Pathophysiology of Coronary Artery Disease with Non-ST Segment Elevation Myocardial Infarction (STEMI) with

Transudate Pleural Effusion

Precipitating Factor:
-

Injury to tunica intima

Fatty streaks begins to build

up
Fatty fibrous plaques
progesses

Sedentary Lifestyle

Platelet lodges to the site

WBC and neutrophils act on
the injured tunica intima
Hypersensivity to fatty
fibrous plaques occurs

Predisposing Factors:
-

Age: 71 years old

Gender (male)
Filipino (CAD is one
of the most common
disease condition of
Filipino)

Platelet: 116

WBC: 15.6
Neutrophils: 73.5
Basophils: 5.1

Process continuous

Coronary artery narrows

Coronary artery obstruction

Decreased oxygen
concentration carried by
hemoglobin
Decreased oxygen
concentration received by the
bone marrow
Erythropoiesis will be
affected causing decrease in
production

Vascular changes

Inability to dilate vessel

Imbalance in oxygen supply
and demand

RBC: 2.89
Hemoglobin: 8
Hematocrit: 24.8

Coronary Artery Disease

Decrease blood flow

Body compensates by increasing

effort to pump blood

Deprivation of

S/S: Cardiac rate: 114bpm

Palpitations

Occlusion of the
right coronary
artery with right
ventricular
infarction (Inferior
wall MI)

oxygen causing an
injury of cardiac
cells

Ischemia to the area inferior

to the chest
S/S: Chest pain

Imbalanced in myocardial oxygen supply and demand

Troponin I:
1.07 mg/ml
Appearance of damage until
zone of ischemia only

ECG:
No ST
elevation

Non-ST Segment
Elevation
Myocardial
Infarction

Myocardial ischemia

Injury to the cardiac tissue

Decreased myocardial oxygen supply

Change in osmotic pressure

Increase cellular hypoxia

Change in osmotic pressure

Altered cell membrane integrity

Edema extending to
periphery

Decreased myocardial contractility

Decreased arterial pressure

Stimulation of baroreceptors

Stimulation of sympathetic receptors

increased myocardial contractility

Increase peripheral vasoconstriction

Increase heart rate to decrease diastolic

filling

Increase afterload

Decrease myocardial tissue perfusion

Myocardial oxygen demand

Decrease perfusion of cardiac muscles

Heart muscles weakens

Further increase oxygen demand by the

body tissue beyond the capability of the
heart to deliver adequate oxygen-rich
blood

Heart will have weak pumping

mechanism

Pulmonary circulation will be affected

Pulmonary circulation will be affected

Body and heart starts to starve for
oxygen rich blood

Heart muscle continue to weaken

Decrease in heart rate and decrease in

blood pressure

Decrease in heart rate

Cardiogenic shock

DEATH

fluid leaks from pulmonary blood

vessels into the pleural space

Transudate Pleural Effusion

s/s: dyspnea
chest pain

D. Course in the Ward

Hospital
Days

August 30,
2011

Diagnostic Procedure

Diet

2D Echo with
Doppler
12 Lead ECG
Chest X-ray
BUN, Creatinine
SGOT, SGPT
CBG
CBC with PT
Urinalysis
Ca, Mg, Albumin
Lipid Profile
BUA

NPO

Activity

Moderate
to high
back rest

Medications

ASA 80mg/tab, OD
Clopidogrel 75mg/tab
4tab
Enoxaparine 0.6cc SQ
q12
Dopaine drip as follows:
Dopamine 200mg/drip
20mg in 250cc D5W to
run for 10gtts/min
Captopril 25mg/tab,
tab q8 defer if SBP
90mmHg
Simvastatin 40mg/tab
2tab
Omeprazole 40mg 4tab
TIV OD
ISDN 5mg/tab 1 tab q8
refer if if SBP 90mmHg
ISDN 5mg/tab 1 tab
PRN for chest pain
Albumin infusion:
Albumin 50cc +
furosemide 40mg to run
for 1hour once BP is

Treatment

Surgery

Giving of due
medications

No
surgery
done.

V/s q1

Nursing Problems

I&O
monitoring
Refer to
Dermatologist
for skin
evaluation

Ineffective airway
clearance related to
presence of fluids in
the lungs
Imbalanced
nutrition: less than
body requirements
related to inability
to ingest food

Grieving related to
anticipatory loss
of significant other

stable
Morphine 2g TIV, TIV
PRN for severe chest
pain
Metropolol 50mg/tab
tab q12
Start ISDN drip 10mg
ISDN + PNSS to
complete 100cc to run
for 10cc/hr
Ranitidine 50mg TIV q8
while on NPO
Lactulose 30cc OD
Diazepam 5g TIV PRN,
defer if SBP 90mmHg
Amnoletan Sachet: 1
sachet in 100cc TID

Hospital
Days

August 31,
2011

Diagnostic
Procedure

Diet

12 Lead ECG
PE

NGT
feeding

Activity

Moderate to
high back
rest

Medications

ASA 80mg/tab, OD
Clopidogrel 75mg/tab
4tab
Enoxaparine 0.6cc SQ
q12
Dopamine drip as
follows:
Dopamine 200mg/drip
20mg in 250cc D5W to
run for 10gtts/min
Captopril 25mg/tab,
tab q8 defer if SBP
90mmHg
Simvastatin 40mg/tab
2tab
Omeprazole 40mg 4tab
TIV OD
ISDN 5mg/tab 1 tab q8
refer if if SBP 90mmHg
ISDN 5mg/tab 1 tab
PRN for chest pain
Albumin infusion:
Albumin 50cc +
furosemide 40mg to run
for 1hour once BP is
stable

Treatment

Surgery

Giving of due
medications

No
surgery
done.

V/s q1

Nursing Problems

I&O
monitoring
Refer to
derma for
skin
evaluation
Insertion of
NGT

Ineffective airway
clearance related to
presence of fluids in
the lungs
Imbalanced
nutrition: less than
body requirements
related to inability to
ingest food

Grieving related to
anticipatory loss of
significant other

 Morphine 2g TIV, TIV

PRN for severe chest
pain
Metropolol 50mg/tab
tab q12
Start ISDN drip 10mg
ISDN + PNSS to
complete 100cc to run for
10cc/hr
Ranitidine 50mg TIV q8
while on NPO
Lactulose 30cc OD
Diazepam 5g TIV PRN,
defer if SBP 90mmHg
Amnoletan Sachet: 1
sachet in 100cc TID
Hydrocortisone 100mg
TIV q8

C. Drug Study
DRUG
NAME
Omeprazole
40mg OD
TIV

CLASSIFICATION

MECHANISM
OF ACTION

Gastric acid
pump inhibitor.
Suppresses
gastric acid
secretion by
specific
inhibition of the
hydrogen
potassium
ATPase enzyme
system at the
secretory
surface of the
gastric parietal
cells; block the
final step of
acid
production.

Proton pump
inhibitor
Anti-secretory

INDICATION

Reduction of
risk of UGI
bleeding for
critically ill
patients
Treatment for
hypersecretory
conditions
Eradication of
H. pylori with
amoxicillin
and
clarithromycin

CONTRAINDICATIONS AND
CAUTION
Possible
contraindications are
the following:
Hypersensitivity

ADVERSE
EFFECTS
The patients
exhibit no
adverse effects
Other possible
side effects:
CNS: headache,
dizziness,
anxiety, asthenia,
Dermatologic:
Rash,
inflammation,
urticaria,
GI: Diarrhea,
abdominal pain,
nausea and
vomiting,
Respiratory: URI
symptoms, cough
& epistaxis
Other: cancer,
back pain, fever

NURSING
CONSIDERATIONS

Administer before
meals
You may experience
side effects
dizziness, headache
cough, nausea,
vomiting, diarrhea,
symptoms of URI.
Dont crush instead
needed to be
swallow whole

DRUG
NAME
Isosorbide
Dinitrate
10 mg 1 tab
q8;
5mg 1 tab
PRN

CLASSIFICATION

Antianginal
Nitrate
vasodilator

MECHANISM
OF ACTION

INDICATION

Relaxes vascular
smooth muscle
with a resultant
decrease in
venous return
and decrease in
arterial BP,
which reduces
left ventricular
workload and
decreases
myocardial
oxygen
consumption.

This drug was

given since the
patient exhibits
chest pain.

CONTRAINDICATIONS AND
CAUTION
Possible
contraindications are
the following:
Hypersensitivity to
nitrates
Severe hypotension
Shock
Acute MI
Low left
ventricular filling

ADVERSE
EFFECTS
The patient
doesnt
exhibits any
adverse effects

CNS: headache,
dizziness,
weakness
Cardiovascular:
orthostatic
hypotension
and
tachycardia,
palpitations,
ankle edema,
fainting and
flushing
EENT: SL
burning
GI: nausea and
vomiting
Skin: cutaneous
vasodilation,
rash

NURSING
CONSIDERATIONS

Give sublingual
preparations under
the tongue or in the
buccal pouch;
discourage client
from swallowing
Give oral
preparations on an
empty stomach
Assess orthostatic
hypotension, blood
pressure at baseline
and during
treatment

DRUG
NAME
Clopidogrel
75 mg. 1 tab,
4 tablets OD

CLASSIFICATION

Antiplatelet
ADP receptor
antagonist

MECHANISM
OF ACTION
Inhibits platelet
aggregation by
blocking ADP
receptors on
platelets,
preventing
clumping of
platelets.

INDICATION

Clopidogrel
treats acute
coronary
syndrome
which was the
patients to
considered
diagnosis.

CONTRAINDICATIONS
AND CAUTION
Possible
contraindications are
the following:
Hypersensitivity
to clopidogrel
Intracranial
hemorrhage

ADVERSE
EFFECTS
The patients
exhibit no
adverse effects

NURSING
CONSIDERATIONS

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

Provide frequent
small meals if GI
upset occurs
Provide comfort
measures and
arrange for
analgesics if
headache occurs.
Assess for
symptoms of
stroke, MI during
treatmet
Take drug with
meals

DRUG
NAME
Simvastatin
40 mg. Tab,
2 tablets OD

CLASSIFICATION

MECHANISM
OF ACTION

INDICATION

Antihyperlipidem
ic
HMG-CoA
inhibitor

Inhibits HMGCoA reductase,

the enzymes
that catalyzes
the first step in
the cholesterol
synthesis
pathway,
resulting in a
decrease in
serum
cholesterol,
serum LDLs,
and either an
increase or no
change in
serum HDLs.

Patient was
given
simvastatin to
reduce the risk
of coronary
disease and to
prevent
hypercholestero
lemia.

CONTRAINDICATIONS
AND CAUTION
Possible
contraindications
are the following:
Hypersensitivit
y to simvastatin

ADVERSE
EFFECTS

NURSING
CONSIDERATIONS

The patient
doesnt exhibit any
adverse effects

CNS: Headache,
sleep disturbances
GI: Flatulence,
diarrhea,
abdominal pain,
cramps,
constipation,
nausea, dyspepsia,
heartburn, liver
failure
Respiratory:
Sinusitis,
Pharyngitis
Other:
Rhabdomyolysis,
acute renal failure,
arthralgia.

Give in evening;
highest rates of
cholesterol synthesis
are between
midnight and 5 am
Arrange for regular
follow-up during
long-term therapy.
Consider reducing
dose if cholesterol
falls below target.
Monitor bowel
pattern daily
Monitor
triglycerides,
cholesterol baseline
throughout treatment

DRUG
NAME

CLASSIFICATION

Aspirin

80 mg. Tab,
4 tablets.
OD

Analgesic
Antiinflammatory
Antiplatelet
Antipyretic
NSAIDS
Salicylate
Antirheumatic

MECHANISM
OF ACTION

INDICATION

Exhibits
antipyretic,
antiinflammatory
and analgesic
effects. The
antipyretic effect
is due to an
action on the
hypothalamus,
resulting in heat
loss by
vasodilation of
peripheral blood
vessels. Antiinflammatory
effects are
mediated by a
decrease in
prostaglandin
synthesis. It also
decreases platelet
aggregation.

This drug was

given to
patient due to
chest pain.

CONTRAINDICATIONS AND
CAUTION
Possible
contraindications are
the following:
Hypersensitivity
NSAID- induced
sensitivity
reactions
G6PD deficiency
or bleeding
disorders such as
hemophilia, o
telangiectasia

ADVERSE
EFFECTS

NURSING
CONSIDERATIONS

The patients
exhibit no
adverse effects

Give drug with food or

after meals if GI upset
occurs

Gastrointestinal:
Bleeding,
dyspepsia, G.I
distress
Hepatic: hepatitis
Skin: ash,
bruising,
urticaria
EENT: tinnitus/
hearing loss
Others:
angioedema,
hypersensitivity
reactions

Do not use aspirin that

has a strong vinegarlike odor
Do not crush or chew
enteric-coated tablets.
Assess pain and
limitation of
movement; note type,
location, and intensity
before and at the peak
after administration.

DRUG
NAME

CLASSIFICATION

Enoxaparine Anticoagulant
0.6 cc SQ
q12

MECHANISM
OF ACTION

INDICATION

A low
molecular
weight heparin
derivative that
accelerates
formation of
anti thrombin
III-thrombin
complex and
deactivates
thrombin,
preventing
conversion of
fibrinogen to
fibrin. Has a
higher anti
factor Xa-toantifactor IIa
activity ratio.

Prevention of
pulmonary
embolism and
deep vein
thrombosis
-Prevention of
ischemic
complications
of unstable
angina and non
Q wave MI

CONTRAINDICATIONS AND
CAUTION
Possible
contraindications are
the following:
Hypersensitivity
Heparin
Bleeding disorder
Thrombocytopenia
Antiplatelet
antibodies

ADVERSE
EFFECTS
The patients
exhibit no
adverse effects

NURSING
CONSIDERATIONS

-Draw blood to establish

baseline coagulation
parameters before the
therapy.
-Monitor platelet counts
regularly. Patient with
GI: nausea
normal coagulation
CV: edema
wont need close
Hematologic;
monitoring of Pt and
hemorrhage,
PTT.
thrombocytope
-Regularly inspect
nia,
patient for bleeding
ecchymosis,
gums, bruises on arms
bleeding
and legs, petechiae,
complications
epistaxis, malena,
Skin: irritation,
hematuria, black tarry
hematoma,
stools.
erythema at
-To treat overdose, give
the injection
protamine sulfate SIVP.
site, rash,
-Patients teaching:
urticaria
Tell patient and family
to watch for signs of
bleeding and bruising
and to notify prescriber
immediately.

DRUG
NAME
Dopamine
20mg in
250 cc D5W

CLASSIFICATION

MECHANISM
OF ACTION

To treat shock
Directly
and correct
stimulates
hemodynamic
dopaminergic,
imbalances, to
alpha and beta
improve
receptors of the perfusion to
symphathetic
vital organs, to
nervous system. increase cardiac
Action is doseoutput to
related; large
correct
doses cause
hypotension.
mainly alpha
stimulation.

Symphathomimetic
adrenergics

INDICATION

CONTRAINDICATIONS AND
CAUTION
Possible
contraindications are
the following:
Hypersensitivity
Arrhythmias
Ventricular
fibrillation

ADVERSE
EFFECTS
The patients
exhibit no
adverse effects

CV: ectopic
beats,
tachycardia,
angina,
palpitations,
hypotension
CNS:
headache
GU: elevated
urinary
catecholamine
levels
GI: nausea,
vomiting
Respiratory:
dyspnea,
asthmatic
episodes
Skin: necrosis
and tissue

NURSING
CONSIDERATIONS
During the infusion,
assess the blood
pressure, pulmonary
artery wedge pressure,
cardiac output and
urine output central
venous pressure, color
and temperature of
limbs. If diastolic
pressure rises
disproportionately ( a
marked decrease in
pulse pressure in a
patient receiving
dopamine, decrease
infusion rate and watch
carefully for further
evidence of
predominant
vasoconstrictor activity,
unless such an effect is
desired.
Monitor urine output
hourly. If urine flow
decreases without

sloughing with
extravasation,
piloerection

hypotension, notify
prescriber because
dosage may be needed
to be reduced.
Check for acidosis, this
may decrease
effectiveness of
dopamine.
Apply dosage slowly to
evaluate stability of
blood pressure.

DRUG

CLASSIFICATION

NAME

MECHANISM OF

INDICATION

ACTION

CONTRA-

ADVERSE

NURSING

INDICATIONS

EFFECTS

CONSIDERATIONS

The patients

Do not freeze laxative

AND CAUTION
Lactulose

Laxative,

The drug passes

30 cc OD

Ammonia

unchanged into the

reduction

colon where bacteria

drug

break it down to

Hypersensitivity

organic acids that

Low galactose

increase the osmotic

Treatment of

Possible

constipation.

contraindications are exhibit no

form. Ask patient to

the following:

report diarrhea,

diet

adverse effects

severe belching, and

GI
Transient

pressure in the colon

flatulence,

and slightly acidify the

distention,

colonic contents,

intestinal

resulting in an increase

cramps,

in stool water content,

belching,

stool softening, laxative

diarrhea,

action. This also results

nausea.

in migration of blood

Other

ammonia into the colon

Acid-base

contents with

imbalances

subsequent trapping
and expulsion of feces.

abdominal fullness.

DRUG
NAME
Morphine
2g TIV
PRN for
Severe
Chest Pain

CLASSIFICATION

MECHANISM OF
ACTION

INDICATION

Opioid
agonist
analgesic

Principal opium
alkaloid; acts as
agonist at specific
opioid receptors in
the CNS to
produce analgesia,
euphoria,
sedation; the
receptors
mediating these
effects are thought
to be the same as
those mediating
the effects of
endogenous
opioids
(enkephalins,
endorphins).

Relief of
moderate to
severe acute
and chronic
pain
Preoperative
medication to
sedate and
allay
apprehension
, facilitate
induction of
anesthesia,
and reduce
anesthetic
dosage
Unlabeled
use: Dyspnea
associated
with acute
left
ventricular
failure and
pulmonary
edema

CONTRAINDICATIONS
AND CAUTION
Possible
contraindications are
the following:
Hypersensitivity
Use cautiously with:
Increased ICP
COPD

ADVERSE EFFECTS

The patients exhibit no

adverse effects

CNS: Lightheadedness,
dizziness, sedation,
euphoria, dysphoria,
delirium, insomnia,
agitation, anxiety,
fear, hallucinations,
disorientation,
drowsiness,
lethargy, impaired
mental and physical
performance, coma,
mood changes,
weakness, headache,
tremor, seizures,
miosis, visual
disturbances,
suppression of
cough reflex
CV: Facial flushing,
peripheral
circulatory

NURSING
CONSIDERATIONS
Caution patient not to
chew or crush
controlled-release
preparations.
Dilute and administer
slowly IV to minimize
likelihood of adverse
effects.
Tell patient to lie down
during IV
administration.
Keep opioid antagonist
and facilities for
assisted or controlled
respiration readily
available during IV
administration.
Use caution when
injecting SC or IM into
chilled areas or in
patients with
hypotension or in
shock; impaired

collapse,
tachycardia,
bradycardia,
arrhythmia,
palpitations, chest
wall rigidity,
hypertension,
hypotension,
orthostatic
hypotension,
syncope
Dermatologic:
Pruritus, urticaria,
laryngospasm,
bronchospasm,
edema
GI: Nausea,
vomiting, dry
mouth, anorexia,
constipation, biliary
tract spasm;
increased colonic
motility in patients
with chronic
ulcerative colitis
GU: Ureteral spasm,
spasm of vesical
sphincters, urinary
retention or

perfusion may delay

absorption; with
repeated doses, an
excessive amount may
be absorbed when
circulation is restored.
Reassure patients that
they are unlikely to
become addicted; most
patients who receive
opioids for medical
reasons do not develop
dependence
syndromes.

hesitancy, oliguria,
antidiuretic effect,
reduced libido or
potency
Local: Tissue
irritation and
induration (SC
injection)
Major hazards:
Respiratory
depression, apnea,
circulatory
depression,
respiratory arrest,
shock, cardiac arrest
Other: Sweating,
physical tolerance
and dependence,
psychological
dependence

DRUG
NAME
Diazepam
5g TIV,
PRN.

CLASSIFICATION

Benzodiazepine

MECHANISM
OF ACTION

INDICATION

CONTRAINDICATIONS AND
CAUTION

A
benzodiazepine
that probably
potentiates the
effect of gamma
aminobutyric
acid, an
inhibitory
neurotransmitte
r. Depressess
the CNS at the
limbic and
subcortical
levels of the
brain and
suppresses the
spread of
seizure activity
produced by
the
epileptogenic
foci in the
cortex,
thalamus and
the limbic
structures.

Anxiety
Acute alcohol
Possible
withdrawal
contraindications are
Muscle spasm
the following:
Adjunct to
Hypersensitivity
seizure disorder
To soy protein
Patients
experience shock,
coma, acute
alcohol
intoxication

ADVERSE
EFFECTS
The patients
exhibit no
adverse effects
CV:
hypotension,
bradycardia
CNS:
drowsiness,
dysarthria,
slurred speech,
tremor,
transient
amnesia,
fatigue, ataxia,
headache,
insomnia
GI: nausea,
constipation

NURSING
CONSIDERATIONS
Monitor respirations
every 5 to 15 minutes
and before each IV
dose. Keep emergency
resuscitation
equipment at the
bedside.
Drug should not be
given for pregnant
women especially
during the first
trimester.
Monitor periodic
hepatic, renal and
hematopoietic function
studies in patients
receiving repeated or
prolonged therapy.
Possibility of abuse and
addiction exists. Dont
withdraw the drug
abruptly after longterm use; withdrawal
symptoms may occur.

Distal recta gel should

be given only by
caregivers who can
distinguish the distinct
cluster of seizures of
events from the
patients ordinary
seizure activity, who
have been instructed
and can give the
treatment competently,
who understand which
seizure may or may not
be treated with Distal,
and who can monitor
the clinical responses
and recognize when
immediate professional
medical evaluation is
needed.

DRUG
NAME
Captopril
25
mg/tab;
1/4 tablet
every 8
hours

CLASSIFICATION

ACE Inhibitor

MECHANISM
OF ACTION

INDICATION

Blocks ACE
from converting
angiotensin I to
angiotensin II, a
powerful
vasoconstrictor,
leading to
decreased
blood pressure,
decreased
aldosterone
secretion, a
small increase
in serum
potassium
levels,
and sodium
and fluid loss;
increased
prostaglandin
synthesis also
may be
involved in the
antihypertensiv
e
action.

Treatment of
hypertensio
n alone or in
combination
with
thiazidetype
diuretics.
Treatment of
CHF in
patients
unresponsiv
e to
conventional
therapy;
used with
diuretics
and digitalis.
Treatment of
left
ventricular
dysfunction
after MI.

CONTRAINDICATIONS AND
CAUTION
Possible
contraindications are
the following:
Hypersensitivity
History of
angiodema
Use cautiously with:
Impaired renal
function
CHF
Salt or volume
depletion

ADVERSE
EFFECTS

NURSING
CONSIDERATIONS

The patients
exhibit no
adverse effects

Administer 1 hr before
or 2 hr after meals.
Monitor patient closely
for fall in BP secondary
to reduction in fluid
volume (excessive
perspiration and
dehydration, vomiting,
diarrhea); excessive
hypotension may
occur.
Reduce dosage in
patients with impaired
renal function.
Take drug 1 hr before
or 2 hr after meals; do
not take with food. Do
not stop without
consulting your health
care provider.
Be careful of drop in
blood pressure (occurs

most often with

diarrhea, sweating,
vomiting,
dehydration); if lightheadedness or
dizziness
occurs, consult your
health care provider.
Avoid over-the-counter
medications, especially
cough, cold, allergy
medications that may
contain ingredients that
will interact with ACE
inhibitors. Consult
your health care
provider.
These side effects may
occur: GI upset, loss of
appetite, change in
taste perception
(limited
effects, will pass);
mouth sores (perform
frequent mouth care);
rash; fast heart rate;
dizziness, light-

headedness (usually
passes
after the first few days;
change position slowly,
and limit your activities
to those that do not
require alertness and
precision).
Report mouth sores;
sore throat, fever, chills;
swelling of the hands,
feet; irregular
heartbeat,
chest pains; swelling of
the face, eyes, lips,
tongue, difficulty
breathing.

DRUG NAME

Hydrocortisone
100mg TIV q8

CLASSIFICATION

Corticosteroid

MECHANISM
OF ACTION

INDICATION

Decreases
inflammation,
mainly by
stabilizing
leukocyte
lysomal
membranes;
suppresses
immune
response;
stimulates
bone marrow;
and influences
protein, fat
and
carbohydrate
metabolism

- severe
inflammation
-shock

CONTRAINDICATIONS
AND CAUTION
Possible
contraindications are
the following:
Hypersensitivity
to drug and its
ingredients

ADVERSE
EFFECTS
The
patients
exhibit no
adverse
effects
EENT:
cataracts,
glaucoma
Musculoske
letal: muscle
weakness,
osteoporosis
Skin:
hirsutism,
acne, skin
eruptions
CNS:
headache,
paresthesia,
seizures,
vertigo
GI: peptic
ulcer, GI
irritation,
increased in

NURSING
CONSIDERATIONS
Monitor patients
weight, electrolyte and
blood pressure levels.
Drug may worsen or
mask the underlying
super infections.
Gradually taper dose
after long term
therapy.
Patients teaching:
-Tell patient not to
stop drug abruptly
rather to taper it down
depending on the
prescribers consent.
-Warn patient about
long term effects such
as cushingoid effects
like moonface, buffalo
hump.

appetite,
nausea and
vomiting

-Warn patient about

easy bruising.
-Advise patient to
have a periodic
examination for
patients receiving long
term therapy.
-Laboratory results:
-May increase glucose
and cholesterol levels.
May decrease
potassium and
calcium levels.

DRUG
NAME

CLASSIFICATION

Aminoleban Caloric Agent

Sachet (
Protein
Amino Acid)
substrate
1 sachet in
100 cc of
water TID

MECHANISM OF
ACTION

Essential and nonessential amino

acids provided in
various
combinations to
provide calories and
proteins and
provide a proteinbuilding and a
protein-sparing
effect for the body.

INDICATION

CONTRAINDICATIONS
AND CAUTION

Possible
Hepatic
Encephalopa contraindications
are the following:
thy in
patients with
Severe Renal
acute and
Disorder,
chronic liver
abnormal
amino acid
disease.
metabolism
other than of
other hepatic
disorder

ADVERSE
EFFECTS

NURSING
CONSIDERATIONS

The patient doesnt

exhibit adverse
reactions as seen on
the data gathered.

AAssess nutritional
status before and
frequently during
treatment.
TTaken by the client
after meal to prevent
GI upset.
. If hypersensitivity
reactions occur, the
solution should be
discontinued.

Hypersensitivity:
rare skin eruptions.
Gastrointestinal:
occasional nausea
and vomiting.
Cardiovascular:
occasional chest
discomfort and
palpitation. Large
and acute
administration:
acidosis was
reported. Others:
occasional chills,
fever, headache and
vascular pain.

DRUG
NAME

Furosemide

CLASSIFICATION

Diuretics

MECHANISM
OF ACTION

Rapid-acting
potent
sulfonamide
"loop" diuretic
and
antihypertensive
with
pharmacologic
effects and uses
almost identical
to those of
ethacrynic acid.
Exact mode of
action not clearly
defined;
decreases renal
vascular
resistance and
may increase
renal blood flow.

INDICATION

CONTRAINDICATIONS
AND CAUTION

Treatment of
Possible
edema
contraindications
associated
are the following:
with CHF,
History of
cirrhosis of
hypersensitivity
liver, and
to furosemide
kidney disease,
or
including
sulfonamides;
nephrotic
increasing
syndrome.
oliguria, anuria,
May be used
fluid and
for
electrolyte
management
depletion states;
of
hepatic coma;
hypertension,
pregnancy
alone or in
(category C),
combination
lactation.
with other
antihypertensi
ve agents.

ADVERSE
EFFECTS

The patient
doesnt exhibit
adverse reactions
as seen on the data
gathered.
CV: Postural
hypotension,
dizziness with
excessive diuresis,
acute hypotensive
episodes,
circulatory
collapse.
Metabolic:
Hypovolemia,
dehydration,
hyponatremia
hypokalemia,
hypochloremia
metabolic
alkalosis,
hypomagnesemia,
hypocalcemia
(tetany),
hyperglycemia,

NURSING
CONSIDERATIONS

Observe patients

receiving parenteral
drug carefully; closely
monitor BP and vital
signs. Sudden death
from cardiac arrest has
been reported.
Observe older adults
closely during period
of brisk diuresis.
Sudden alteration in
fluid and electrolyte
balance may
precipitate significant
adverse reactions.
Report symptoms to
physician.
Monitor for S&S of
hypokalemia.
Monitor I&O ratio
and pattern. Report
decrease or unusual
increase in output.
Excessive diuresis can
result in dehydration

glycosuria,
elevated BUN,
hyperuricemia.
GI: Nausea,
vomiting, oral and
gastric burning,
anorexia, diarrhea,
constipation,
abdominal
cramping, acute
pancreatitis,
jaundice.
Urogenital:
Allergic interstitial
nephritis,
irreversible renal
failure, urinary
frequency.
Hematologic:
Anemia,
leukopenia,
thrombocytopenic
purpura; aplastic
anemia,
agranulocytosis
(rare). Special
Senses: Tinnitus,
vertigo, feeling of
fullness in ears,

and hypovolemia,
circulatory collapse,
and hypotension.
Weigh patient daily
under standard
conditions.

hearing loss
(rarely
permanent),
blurred vision.
Skin: Pruritus,
urticaria,
exfoliative
dermatitis,
purpura,
photosensitivity,
porphyria cutanea
tarde, necrotizing
angiitis
(vasculitis). Body
as a Whole:
Increased
perspiration;
paresthesias;
activation of SLE,
muscle spasms,
weakness;
thrombophlebitis,
pain at IM
injection site.

B. 1. Nursing Care Plan

Cues

Inference

Nursing

Planning

Interventions

Rationale

Evaluation

Diagnosis
Subjective:
(None)
Objective:

Presence of
crackles on
both lungs

Pallor

Diminished
breath sounds

Difficulty of
breathing

Irritant from
external
environment
Inflammatory
response in
the lungs
Increased
production of
secretions
Airway
obstruction

RR: 24
breaths/min

airway

Short-Term

Assessment:

Goal:

clearance

After 4 hours of

related to

nursing

presence of

interventions

fluid in the

the client

lungs

demonstrate
reduction of

Difficulty of
breathing

Short-Term:
To determine

The client

current

the clients

shall have

condition of

condition

demonstrated

Assess the

reduction of

the client

To know the

congestion

previous

effectiveness

with breath

diagnosis and

of treatment

sounds clear,

Determine the

congestion

previous

respiration

with breath

treatment

noiseless, and

sounds clear,
respiration
noiseless, and

Excessive
sputum

Ineffective

improved
oxygen

Independent:

Monitor

To assess

improved

respirations

respiratory

oxygen

and breath

distress and

sounds

accumulation

exchange.

exchange.

Long-Term
Goal:

Evaluate

of secretions

Long-Term

To determine

The client

After 1-2 days

clients

ability to

shall have

the client will

cough/gag

protect own

maintained

maintain

reflex and

airway.

airway

airway.

swallowing

patency.

ability

Suction

To clear

endotracheal

airway when

tube as

excessive

necessary

secretions are
blocking
airway or
client is
unable to
swallow

Elevate head of
bed

To promote
and maintain
airway

Keep
environment

patent

To avoid
inhalation of

clean and free

it that may

of allergens

irritate
passageway
and cause
airway
obstruction

Dependent:

Administer
prescribed

To improve
the condition

medication

Provide

It helps to

supplemental

liquefy the

humidification

secretions

via use of
nebulizer
Collaborative:

Assist with

To improve

use

respiratory

mechanical

function

ventilator and
other devices

B. 2. Nursing Care Plan

Cues

Inference

Nursing

Planning

Intervention

Rationale

Evaluation

Diagnosis
Subject:

Coronary
artery disease

(None)
Objective:

Pale
conjunctiva
and mucous

Decrease
blood
formation
Insufficient
oxygen
supply to
muscles for
eating

membrane

Poor muscle
tone

Inability to
independently
ingest food

Presence of
nasogastric
tube

Loss of gag
reflex
Inability to
ingest food
Altered
nutrition less
than body
requirements

Imbalanced
nutrition less

Short-term

Assessment:

Goal:

Assess patient

than body

After 4 hours of

nutritional dietary

requirements

nursing

pattern to plan the

related to

intervention,

inability to
ingest food as

tolerate 250 ml

changes

manifested by

of nasogastric

Assess for

the presence of

tube feedings.

anorexia,

tube

For baseline
data

Goal partially
met. Patient
tolerated
nasogastric

proper meals

the patient will Assess weight

nasogastric

Short-term:

For baseline

tube

data

feedings

For baseline

without

data

adverse
effects.

vomiting, nausea
Long-term
Goal:
After 1-2 days
of continuous

Monitor fluid

intake and output

nursing

Check nasogastric

interventions,

tube placement

the client will

Long-term:

Independent:

For baseline

The client

data

shall have

To ensure
proper

attained high
level of
nutrition that

attain high

placement

level of

when

nutrition that

especially

can sustain
bodys

when feeding

physiologic

Begin the
regimen with

function.

small amount of
water and
diluted
concentration,
increase the
volume and
concentration as
tolerated

Elevate the head

To reduce the

of the bed during

risk of

tube feeding

aspiration

Ensure proper

To maximize

temperature of

tolerance and

each feeding

minimize
infection

can sustain
bodys
physiologic
function.

Assess and

To monitor

record bowel

for increase

sounds once per

and decrease

shift

Dependent:

Administer the

To decrease

prescribed

diarrhea and

amount of food

improve

to provide

absorption

patient with
needed nutrition.
Collaborative:

Instruct the

To decrease

significant others

anxiety and

in the needs of

to help in the

the patients

patients

especially in

care

medications and
feeding regimen.

B. 3. Nursing Care Plan

Cues

Subject:
(None)
Objective:
Crying
Altered
affect
Difficulty in
expressing
anticipatory
loss

Inference

Nursing
Diagnosis

Planning

Dysfunctional
grieving is a
maladaptive
process that
occurs when
grief is
intensified to the
degree that the
person is
overwhelmed,
becomes stuck in
one phase of
grieving and
demonstrates
excessive
prolonged
emotional
responses to a
significant loss.
(Nursing
Diagnosis and
interventions by

Grieving
related to
anticipatory
loss of
significant
other

Short-term
Goal:
After 2 hours of
interventions,
the family of the
client will
identify and
express feelings,
and will
verbalize
anticipated
changes of
seeking support
from others.

Intervention

Assessment:
Determine
circumstances of
anticipatory loss of
loved one
Evaluate familys
perception of
anticipated loss of
loved one
Independent:
Encourage
expression of
feelings

Long-term
Goal:
Provide open
After 5 hours of environment in
interventions,
which family feel
the family of the free to realistically
client will be
discuss feelings and

Rationale

Evaluation

Short-term:
The family of
Grief can
provoked a wide the client shall
range of intense have identified
and conflicting
and expressed
feelings.
feelings, and
verbalized
To assess their
anticipated
feelings of the
changes of
situation
seeking
support from
others.
To help identify
subjective feeling
and to encourage Long-term:
family to express The family of
the client shall
emotions.
have
Therapeutic
demonstrated
communication
progress in
skills such as
accepting
active listening,
anticipatory
silence, being

McFarland et.al.
2nd Ed. 1993)

able to
concerns.
demonstrate
progress in
accepting
anticipatory loss
and will
continue life
with anticipated
loss of loved Provide privacy
one.
during times of
emotional
ventilation.
Encourage the
family the
opportunity to talk
and practice
attentive listening.
Discuss healthy
ways of dealing
with difficult
situation.

Discourage
shielding the
grieving process
with medications or

available and
acceptance
provide
opportunity and
encourage family
to talk freely and
deal with actual
loss.
To protect ones
sense of dignity.

It may help to
vent emotions
before actually
being able to deal
with the loss.
Provides
opportunity to
look forward to
the future and
plan family
needs.
To prevent delay
in working
through the loss.

loss and shall

continue life
with
anticipated
loss of loved
one.

other temporary
relief outlet.
Determine the

degree to which the

anticipated loss
threatens the
familys self concept.
Collaborative:
Solicit the help of

others (family
friends, health care
professionals) to
support expression
of grief.

To identify when
referral to
professional
counseling is
needed.

A consistent
approach by
those who are
caring and
knowledgeable
may help the
family to begin to
grieve.