A.

BACKGROUND OF THE STUDY Abdominal aortic aneurysm, also written as AAA and often pronounced 'triple-A', is a localized dilatation of the abdominal aorta, that exceeds the normal diameter by more than 50%. The normal diameter of the infrarenal aorta is 2 cm. of the aorta, the cause of which remains unclear. The most common associated risk factors (80%) are atherosclerosis. The atherosclerosis a weaken the aortic wall and the pressure of the blood being pumped through the aorta causes expansion at the site of weakness. Other possible risk factors are Cigarette smoking, high serum cholesterol, diabetes mellitus, genetic; individuals with first-degree relatives having AAA, rare inheritable genetic diseases of connective tissue of the aorta. Also, after physical trauma to the aorta, Arteritis and relapsing polychondritis, fungal infection that may be associated with immunodeficiency, IV drug abuse, heart valve surgery. AAAs is most common in the age of 40 - 70 years old, more predominantly males. affected. . Most AAAs produces no symptoms. They are often incidentally discovered when abdominal ultrasounds and/or CT scan studies are ordered for other conditions. When they produce symptoms, the most common symptom is pain. The pain typically has a deep quality as if it is boring into the person. It is felt most prominently in the lower back region and lower abdomen. The pain is usually steady but may be relieved by changing position. The person may also become aware of an abnormally prominent abdominal pulsation. AAA can remain asymptomatic or produce mild to moderate symptoms for years. However, a rapidly expanding abdominal aneurysm can cause sudden onset of severe, steady, and worsening lower back and lower abdominal pain. A rapidly expanding aneurysm is also at imminent risk of rupture. Actual rupture of an abdominal aneurysm can cause sudden onset of back and abdominal pain, sometimes associated with abdominal distension, a pulsating abdominal mass and even shock and is an emergency condition. Males are 4 times more likely than females to be

AAA is commonly divided according to their size and symptomatology. An aneurysm is usually considered to be present if the measured outer aortic diameter is over 3 cm. The natural history is of increasing diameter over time, followed eventually by the development of symptoms. If the outer diameter exceeds 5 cm, the aneurysm is considered to be large. For aneurysms under 5 cm, the risk of rupture is low and is keep on a watch and wait approach until such time as they become large enough to warrant repair, or develop symptoms. The risk of rupture is high in a symptomatic aneurysm, which is therefore considered an indication for surgery. Possible symptoms include low back pain, flank pain, abdominal pain, groin pain or pulsating abdominal mass. Presence of AAAs is usually revealed during an abdominal examination - the most common being abdominal ultrasonography, provides the initial assessment of the size and extent of the aneurysm. A physician may also detect the presence of an AAA by abdominal palpation. Preoperative examinations include CT, MRI and special modes like CT/MRI and Angiography. Angiography is the imaging modality that remains the criterion standard for the diagnosis of AAA The treatment options for asymptomatic AAA are immediate repair, surveillance with a view to eventual repair, and conservative. There are currently two modes of repair available for an AAA: open aneurysm repair (OAR), and endovascular aneurysm repair (EVAR). Conservative treatment is indicated in patients where repair carries a high risk of mortality and also in patients where repair is unlikely to improve life expectancy. The two mainstays of the conservative treatment are smoking cessation and blood pressure control.

Open repair (operation) is indicated in young patients as an elective procedure, or in growing or large, symptomatic or ruptured aneurysms.

Endovascular repair is now an established alternative to open repair. It is generally indicated in older, high-risk patients unfit for open repair. Not all patients qualify for endovascular repair. The main advantage is it lessens patients time in intensive care and in the hospital. It also facilitates earlier recovery. Regarding unruptured aneurysms, EVAR is associated with lower operative mortality than open repair but unknown long-term mortality. B. RATIONALE FOR CHOOSING THE CASE Aneurysm may be a familiar medical term to most nursing students particularly those in 3rd year level, but not the knowledge that aneurysm presents itself in different kinds such true aneurysm vs. pseudoaneurysm, aortic aneurysm vs. peripheral aneurysm. This prompted the presenters to choose to cite one type of true aneurysm, aortic type which is the Abdominal Aortic Aneurysm. Since AAA may be present in a client for several years without symptoms (3 of every 4 cases of abdominal aortic aneurysm are asymptomatic), especially if it is not rapidly growing in size (growth rate less than 0.5 cm over 6 months period to 1 year), it is referred to as the silent killer because it may rupture before being diagnosed. And as the physical assessment findings of peri-umbilical or upper abdominal mass with expantile pulsations in an adult person, where it is more predominantly diagnosed, strongly suggests an AAA. These simply indicate that a prompt and accurate physical assessment of the presented disease may be enough to save a life of an unsuspecting client who has AAA.

C. SIGNIFICANCE OF THE STUDY This study is made significant to the following: Individual: This will help the client and his/her family to the better understanding of the clients condition. Knowledge of disease process and expectations can facilitate adherence to the prescribed treatment regimen of the client. Also, with the effective care for the client, the client as well as his/her significant others will have a sense of satisfaction and progress of the condition of their loved one. Profession: Clinical Instructors This will serve as an assessment of his/her students performance during their clinical duty. It will also evaluate the C.I. as well, in his/her competency in teaching and imparting knowledge and skills in nursing to the students. Nursing Students This study will serve to deepen their knowledge and harness their skills in an accurate initial assessment of existing abdominal aortic aneurysm upon clients physical examination making possible for prompt, appropriate nursing care and bringing the significant findings for medical attention of the physician. Community This study hopes to inspire a person to read more on Abdominal Aortic Aneurysm especially fellow Filipinos which is one of the races with reported significant incidence worldwide. This study will provide them with necessary information on how to prevent the disease through the identification of the risk factors since the underlying cause is unknown as of this date.

D. SCOPE AND LIMITATION This study only focuses to the patient with Abdominal Aortic Aneurysm. It also includes the medications and treatments for the disease. The data were gathered by observing, interviewing and reviewing the patients medical records. Any complications of the disease will not also be considered for lengthy discussion. II. HEALTH HISTORY A. GENERAL DATA Patients Name: Spongebob XXX Age: 45 y/o Religion: Roman Catholic Nationality: Filipino Sex: Male Civil status: Married Source of Information: patient, patients chart Date of Admission: December 3, 2007 Occupation: Barangay Chairman and insurance agent B. CHIEF COMPLAINT Abdominal pain C. HISTORY OF PRESENT ILLESS Two months prior to admission, Patient had experienced chest pain associated with abdominal pain. The patient consulted his attending physician and requested to have laboratory test (chest x-ray). Laboratory findings showed that he has a cardiomegaly, pulmonary edema, and abdominal aortic aneurysm. Client was prescribed with medications such as Capoten, Vastril, and Lanoxin, which provided him a relief.

One week prior to admission, client has felt a mass, described as tender and pulsating, on his right lower abdominal quadrant. He consulted his attending physician again and was advised for an admission but he chose to go home. Persistence of symptom prompted consults at the emergency room and client was admitted. Date of onset problem: October 4, 2007 Aggravating factor: Hypertension Location of symptom: Right lower quadrant (RLQ) of the abdomen Pain scale assessment: 8 (very severe pain) Character of symptom: Tender and pulsating Admitting diagnosis: Abdominal Aortic Aneurysm D. PAST MEDICAL HISTORY General Health and Strength work Appetite: Good Stability of weight: Maintain Usual Activities: Paper works in the barangay office and daily the barangay. Sleeping pattern: no definite pattern or time of sleep due to his

patrol in

Acute Infectious Disease Measles Mumps Varicella

Immunization BCG

Operations Surgery done: Nasal Surgery Diagnosis: Anatomic Nasal Obstruction

Date: 1980 Hospital: Mary Johnson Hospital Complications: None

Injuries None

Allergies No known food and drug allergies E. FAMILIAL RISK FACTOR (+) Hypertension (father side) (+) Heart Disease (mother side) (-) DM (-) Tuberculosis (-) CVA/ Stroke (-) Asthma (-) Cancer F. PERSONAL AND SOCIAL HISTORY Alcohol Drinking Habitual: every weekend and every holiday. Frequency per week: Twice Amount: 5-7 Bottles Preferred Alcoholic Beverage: Gin and Beer

Smoking Non-smoker

Prohibited Drug Intake: None

G. PHYSICAL ASSESSMENT Height: 57 Vital signs: Weight: 70 kg BP: 140/90mmHg RR: 35breaths/min Date assessed: December 5, 2007 Shift: 1-7pm Assessed Part Head Technique Used Inspection & Palpation Normal Findings Rounded, Smooth skull contour. Smooth, uniform consistency; absence of nodules or masses. Symmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Symmetric facial movements. Eyebrows: Hair evenly distributed; skin intact. Eyelashes: Equally distributed; Eyes Inspection and Palpation curled slightly outward. Eyelids: Skin intact; no discharge; no discoloration, lids close symmetrically, bilateral blinking, when lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. Bulbar Conjunctiva: Transparent; capillaries sometimes evident; sclera appears white. Palpebral Conjunctiva: Shiny, smooth, and pink or red. Visual acuity is farsighted Deviation to Normal PR: 95bpm Temp: 36.7C

Lacrimal Gland: No edema or tearing Cornea: Transparent, shiny, and smooth; details of the iris are visible. Anterior Chamber: Transparent, no shadows of light on iris. Pupils: black in color; equal in size, round, smooth border, iris flat and round. Illuminated pupil constrict (direct response) Non Illuminated pupil constricts (consensual response) Pupils constrict when looking at near object; pupils dilate when looking at far object, pupils converge when near object is moved toward nose. Both eyes coordinated, move in unison, with parallel alignment. Auricles color same as facial skin, symmetrical, firm, no Ears Inspection and Palpation Inspection Nose and Palpation tenderness, pinna recoils after it is folded, no discharges, normal voice tones audible Symmetric and straight, no discharge, uniform color, not tender, air moves freely as the client breaths through the nares. Mucosa pink, nasal septum intact and in midline. Outer Lips: Uniform pink color, soft, moist, smooth texture,

symmetry in contour, ability to purse lips. Inner lips: Uniform pink color, moist, smooth, soft, glistening, and elastic texture. Teeth and Gums: 32 adult Pink gums with bluish patches. Mouth and Throat Inspection & Palpation Moist, firm texture to gums. Tongue: Midline, pink color, smooth, lateral margins; no lesions, raised papillae, moves freely; no tenderness, smooth tongue base with prominent veins, no palpable nodules. Palates and Uvula: light pink, smooth, soft palate. Lighter pink hard palate, more irregular texture. Uvula positioned in midline of soft palate. Tonsils: pink and smooth, no discharge. Deep brown color, skin color is Inspection Skin and Palpation uniform except in areas exposed to sun, no edema, no lesion, moisture in skin folds and the axillae. Skin temperature is uniform. When pinched, skin springs back to previous states. Muscles equal in size; head Inspection Neck & Palpation centered. Coordinated, smooth movements with no discomfort. Lymph nodes not palpable, no lesion, equal muscle strength. Symmetric chest, uniform Inspection, Chest, Lung Auscultation & Palpation temperature, no tenderness expansion, no retraction. Chest Adventitious (crackles) and masses, symmetrical chest breath sounds

10

wall intact, bilateral symmetry of vocal fremitus. Regular rhythm, no pulsation in Inspect, Heart Auscultation & palpation tricuspid area, aortic and pulmonic area, s1 and s2 are heard at all sites. PMI laterally enlarged (Enlarged heart muscles). Bounding abdominal pulsation. Abdominal pulsation, distended, loud bruit over aortic area. Spine vertically aligned no Back/spine Inspection & Palpation deformities, no masses, spinal column is straight, right and left shoulders and hips are at same height. Palpable pulses, no deformities, equal in size on Upper and Lower Extremities Inspection & Palpation both sides of the body, no tremors, smooth coordinated movements, equal strength on each body side, joints move smoothly. Groin pain (lower extremities) Flank pain

Unblemished skin, uniform Inspection & Abdomen Auscultation color, no visible vascular pattern.

H. PATTERNS OF FUNCTIONING

11

SUBJECTIVE

OBJECTIVE

ACTIVITY/ REST Occupation: barangay captain/ Observed response to activity: insurance agent Leisure time Activities/Hobbies: watching TV, playing chess and exercise such as jogging and Stretching. Sleep: Hours: at least 6 to 8 hours of sleep per day Naps: none Insomnia: (+) related to: paroxysmal nocturnal dyspnea Feelings of boredom and dissatisfaction: none History of: Hypertension: yes (father side) Heart trouble: yes (cardiomegaly left ventricle) Bleeding episodes: none Palpitation: none Extremities: Numbness: none Tingling: none Cough/character of sputum: none Change in frequency/amount of urine: No EGO INTEGRITY Stress factors: too much physical Emotional status: calm activity, family and community problems, delayed barangay project, too much paper works. Ways of handling stress: sleep for 6 to 8 hours daily Relationship status: Married Religion: Roman Catholic Feelings of helplessness: (-) CIRCULATION BP: 140/90 mmHg Heart sounds: Rate: 95bpm Murmur: none Extremities: Capillary refill time: after 3 seconds Nails: thick and pink Homans sign :(-) Respiratory: with DOB Mental status: conscious and coherent Neuromuscular assessment: Muscle tone: firm Posture: normal Tremors: none Deformity: none

12

Hopelessness: (-) Powerlessness: (-) ELIMINATION Usual bowel pattern: regular (1-2x a Abdomen: day) Laxative use: none Character of stool: soft Usual voiding pattern: 1-2x every morning and afternoon, 2-3x at night Frequency: 5-7x a day Character of urine: aromatic and yellow. Diuretic use: none FOOD/FLUID Usual diet: vegetables, fish, bread, Current weight: 70 kg rice, water. Food preferences: any food will do except for fatty foods No. of meals: 3 meals with 2-3 snacks Vitamin/ food supplement use: none Loss of appetite: not yet experienced Swallowing problems: none Allergies: no known allergies Dentures: none HYGIENE Activities in daily living: independent General appearance: clean, shaven, Mobility: active and independent Preferred time of personal care/bath: morning Assistance required: none short haircut Manner of dress: casual Personal habits: use of body deodorant after taking a bath Body odor: none NEUROSENSORY Mental status: cooperative and alert Glasses: yes Hand grasp: equal bilateral strength Swallowing: normal, no difficulty Pupil: PERRLA Posture: good Body Build: large frame Skin turgor: firm, elastic and intact Mucous membranes: moist Breath sounds: crackles Edema: yes (pulmonary edema) Appearance of tongue: pink, midline, raised papillae Mucous membranes: pink and moist Tender: yes Size: Large cystic focus measuring about 12.97 x 9.81 cm with thickened & irregular posteriorinferior wall diameter = 9.41 x 6cm Location: right lower quadrant

Headache: none Tingling/ Numbness: none Drowsiness: none Stroke: none Vision: farsighted

Ears: normal hearing senses in both

13

ears Epistaxis: none Location: abdomen Intensity: 8 (very severe pain) Quality: pulsating Precipitating or aggravating factor: hypertension and trauma to the site Effects on activities: limit the normal activities Dyspnea: (+) 3 pillow orthopnea dyspnea Cough/sputum: none History of: Asthma: (-) TB: (-) Oxygen: yes Allergies: no known allergies History of STD: none Fractures: none Impaired vision/hearing: Farsighted Seatbelt/ helmet: yes Arthritis/joint pain: none Delayed healing: no Cognitive limitations: none Sexually active: yes Use of Condom: yes Birth Control Method: condom Sexual Concerns/difficulties: none MALE: Penile Discharge: none Prostate Disorder: none Circumcised: yes Vasectomy: no Last proctoscopic exam/prostate Emphysema: (-) Pneumonia: (-)

Paralysis: none Deep tendon reflex: active PAIN Facial Grimacing: yes Guarding affected area: yes

RESPIRATION Respiratory rate: 35 breaths/min Depth: shallow Symmetry: symmetrical Nasal flaring: yes Fremitus: low pitched Breath Sounds: with crackles

(+) paroxysmal nocturnal

SAFETY Temp: 36.7C Scars: no prominent scars visible Lacerations: none Bruises: none Burns: none Strength: good, equal bilateral Muscle tone: firm SEXUALITY Comfort level with subject matter: slightly Comfortable

Breast: asymmetric Testicles: asymmetric Genital warts: none Discharge: none

14

exam: none Marital status: Married Living with: his family Reports of problem: seldom have family problems Role within the family: father Feelings of mistrust: (-) Rejection: (-) Unhappiness: (-) Loneliness/isolation: (-) Problems with communication: none SOCIAL INTERACTION Speech: clear Verbal/nonverbal communication with family: speaks with relatives and others

Dominant language: Filipino Graduate Familial risk factors:

TEACHING/LEARNING Amount of alcohol: 5-7 beer bottles per session Admitting diagnosis: abdominal aortic Aneurysm Reason for hospitalization: Abdominal pain due to abdominal aortic aneurysm Patients expectation of his hospitalization: to be well again Previous illness & or hospitalizations/ surgeries: Nasal Surgery (Anatomic Nasal Obstruction) last 1980 at Mary Johnson Hospital Last complete physical exam: none

Educational attainment: College

(+) Hypertension (father side) (+) Heart disease (mother side)

I. IMPRESSION/MEDICAL DIAGNOSIS Abdominal aortic aneurysm III. DISCUSSION OF THE DISEASE A. ANATOMY AND PHYSIOLOGY Abdominal Aorta It begins at the aortic hiatus of the diaphragm, in front of the lower border of the body of the last thoracic vertebra, and, descending in front of the

15

vertebral column, ends on the body of the fourth lumbar vertebra. The branches of the abdominal aorta may be divided into three sets: the visceral branches, which supply the organs in the abdomen, renal, testicles and ovaries; the parietal branches, which supply the diaphragm from below and the posterior abdominal walls; and the terminal branches, which descend to supply the organs of the pelvis, the pelvic wall and the paired common iliacs which supply the lower extremities.

PATHOPHYSIOLOGY

16

MODIFIABLE
Beer/Alcohol - drinks 5-7 bottles (Contains tyramine) Stress increase peripheral vascular resistance and stimulates sympathetic nervous system

NON MODIFIABLE
Age 40 to 70 years old (45 years old) Heredity family history of heart disease (Mother side) Hypertension (Father side) Gender male (4 times likely to have AAA)

Alcohol

Stress

Non specific injury to arterial wall (endothelium)

Tyramine

Stimulation of sympathetic system

Desquamation of endothelial lining

Release of catecholamine Increased permeability Heart rate

Myocardial action

Lipids (LDL, VLDL) and platelets assimilate into the area

Stimulates kidney

Release of renin

Venous return

T-Lymphocytes and monocytes infiltrates into the site

Cardiac output Splits angiotensinogen to angiotensin 1 Constrict arterioles

Fatty deposits are ingested and die causing smooth muscle cells in the vessel wall proliferates

Peripheral vascular resistance

ACE converts angiotensin 1 to angiotensin 2

Formation of fibrous cap over the dead fatty core (atheromas/plaques)

ATHEROSCLEROSIS Triggers release of aldosterone Protrusion of plaques in the lumen of the vessel

Erodes the vessel wall (Tunica Media)

Retain sodium and excrete potassium

Narrowed blood vessel and obstruction the blood flow Decreased coronary tissue perfusion

BLOOD PRESSURE

Thinning of the tunica media

BP and Blood volume

Aortic wall weakens

17

1
Sympathetic stimulation Heart rate

2
Tension in the weaken wall

Venous return Bulging/Dilation of the aortic vessel wall

Ventricular load

Pressure on the other organs and lumbar nerves in the abdomen

ANEURYSM

Pulsating mass in the abdomen

Ventricular distention Release of algogenic substances Cardiac muscle force to eject blood Stimulation of nociceptors CARDIOMEGALY Sluggish blood flow within the dilated wall

Cardiac muscle wears off (left ventricle)

Blood backs up in pulmonary circulation

Clot formation in the wall Action potential/ electrical activity Surgical Perception of pain management (Abdominal, flank and groin pain)

Blood vessels swells

THROMBUS

If untreated

Pressure in the blood vessels

Rupture of the aneurysm Blood loss

If treated

Fluid leaks Pulmonary edema

Partial occlusion of bronchioles or alveoli

Crackles

Post operative care Assess for pain and swelling Monitor peripheral perfusion Ambulation as tolerated

Intra vascular volume Venous return Cardiac output

18

 heart rate; respiratory rate; vasoconstriction; ICF shift to ECF in alveolar oxygen tension Multiple organ failure Interferes with diffusion of oxygen and carbon dioxide Blood pressure will continue to fall Hypovolemic shock

DOB

Death

19

B. DRUG STUDY GENERIC NAME/BRAND NAME Generic name: Clopidogrel bisulfate 7mg 1 tab OD Antiplatelet drug It prevents the To the and Brand name: (Plavix) binding adenosine diphosphate thus, It to platelet receptor platelet helps formation stops. of reduce CNS: fatigue edema abdominal and Lactation. pathological Active Use cautiously in patients at bleeding risk for increase bleeding other pathologic conditions and in those with hepatic impairment. Inform platelet tract patient that aggregation CLASSIFIC ATIONS ACTION INDICATION ADVERSE REACTION CONTRAINDICATIONS NURSING RESPONSIBILITY

exacerbation of atherosclerotic atherosclerosis formation.

depression

patients events in patients CV: thrombus documented peripheral by GI:

and such as peptic ulcer or from trauma, surgery, or intracranial hemorrhage. pain, diarrhea gastritis,

with atherosclerosis hypertension recent CVA, MI, or dyspepsia, arterial constipation, and ulcers GU: infection Hematologic: Purpura Musculoskeletal: arthralgia Respiratoty: Bronchitis, coughing, dyspnea and urinary

It prevents the disease.

wont return to normal for at least five days after drug has been discontinue from which activities trauma thus, in and he/she must refrain

20

minimize exhaustion occurrence atherosclerotic events. of of blood vessels or

Upper respiratory tract infection Skin: Pruritus Other: Flu syndrome and pain

bleeding may occur.

21

GENERIC NAME/BRAND NAME

CLASSIFICA TIONS

ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATIONS

NURSING RESPONSIBILITY

Generic name: BetaMetoprolol tartrate 50mg I tab BID adrenergic blocking agent

It decreases cardiac

helps Hypertension output,

CNS: depression GI: nausea diarrhea Respiratory: dyspnea Skin: rash

Myocardial infarctions in and clients with a HR of less than 45bpm, in secondor third-degree heart block, or if systolic blood pressure is less than 100 mm Hg. Moderate to severe cardiac failure.

Always

check

patients

apical pulse rate before giving drug. If its slower than 60 beats per minute, withhold drug and call doctor immediately. Monitor blood pressure metoprolol frequently;

peripheral resistance, and cardiac oxygen

Brand name: (Betaloc)

consumption by depressing renin secretion.

masks common signs and symptoms of shock. Caution patient to avoid driving and other task requiring mental alertness until response to therapy has been established. Instruct patient not to stop drug suddenly to notify

22

doctor about unpleasant adverse reactions. Inform him that drug must be withdrawn gradually over 1-2 weeks.

23

GENERIC NAME/BRAND NAME Generic name: Nitroglycerine patch ACW OD

CLASSIFIC ATIONS Coronary vasodilator It

ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATIONS

NURSING RESPONSIBILITY

helps

reduce Hypertension by heart left after end- angina pectoris acute

CNS: Weakness

Myocardial infarctions in Closely clients with a HR of less than 45bpm, in secondand or third-degree 100 mm to heart Hg. block, or if SBP is less during blood patient MI.

monitor infusion, pressure with MI.

vital

signs

cardiac demand

oxygen from surgery, CV: Fainting failure EENT: S.L, burning MI, GI: in Skin: Nausea vomiting vasodilation, to dermatitis, rash Other: hypersensitivity reactions

particularly especially Excessive

decreasing ventricular Brand name: (Transderm Nitro) diastolic

hypotension may worsen the transdermal patch

Cutaneous than

pressure(preload) extent, vascular resistance load).Also increases collateral coronary vessels.

contact Moderate

severe Remove

and, to a lesser situations, systemic produce controlled (after hypotension

cardiac failure.

before defibrillation. Because of the aluminum backing on the patch, the electric current may cause arcing that can damage the paddles and burn patient. Instruct caution microwave radiation patient patch oven. may heat when wearing to near use a transdermal

during surgery blood (by IV

flow through the infusion).

Leaking patchs

metallic backing and cause

24

burns. Advice patient to avoid alcohol. To minimize tell to orthostatic patient to position hypotension, change

upright

slowly. Advice him to go up and down stairs carefully and to lie down at the first sign of dizziness.

25

GENERIC NAME/BRAND NAME Generic name: Captopril 25mg/ tab BID

CLASSIFIC ATIONS Antihyperte inhibitor

ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATIONS

NURSING RESPONSIBILITY

Selectively renin angiotensinaldosterone

Hypertension, congestive heart

CNS: dizziness, fainting, Use with a history of headache, malaise, fatigue abdominal dry angioedema related to previous ACE inhibitor pain, use. mouth

Monitor syncope;

BP, if

check

for

nsive, ACE suprepresses

orthostatic

hypotension, changes

failure CV: Angina pectoris anorexia, diarrhea, constipation,

(CHF), diabetic GI: nephropathy

occur, dosage adjustment may be required. Caution patient not to use OTC products such as cough, colds, and allergy preparations directed occur. coffee, drug. by Inform tea, unless physician, patient chocolate,

Brand name: (Capoten)

system; prevents conversion of angiotensin I to angiotensin II and by this the aldosterone production & vaso constriction will inhibited. be

nausea and vomiting Hematologic: anemia Metabolic: Hyperkalemia Respiratory: dyspnea Skin: pruritus, alopecia Other: Fever

serious side effects may those xanthines such as cola can prevent action of Emphasize the

importance of rising slowly

26

to

sitting

or to

standing minimize

position orthostatic weather

hypotension: or increased

not to exercise in hot hypotension can occur. Advice patient to report excessive dehydration, in B/P. Caution patient that drug may cause dizziness, fainting, lightheadedness; may occur during 1st few days of therapy; to avoid activities that may be hazardous. perspiration, vomiting,

diarrhea; may lead to fall

27

GENERIC NAME/BRAND NAME Generic name: Pantoprazole 40 mg IV

CLASSIFIC ATIONS

ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATIONS

NURSING RESPONSIBILITY

Proton pump inhibitor

Inhibits basal

both Duodenal and gastric moderate by esophagitis. Zollingeracid severe

and CNS: headache, insomnia, Hypertensive ulcer, asthenia, and anxiety, dizziness reflux CV: Chest pain EENT: pharyngitis, rhinitis, sinusitis GI: diarrhea, flatulence constipation, dyspepsia, GI disorder, nausea and vomiting, rectal disorder GU: urinary frequency, UTI of Metabolic: Hyperglycemia Musculoskeletal: Back pain, neck pain, arthralgia, Lactation.

to

any Assess pain,

GI

symptoms: and

migraine, component of the formulation.

epigastric/abdominal bleeding, anorexia. Instruct patient to take drug as prescribed and as approximately the same time each day. Advice patient to report persistence symptoms, bleeding, stools. Advice patient not to drink alcohol, eat food or take drugs (aspirin, NSAIDs) and of diarrhea, tarry

stimulated gastric secretion

Brand name: (Pantoloc)

suppressing in that will prevented.

the final step Ellison production so other ulcer pathologic hypersecretory Prevention gastroduodenal be conditions. development

acids syndrome and abdominal pain, eructation,

ulcers induced hypertonia

28

by

NSAID

in Respiratory:

Bronchitis, tract

that could cause gastric irritation.

patients at risk increase cough, dyspnea, with a need for Upper continuous NSAID treatment. infection Skin: rash Other; flu syndrome, Infection and pain respiratory

29

GENERIC NAME/BRAND NAME Generic name: Digoxin 0.25 mg/IV

CLASSIFIC ATIONS

ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATIONS

NURSING RESPONSIBILITY

Cardiac glycoside

Inhibits potassium adenosine

sodium- Chronic cardiac CNS: fibrillation, ventricular the supraventricular arrhythmias vertigo,

Headache, Ventricular fibrillation or Assess and document apical pulse failure after in (rate, rhythm, stupor, congestive supervenes to digitalis), of character) for 1 full min before giving drug. If pulse <60 in adult or <90 in an infant or is significantly different, reassess after 1 hr, if <60 in adult, inform physician. antacids or other drugs that decrease absorption. Teach each patient day, take to take missed medication at the same time doses within 12 hours and do not double doses. Notify

activated failure with atrial malaise, dizziness, tachycardia(unless paresthesia EENT: visual flashes, photophobia, diplopia GI: vomiting diarrhea

triphosphatase, Brand name: (Lanoxin) of calcium into

thereby allowing influx dilatation, intracellular space(cytoplasm), more available calcium promotes force of increased myocardial cardiac

Yellow- protracted episode not images, presence cardiac certain digoxin

green halos around due

blurred vision, light toxicity, hypertensive to glycosides, cases of carotid

beriberi heart disease, Do not give at same time as and hypersensitive sinus syndrome.

contraction resulting to increased output. It also acts on the CNS to enhance vagal tone, causing the decrease of conduction

30

speed between the SA and AV nodes. This vagal rate to stimulation prevent decreases the cardiac arrhythmia.

physician

if

doses

are

missed for 2 days or more. Advice patient to maintain a sodium-restricted diet and to toxicity. Advice patient to carry/wear emergency dosage ID describing reason for and take to potassium prevent supplements

digoxin medication.

31

GENERIC NAME/BRAND NAME Generic name: Cefuroxime axetil 750mg IV q 8 hours Brand name: Ceftin

CLASSIFICATIONS ACTION

INDICATION

ADVERSE REACTION Diarrhea, nausea, associated colitis. Hypersensitivity: rash, pruritis, urticaria, and positive Coombs test. Renal: increased serum creatinine and bun, decreased creatinine clearance. other: local reactions: thrombophlebitis ; pain, burning, cellulitis; super infection

CONTRAINDICATIONS NURSING RESPONSIBILITY Hypersensitivity to cephalosporins and related antibiotics.

Anti-infective, antibiotic, second generation cephalosporin

Resistance againts betalactamase producing strains exceed that of first generation cephalosporins. Antimicrobial spectrum of activity resembles that of cefonicid. preferentially binds to one or more of the penicillin binding proteins

Infections caused by susceptible organism in the lower respiratory tract, urinary tract, skin and skin structures; also used for treatments of meningitis, gonorrhea and otitis media and for perio operative prophylaxis

culture and susceptibility test should be performed before initiation of therapy and periodically during therapy, if indicated report onset of loose stools or diarrhea. although pseudomembr aneous colitis rarely occurs, this potentially life-threatening complication should be ruled out as the cause of diarrhea during and after antibiotic

32

therapy

GENERIC NAME/BRAND NAME Generic name: famotidine 20 mg IV q 12 hours Brand name: Pepcid

CLASSIFICATION S

ACTION

INDICATION

ADVERSE REACTION CNS: dizziness, headache GI: constipation, diarrhea. SKIN: rash, acne, pruritus, dry skin, flushing OTHER: thrombocytopenia, increases BUN and serum creatinine

CONTRAINDICATIONS NURSING RESPONSIBILITY safe use during pregnancy, by nursing mothers, or in chi8ldren not established

Gastrointestinal A potent agent; antisecretory competitive agent inhibitor of histamine at histamine receptor site in gastric parietal cells. This action reduces parietal cell output of hydrochloric acid; thus detrimental effect of acid

Short term treatments for duodenal ulcer Maintenance therapy for duodenal ulcer patients on reduced dosage after healing of an active ulcer Treatment of pathologic

monitor for improveme nt in GI distress monitor for signs of GI bleeding

33

on gastric mucosa is diminished. inhibits basal, nocturnal, mealstimulated, and pentogastrin -stimulated gastric secretion; also inhibits pepsin secretion

hypersecret ory conditions, benign gastric ulcer

34

GENERIC NAME/BRAND NAME Generic name: Ketorolac Thrometamine 30 mg IV q 8 hours Brand name: Toradol

CLASSIFICATIONS ACTION

INDICATION

ADVERSE REACTION CNS: drowsiness, sedation, headache, dizziness CV: edema, hypertension, palpitation, arrythmias GI: nausea, dyspepsia GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis

CONTRAINDICATIONS NURSING RESPONSIBILITY

Non-steroidal antiinflammatory drugs

May inhibit prostaglandin synthesis to produce antiinflammatory, analgesics, anti-pyretic effects

Short term manage ment of moderat ely severe acute pain

Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, GI bleeding or perforation, advance renal impairment, cerebrovascular bleeding, or incomplete hemostatis, and those at risk for renal impairment from volume depletion or at

Correct hypovolemia before giving Dont give drug epidurally or intrathecally because of alcohol content Dont give drug epidurally or intrathecally because of alcohol content Carefully observe patients with

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risk of bleeding. GU:Polyuria,oliguria HEMATOLOGIC: decreased platelet adhesion, purpura, prolonged bleeding time SKIN: pruritus, rash, diaphoresis OTHER: Pain at injection site

Contraindicated in children younger at age 2 and in patients with history of peptic ulcer disease or GI bleeding, past allergic reaction to aspirin and other nsaids and during labor and delivery or breastfeeding

coagulopathies and those taking anti coagulants. Drug inhibits platelet aggression and can prolong bleeding time. This effect disappears within 48 hours of stopping drug and doesnt alter platelet count, PTT, OR PT. NSAIDs may mask signd and symptom of infections because of their anti pyretic and antiinflammatory actions, serious GI toxicity, including peptic ulcers and bleeding, can occur in patients taking NSAIDs

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despite lack of symptoms

GENERIC NAME/BRAN D NAME Generic name: furosemide 40 mg IV OD Brand name: Ceftin

CLASSIFICATION S Loop Diuretic

ACTION

INDICATIO N

ADVERSE REACTION

CONTRAINDICATION S Allergy to furosemide, sulfonamides, allergy to tartrazine(in oral solution) Electrolyte depletion, anuria severe renal failure, hepatic coma, pregnancy, lactation Use cautiously with SLE, gout, diabetes mellitus

Inhibits the Acute reabsorptio pulmonary n of sodium edema and chloride from the proximal and distal renal tubules and the loop of Henle, leading to sodium-rich diuresis

CNS: dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice CV: Orthostatic hypotension, volume depletion, cardiac

NURSING RESPONSIBILIT Y Administer with food or milk to prevent GI upset Give early in a day so that increased urination will not disturb sleep Do not expose to light, may discolor tablets or solution, do not use discolored drug or

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arrhythmias,thrombophlebiti s Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances GU: Polyuria, nocturia, glycosuria, urinary bladder spasm Dermatologic: Photosensitivity, rash pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme Other: Muscle cramps and muscle spasms

solutions Arrange for potassium rich diet or supplemental potassium as needed

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D. DIAGNOSTIC/LABORATORY EXAMS I. Roetnographic Findings Examination: Chest PA Date: October 16, 2007 accentuation of the lung markings. Impression: CARDIOMEGALY WITH PULMONARY CONGESTION BORDERING EDEMA II. Ultrasound A The diaphragm and sulci are intact. The heart is naked enlarged with marked bronchovascular and interstitial

Examination: Whole abdomen Date: October 26, 2007 The liver is border line in size measuring 14.5cms. Parenchymal endo pattern is homogenous with no focal mass. The intra hepatic dilated. The inter vena cava is likewise is dilated. The gallbladder measures 5.9 x 2cms wit no intra luminal echoes seen. The pancreas measures 1.9x 10cms to head and body, respectively there is no fecal mass seen. The spleen is not enlarged. The kidney appears normal in size measuring 9.4 x 5.6 x 4.3cms. With no mass calcification seen. The central complex is not dilated the left kidney measures 9.3 x 5.4 x 5.0cms with no mass or calcification noted. The prostate gland is not enlarge measures 3.1 x 2.8 x 2.1cms with no masses noted. Urinary bladder is distensible with previous volume of 115.6cms. There are intraluminal echoes seen. The wall is not thickened. Posterior scan shows satisfactory drainage. Impression: Borderline liver size with dilated vessels and inferior vena cava Normal gallbladder, pancreas, spleen, kidneys, prostate & urinary bladder.

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III.

Ultrasound B

Examination: Whole abdomen Date: November 27, 2007 There is large cystic focus measuring about 12.97 x 9.81cms with thickened and irregular postero inferior wall noted at the periumbical region apparently contiguous with the abdominal aorta. The said cystic focus has functional luminal diameter of about 9.41 X 6cms. Impression: Infrarenal abdominal aortic aneurysm with thrombi and plaque formation considered CT scan and Doppler Scanning Suggested for further evaluation. IV. Ultrasound C

Examination: Scout film of the abdomen Date: December 4, 2007 Homogenous opacity is noted in the mid pelvocalyces abdominal area. There are gas filled intestinal loops. Negative for pnuemoperitoneum.

Impression: Consider a large pelvo abdominal mass. Aneurysm Ileus. V. Radio logic Findings

Examination: CXR Date: December 4, 2007 There is prominence of pulmonary vascularity. Interstitial infiltrates are seen in both middle and lower lung fields. Heart is globularly enlarged. Right hemidiaphragm is slightly elevated. Costophrenic sulci are intact.

Impression: Cardiomegaly with pulmonary congestion or intestinal edema. Cannot role out concaminant pericardial effusion.

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VI. Component

Hematology Complete Blood Chemistry Normal Value Date: 12-04-07 Result 2.09 2.74 mmol/L 2.0615 mmol/L

Clinical significance anemia/ hemorrhage It may indicate Infection, AMI and inflammation.

Hemoglobin

Slightly It may indicate low

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Leukocytes

4.5 11

x10 /L

13.0 10 /L

HIGH

Segmenters Eosinophils

.55 0.65 mmol/L 0.65 mmol/L 0.03 0.05 mmol/L 0.02 mmol/L Slightly It may indicate low stress from trauma, shock or surgery

Lymphocytes 0.34 Monocytes 0.04 ELECTROLYTES 135 145 meq/L

0.30 0.03

Slightly low Slightly low

SODIUM

134 meq/L

LOW

It may indicate with edema or nephritis

VII. Coagulation Studies Blood type: O Prothrombin Time: 14seconds (12 14 secs. Normal time)

IV. NURSING PROCESS

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A. LONGTERM OBJECTIVES After 2 days of nursing interventions as a parameter of the treatment regimen, the patient will attain and maintain stable vital signs and pain at tolerable level in the entire shift to avoid rupture B. PROBLEM LIST

Date of onset 12/04/07

Active problems Abdominal Pain

Date identified 12/04/07

Date resolved 12/04/07

12/04/07

Difficulty of Breathing Potential Complication: impending rupture of the abdominal aorta

12/04/07

12/04/07

12/04/07

12/04/07

12/04/07

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C. NURSING CARE PLAN Nursing Problem Nursing Diagnosis Acute pain related to pressure of aortic wall against organs and nerves within the abdominal cavity as evidenced by pain scale of 8 facial grimace, and guarded behavior Rationale of Nursing Diagnosis Increase pressure in organs and nerves in the abdominal cavity Nerve stimulation Activation of pain receptors Perception of abdominal pain Objectives Nursing Interventions Rationale of Nursing Intervention Evaluation

Abdominal pain Subjective cue: Masakit yung dito ko" (pointing to abdomen) as verbalized by the patient Objective cues: Pain scale of 8 (very severe) BP 140/100 RR 35 BPM Facial grimace Guarded/ protective behavior Irritable at times

After 3 hours of Independent: nursing interventions, the Placed the client patients in low fowlers abdominal pain position will be lessen as evidence by pain scale of 8 to 5, absence of facial Provided quiet grimace, and environment and guarded behavior calm activities

To limit the pressure and prevent rupturing of the abdominal aorta It promotes relaxation which reduces the tension in the muscles. To reduce stress, fatigue, and muscle tension.

After 3 hours of nursing interventions, the patients abdominal pain was lessened as evidenced by pain scale of 8 to 5, absence of facial grimace, and guarded behavior

Instructed and encouraged use of relaxation exercise, such as focused breathing and music therapy.

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Encouraged diversional activities like watching TV, reading bible,listening to music Encouraged adequate rest periods

Converts patients mind/attention into different things that help the patient ignores pain To reduce fatigue and promotes comfort

Dependent: Administered medication as ordered -Ketorolac 30mg/IV every 8 hours To be able to relieve pain and treat underlying condition

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Problem

Nursing Diagnosis

Rationale of Nursing Diagnosis Formation of plaques Narrowing of blood vessels BP Increase heart rate Increase venous return Increase cardiac output Wearing off heart ventricles Blood back up in the pulmonary circulation Vessel wall swollen Fluid leaks Pulmonary edema

Objectives

Nursing intervention Independent: Positioned the client in a semi-fowlers position Encouraged deep breathing exercise -Pursed-lip breathing exercise Encouraged adequate rest and limit activities to within patients tolerance

Rationale of Nursing Intervention

Evaluation

Impaired gas exchange related to Subjective cues: ventilation perfusion Nahihirapan akong imbalance huminga, para secondary to akong nalulunod pulmonary as verbalized by the edema as patient evidenced by nasal flaring Objective cues: and RR of 35bpm RR 35 BPM PR 95 BPM Orthopnea (+) Crackles Nasal flaring

Difficulty of Breathing

After 4 hours of nursing interventions, the patient will demonstrate improve ventilation as evidence by absence of nasal flaring and decrease RR from 35bpm to 22bpm

After 4 hours of nursing interventions, the To promote optimal chest patient was able to demonstrate expansion improved ventilation and easy as evidenced by breathing absence of nasal flaring and Improves decrease RR from ventilation 35bpm to 22bpm and the simplest and the easy way to control shortness of breath Helps limit oxygen needs/ consumption

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Occlusion in the bronchioles and alveoli Interferes gas exchange DOB

Dependent: Administered oxygen as ordered 23Lpm via nasal cannula Administered medication as ordered -Furosemide 40mg/IV To maintain adequate oxygen needs To reduce edema

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Nursing Problem

Nursing Diagnosis

Rationale of Nursing Diagnosis

Objectives

Nursing Interventions

Rationale of Nursing Intervention

Evaluation

Potential Complication: Impending rupture of the aortic wall Objective cues: Abdominal distention (Nov. 27, 2007 UTZ done Result : Size of whole abdomen large cystic focus measuring about 12.97 x 9.81 cm with posterior inferior wall diameter of about 9.41 x 6 cm) Other cues: Pain scale of 8/10

Risk for fluid Dilation of the volume deficit r/t abdominal aorta potential blood loss secondary to Increase in size of potential rupture the upper of the abdominal abdominal mass aorta Right lower abdominal pain radiates to lower back with increasing severity of pain Potential complication: Impending rupture of the aortic wall

At the end of the Independent: shift, the patient will not manifest any signs & Monitored for symptoms of the patients report given of increasing complication; abdominal rupture of the pain that abdominal aorta radiates from as evidence by the lower back stable vital signs, or groin area skin of usual with increasing color, no cyanosis severity which and pain scale of is a sign of 8 to 6-5. imminent rupture of the abdominal aorta. Implemented measures to decrease the risk of rupture: 1. Instructed

Pain results from massive tissue hypoxia and profuse bleeding on the abdominal cavity.

At the end of the shift, the patient was not shown any signs & symptoms manifestation of the potential complication; rupture of the abdominal aorta as evidenced by stable vital signs, usual skin color, no cyanosis and pain scale of 8 t0 6-5.

To prevent restriction of blood flow to the lower extremities

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BP = 140/90 mm Hg RR = 35 bpm PR = 95 bpm Temp = 36.7 C

client to avoid elevating legs when in bed & crossing legs. 2. Limited clients activity as tolerated

subsequent increase vascular pressure.

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D. COURSE IN THE WARD Date/Time Activities

12/03/07 10:35am December. 3, 2007 at 10:35am a 43 year old male was rushed to the ER accompanied by relatives due to abdominal pain. With vital signs of BP: 130/90mHg, CAR: 95, RR: 20, and was seen and examined by Dr. Bayani and Dr. Perez with orders made and carried out and was advised to admission

12/04/07 12:45pm 1:30am Intravenous fluid of D5 LR was inserted and regulated at 40cc/hr. ECG and X-ray done and CBC was requested. Patient is admitted and endorsed to staff. The patient was transferred to surgery ward via wheelchair accompanied by the relatives, and transferred to bed safely, with an IVF of D5 LR 1L x 40cc/hr at 960cc level and was instructed on NPO. Patient was referred to Dr. S. Andin (TCVS) and DR. Bongosin (IM Cardio) for co-management Patient was seen and examined by Dr. Ombao with orders made and carried out. And medication given (Anoxin 0.25/IV) Patient was instructed on full diet and still on CT- scan of abdominal aorta and ultrasound Patient is on bed, conscious and has an ongoing IVF of D5 LR 1Lx 40cc/hr at 400cc level. Regular diet maintained and still referred to TCVS and IM-Cardio. Patient is for 2D-echo and is on oral preparation. Patient was transferred to CT-Scan room via stretcher.

2:00am 8:00am 2:00pm

8:00pm 12/05/07 12:00am 10:00am

Vital sign taken ad recorded, IVF consumed and D5 LR was hooked as follow up Patient was sent back to x-ray room. Was seen and examined by Dra. Landayan with orders made and carried out. On CP evaluation and is instructed on soft diet.

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E. DISCHARGE PLANNING Medicines Captopril (Capoten) 25mg/tab BID Instruct patient to ambulate as tolerated, including climbing stairs and walking outdoors. Treatment

Exercise

Advised patient to comply with the medication prescribed. Remind patient to undergo to the different laboratory exams the doctor ordered.

Health Teachings Diet Full diet Advised patient to attend to the church or other religious gathering to lessen his burden in life. Spiritually Advised the relatives or patient to note or assess if there is a complication secondary to the disease. Encouraged rest when fatigue or when there is discomfort. Assess for any allergic reaction towards the prescribed drugs. Review all medication to be used by the client to be certain that he or she understand their purpose, schedule, and side effects. Instruct patient to restrict activities that are strenuous and includes pushing, pulling and lifting heavy objects The patient may resume his or her sexual activity in about 4 to 6 weeks No definite visit. Outpatient visit

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