I.

INTRODUCTION
A. Brief Description

Ischemic or ischemic heart disease (IHD), or myocardial ischemia, is a disease

characterized by reduced blood supply to the heart muscle, usually due to coronary artery
disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking,
hypercholesterolemia (high cholesterol levels), diabetes, hypertension (high blood pressure)
and is more common in men and those who have close relatives with ischemic heart disease.

Myocardial ischemia is a disorder that is usually caused by a critical coronary artery

obstruction, which is also known as atherosclerotic coronary artery disease (CAD). CAD is the
 leading cause of death worldwide, and it is the second most common cause of emergency
department visits in the United States. More than $140 billion are spent each year for the
diagnosis and management of CAD.

B. Statistics

a) International

Diagnosing myocardial ischemia prior to a heart attack is important because ischemic

heart disease is responsible for approximately 14% of all deaths worldwide. Approximately 1.5
million Americans will have a heart attack this year as a result of myocardial ischemia; about
500,000 of those will be fatal.

Angina occurs more frequently in women than in men, and in blacks and Hispanics more
than in whites. It also occurs more frequently as people age--25% of women over the age of 85
and 27% of men who are 80-84 years old have angina.

Number one killer in the United States and worldwide. Every minute, an American dies
of coronary heart disease. Coronary heart disease afflicts over 13 million Americans.

b.) Local
MORTALITY: TEN LEADING CAUSES BY SEX
Number, Rate/100,000 Population and Percent Distribution
Philippines, 2004
Source: The 2004 Philippine Health Statistics
* Percent share from total deaths, all causes, Philippines
** External Causes of Mortality
Last Update: February 11, 2008

I. OBJECTIVES

A. General Objectives

At the end of the clinical exposure, we should be able to attain and enhance our
knowledge, skills and attitude to provide nursing care to our patient with chronic kidney failure.

B. Specific Objectives
During the exposure, we should be able to:

Cognitive:
➢ Give brief discussion or description about the case of the patient.
➢ Understand Myocardial Ischemia, its causes and pathophysiology.
 ➢ Design a plan of care for patient with Myocardial Ischemia.
➢ Discuss the different data gathered for the patient’s health assessment.
➢ Discuss the different nursing intervention.
➢ To be able to set priorities and goal outcomes in collaboration with the patient.
➢ To be able to document patient responses to care and verbal reports, if any.

Skills:
➢ Conduct physical assessment and organize data efficiently.
➢ Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.

Attitude:
➢ To be able to establish rapport with the patient and folks.
➢ To be able to develop respect and trust.

I. ANATOMY AND PHYSIOLOGY OF THE DISEASE

CARDIOVASCULAR SYSTEM

Your heart and circulatory system make up your cardiovascular system. Your heart
works as a pump that pushes blood to the organs, tissues, and cells of your body. Blood
delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products
made by those cells. Blood is carried from your heart to the rest of your body through a complex
network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules
and veins. If all the vessels of this network in your body were laid end-to-end, they would extend
for about 60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth
more than twice!
The one-way circulatory system carries blood to all parts of your body. This process of
blood flow within your body is called circulation. Arteries carry oxygen-rich blood away from your
heart, and veins carry oxygen-poor blood back to your heart.
In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings
oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to
your heart.
In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vessels
that carry oxygen-poor blood are colored blue.
Twenty major arteries make a path through your tissues, where they branch into smaller vessels
called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and
nutrients to your cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one
blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients
and pick up carbon dioxide and other waste, they move the blood back through wider vessels
called venules. Venules eventually join to form veins, which deliver the blood back to your heart
to pick up oxygen.
Coronary Arteries. Because the heart is composed primarily of cardiac muscle tissue that
continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The
coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to
the cardiac muscle tissue. The blood leaving the left ventricle exits through the aorta, the body’s
main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge
from the beginning of the aorta, near the top of the heart. The initial segment of the left coronary
artery is called the left main coronary. This blood vessel is approximately the width of a soda
straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior
descending coronary artery and the left circumflex coronary artery. The left anterior descending
coronary artery is embedded in the surface of the front side of the heart. The left circumflex
coronary artery circles around the left side of the heart and is embedded in the surface of the
back of the heart. Just like branches on a tree, the coronary arteries branch into progressively
smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller
branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow
that the red blood cells must travel in single file. In the capillaries, the red blood cells provide
oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other
metabolic waste products, taking them away from the heart for disposal through the lungs,
kidneys and liver. When cholesterol plaque accumulates to the point of blocking the flow of
blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond
the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue
ceases to function properly. The condition when a coronary artery becomes blocked causing
damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.
Superior Vena Cava. The superior vena cava is one of the two main veins bringing de-
oxygenated blood from the body to the heart. Veins from the head and upper body feed into the
superior vena cava, which empties into the right atrium of the heart.
Inferior Vena Cava. The inferior vena cava is one of the two main veins bringing de-oxygenated
blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena
cava, which empties into the right atrium of the heart.
Aorta. The aorta is the largest single blood vessel in the body. It is approximately the diameter
of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts
of the body.
Pulmonary Artery. The pulmonary artery is the vessel transporting de-oxygenated blood from
the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich
blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.
Pulmonary Vein. The pulmonary vein is the vessel transporting oxygen-rich blood from the
lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It
is more appropriate to classify veins as vessels carrying blood to the heart.
Right Atrium. The right atrium receives de-oxygenated blood from the body through the
superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The
sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract
in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from
the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow
into the right ventricle.
Right Ventricle. The right ventricle receives de-oxygenated blood as the right atrium contracts.
The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with
blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid
valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood
from backing into the right atrium and the opening of the pulmonary valve allows the blood to
flow into the pulmonary artery toward the lungs.
Left Atrium. The left atrium receives oxygenated blood from the lungs through the pulmonary
vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood
passes through the mitral valve into the left ventricle.
Left Ventricle. The left ventricle receives oxygenated blood as the left atrium contracts. The
blood passes through the mitral valve into the left ventricle. The aortic valve leading into the
aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract.
As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of
the mitral valve prevents blood from backing into the left atrium and the opening of the aortic
valve allows the blood to flow into the aorta and flow throughout the body.
Papillary Muscles. The papillary muscles attach to the lower portion of the interior wall of the
ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the
right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles
opens these valves. When the papillary muscles relax, the valves close.
Chordae Tendineae. The chordae tendineae are tendons linking the papillary muscles to the
tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary
muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease
in tension to the respective valves, causing them to open and close. The chordae tendineae are
string-like in appearance and are sometimes referred to as "heart strings."
Tricuspid Valve. The tricuspid valve separates the right atrium from the right ventricle. It opens
to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It
closes as the right ventricle contracts, preventing blood from returning to the right atrium;
thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.
Mitral Value. The mitral valve separates the left atrium from the left ventricle. It opens to allow
the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left
ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit
through the aortic valve into the aorta.
Pulmonary Valve. The pulmonary valve separates the right ventricle from the pulmonary artery.
As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right
ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to
the heart.
Aortic Valve. The aortic valve separates the left ventricle from the aorta. As the ventricles
contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout
the body. It closes as the ventricles relax, preventing blood from returning to the heart.

The Nervous System

 The nervous system is a network of specialized cells that communicate information
about an animal’s surroundings and its self; it processes this information and causes reactions
in other parts of the body. It is composed of neurons and other specialized cells called glia, that
aid in the function of the neurons.

The nervous system is divided broadly into two categories; the peripheral nervous
system and the central nervous system. Neurons generate and conduct impulses between and
within the two systems. The peripheral nervous system is composed of sensory neurons and
the neurons that connect them to the nerve cord, spinal cord and brain, which make up the
central nervous system. In response to stimuli, sensory neurons generate and propagate
signals to the central nervous system which then process and conduct back signals to the
muscles and glands.

The neurons of the nervous systems of animals are interconnected in complex

arrangements and use electrochemical signals and neurotransmitters to transmit impulses from
one neuron to the next. The interaction of the different neurons form neural circuits that regulate
an organism’s perception of the world and what is going on with its body, thus regulating its
behavior. Nervous systems are found in many multicellular animals but differ greatly in
complexity between species

The central nervous system (CNS) is the largest part of the nervous system, and
includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while
the head contains and protects the brain. The CNS is covered by the meninges, a three layered
protective coat. The brain is also protected by the skull, and the spinal cord is also protected by
the vertebrae.

Brain is a part of the Central Nervous System, it plays a central role in the control of
most bodily functions, including awareness, movements, sensations, thoughts, speech, and
memory. Some reflex movements can occur via spinal cord pathways without the participation
of brain structures.

The cerebrum is the largest part of the brain and controls voluntary actions, speech,
senses, thought, and memory.

The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which
are termed fissures. Some fissures separate lobes.

The convolutions of the cortex give it a wormy appearance. Each convolution is

delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two
halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum
links the hemispheres. The right hemisphere controls voluntary limb movements on the left side
of the body, and the left hemisphere controls voluntary limb movements on the right side of the
body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four
lobes, or areas, which are interconnected.
 The frontal lobes are located in the front of the brain and are responsible for voluntary
movement and, via their connections with other lobes, participate in the execution of sequential
tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.

The parietal lobes are located behind the frontal lobes and in front of the occipital lobes.
They process sensory information such as temperature, pain, taste, and touch. In addition, the
processing includes information about numbers, attentiveness to the position of one’s body
parts, the space around one’s body, and one's relationship to this space.

The temporal lobes are located on each side of the brain. They process memory and
auditory (hearing) information and speech and language functions.

The occipital lobes are located at the back of the brain. They receive and process
visual information (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)

II. VITAL INFORMATION

Name (initials): A.L
Age: 67 years old
Sex: Male
Address: Panit.an, Capiz
Civil Status: Widow
Religion: Roman Catholic
Occupation: Businessman
Date and Time admitted: November 5, 2009 at 4:00 pm
Ward: ICU- D
Chief Complaint: Difficulty of Breathing
Admitting Diagnosis: DM Type II, Pneumonia, Myocardial Wall Ischemia
Final Diagnosis: Myocardial Ischemia
Attending Physician/s: Dr. M. B.

III. CLINICAL ASSESSMENT

A. Nursing History
 Mr. AL is an excessive alcohol drinker. He stays on his shop often because of his
business. One day prior to admission, he has onset of whitish productive cough and difficulty of
breathing and chest pain. He has high blood pressure of 130/90 mmhg.

B. Past Health Problem / Status

Past Illnesses: Mr. A.L. is a 67 year old male suffering from hypertension, diabetes
mellitus type – 2. He also experienced chickenpox and measles during his childhood.
Allergies: He has no known allergies to food or drugs.
Previous Hospitalization: Previous hospitalization was May 2006 due to difficulty of
breathing with a diagnosis of Myocardial Infarction.

C. Family History of Illness

Upon interview, Mr. AL was diagnosed of Diabetes Mellitus Type II in the year 2004, and
he is taking Glibenclamide as his medication, according to his daughter he is also fond of eating
foods which are rich in fat and cholesterol. She has also that Mr. AL cannot eat without putting
extra salt on her food.
Both of his parents have hypertension, diabetes mellitus type -2 and a history of
bronchial asthma, eventually, he may acquire these diseases. Some of his siblings have it too,
and also to his children especially bronchial asthma.
 HPN
DM-type II
FAMILY GENOGRAM

HPN

HPN, PTB, Myocardial IschemiaCCCCCCCC

HPN BA
HPN

Legend:
Deceased male

Deceased female
BA
Indicates patient

Living male

Living female
 I. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND

A. Educational Background
Mr. AL is a college graduate.

B. Occupational Background
He is working as a business man.

C. Religious Background
He is a Roman Catholic and attends mass on Sundays and prays the rosary at night
together with his children.

D. Economic Status
They belong to a middle class type of family and most of his children are
professionals and have a job of their own.

I. CLINICAL INSPECTION
A. Vital Signs
Upon Admission During Care
Temperature 36.8C 36.5°C
Pulse Rate 88 bpm 95 bpm
Respiration 30 bpm 36 bpm
Blood 140/90 mmHg 130/80 mmHg
Pressure
Cardiac Rate 120 bpm 130 bpm

B. Height, Weight, BMI – no data

C. Physical Assessment
General
Patient is wearing a hospital gown, with unkempt
hair, appears weak; conscious and coherent. He is
lying on bed with an ongoing IVF of #4 PLRS 1 L
xKVO 5 µgtts/ min infusing well on the right
metacarpal vein currently at 770 cc level. Oxygen
inhalation at 2/L min via nasal cannula.

Skin, Hair, Nails

Dry skin, uniform in color. Hair is black with visible
white hair, no lice and dandruff and dry scalp.
Fingernails are trimmed, (+) cyanotic nailbeds,
toenails are not trimmed and unclean.
Head, Face, Lymphatics
(+) Headache. No head injuries, round in shape
and oily face.

HEENT
Upon the assessment of the client, most of the
findings are of normal findings characterized by
pupils which are equally round in shape, reactive to
light and accommodation, with her right eyebrows
evenly distributed and symmetrically aligned. With
eyelashes of normal growth, there are no purulent
or any discharges seen on the client’s eyes. No
periorbital edema noted, cornea is transparent and
shiny. Ears are of normal findings. Nose is also of
normal findings. Lips that are dark and gums
are pale
Neck and Upper extremities
No lumps or swollen glands. No reports of neck
pain and stiffness. Arms able to move freely.
Presence of palpitation in his wrist.

Chest, Breast and Axilla

Abnormal respiration upon admission with RR of
30 bpm and 36 bpm during care. Presence of chest
pain, (+) history of bronchial asthma, (+) crackles,
(+) wheezing.

Respiratory System (Chest and Lungs)

Thorax is symmetric. (+) history of bronchial
asthma, RR is above normal. (+) dyspnea, (+)
wheezing.(+) difficulty of breathing (+) productive
cough with presence of whitish phlegm.CXR
results: (+)PTB, both upper lobe with regression
and Atheromatous Aorta
Cardiovascular System
(+) history of hypertension with blood pressure of
140/90 upon admission and during care with the
BP of 130/80 mmHg. (+) dyspnea, (+) tachycardia,
(+) chest pain with discomfort. Cardiac rate is
above normal with AR of 130 bpm and respiration
of 36 bpm.

Gastrointestinal System
During Bowel Elimination
Frequency: Once a day
Pattern: Every morning
Consistency: Normal Stool
Color: Light Brown
Odor: Normally foul stool odor

Genito – Urinary System

Quantity: 1000cc to 1200cc per shift

Color: Lt. Yellow

Musculoskeletal System (+) weakness, (+) limitation of motion or activity,

D. General Appraisal

Speech: He speaks clearly, attentive and conversive.

Language: The patient knows how to speak English, Tagalog, Bisaya.
Hearing: The patient’s hearing is good.
Mental Status: The patient is alert and attentive when asked but sometimes he is
grumpy, depending on his mood.
Emotional status: He is worried about his condition and thinks that he brings problem
to his family due to his situation.
 I. LABORATORY AND DIAGNOSTIC DATA

A. Hematology
Hematology is the branch of biology (physiology), pathology, clinical laboratory, internal
medicine, and pediatrics that is concerned with the study of blood, the blood of forming organs,
and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis,
and prevention of blood diseases.
Test Result Normal Significance
Values
Date: 11/05/09
WBC count 18.3x10^9/L 4.5-11.0 ↑ Susceptible to infection
RBC count 4.78x10^12/L 4.2-5.4 The result is Within Normal Range.

Hemoglobin 140g/L 120-160 The result is Within Normal Range.

Hematocrit 0.42vol.fr 0.37-0.47 The result is Within Normal Range.
Mean Corpuscular 86.0cu.u 80-96 The result is Within Normal Range.
Volume (MCV)
Mean Corpuscular 28.5uug 27-31 The result is Within Normal Range.
Hemoglobin (MCH)
Mean Corpuscular 33.0g/dL 32-36 The result is Within Normal Range.
Hemoglobin the
Concentration (MCHC)
RDW 12.8% 11-16 The result is Within Normal Range.
Neutrophils 65.0% 50-70 The result is Within Normal Range.
Eosinophils 4.0% 0-3 ↑ Allergic reactions
Basophils 0.0% 0-1 The result is Within Normal Range.
Lymphocytes 11.0% 20-45 ↓ It signifies severe
debilitating illnesses.
Monocytes 0.0% 0-8 The result is Within Normal Limits.
Platelet 118000 15000-35000 The result is Within Normal Limits.
Protrombin Time 14.6sec 10-15 sec The result is within Normal Limits.
A. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly
performed on sick or aging patient. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a machine
called centrifuge. The serum layer is drawn off and a variety of compounds are then measured.
These measurements aid the veterinarian in assessing the function of various organs and body
systems.

Test Result Normal Values Significance

Date: 11/07/09
Glucose 678 mmol/L 4.10 – 5.90 ↑ Hyperglycemia
Sodium 140.0 mmol/L 137.0 – 145.0 The result is Within Normal
Limits.
Magnesium 1.10 mmol/L .70 – 1.00 The result is Within Normal
Limits.
Creatinine 129.3 mmol/L 71.0 – 133.0 ↑ Impaired renal
function, shock
Cholesterol 9.34 mmol/L 0.00 – 5.20 ↑ Elevation
 indicates increase
risk in CAD
Direct HDLC .45 mmol/L 1.00 – 1.60 ↓ Indicates risks in
CAD
LDL 7.40 1.71 – 4.60 ↑ Elevation
indicates risk in
CAD
VLDL 1.52 0.00 – 1.03 ↑ Elevation
indicates increase
risk in CAD
Potassium 3.8 3.5 – 5.10 The result is Within Normal
Limits.

A. Radiology
It provides a radiographic image of the organs or tissues, to detect abnormality such as
tumor, perforation, abscess, infection, foreign body or fracture.

Test X – ray Findings Impression

Date: 11/05/09
Shows regression of TB infiltrates in both PTB, both upper lobe
Chest PA upper lobes. with regression
(mobile) Atheromatous aorta.

B. Serology and Immunology

It is the science that deals with the properties and reactions of serums, especially blood
serum. It analyzes the contents and properties of blood serum.

Serum Specimen Result/s Normal Value Significance

Date: 11/07/09
Troponin – 1 (+) Positive 3.13 ug/L <0.01ug/L Indicates
Determination Myocardial
Infarction.

HbA1c is a test that measures the amount of glycated hemoglobin in your blood.
Glycated hemoglobin is a substance in red blood cells that is formed when blood sugar
(glucose) attaches to hemoglobin

Serum Specimen Result/s Normal Value Significance

Date: 11/07/09
Hba1C (+) Positive 12.0% 4.2-6.2% It means that
your diabetes
control may not
be as good as it
should be.
High values
mean you are at
 greater risk of
diabetes
complications.

I. PATHOPHYSIOLOGY
Non modifiable Factors: Modifiable Factors:

Age Abnormal lipids

Smoking
Sex
Hypertension
Family History
Diabetes mellitus
Abdominal obesity
Too much alcohol
Lack of regular exercise

Atherosclerosis

Formation of
plaque deposits

Thrombosis

Occlusion by
Major blood
vessel

If not
Vascular wall
managed:
becomes
Lyses a moved
weakened and
thrombus from
fragile
the vessel.
Leaking of blood
from the vessel
wall

continuation

Cerebral
Hamorrhage

Mass of blood
from and grows

Isospasm of
tissue and
anterior

Cerebral
Hypoperfusion

Impaired
distribution of
oxygen and
glucose

Tissue hypoxia
and cellular
starvation
II. MEDICAL MANAGEMENT
A. Drug Study
 Name of the
Drug with
Generic Name Action Mechanism of Indications Side Effects Contraindications Nursing Responsibilities
Dosage
Action

Vastarel Mr Trimetazidine Antianginal Acts by directly Long treatment Nausea and Hypersensitivity to Assess patient for chest pain or
35mg/tab 1 tab Drugs counteracting all of coronary vomiting slight Trimetazidine what its type of severity.
BID the major insufficiency, weakness and
Use cautiously with Instruct the client to take drugs
metabolic angina head ache.
renal dysfunction. only for 3 times and refer
disorders pectoris.
physician if frequent angina
occurring within
attack will occur.
the ischemic cell.
The actions of Monitor VS and refer if there is
trimetazidine an abnormality
include limitation
Take the medicine with a full
of intracellular
glass of water.
acidosis,
correction of Administer before meals.
disturbances of Caution patient to swallow
transmembrane capsules whole—not to open,
ion exchanges, chew, or crush them. If using
and prevention of oral suspension, empty packet
excessive into a small cup containing 2
production of free tbsp of water. Stir and have
radicals.decrease patient drink immediately; fill
myocardial oxygen cup with water and have
requirement by patient drink this water. Do not
 A. Other Treatments

ECG

Electrocardiography (ECG or EKG) is a transthoracic interpretation of the electrical

activity of the heart over time captured and externally recorded by skin electrodes. It is a
noninvasive recording produced by an electrocardiographic device. The etymology of the word
is derived from electro, because it is related to electrical activity, cardio, Greek for heart, and
graph, a Greek root meaning "to write".

Electrical impulses in the heart originate in the sinoatrial node and travel through the
intimate conducting system to the heart muscle. The impulses stimulate the myocardial muscle
fibres to contract and thus induce systole. The electrical waves can be measured at electrodes
placed at specific points on the skin. Electrodes on different sides of the heart measure the
activity of different parts of the heart muscle. An ECG displays the voltage between pairs of
these electrodes, and the muscle activity that they measure, from different directions, also
understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in
different parts of the heart muscle. It is the best way to measure and diagnose abnormal
rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue
that carries electrical signals, or abnormal rhythms caused by electrolyte imbalances. In a
myocardial infarction (MI), the ECG can identify if the heart muscle has been damaged in
specific areas, though not all areas of the heart are covered. The ECG cannot reliably measure
the pumping ability of the heart, for which ultrasound-based (echocardiography) or nuclear
medicine tests are used.

Placement of electrodes
Ten electrodes are used for a 12-lead ECG. They are labeled and placed on the patient's body
as follows
ELECTRODE ELECTRODE PLACEMENT
LABEL (in the
USA)
V1 In the fourth intercostal space (between ribs 4 & 5) to the right of the
sternum (breastbone).
V2 In the fourth intercostal space (between ribs 4 & 5) to the left of the
sternum.
V3 Between leads V2 and V4.
V4 In the fifth intercostal space (between ribs 5 & 6) in the midclavicular line
(the imaginary line that extends down from the midpoint of the clavicle
(collarbone).
V5 Horizontally even with V4, but in the anterior axillary line. (The anterior
axillary line is the imaginary line that runs down from the point midway
 between the middle of the clavicle and the lateral end of the clavicle; the
lateral end of the collarbone is the end closer to the arm.)
V6 Horizontally even with V4 and V5 in the mid-axillary line. (The mid-axillary
line is the imaginary line that extends down from the middle of the patient's
armpit.)

Limb leads
In both the 5- and 12-lead configuration, leads I, II and III are called limb leads. The
electrodes that form these signals are located on the limbs—one on each arm and one on the
left leg. The limb leads form the points of what is known as Einthoven's triangle.
• Lead I is the signal between the (negative) RA electrode (on the right arm) and the
(positive) LA electrode (on the left arm).
• Lead II is the signal between the (negative) RA electrode (on the right arm) and the
(positive) LL electrode (on the left leg).
• Lead III is the signal between the (negative) LA electrode (on the left arm) and the
(positive) LL electrode (on the left leg).

Precordial leads
The electrodes for the precordial leads (V1, V2, V3, V4, V5, and V6) are placed directly
on the chest. Because of their close proximity to the heart, they do not require augmentation.
Wilson's central terminal is used for the negative electrode, and these leads are considered to
be unipolar (recall that Wilson's central terminal is the average of the three limb leads. This will
approximate ground). The precordial leads view the heart's electrical activity in the so-called
horizontal plane. The heart's electrical axis in the horizontal plane is referred to as the Z axis.

Waves and intervals

A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P wave, a
QRS complex and a T wave.[23] A small U wave is normally visible in 50 to 75% of ECGs. The
baseline voltage of the electrocardiogram is known as the isoelectric line. Typically the
isoelectric line is measured as the portion of the tracing following the T wave and preceding the
next P wave.
P wave During normal atrial depolarization, the main electrical vector
is directed from the SA node towards the AV node, and
spreads from the right atrium to the left atrium. This turns into
the P wave on the ECG.
QRS The QRS complex is a recording of a single heartbeat on the
complex ECG that corresponds to the depolarization of the right and
left ventricles.
PR The PR interval is measured from the beginning of the P It is usually 120 to 200 ms
interval wave to the beginning of the QRS complex. long.
ST The ST segment connects the QRS complex and the T wave. It has a duration of 0.08 to
segment 0.12 sec (80 to 120 ms).
T wave The T wave represents the repolarization (or recovery) of the
ventricles. The interval from the beginning of the QRS
complex to the apex of the T wave is referred to as the
absolute refractory period. The last half of the T wave is
referred to as the relative refractory period (or vulnerable
period).
QT The QT interval is measured from the beginning of the QRS Normal values for the QT
interval complex to the end of the T wave. interval are between 0.30
and 0.44 seconds.[citation needed]
U wave The U wave is not always seen. It is typically small, and, by
definition, follows the T wave.

Echocardiogram
 An echocardiogram uses sound waves to produce images of your heart. This common
test allows your doctor to see how your heart is beating and pumping blood. Your doctor can
use the images from an echocardiogram to identify various abnormalities in the heart muscle
and valves.

Depending on what information your doctor needs, you may have one of several types of
echocardiograms. Each type of echocardiogram has very few risks involved.

Your doctor may suggest an echocardiogram if he or she suspects problems with the
valves or chambers of your heart or your heart's ability to pump. An echocardiogram can also
be used to detect congenital heart defects in unborn babies.

Depending on what information your doctor needs, you may have one of the following
kinds of echocardiograms:

Types
Transthoracic echocardiogram. This is a standard, noninvasive echocardiogram. A
technician (sonographer) spreads gel on your chest and then presses a device known as a
transducer firmly against your skin, aiming an ultrasound beam through your chest to your heart.
The transducer records the sound wave echoes your heart produces. A computer converts the
echoes into moving images on a monitor. If your lungs or ribs obscure the view, a small amount
of intravenous dye may be used to improve the images.

Transesophageal echocardiogram. If it's difficult to get a clear picture of your heart

with a standard echocardiogram, your doctor may recommend a transesophageal
echocardiogram. In this procedure, a flexible tube containing a transducer is guided down your
throat and into your esophagus, which connects your mouth to your stomach. From there, the
transducer can obtain more detailed images of your heart.

Doppler echocardiogram. When sound waves bounce off blood cells moving through
your heart and blood vessels, they change pitch. These changes (Doppler signals) can help
your doctor measure the speed and direction of the blood flow in your heart. Doppler techniques
are used in most transthoracic and transesophageal echocardiograms.

Stress echocardiogram. Some heart problems — particularly those involving the

coronary arteries that feed your heart muscle — occur only during physical activity. For a stress
echocardiogram, ultrasound images of your heart are taken before and immediately after
walking on a treadmill or riding a stationary bike. If you're unable to exercise, you may get an
injection of a medication to make your heart work as hard as if you were exercising.

Risks
 There are minimal risks associated with a standard transthoracic echocardiogram. You
may feel some discomfort similar to pulling off an adhesive bandage when the technician
removes the electrodes placed on your chest during the procedure.

If you have a transesophageal echocardiogram, your throat may be sore for a few hours
afterward. Rarely, the tube may scrape the inside of your throat. Your oxygen level will be
monitored during the exam to check for any breathing problems caused by the sedation
medication.

During a stress echocardiogram, exercise or medication — not the echocardiogram itself

— may temporarily cause an irregular heartbeat. Serious complications, such as a heart attack,
are rare.

During the procedure

An echocardiogram can be done in the doctor's office or a hospital. After undressing
from the waist up, you'll lie on an examining table or bed. The technician will attach sticky
patches (electrodes) to your body to help detect and conduct the electrical currents of your
heart.

If you'll have a transesophageal echocardiogram, your throat will be numbed with a

numbing spray or gel. You'll likely be given a sedative to help you relax.

During the echocardiogram, the technician will dim the lights to better view the image on
the monitor. You may hear a pulsing "whoosh" sound, which is the machine recording the blood
flowing through your heart.

Most echocardiograms take less than an hour, but the timing may vary depending on
your condition. During a transthoracic echocardiogram, you may be asked to breathe in a
certain way or to roll onto your left side. Sometimes the transducer must be held very firmly
against your chest. This can be uncomfortable - but it helps the technician produce the best
images of your heart.

After the procedure

If your echocardiogram is normal, no further testing may be needed. If the results are
concerning, you may be referred to a heart specialist (cardiologist) for further assessment.
Treatment depends on what's found during the exam and your specific signs and symptoms.
You may need a repeat echocardiogram in several months or other diagnostic tests, such as a
cardiac computerized tomography (CT) scan or coronary angiogram.

Results
Information from the echocardiogram can reveal many aspects of your heart health,
including:
 Heart size. Weakened or damaged heart valves, high blood pressure or other diseases
can cause the chambers of your heart to enlarge. Your doctor can use an echocardiogram to
evaluate the need for treatment or monitor treatment effectiveness.

Pumping strength. An echocardiogram can help your doctor determine your heart's
pumping strength. Specific measurements may include the percentage of blood that's pumped
out of a filled ventricle with each heartbeat (ejection fraction) or the volume of blood pumped by
the heart in one minute (cardiac output). If your heart isn't pumping enough blood to meet your
body's needs, heart failure may be a concern.

Damage to the heart muscle. During an echocardiogram, your doctor can determine
whether all parts of the heart wall are contributing equally to your heart's pumping activity. Parts
that move weakly may have been damaged during a heart attack or be receiving too little
oxygen. This may indicate coronary artery disease or various other conditions.

Valve problems. An echocardiogram shows how your heart valves move as your heart
beats. Your doctor can determine if the valves open wide enough for adequate blood flow or
close fully to prevent blood leakage. Abnormal blood flow patterns and conditions such as aortic
valve stenosis — when the heart's aortic valve is narrowed — can be detected as well.

Heart defects. Many heart defects can be detected with an echocardiogram, including
problems with the heart chambers, abnormal connections between the heart and major blood
vessels, and complex heart defects that are present at birth. Echocardiograms can even be
used to monitor a baby's heart development before birth.
 I. NURSING MANAGEMENT
A. Concept Map of Nursing Problems
1. Ineffective airway clearance2.related
Acute to
(Chest) Pain r/t myocardial
presence of secretionsischemia
in the resulting from coronary artery
tracheobronchial tree.
occlusion with loss/restriction of blood
flow to an area of the myocardium and
Objective/s: necrosis of the myocardium.
(+) Crackles, (+) Whitish productive cough,
(+) Chest Pain, (+) DOB, (+) Tachycardia,
Objectives: (+)
Weakness, (+) Confusion, RR= (+)Restlessness,
36 bpm, CXR- (+) Facial grimacing, (+)
PTB, both lobe with regressionFatigue,
Atheromatous
(+) Peripheral cyanosis, (+) Cold and
aorta clammy skin, (+) Palpitations (+) Shortness of
breath, (+) Pain scale of 8/10
`
6. Deficient Knowledge r/t new
diagnosis and lack of understanding
of medical condition. CC: Difficulty of Breathing
Objectives:
Medical Diagnosis:
(+)Lack of improvement of previous
regimen
Myocardial Ischemia
(+)Inadequate follow-up on
instructions given.
(+)Anxiety 3. Activity Intolerance r/t cardiac
(+)Lack of understanding dysfunction, changes in oxygen
supply and consumption as
evidenced by shortness of breath.
5. Low self-esteem
r/t chronic illness specifically myocardial Objectives:
ischemia. (+)Increased heart rate 130 bpm.
Objective/s: 4. Infection r/t invasion of bacterial (+)Increased blood pressure130/80
(+) indecisive nonassertive behavior, (+) microorganism in the lungs (+)Difficulty of breathing
Weakness, Lack of eye contact, Refusal (+)Pallor
to participate in hospital procedures, Objective/s: (+)Fatigue and weakness
increasingly dependent on her wife Based on the Laboratory results: (+)Ischemic ECG changes
Eosinophils = 4.0% (0-3%), WBC =
18.3X10^9/L (4.5 – 11.0 X 10 ^ 9/L),
CXR results: PTB, both upper lobe with
B. Nursing Care Plan regression
Atheromatous aorta
(+) whitish productive cough,
ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION
DIAGNOSIS THEORIST/S
Subjective: Ineffective After 8 hours of Independent: Faye Abdellah’s theory Goal partially
“Nabudlayan ako mag airway nursing 1. Assist the Mr. 1. This of 21 Nursing Problems met.
ginhawa” as verbalized. clearance r/t intervention, Mr. AL improves (Problem Solving to
presence of AL will be able to in performing the productivity of move the patients After 8 hours of
Objective/s: secretions in the expectorate coughing and cough towards health.) nursing
• (+) Crackles tracheobronchial secretions and breathing maneuvers. interventions,
• (+) Whitish tree. have normal Faye Abdellah’s theory Mr. AL
productive cough respiratory rate. 2. Instruct the Mr. 2. Controlled of 21 Nursing Problems secretions are
• (+) Chest Pain AL in the coughing (Doing the for the mobilized and
• (+) DOB following: techniques help patient what they cannot cough out but
• (+)Tachycardia • Optimal mobilize do for themselves.) the airway is
• (+) Weakness positioning (semi secretions from not totally free
• (+) Confusion fowlers) smaller airways to Virginia Henderson’s from excessive
• RR= 36 bpm • Use of pillow or larger airways theory of 14 secretions AEB
• CXR- PTB, both Hand splints when because coughing Components of Nursing abnormal lung
lobe with regression coughing. is done at varying Care (Process or sounds or
Atheromatous aorta • Use of times. movements from crackles.
abdominal muscle dependence to
for more forceful independence.)
cough
• Temperance of Florence Nightingale’s
ambulation and theory of Environment
frequent position (Alleviate unnecessary
change. source of pain and
 1. Provide back 3. To loosen suffering)
Tapping to patient. Secretions
Dorothy Johnson’s
theory of Human
Dependent: Behavioral System
1. Administer 02 1. For effective (Medicine focus: Cure)
therapy as ordered oxygenation
2L/minute via nasal Lydia Hall’s theory of
cannula Components of Nursing
Caring (Core and Cure
2. Nebulization of 2. To promote -shared with other
salbutamol 1neb x softening of health care providers.)
3doses/15min secretions for
better
expectoration of
secretions
 ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION
DIAGNOSIS THEORIST/S

Objective/s: Infection r/t Mr. AL is free of Independent: Goal Partially met.

Based on the invasion of bacterial infection as 1. Note for 1. Infections Ernestine
Laboratory results: microorganism in evidenced by physical evidence must be treated to Weidenback After nursing
○ Eosinophils the lungs laboratory results of infection stop the immune (Nurse meets intervention Mr. AL
4.0% (0-3%) are within normal response and through is still having
○ WBC limits throughout glomerular identification of abnormal laboratory
18.3X10^9/L (4.5 – hospital stay. inflammation. needs) results AEB Chest
11.0 X 10 ^ 9/L) X-ray reveals:
○ Chest X-ray 2. Implement 2. Hand washing Dorothea Orem’s PTB , both upper

reveals: appropriate by all people in theory of Nursing lobe with regression

PTB , both upper lobe measures to protect contact with the Concepts Atheromatous Aorta

with regression the patient from patient is the primary (Identifies what but Eosinophils and

Atheromatous Aorta potential infection method to reduce the Nursing Care is WBC are within

• (+) whitish sources. risk of infection. needed) normal limits.

productive cough
3. Obtain a 3. Symptoms of Dorothea Orem’s
recent Acute theory of Nursing
history for signs glomerulonephritis Concepts
and symptoms of appear 10 to 14 days (Identifies what
infection or after initial Nursing Care is
exposure to streptococcal illness. needed.)
infected individual.
ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION
DIAGNOSIS THEORIST/S
Objective/s: Low self-esteem After 8 hours of Independent: Goal met.
• (+)indecisive r/t chronic illness nursing 1. Actively listen to 1. Listening and respect Imogene King’s
nonassertive specifically intervention, Mr. and respect Mr. increase the theory of Nurse – After 8 hours of
behavior myocardial AL will manifests AL development of Patient interactions nursing intervention
• (+) ischemia. more positive therapeutic relationship (Integrating personal Mr. REB was able to
Weakness self-esteem and with the client. system; interpersonal participate in all the
• Lack of eye positively respond system; social nursing procedure
contact to medical and system) without any refusal
• Refusal to nursing as evidence by
participate in interventions 2. The nurse patient Hildegard Peplau’s presence of smile on
hospital without any 2. Assist Mr. AL in relationship can provide theory of his face and
procedures refusal. Identifying the major a strong basis for Interpersonal / conversant attitude
• Increasingly areas of concern r/t implementing other Interactive towards the health
dependent on altered self-esteem. strategies to assist the (therapeutic care provider.
his grandson. patient and family with interaction between
adaptation. Nurse and Patient)

3. As Mr. REB’s Hildegard Peplau’s

3. Assist Mr. AL in condition worsen with theory of
Incorporating changes Myocardial Ischemia, it Interpersonal /
in health status into
activities of daily living,
social life, interpersonal
relationships, and
occupational activities.
4. Allow Mr. REB’s
time to voice concerns
and express anger
related to having a
chronic condition.
Collaborative:
1. Use case managers
and social workers as
necessary.
2. Refer to psychiatric
consultant as
necessary
is more difficult to Interactive
engage in even routing (Orientation,
activities. Identification)
4. Denial and anger Jean Watson’s
are anticipated theory of
responses to the Interpersonal nature
diagnosis of a chronic of caring (Help
illness. persons / patients
achieve a degree of
harmony within
themselves.)
1. They can Lydia Hall’s theory
provide of Components of
psychological support Nursing Caring (Core
and assist in financial and Cure -shared
arrangement. with other health
care providers.)
Dorothy Johnson’s
2. Most patient theory of Human
experiences some Behavioral System
degree of emotional (Nursing focus: The
 imbalance. With behavior of the
professional psychiatric person threatened
consultation, most with illness or is ill.)
patients can gradually
accept changed self-
esteem
Lydia Hall’s theory
3. Encourage use of 3. Groups that come of Components of
support groups. together for mutual Nursing Caring (Core
goals can be most and Cure -shared
helpful. with other health
care providers.)
 I. DISCHARGE PLANNING

M – edications
Medications prescribed by the physician should be taken properly, to help the patient lessen
unusual condition.
The following are take home medications prescribed by the physician:
Vastarel mr 35mg/tab
Clovipaz 75mg/tab
Aldactone 25 mg subcutaneous
Transderm patch 5 mg
Lipitor 80 mg/tab
Lanoxin 0.25 mg/tab
Accupril 5.0 mg/tab
Rivotril 2 mg/tab
Insulatard 15 units prebreakfast
12 units presupper
Clarithomycin 500 mg.tab

E – xercise and Activity

Encourage Mr. AL to have an active range of motion exercises thrice daily to maintain his
muscle strength.

T – reatment
Continue monitoring blood pressure and ECG results and comply with the medications given
prescribed by the attending physician to prevent further complications that may occur and to
have a faster recovery.

H – ome Teaching/s
1. Instruct the client/folks on how to monitor fluid status, as well as, the signs and
symptoms in order to determine existing problems and to prevent further complications.
2. Teach/ educate the client and folks on infection prevention.
3. Instruct the client on how to delay weights and how to interpret the relationship of weight
loss/gain to need for sodium and water.
4. Instruct the client and folks about the medication metabolism.
5. Teach the client and folks about the dietary regimens such as low salt, low fat and high
fiber.
6. Importance of follow-up and physician appointment.

O – ut patient follow up
After discharge, Mr. R.E.B will have a regular follow-up check up with the physician to check
and monitor the patient’s medical condition and have a dialysis thrice a week to remove waste
products from the body and to prevent future complications.

D – iet
Maintain a low salt, low fat, and high fiber diet as prescribed by the attending physician. Advice
the patient not to eat foods that is high in cholesterol such as the fatty portion of the pork that
may increase the level of his blood pressure but to eat more green and leafy vegetables.

S – pirituality and Sexuality

In order to improve his spiritual aspects, he may attend holy masses or listen to gospel readings
and pray the holy rosary or he may seek for divine providence to the Lord. Assist the patient that
may include spiritual resources to help him deal with it.

I. My Journey
 Anticipating the unknown is something that is scary. This is one of my usual thoughts
when we will be assigned to another ward. There will be different patient, different attitude and
behavior, and lastly with different personality. I haven’t even experience some of the procedures
that might be performed. I fear o doing wrong things or mistakes that might disappoint everyone
especially to my patient. I was expecting that the staffs would be mean to us and the doctors
might be a bit of intimidated. I was expecting to be very busy and that came true.
I was wrong. The staff nurses were glad and welcomed us with a smile. It was a
satisfaction working with them when they teach us and correct the things that we’ve been doing.
They seem to be our CI because they ask questions about the drugs, procedures and IV which I
find it more interesting. These enhanced my knowledge, skills and attitude toward my patient.
I am enjoying every step of this journey, both the challenges and the success,
because I know that I control of my future. Failures are merely learning experiences that lead to
the next success. There would come times that they would be stricter to us but it is for our own
good. There would be learning if you would learn from your mistakes.
I am thankful to my CI, Mrs. Edrelyn Venturanza and Ms. Jimmelle Ellen Olilang, for
being so patient and kind to us. I like the manner she tries to emphasize our responsibilities and
obligations to our patients. She always carries a smile on her face which tells me deep inside
that I must enjoy the field of profession that I choose in every chooser carrier, there is always
hardship, sacrifices and trials that will come across the way. These 3 elements made me
stronger enough the challenge to be a successful nurse someday. I also learned that you must
grab every opportunity when you are still a student nurse, in this way we would be able to
develop skills in performing different procedure. This includes skin test, IV follow-up, OTF
feeding and subcutaneous injections.
The days of duty has seems to end so fast. I didn’t notice and feel that I will soon leave
the ICU. In our duty, I am always reminded that the life of your patient depends on my hands. I
have given the responsibility to take good care of my patients.
This month stay here in ICU would be cherished and reminisced in my life. I learned
many values, learning and procedure that would help me in rendering care to my patient.
Doing the case of my patient seems so hard yet full of learning. Even though it’s hard, I
just think that it would contribute to gain further knowledge.
Doing what you love is success. Success is not defined by fortune alone. It doesn't come
while you're looking for it. It comes unexpectedly while you're filling the needs of your clients. It
arrives in the moment you discover the key to your case and put the last piece of the puzzle in
place.