance of the
heart’s electrical
activity
To monitor the health
VS qh & record status of the patient &
have baseline data in
giving medications
Adjunct to diet to
Lipitor 1 tab OD start reduce LDL
tonight cholesterol, total
cholesterol, and to
increase HDL
cholesterol of the
patient
July 1. 2007
To determine the level
CBC after 2’U’ PRBC of the blood
components of the
patient after
July 2, 2007
transfusion
12:20am
BP: 190/90mmHg
Antihypertensive drug;
Give captopril 25mg to lower the BP of the
10:25am
tab SL now, T.O. patient
BP: 160/80mmHg
Dr. Taboclaon
HR: 88bpm Antihypertensive drug;
Give captopril 25mg to lower the BP of the
SL now, T.O. patient
Dr. Espina
To keep vein open; to
IVF PNSS1L @ have patent line in
10gtts/min cases of administering
13
IVT drugs
BP: 200/80mmHg
Antihypertensive drug;
HR: 94bpm Give captopril 25mg to lower the BP of the
tab SL now patient
For hypertension; For
Bepridil (Vascor) 10 chronic stable angina,
mg. 1 tab now then used alone or in
OD P.O. combination ĉ B-
blockers nitrates
Increases myocardial
O2 inhalation 2l/min oxygen supply &
relieves pain
July 3, 2007
BP: 200/110mmHg
Antianginal; to reduce
Give Isordil 5mg tab cardiac oxygen
SL for 3 doses q 5 demand by
minutes if chest pain decreasing preload
is not relieved and afterload.
Increases myocardial
Increase O2 oxygen supply &
12:50pm inhalation to 4L/min relieves pain
Antihypertensive drug;
Give captopril 25mg to lower the BP of the
tab SL now patient
Antianginal; to reduce
Give Isordil 5mg SL cardiac oxygen
now demand by
decreasing preload
and afterload
For continued
Repeat ECG in AM surveillance of the
5:30pm heart’s electrical
activity
Antihypertensive drug;
Therabloc 50mg 1tab to lower the BP of the
now then OD patient
IVT drugs
RESULTS IMPLICATIONS
1.) HEMATOLOGY
Date: June 30, 2007
Time: 3: 46 pm
Cross- matiching
Patient’s blood type Blood Rh (D) positive RBCs have antigen- can
Donor’s blood type Blood Rh (D) positive initiate antibodies reaction
higher in patients
with increased
risk for coronary
44.33 mgs/dl 0.00- 40.00 heart disease
VLDL . Increased- Risk
of nephrotic
106.18 mgs/dl 70.00- 99.00 syndrome
Fasting blood Increased- risk
sugar for diabetes
mellitus and
chronic renal
insufficiency
3.)
HEMATOLOGY
Date: June 30,
2007
Time: 1:02 am Increased Troponin levels
rise rapidly and
Troponin- T are detectable
within 1 hour of
myocardial cell
injury and renal
diseases
ABO + Rh
Blood Rh (D) positive
Blood group
4.) CHEMISTRY
Date: June 29,
2007
Time: 11:43 pm
6.17 mgs/ dl 0.90 – 1.50 Increased- risk
Creatinine of nephritis;
chronic renal
insufficiency;
diabetic
nephropathy;
reduced renal
blood flow
5.)
HEMATOLOGY
Date: June 29,
2007
Time: 11:43 pm
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6.)
HEMATOLOGY
Date: July 1, 2007
Time: 6: 36 pm
Complete Blood
Count 3.49 x10^ 9/L 3.69- 5.90 Decreased- risk
Total RBC of renal failure;
dietary deficiency
11.1 g/dl 13.70- 16.70 Decreased- risk
Hgb of dietary
deficiency and
kidney disease
32.5 40.0- 49.70 Decreased- risk
Hct of nutritional
deficiency
physical or
15.4 20.0- 40.0 emotional stress
Increased- viral
Lymphocytes 13.1 4.0- 10.0 infection
Increased- viral
Monocytes infection; other
chronic disease
18
C.) DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M.
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
Isosorbide 7-2-07 Antianginals 5 mg tab Thought to Acute anginal Contraindicated Flushing, To prevent
dinitrale SL for 3 reduce cardiac attacks potentials ĉ vascular tolerance a
(Isordil) doses every 5 oxygen hypersensitivity headache, nitrate-free
minutes if demand by or idiosyncrasy cerebral interval of 8 to
chest pain is decreasing to nitrates & in ischemia 12 hours per
not relieved preload & those ĉ severe associated ĉ day is
afterload: also, hypolension postural recommended.
may increase hypotension,
blood flow
N/V
through the
weakness,
collateral
coronary
restless,
vessels pallor,
persipiration &
collapse
Bepridil 7-2-07 Calcium 10 mg. 1 tab Inhibits calcium Hypertension Pts. ĉ history of Rarely: CHF,
(Vascor) Channel Blocker now then OD ion influx For chronic angineurotic fatigue, hypotension,
Antianginal P.O. across cell stable angina, edema & other dizziness, hot- hepatic injury,
Antihypertensive membrane used alone or allergic flush, pregnancy C,
during cardiac in combination reactions due to diarrhea, lactation, renal
depolarization, ĉ B-blockers ACE inhibitors: nausea, disease,
produces, nitrates pregnancy vomiting concomitant B-
relaxation of lactation Discomfort in blocker
coronary
the throat, therapy
vascular
non-
muscle
diseases
productive
coronary cough,
vascular palpitation
arteries, headache &
myocardial 02 rash
delivery in pts ĉ
vasospastic
angina SA/AV
node
conduction
inhibits fast
sodium current.
19
DRUG STUDY
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
Ranitidine 6-29-07 Anti-ulcer drug 50 mg IV q Completely NSAID- Contraindicated Occasionally, Assess pt. for
Hydrochloride 9:45 pm 8H inhibits action associated in patients reversible abdominal
(Zantac) 6-2-10 of histamine on peptic ulceration hypersensitive hepatitis. Rarely pain. Note
the H2 at to drug and agranulocytosis, presence of
receptors sites those ĉ acute acute blood in
of parietal cells, porphyria acute pancreatic, emesis, stool
decreasing dosage in pt. ĉ hypersensitivity, or gastric
gastric acid impaired renal reversible aspirate
secretion function mental
confusion, skin
rash; headache
Olmesartain 6-29-07 ACE inhibitors 20 g/mL Selectively For Contraindicated CNS: headache Administers
Medoxomil antihypertensive 1 tab OD blocks the hypertension, ĉ CU: regard to
(Olmetec) binding of alone or in hypersensitivity hypertension meals
angiotensin to combination ĉ to any SKIN: rash, dry
specific issue other component of GI: diarrhea, Monitor pt.
receptors found antihypertensive the drug, abdominal pain closely in any
in the vascular pregnancies nausea, situation that
smooth muscle lactation constipation may lead to a
& adrenal gland decrease BP
this action Use caution ĉ Respiratory 20 to
blocks the renal URL, seduction in
vasoconstrictio dysfunction symptoms, fluid volume
n effect of the bronchitis,
rennin. cough,
Angiotensin angioedema,
system as well flue like
as the release symptoms
of aldosterone
to decrease BP.
DRUG STUDY
20
Name of Patient: SARMIENTO, AGUSTIN M.
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
tramadol HCI 6-30-07 Opioid 50 mg IV now A centrally For moderate Contraindicated Respiratory Releases pt’s
(Dolmal) Analgesics then PRN for acting to severe pain in patients depression, level of pain at
moderate to synthetic hypersensitive palpitations, least 30 min.
severe pain analgesic to drug or other chills, chest after
compound not opioids, in pain, decrease administration.
chemically breast feeding in BP, Monitor CV
related to women and in arrhythmia, and respiratory
opioid. those ĉ acute vomiting, status w/hold
Thought to intoxication nausea, GI dose & notify
bind to opioid from alcohol distention, prescribe if RR
receptors & of use cautiously borborygymi, is below 12
norepinephrine in pts. at risk for urticaria, cm. Monitor
& serotonin renal or hepatic excessive bowel &
impairment bronchial bladder
secretions function
anticipate
need for
laxative for
better
analgesic
effect give
drug before
onset of pain.
pantoprazole 6-30-07 Antiulcer 40 mg IV OD Inhibits proton Doudenal & Contraindicated Headache, Stop treatment
sodium drugs (-6) pump activity gastric ulcer in in pts. diarrhea, ĉ IV
(ulcepraz) by finding to combination ĉ hypersensitive rarely, nausea, pantoprazole
hydrogen 2 appropriate to any upper when P.O. form
potassium antibiotics for component of abdominal is warranted
oderosine the reduction the formulation pain, drug can’t be
triphosphatase, of H Pylon in safety & flatulence, skin given regard to
located at pts. ĉ peptic efficacy of using rash, pruritus meals
secretory or dizziness, symptomatic
ulcer of the the IV for
surface of edema, fever, response to
objective of mutation to
gastric parietal onset of therapy doesn’t
cells, to
reducing the start, therapy depression & preclude the
suppress recurrence of for GERD are disturbance in presence of
gastric acid duodemal are unknown. vision gastric
secretion unknown malignancy.
21
DRUG STUDY
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
captopril 7-2-07 Antihypertensive 1. 25 mg Tab Inhibits ACE, Hypertension Contraindicated CNS: Monitor
(Capoten) SL now preventing diabetic in pts. dizziness patient’s blood
12:10 pm conversion of nephropathy hypersensitive fatigue; rash, pressure &
Angiotensin II, to drug or ACE pruritus, pulse rate
2. 25 mg ½ a potent inhibitors use flushing, frequently
tab vasoconstrictor cautiously in angioedema, elderly pts
SL now less pts. ĉ impaired loss of taste may be moiré
angiotensin II renal function perception; sensitive to
decreasing stomatitis, GI drug’s
aldosterone irritation & hypotensive
secretion, abdominal effects in
which reduces pain; patients ĉ
sodium & leucopenia; impaired renal
water retention cough function or
& lowers blood collagen
pressure. vascular
disease,
monitor WBC
and differential
counts before
starting
treatment,
every 2 wks
for the first 3
months of
therapy and
periodically
thereafter.
DRUG STUDY
22
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
atenol 7-3-07) Antihypertensives 50 mg 1 tab A beta-blocker Hypertension Contraindicated CNS: fatigue Check apical
(Therabloc) now then OD that Angina in patients ĉ dizziness pulse before
(-6-) selectively Pectoris, sinus CV: hypotension giving drug if
blocks beta- Acute MI bradycardia, heart failure slower than
adrenergic heart blocker GI: nausea, 60 beats /min.
receptors, greater than diarrhea withhold drug
decreases first degree Musculoskeletal: & call
cardiac output overt cardiac leg pain prescriber.
and cardiac failure, or Respiratory Monitor pts
oxygen cardiogenic bronchospasm blood
consumption shock use Skin: rash pressure drug
and cautiously in pts may mask
depresses at risk for heart signs &
rennin failure diabetes symptoms of
secretion & impaired hypoxemia in
renal function diabetic pts
drug may
cause
changes in
exercise
tolerance &
ECG
23
DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M.
Generic name Brand Date Ordered Classification Dose/ Mechanism Specific Contra- Side Nursing
of Ordered Name Frequency/ Of Indication Indication Effects/ Precaution
Drug Route Action Toxic
Effects
Senna Senokot 7-3-07 Laxatives 2 tabs Stimulant laxative Acute Contraindicated GI: nausea, Before giving
tonight -9 that increases constipation in pts. ĉ abdominal drug for
pm peristalsis, preparation, for ulceration bowel cramps constipation
probably by bowel lesions, fecal GU: red-pink determine
relaxing the effect elimination infaction, S/sx of discoloration in whether pt. has
on smooth appendicitis, alkaline urine, adequate fluid
muscle of the acute surgical yellow brown intake exercise
intestine. Drug abdomen, N/V discoloration in & diet
also promotes abdominal pain acid urine Limit diet to
fluids clear liquids
accumulation in after X-prep
colon and small liquid is taken.
intestine.
fondaparimux Arixtra 6-30-07 Anticoagulants 2.5 mgs SC Binds to To prevent Contraindicated CNS: fever, Give by S.C.
sodium now then antithrombin III deep-vein in pts with dizziness, injection only
OD 9 pm-8 (at-III) and thrombosis creatirine confusion never I.M.
am potentates the (VDT) w/c may clearance less CU: Don’t mix ĉ
neutralization of lead to acute than 30 mL/min. hypotension, other injections
factor Xa by III pulmonary and in those edema or infusions to
which interrupts embolism who are GI: nausea avoid loss of
coagulation and hypertensive to GU: UTI, urine drug don’t
inhibits formation the drug or retention expel air
of thrombin and weigh less than Hematologic: bubble from
blood clots. 50 kgs. hemorrhage, the syringe
thrombocylopeni
a
clopidogrel Plavix 6-30-07 Antiplatelet 45 mgs, 4 Inhibits the To reduce Contraindicated GI Bleeding Platelet
bisulfate agents tabs now, binding of thrombotic in patients purpora, aggregation
then 1 tab adenosine events with hypersensitive bruising, wont return
OD P.O. 10- diphosphale to its acute coronary to drug or its hematoma, normal for at
6 platelet, receptors syndrome, ĉ components and epistaxis, least 5 days
infecting ADP- atherosderosis in those with hematutia, after drug has
mediated documented by pathologic ocular been stopped
activation and recent MI, or bleeding (such hemorrhage
subsequent established as peptic ulcer) intracranial Don’t confuse
platelet peripheral use cautiously in bleeding, plavix with
aggregation artenal patients at risk abdominal pain, Paxil
clopedogiel disease. for increased dyspepsia
irreversibly bleeding from gastritis &
modifies the trauma or other constipation,
platelet ADP pathologic rash, pruritus
receptor conditions
24
DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M.
Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
name of Name Ordered Frequency/ Of Indication Indication Effects/ Precaution
Ordered Route Action Toxic
Drug Effects
isosorbide Imdur 6-30-07 Anti-anginal 60 mgs 1 Tab Thought to Acute anginal Contraindicat CNS: To prevent
mononitate OD P.O. reduce attacks, post-MI ed in pts. headache tolerance a nitrate
-6- cardiac angina; to hypersensitiv CV: free interval of 8 to
60 mgs ½ tab oxygen prevent situations e or orthostatic 12 hours per day is
OD P.O. demand by that may cause idiosyncratic hypotensio recommended.
-6- decreasing anginal attacks to nitrates & n, The regimen for
preload and in those ĉ tachycardia isosobide
afterload.. severe , mononitrate (1
drug also hypotension palitations, tab.) on awakening
may blood or acute MI ĉ edema with the second
through low left nausea dose in 4 hrs. or 1
collateral ventricular extended release
coronary filling tab. Daily is
vessels pressure. intended to
minimize nitrate to
tolerance by
providing a
substantial nitrate
free interval
Monitor BP and
intensely and
duration of drug
response
atorvastatin Lipitor 6-30-07 Antilipemics 80 mgs 1 tab Inhibits HMG- Reduction of Withhold or GI Use only after diet &
OD tonight COA elevated total L stop drug in disturbances other condition
reductase, an LDL cholesterol, pts. at risk for , headache, therapy prove
early (and apolipoprotein B renal failure myalgia infective Pt should
asthenia, follow a standard low
rale-limiting) & triglycerides & caused by insomnia cholesterol diet
step in increase HDL rhabdomyoly muscle before & during
cholesterol cholesterol in pts. sis resulting cramps, therapy.
biosynsthesis ĉ primary from trauma, bronchitis, Before starting
hypercholesterole in serious rash treatment assess pt
mia acute infection, flu for underlying
conditions like causes for
like myopathy syndrome hypercholesterolemi
allergic a.
reactions
25
1. The superior (a) and inferior (b) vena cava are the main veins that receive
blood from the body. The superior vena cava drains the head and arms, and the
inferior vena cava drains the lower body.
2. The right atrium receives blood from the body via the vena cavae. The atria are
on the top in the heart.
3. The blood then passes through the right atrioventricular valve, which is forced
shut when the ventricles contract, preventing blood from reentering the atrium.
4. The blood goes into the right ventricle (note that it has a thinner wall; it only
pumps to lungs). The ventricles are on the bottom of the heart.
5. The right semilunar valve marks the beginning of the artery. Again, it is
supposed to close to prevent blood from flowing back into the ventricle.
27
7. Blood goes to the right and left lungs, where capillaries are in close contact with
the thin-walled alveoli so the blood can release CO2 and pick up O2.
8. From the lungs, the pulmonary vein carries oxygenated blood back into the
heart.
11. The blood enters the left ventricle. Note the thickened wall; the left ventricle
must pump blood throughout the whole body.
12. The blood passes through the left semilunar valve at the beginning of the aorta.
13. The aorta is the main artery to the body. One of the first arteries to branch off is
the coronary artery, which supplies blood to the heart muscle itself so it can
pump. The coronary artery goes around the heart like a crown. A blockage of the
coronary artery or one of its branches is very serious because this can cause
portions of the heart to die if they don’t get nutrients and oxygen. This is a
coronary heart attack. From the capillaries in the heart muscle, the blood flows
back through the coronary vein, which lies on top of the artery.
14. The aorta divides into arteries to distribute blood to the body.
28
17. These join again to form venules, the smallest of the veins.
These, in turn, join to form the larger veins, which carry the blood back to the superior
and inferior vena cava.
The work of the heart is to pump blood to the lungs through pulmonary
circulation and to the rest of the body through systemic circulation. This is
accomplished by systematic contraction and relaxation of the cardiac muscle in the
myocardium.
Conduction System
An effective cycle for productive pumping of blood requires that the heart be
synchronized accurately. Both atria need to contract simultaneously, followed by
contraction of both ventricles. Specialized cardiac muscle cells that make up the
conduction system of the heart coordinate contraction of the chambers.
Cardiac Cycle
The cardiac cycle refers to the alternating contraction and relaxation of the
myocardium in the walls of the heart chambers, coordinated by the conduction system,
during one heartbeat. Systole is the contraction phase of the cardiac cycle, and
diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8
second.
29
Heart Sounds
The sounds associated with the heartbeat are due to vibrations in the tissues
and blood caused by closure of the valves. Abnormal heart sounds are called
murmurs.
Heart Rate
The sinoatrial node, acting alone, produces a constant rhythmic heart rate.
Regulating factors are reliant on the atrioventricular node to increase or decrease the
heart rate to adjust cardiac output to meet the changing needs of the body. Most
changes in the heart rate are mediated through the cardiac center in the medulla
oblongata of the brain. The center has both sympathetic and parasympathetic
components that adjust the heart rate to meet the changing needs of the body.
Peripheral factors such as emotions, ion concentrations, and body temperature may
affect heart rate. These are usually mediated through the cardiac center.
30
Decreased
Myocardial Contractility Heart rate Diastolic Filling Myocardial Tissue
Per.
Increased myocardial
oxygen demand
S/Sx:- chest pain, oliguria, ECG changes, Elevated CK-M, Troponin T, LDH, AST
Myocardial
Oxygen Demand
31
Mechanisms of Occlusion
myocardium at risk of necrosis. The larger the MI, the greater is the chance of
death due to a mechanical complication or pump failure. The longer the time
period of vessel occlusion, the greater the chances of irreversible myocardial
damage distal to the occlusion.
The death of myocardial cells first occurs in the area of myocardium that
most distal to the arterial blood supply—that is, the endocardium. As the duration
of the occlusion increases, the area of myocardial cell death enlarges, extending
from the endocardium to the myocardium and ultimately to the epicardium. The
area of myocardial cell death then spreads laterally to areas of watershed or
collateral perfusion. Generally, after a 6- to 8-hour period of coronary occlusion,
most of the distal myocardium has died. The extent of myocardial cell death
defines the magnitude of the MI. If blood flow can be restored to at-risk
myocardium, more heart muscle can be saved from irreversible damage or
death.
33
• Nursing Diagnosis:
• Possibly evidenced by
• Desired outcomes
INTERVENTIONS RATIONALE
Independent
1. Obtain full description of pain from Pain is a subjective experience and
patient including location, intensity (0- must be described by the patient.
10), duration; quality (dull/crushing); Assist patient to quantify pain by
and radiation comparing it to other experiences.
Collaborative
5. Administer supplemental oxygen by Increases amount of oxygen available
means of nasal cannula for myocardial uptake and thereby may
relieve discomfort associated with
tissue ischemia
Administer medications as
indicated, e.g.:
• Nursing diagnosis
Risk for decreased cardiac output may include changes in rate, rhythm,
electrical conduction, reduced preload/ increased SVR,
infracted/dyskinetic muscle
• Possibly evidenced by
INTERVENTIONS RATIONALE
Independent
1. Evaluate quality and equality of Decreased cardiac output results in
pulses, as indicated diminished weak/ thready pulses.
Irregularities suggest dysrhythmias,
which may require further evaluation.
Monitoring.
3. Monitor heart rate and rhythm. Heart rate and rhythm respond to
Document dysrhythmias via medication and activity, as well as
telemetry developing complications/
dysrhythmias, which could compromise
cardiac function or increase ischemic
damage.
• Possibly evidence by
• Desired outcome
INTERVENTIONS RATIONALE
Independent
1. Inspect for pallor, cyanosis, Systemic vasoconstriction resulting
mottling, cool/ clammy skin. Note from diminished cardiac output may be
strength of peripheral pulses evidenced by decreased skin perfusion
and diminished pulses.
• Nursing diagnosis
• Possibly evidenced by
• Desired outcomes
INTERVENTIONS RATIONALE
Independent
1. Promote rest (bed/ chair) initially. Reduces myocardial workload. Oxygen
Limit activity on basis of pain/ consumption, reducing risk of
hemodynamic response. Provide complications (e.g., extension of MI)
nonstress diversional activities.
2. Instruct patient to avoid increasing Activities that require holding the breath
abdominal pressure, e.g., straining and bearing down (Valsalva maneuver)
during defecation can result in bradycardia, temporarily
reduced cardiac output, and rebound
tachycardia with elevated BP.
• Nursing diagnosis
• Possibly evidenced by
Fearful attitude
Apprehension, increased tension, restlessness, facial tension
Uncertainty, feelings of inadequacy
Somatic complaints/ sympathetic stimulation
Focus on self, expressions of concern about current and future
events
Fight or flight behavior
• Desired outcomes
INTERVENTIONS RATIONALE
Independent
1. Maintain confident manner (without Patient and SO can be affected by the
false reassurance) anxiety/uneasiness displayed by health
team members. Honest explanations
can alleviate anxiety.
Collaborative
5. administer antianxiety/ hypnotics as Promotes relaxation/ rest and reduces
indicated, e.g., diazepam (Valium), feelings of anxiety
lorazepam (Ativan), flurazepam
(Dalmane)
“Ah! Dili jud makatarong ug tulog. Maka mata-mata man jud labi
S na dini sa hospital. Ug tigulang naman “ as verbalized by the
patient
Rationale:
Increases comfort for sleep as well as physiologic and psychologic
support
Rationale:
This Provides atmosphere conducive to sleep
I
3. Encouraged position of comfort, assist in turning
Rationale:
Repositioning alters areas of pressure and promotes rest
4. Provided nursing aids (e.g. back rub, bedtime care, pain relief,
comfortable position [semi- fowler’s], relaxation techniques)
Rationale:
To promote rest, relaxation; to induce sleep
Rationale:
Experimental studies have indicated that 60- 90 minutes are
needed to complete one sleep cycle and the completion of an
entire cycle is necessary to benefit from sleep.
At the end of 4 hours, the patient was able to have sleep and
verbalized of feeling rested.
E
At the end of 2 days, the patient was able to verbalize a fair
improvement of his sleep/ rest pattern in between his medication/
treatment regimen.
41
O weakness
Patient’s report of pain
43
Changes in v/s
P At the end of 2 hours, patient will verbalize a relief from pain and
discomfort.
3.) Assess GI functions and monitor fluid intake and urine output.
4.) Obtained a 12- lead ECG recording during the symptomatic event
as prescribed to determine extension of infarction
COLLABORATIVE:
5.) Administered oxygen @ 3L/min via nasal cannula.
Rationale:
Increases amount of oxygen available for myocardial uptake and
thereby may relieve discomfort associated with tissue ischemia
E At the end 2 hours, patient verbalizes the relief from discomfort around
the chest.
44
1.) Monitored BP using proper equipment with cuff bladder that is two-
thirds diameter.
Rationale:
To detect changes from baseline that indicate changes in
cardiovascular status
3.) Discouraged intake of coffee, tea, cola and chocolate which are
high in caffeine.
Rationale:
Caffeine stimulates sympathetic nervous system
45
Recommendations
Advised the patient for followed up check up from his assigned physician.
Advised patient peer for frequent monitoring of his vital sign to avoid any
risk and possible complication
Explain the purpose and preparation for diagnostic test to have clear
understanding of procedures and what is happening increase feeling of
control and lessens anxiety.
Provide positive reinforcement for gains/ improvement and participation in
self care/treatment program. This encourages continuation of healthy
behavior.
47
The patient was able to understand the imparted health teachings and
verbalized to consistently follow his treatment regimen in home care
management. Although patient’s blood pressure did not lower down to his normal
range of blood pressure, other clinical manifestations such as severe chest pain
was not subjectively verbalized by the patient and labored breathing was not
evident. Still, patient has unproductive, dry cough. Mr. Sarmiento is progressing
well in his health condition and is for discharge any soon. Patient may have an
uncomplicated episode of myocardial infarction and may return to normal
activities and lifestyle with moderation and modification to some of those.
IX. DOCUMENTATION
Upon assessment last July 3, 2007, patient X was received with a diagnosis
of Acute myocardial infarction; Hypertensive cardiovascular disease; ruled out
48
PUD; diabetic nephropathy. Pt. was sitting on bed and complaint on pain on
chest area upon coughing was noted. Instructed to do deep, breathing exercises
everytime chest pain is recurring. Pertinent data about the patient’s family and
personal health history were gathered.
The next day on the group’s duty, pt. has oxygen inhalation regulated at
3l/min via nasal cannula and vital signs were monitored every 4 hours with
special consideration to the client’s blood pressure. Due medication were
properly given and kept patient in moderate, high back rest and kept comfortably
on bed, keeping back dry. Pt. was observed for any unsualties during the shift.
No further complaints were noted from the patient.
On the 2nd day of duty the doctor ordered that client may go home the next
day if stable. So, the group imparted health teachings important for the client to
follow as his home care management. We helped the client in discharged
planning and reminded them the health teachings that we had discussed.
This study also tests our abilities and skills on how to find answers to the
patient’s problem, what action to be done in order to solve it and how to properly
and correctly use our initiative for the success and for the good outcome of our
care study. This is one of our tasks as a student or future nurses and it serves as
our training ground backed up with strict training in order for us to become
equipped, productive, efficient, and world-class nurses in the future.
B I B L I O G R A P H Y
• Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education
Inc.,Copyright 2000
•
• HTML1Rollins Gina. "With smoking cessation drugs, dosing is key", ACP-
ASIM Observer, 22(4); 1,16-17.
W E B L I O G R A P H Y
• http://biology.clc.uc.edu/courses/bio105/circulat.htm
• wwwmedlib.med.utah.edu\webpath\TUTORIAL\MYOCARD\MYOCARD