Introduction

A heart beat signifies life, from the day it starts to beat in the womb, till it stops, and where death conquers us. The heart beats not only to one tune but it also responds to the tune of emotions and physical stress. As some of us may have also experience moments of joy or sorrow and the heart may feel pain or pleasure. In medicine, an acute disease is a disease with a rapid onset or a short course. The term Acute may often be confused by the general public to mean severe, however, this has a different meaning. Coronary, may refer to as the heart or relating to the heart. While syndrome is defined as a set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease. Acute Coronary Syndrome is defined as a spectrum of conditions involving chest discomfort or other symptoms caused by lack of oxygen to the heart muscle (the myocardium). The unification of these manifestations of coronary artery disease under a single term reflects the understanding that these are caused by a similar pathophysiology (sequence of pathologic events) characterized by erosion, fissuring, or rupture of a pre-existing plaque, leading to thrombosis (clotting) within the coronary arteries and impaired blood supply to the heart muscle. According to the morbidity rate, taken from the records of the Department of Health for region X, the occurrence of cardiovascular diseases per 100,000 populations is 3,356. This data is taken from the 2001-2005, a 5 years average record. While the occurrence rate for cardiovascular disease for region X by 2006 is recorded to be 4,373 per 100,000 populations.

OBJECTIVES OF THE STUDY The study aims to explore the concepts about the condition and the quality of nursing care being rendered to our client Mrs. F that was diagnosed with Acute Coronary Syndrome. In order to learn more about the health condition of the patient, the study wants to fathom about the predisposing and precipitating factors, anatomy and physiology and the pathophysiology of the condition experienced by the client. Basically the main goal of this study in relation to knowledge is to identify the nursing interventions after the condition of patient Mrs. F. The study aims to critically analyze the qualitative and quantitative data gathered in order to establish connection between the different manifestations experienced by the patient with that of the disease process. To be able to improve skills, the students also endeavors to come up with nursing care plans that will alleviate Mrs. F.s condition. The presentors also intend to compare and contrast the ideal management for Acute Coronary Syndrome with that of the actual management. In addition, the study seeks to disseminate essential information to everybody for awareness. Furthermore, by this study, the provider will be able to exercise that attitude of determination and in order to come up with a successful study.

SCOPE AND LIMITATIONS OF THE STUDY This case study tackles about Acute Coronary Sydrome specifically on the case of patient Mrs. F. It includes essential concepts in relation to the said condition such as the patients profile and health history, nursing assessment and clinical manifestations, drug study and diagnostic exams done. The anatomy and physiology is also included as well as the pathophysiology of Acute Coronary Syndrome with its associated factors. The Medical and Nursing Management along with the discharge plans with its referrals are also being covered. The prognosis is also given. The scope of the plan encompasses during the Recovery Phase which was on February 12, 13, 14, 15, 16, 18 and 19 of year 2008 wherein the assigned students who have assessed the client with cumulative interaction and good rapport to the patient and significant others. Nursing Management covers the above mentioned dates which encompasses the clients Recovery Phase. Data gathering about the Laboratory results covers from February 05 to February 16, 2008. The areas of concerns are limited to the discussions of Acute Coronary Syndrome and the quality of Nursing Care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and his medical records. Immediate family background is limited because the patient has difficulty in recalling necessary information that would aid in the data gathering. Data gathering was limited in the confines of Maria Reyna Hospital, Cagayan de Oro City and Aluba, Cagayan de Oro. Generally, the content of the report is limited to the elaboration of the diagnosis given to the patient and the corresponding Nursing Management.

PATIENTS PROFILE

Name: Age: Sex: Birthday: Birth rank: Number of siblings: Religion: Civil Status: Number of children: Nationality: Height: Weight: Address: Occupation: Income:

Mrs. F 81 years old Female June 3, 1926 2nd to the eldest 7 Roman Catholic Married 13, with 10 living and 3 deceased Filipino 5 Ft. 73 kg Baungon, Bukidnon House wife Php. 15,000/ mo.

Educational Attainment: 1st year H.S. Date Admitted: Time Admitted: Chief Compliant: Date Discharged: Time Discharged: Final Diagnosis: February 05, 2008 12: 05 PM Shortness of breath and chest pain February 16, 2008 4:15 PM Acute Coronary Syndrome, hypertension, Myocardial Infarction

Significance of the study The study is significant to the following people, the client, the clients family, the researchers, nursing student, and future researchers. The study is significant to the client, because it enlightens the clients queries and doubts regarding her condition. Allowing her to understand the situation of her present state, this would allow her to be more aware of the importance of following the

treatment regimen. Clients family must also be aware of the condition of the client. With the study, the clients family will be able to participate in the clients treatment, and they will be able realize the importance of the support system in participating in the clients care. The study is also important to the researchers, since it allows them to explore the clients condition, giving them first hand experience in observing the manifestations of the disease condition and allowing them to apply theoretical knowledge regarding nursing managements for the manifested signs and symptoms. Nursing students and future researchers may use the study for reference or basis purposes in planning an intervention or understanding a condition which could be similar or related to the study presented.

Health History
Family History History of hypertension was present to both paternal and maternal side, in addition to the given datas from the informant; theres no history of CA on the clients lineages. However, on her maternal side a history of diabetes mellitus and heart problems was present. Mrs. F.s grandfather (father side) died due to liver abscess. It was known that her grandfather was a chain tobacco smoker consuming 24 sticks or approximately 1pack of cigarette per day and drinks alcoholic beverages such as tuba. Additionally, patients grandmother (father side) died due to normal aging with high blood pressure. Patients maternal side history revealed that grandparents died due to aging. Furthermore, patients father died due to normal aging with hypertension. It was mentioned that her father was also a smoker, consuming 15-20 estimated sticks of cigarette per day. He also drinks alcoholic beverages like tuba. Her mother died at her 88 years of age due to normal aging process. On the siblings of the clients father side, all had hypertension. Some of her mothers siblings had hypertension and one had CVA.

Personal Social history Mrs. F. had her menarche at the age of 13 years old. At the age of 20 years old, Mrs. F. met Mr. S. at Baungon, Bukidnon and got married. Mrs. F.s reproductive profile was G13, P13, T13, P0, A0, and L10. She has 13 children. Her first pregnancy was on February 3, 1947 with their first child named Sohrab through Normal Spontaneous Vaginal Hospital delivery. Sorab died on January 29, 1989 due to an accident. Second delivery was a pregnancy uterine full term, normal Spontaneous delivery with a baby

boy named after his father, Santiago Jr. History divulges that the patients second child died after birth. Third pregnancy was still a normal spontaneous vaginal delivery. The baby was named Leopoldo, Leopoldo died due to measles at the age of 3months. Her fourth pregnancy was still normal named her third child Elleonor with an educational attainment of High School level who was born February 22, 1949. Mrs. F.s 10 remaining pregnancies were all full term and were all delivered through normal spontaneous vaginal delivery. The remaining 10 children were the following: Gemma who was born on December 18 1950, married and with an educational attainment of High School Grad, Rosalina born aug. 18, 1951 with an educational attainment of High School graduate ,married (female), Efren born Sept. 18 1952 with an educational attainment of High School level and is married (male), Salvacion born on Feb. 15, 1953 a High School level and is married (female), Marjorie born on Oct. 16, 1962 a High School graduate and is married (female), Jose born on 0ct. 18, 1963 a High School level and is single (male), Marites born on Dec. 10, 1964 a High School level and is married (female), Nancy born on Aug. 22, 1966 a college graduate and is married (female),Edgardo born on Nov. 2 1967 a High School Grad and is single(male). Patients husband, Mr. S. was the Former vice Mayor of Baungon, Bukidnon. On the year 1963- 1965.Being a wife of the vice mayor, she participated well in politics and has a lot of programs and campaigns for her husband. She was also a member of the Catholic Womens League and has done a lot of outreach programs for the church. Their family social status was at peak that time, but then a great downfall happened in their lives. At the age of 39 years old, Mr. Santiago was stabbed due to political conflicts which caused his death. She hardly accepted it because of the traumatic experience they had. After two years, Mrs. F. got married to Mr. V. He is a Cebuano who came to Baungon, Bukidnon in search for work and found more than what he had expected. Mr. V was afraid in marrying her because he has to face all of her children to ask for the hands of their mother. Luckily, all of her children understood and accepted him and they got married. Mr. V. and Mrs. F. were not blessed with children somehow blessed with their adopted children who were Margie and Kristine.

They have their own house in Baungon, Bukidnon and took cared by her adopted daughter Margie. When visiting in Cagayan de Oro wherein her sons and daughters are residing in the same area, they stay in her daughters house Marites in Aluba, Cocacola compound where they are warmly welcomed. Our clients source of income is only P15,000 pesos a month from her pension pay.

Past medical History On 1965, the year of Mr. S.s death, Mrs. F. had traumatic experience that caused her psychological and physical stress. It was claimed by the informant that at the year 1984, patient was admitted to City Hospital due to her first stroke attack. That admission lasts for a week and she was diagnosed to have Cerebro Vascular Accident or CVA. Her, second attack was on year 1991 at Madonna Hospital Intensive Care Unit (ICU). After a couple of years from her 2nd admission, patient suffered from persistent chest pain thus gave way to her third admission at Maria Reyna Hospital the year 2006. After that admission, patient was given home medications to be maintained which are: Telmisartan (pritor) 40mg 1 tab/day, Clopidogrel (Plavix) 75mg 1 tab OD, Metroprolol 50mg tab BID, Amniodarone (Cordarone) 200mg 1 tab TID, ASA 80mg 1 tab OD, Atorvastatin (Lipitor) 80mg 1 TAB OD @ hs, SMN (imdur) 60mg 1 TAB BID. One year after her third admission patient underwent surgery on her left eye. An Extra Capsular Cataract Lens Extraction (ECCLE) was done on the year 2007.

History of Present Illness One week prior to admission patient experienced blurring of vision and headache which continue until the day of admission. She didnt do anything because she thought that its just a symptom of her cataract. 3days prior to adm. Client took Isodril for her moderate chest pains radiating from the left shoulder to her back but wasnt relieved. Informant stated that, 1 day prior to admission, patient had shortness of breath with

inability to lie flat on bed and the night of the same date (February 4, 2008), patient noted and complained for moderate chest pain radiating to her left shoulder and back. On the 5th day of February 2008, Severe Chest pain suffered by the patient persisted with difficulty in breathing and shortness of breath which prompt her admission at Maria Reyna Hospital and was initially diagnosed with Hypertensive Cardiovascular disease. The client was ruled with the final diagnosis of Acute Coronary Syndrome and was under the observation and medical treatment of Dr. Alenton.

Chief Complaint Shortness of breath

Developmental Data
GROWTH AND DEVELOPMENT
Patient: Mrs. F Gender: Female Age: 81 years old

Psychosocial Theory Erik Erikson Erik Eriksons theory of psychosocial development is one of the best-known theories of personality in psychology. His theory describes the impact of social experience across the whole lifespan. In each stage, Erikson believed people experience a conflict that serves as a turning point in development. In Eriksons view, these conflicts are centered on either developing a psychological quality or failing to develop that quality. During these times, the potential for personal growth is high, but so is the potential for failure. In this theory, the patient has the task of Integrity vs. Despair which is the final task of psychosocial theory which ranges at 65 years old until death. This phase occurs during old age and is focused on reflecting back on life. Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death. The patient has developed a feeling of despair. Shes destructed by her worries for things that might worsen her condition and for things that might happen to her offspring. Patient was even afraid of facing death because she felt that she hasnt done

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her best yet for the future of her grown children for the reason that some of her children didnt have a stable job and others were unemployed. Another reason of despair was that the client wasnt able to prepare for the current health condition she is experiencing brought by aging. For instance, the client wasnt able to prepare by saving or by making investments that could have had supported her health needs and maintenance. Normally, it is usually anticipated by any person during younger years when she/he is still able and strong. She verbalized that these emotions triggered her to have the disease condition. Developmental Task theory Robert Havighurst Havighurst (1972) defines a developmental task as one that arises a t a certain period in our lives. The successful achievement of which leads to happiness and success with later tasks while, failure leads to unhappiness, social disapproval, and difficulty with later tasks. These tasks provide a framework that a nurse can use to evaluate a persons general accomplishments. Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. He believed that in each stage in a persons life, a person has different tasks to be learned. In later maturity (61+) where the patient belongs, there are six (6) tasks to be learned, as follows; 1. Adjusting to decreasing physical strength and health. 2. Adjusting to retirement and reduced income. 3. Adjusting to death of a spouse. 4. Adopting and adapting social roles in a flexible way. 5. Establishing satisfactory physical living arrangements. 6. Establishing an explicit affiliation with ones age group. These tasks are arranged in chronological order;

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(1) Adjusting to death of a spouse. At an early age of 39, she became a widow and left with 11 children. This was not an easy situation after the tragic death of her husband especially raising the kids. Presently, patient is happily married with her second husband Mr. V. (2) Adopting and adapting social roles in a flexible way. She used to be the wife of a vice mayor in their place. She attended most of the social functions her husband was connected and interact very well to the constituents in the community. She remarried at age 41 and she didnt have a child with her present spouse. She was able to adopt her second marriage for her husband loves her children as his and was also very supportive. (3) Adjusted to reduced income. Patient had stopped working at the age of 58. That was the time when she was admitted in the hospital due to CVD. She used to work in an eatery but due to her age and physical condition, her children advised her to stay at home as they were grown up and would support her. (4) Establishing physical living arrangements with her family. At present, the couple is no longer working and is supported by the children. They are happily living together in their house at Baungon, Bukidnon. (5) Adjusting to decreasing physical strength and health due to her present health condition and her old age. (6) Establishing an explicit affiliation with ones age group. Until now the patient has casual communication with her age level. She still could recognize some of her friends during her younger years and at present. Much as she wanted to be with them always but her health and age condition would not allow anymore.

Interpersonal Theory Harry Stack Sullivan Harry Stack Sullivan was an American psychiatrist who extended theory of personality development to include the significance of interpersonal relationships. He 12

thought that inadequate or nonsatisfying relationships produced anxiety, which he saw as the basis for all emotional problems. Sullivan saw interpersonal development as taking place over seven stages, from infancy to mature adulthood. Personality changes can take place at any time but are more likely to occur during transitions between stages. In this theory, the patient falls under the final stage which is the adulthood stage which starts from 23 years of age. This is the time when a person establishes a stable relationship with a significant other person and develops a consistent pattern of viewing the world. The struggles of adulthood include financial security, career, and family. With success during previous stages, adult relationships and much needed socialization become easier to attain. Without a solid background, interpersonal conflicts that result in anxiety become more commonplace. The patient has developed well according to this theory. In fact, two years after the death of her first husband, she was able to find herself again, started a new life and got married with her second husband. She was able to get over her first husbands death in just 2 years. The patient can also be considered as having a good coping mechanism because she was able to adjust to possible crises in life. For instance, though they were not living a lavish life, but they were able to adopt well a life that suits their resources. As a couple, they were able to meet their basic needs in life.

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Medical Management
Doctors Orders DATE February 05, 2008 2:30 pm ORDERS Pls. admit under the service of Dr. Alenton. RATIONALE To render proper medical management

Secure consent to care.

For legal purposes which pertains to medical treatment and procedures. To obtain baseline data.

Temperature Pulse Respirations q 4 hrs. Nothing Per Orem temporary Start venoclysis with D5W 500cc at 10cc/hr. Labs. Complete Blood Count Sodium

To prevent the risk for aspiration. For saline lock; emergency IVTT drugs used.

To check for any hematologic unusualities. To check for serum sodium content in the body. To check for potassium content in the body. To check for any tissue damage. To check for liver functioning.

Potassium

Creatinine Serum Glutamic

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Pyrovic Transimenase Trop T (quantitative) Creatinine Kinase-MB-stat! Electrocardiogram 12 Leads To detect and diagnose Myocardial infarction. To immediately check for the degree of infarction To monitor cardiac functioning.

Chest X-ray Antero posterior (portable) Fasting Blood Sugar =Lipid Profile

To detect mediastinal abnormalities

To check for blood sugar level.

Meds. Nitroglycerin (Transderm) patches 5mg now x 12 OD. Aspirin 80mg 4 tabs now then 1 tab OD after(pc) lunch Treatment of Angina

Treatment and prophylaxis of Myocardial infarction

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 Clopidrogrel (Plavix) 75g 4 tabs now then once a day(OD) Captopril 25g tab now then three times a day (BID) Fondaparinux (Arixtra) 2.5mg Subcutaneous (SQ) now then OD Tramadol (Dolcet) 1 cap now then three times a day (TID) Tramadol (Dolcet) 1 cap now then three times a day (TID) Metoprolol (Neobloc) 80mg 1 tab now then twice a day (BID) Oxygen inhalation at 2 liters/ minute via nasal cannula. Moderate high back rest Complete Bed Rest without toilet privilege Intake and Output every shift.

Treatment of patients with acute coronary syndrome and myocardial infarction Treatment for Hypertension

Prevents the formation of thrombus

Prophylaxis for pain

Prophylaxis for pain Prevention of reinfarction in Myocardial infarction

To provide supplemental oxygen.

To promote lung expansion To prevent increase workload of the heart. To determine fluid retention and dehydration.

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 Monitor vital signs every hour and record Will inform Attending Physician Refer accordingly 5:13pm Adds meds.

To check for any unusualities

For proper management and care. To aid for further medical intervention

Atorvastatin (lipitor) 80mg 1 tab now then OD at Lactulose 20cc OD at hs. Decrease Captopril to 25g tab now then every 8hour. Decrease Metoprolol to 50g tab then BID Start Isoket drip: D5W 90cc +1 amp Isoket at 10cc/hr. Repeat ECG 12 Leads in morning Increase Aspirin to 80mg 2 tabs OD PC lunch Remove transderm patch.

Treatment of elevated Low density lipoprotein

Prevent Constipation Reduce the risk of hypotension

Reduce the risk of hypotension

Treatment for left ventricular failure secondary to acute Myocardial infarction For comparison purposes and to check for the effectivity of drugs To attain drug efficacy level.

Chest pain subsides; not needed for treatment.

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Attached to cardiac monitor. Ranitidine(Ulcin) 150g 2 tab BID PO May have soft, low salt. Low fat diet. Shift ranitidine PO to 50mg IVTT q 8hrs. Soft diet

To monitor cardiac functioning

7:03pm

Treatment for sour stomach in adults To meet nutritional needs intended for MI patient For fast drug absorption.

8:07pm

To meet nutritional needs intended for MI patient.

12 lead ECG with long lead 2 FBS lipid profile, uric acid, SGPT in am

To assess cardiac status

Aid to diagnosed for hyperglycemia, hyperuricemia and M.I Treatment for hypokalemia

Kalium durule 1 tab TIDx6 doses.

10:45pm

Increased Isoket to15cc/hr Give Tramadol 50mg IVTT now Increased Isoket to20cc/hr

To attain drug efficacy level

Treatment for moderate to severe pain To attain drug efficacy level.

10:50pm

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Increased Isoket to25cc/hr Increased Isoket to30cc/hr

To attain drug efficacy level.

11:00pm

To attain drug efficacy level.

11:30pm

Give morphine 4mg IVTT now. Shift ranitidine PO to 50mg IVTT q 8hrs. Pls. Follow-up repeat ECG with long lead 3 care of heart station.

Relief of moderate to severe acute pain For fast drug absorption

February 06, 2008 6:05 am

For continuous monitoring.

To follow Isoket drip: D5 water 90cc. plus 1 amp. Isokit at 30cc. / min. Metformin (Imax) 500mg. 1 tab BID Isoket drip to consume

Left ventricular failure secondary to acute Myocardial infarction Oral treatment for type 2 diabetes To obtain effectivity of medication Prophylaxis and treatment for angina pectoris. For saline lock; emergency IVTT drugs used. Aid to increase serum potassium level.

Imdur 60mg. 1 Tab BID

4:30 pm

IV follow-up with D5 Water 500cc.10cc/hour Add 1 banana per meal.

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February 07,2008 6:05pm

Limit visitors

To promote rest and decrease fatigue.

Facilitate ECG with long lead 2 in a.m February 08,2008 7:15 am Summary of meds:

For continuous monitoring.

Isosorbide Mononitrate (Imdur) 60mg 1 tab OD Isosorbide Dinitrate (Isordil) 5mg 1 tab 5L PRN for chest pain Aspirin 80mg 2 tabs OD PC lunch Clopidrogrel (Plavix) 750mg 1 tab OD Captopril 25mg tab q 8hrs Fondaparinux (Arixtra) 2.5mg OD SQ

Left ventricular failure secondary to acute Myocardial infarction

Treatment and prophylaxis of Myocardial infarction

Treatment of patients with acute coronary syndrome and myocardial infarction Treatment of patients with acute coronary syndrome and myocardial infarction Treatment for hypertension

Prophylaxis of Deep Vein thrombosis

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 Metoprolol 50mg tab BID PO Atorvastatin (lipitor) 80mg 1 tab OD at HS. Lactulose 20cc at HS hold for BM >/= 2x/day Metformin 500mg (Imax) 1 tab BID PO Ranitidine Hydrochloride (Zantac) 150mg 1 tab BID PO Increase Imdur to 60mg 1tab BID Vastaril MR 1 tab BID Now give Isordil q 5 mins for 3 doses of chest pain if not relieved by first dose. IVF to follow with PNSS 500c at 10cc/hr.

Prevention of reinfarction in Myocardial infarction Treatment of elevated Low density lipoprotein

Prevent constipation

Oral treatment for Type II diabetes mellitus

Prophylaxis for GI irritation

To attain drug efficacy level

Prophylaxis and treatment for Angina pectoris. Treatment and prevention of angina pectoris

2:00pm

For saline lock; emergency IVTT drugs used.

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February 2008 1:08am

9,

Metoclopramide (plazil) 10mg IVTT now

Prevention of nausea and vomiting

Aluminum Magnesium Hydroxide (maalox) 10ml now then TID 5:40am IVF to ff: PNSS 500cc @ 10cc/hr Repeat ECG today

Treatment for hyperacidity

Saline lock; for emergency IVTT drugs used For comparison purposes and to check for the effectiveness of the drug To attain drug efficacy level.

8:40am

Increase Maalox 10ml to QID before meals and HS Inform IMROD for any recurrence of chest pain and SOB 4:00pm Off O2 may have 02 PRN for dyspnea 200mg Cordarone 1 tab TID February 11,2008 May sit on bed with dangle legs.

For further medical management To aid patient during SOB

Treatment of ventricular arrhythmias To determine pt. ability to sit upright in her own

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February 12,2008

Summary of meds

Aspirin 80mg 2 tabs OD PC lunch PO Clopidogrel (Plavix) 75mg 1 tab OD PO

Treatment and prophylaxis of Myocardial infarction Treatment of patients with acute coronary syndrome and myocardial infarction Prophylaxis and treatment for hypertension Prophylaxis of Deep Vein thrombosis

Captopril 25mg tab q 8h Fondaparinux (Arixtra) 2.5mg OD SL Day 7 last dose at 6pm Tramadol(dolcet) 1 tab TID prn for pain Metoprolol 50mg tab BID

Moderate to severe pain

Hypertension , Angina Pectoris, Prevention of reinfarction in Myocardial Infarction Treatment of Low density Lipoproteins Prevent constipation

Atorvastatin (Lipitor) 80mg 1tab OD @ HS Lactulose 20cc OD, hold for BM > 2x/day Metformin (I-max) 500mg 1tab BID Ranitidine (Zantac) 150mg 1tab BID

Oral treatment for Type II diabetes Prophylaxis for GI irritation

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 Isosorbide Mononitrite (Imdur) 60mg 1tab BID Aluminum Magnesium Hydroxide (Maalox) 10ml QID Amniodarone (cordarone) 200mg 1tab tid 10:20am Repeat ECG 12 leads now DIET: decreased fat, decreased Na, hypertensive diet May sit on bedside chair

Relieve and prevent angina Neutralizes gastric acidity

Treatment of ventricular arrhythmias

For comparison purposes

To prevent hypertension( a precipitating factor) Ready for ambulation and slow assumption of activity daily living. To promote exercise and prevent sudden orthostatic hypotension. To assess cardiac status

May walk @ bedside with assistance.

7:55pm

ECG 12 lead now

Give metoclopramide(Plazil) 10mg IVTT now Refer for recurrent of vomiting and save vomitus care of IMROD May decrease Aspirin 80mg 1 tab OD pc lunch

Prevention of nausea and vomiting

For ocular inspection.

To prevent the risk of bleeding.

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 Hold Ranitidine

Shift to new drug ordered Pantoprazole

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Feb. 13, 2008

Start Pantoprazole (Pantoloc) 20mg 1 tab now then O.D P.O May walk inside the ward. B/P and Cardiac rate after walking.

Prophylaxis for epigastric hyperacidity

12:55p.m

To promote exercise, and improved blood circulation To monitor cardiac changes when doing certain activities. Epigastric hyperacidity subsides.

Feb. 14, 2008 8:10p.m

Discontinue Maalox

May walk to the bathroom with assistance Give Domperidone (Motilium) 1 tab am then BID.

Enhances self care and prevent from sudden orthostatic hypotension Treatment for flatulence

Feb.15, 2008 8:00am

I.V.F to consume then discontinue

Patients fluid status is stable, and in preparation for patients may go home.

May walk inside the ward B/P and Cardiac rate after walking and record

To promote exercise and blood circulation. To monitor cardiac changes when doing certain activities.

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12:30pm

Metoclopramide (plazil) 10mg. IVTT every 8 hours prn MGH

Prevention of nausea and vomiting

Feb. 16,2008 11:02 am

Patient may continue treatment at home For treatment compliance regimen. Treatment of essential Hypertension

Home medications

Telmisartan (Priton)40mg tab O.D

Clopidogrel (Plavix) 75mg 1 tab O.D Metoprolol 50mg tab BID Atorvastatin (Lipitor) 80mg 1 tab OD @ H.S ISMN (Imdur) 60mg 1 tab BID Amniodarone (Cordarone) 200mg 1 tab TID Aspirin 80mg 1 tab OD pc lunch Metformin (Imax)

Treatment of patients with acute coronary syndrome and Myocardial infarction Treatment for hypertension Prophylaxis and treatment for hyperlipidemia

Prophylaxis and treatment for Angina pectoris Treatment of ventricular arrhythmias

Prophylaxis for MI

Treatment for Type II

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500mg 1 tab BID Day Feb.20, 2008 at MRH clinic follow-up check-up. Photocopy all labs. Results (2copies)

diabetes mellitus To evaluate for the effectiveness of medical and nursing care. For legal and documentation purposes.

Blood Chemistry 02-05-08 Test Creatinine Na K ALT Normal Range .7 - 1.2 137 145 3.5 5.1 9 52 Results 1.3 mg/dl 132 mmol/L 3.4 mmol/L 3.0 u/L Implications Myocardial Infarction Hyponatremia Hypokalemia liver functioning decrease r/t drugs adverse effect and gerontologic consideration

CK-MB

0 18

7 u/L

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Differential Count 02-05-08 Test Segmenters Lymphocytes Eosinophils Normal Range 55 65 % 25 35 % 13% Results 46 53 01 Implications Suggest anemia Anemia Reduced in Stress

Hematology 02-05-08 Test HCT HGB RBC WBC Platelet Count Normal Range 35 50 % 11 16.5 g/dl 3.8 5.80 10/mm 5 10 10/mm 140,000 440,000 9,100 333,000 Results 29.4 9.8 Implications Iron Deficiency Anemia Iron Deficiency Anemia

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Chest x-ray Report 02-05-08 Examination Desired: CCXR Port Haziness seen in the left base Heart I magnified Aorta is calcified Spurs seen at the margins of the thoracic spine.

Impression: Probable left basal Pneumonia Atherosclerotic Aorta Thoracic Spondylosis

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Fasting Blood Sugar Lipid Profile 02-06-08 Test Glucose Uric Acid Normal Range 74 106 2.5 6.2 Results 132 mg/dL 8.4 mg/dL Implications Hyperglycemia Hyperuricemia,

Cholesterol Triglycerides Direct HGL LDL VDRL ALT

0 200 0 150 40 60 60 180 25 50 8 - 52

187 mg/dL 60 mg/dL 38 mg/dL 137 mg/dL 12 mg/dL 27 U/L

Hypercholesterolemia Atherosclerosis

Troponin T (Quantitative) 2.0 ng/ml 02-06-08 Interpretation of Results 1. < 0.03 ng/ml 2. Between 0.03 ng/ml &0.1 ng/ml 3. Between 0.1 ng/ml & 3.0 ng/ml 4. > 2.0 ng/ml Rationale Low Cardiac Risk Medium Cardiac Risk (Possible Myocardial damage) High Risk (Myocardial damage detected) Massive Myocardial damage has been detected

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HGT (Hemoglucotest) 02-08-08 94 mg/dL (N)

IVF Sheet 02-05-08 Bottle # 1 2 3 4 5 Types of Solution D5W 500cc Running hours Time Started gtts/min 10 cc/hr 2:45 PM 3:25 PM Rationale Isotonic solution Isotonic solution Isotonic solution 2:45 PM Isotonic solution Isotonic solution

D5W 90cc + 1 amp 10 cc/hr + 1 amp Isoket PNSS 500cc PNSS 500cc PNSS 500cc 10 cc/hr 10 cc/hr 10 cc/hr

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Electrocardiograph tracing

ECG findings Rhythm Rate: P.R. 0.20sec ECG Diagnosis sinus rhythm inferolateral and anterior wall ischemia Sinus Atrial 93bpm Q.R.S 0.10sec Axis Ventricular 93bpm Q.T. 0.44sec +39 Position Q.T. Ratio

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ECG findings Rhythm Rate: Atrial 93bpm P.R. 0.20 sec ECG Diagnosis - sinus rhythm

sinus Ventricular 93bpm Q.R.S. 0.08 sec

Axis Position Q.T. 0.44 sec

+10

- anterolateral wall ischemia - left ventricular hypertrophy by voltage criteria

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Pathophysiology with Anatomy and Physiology

A. Review of Anatomy and Physiology of the Organs Involved Cardiovascular System Heart For all its might, the cone-shaped heart is a relatively small, roughly the same size as a closed fistabout 12 cm (5 in) long, 9 cm (3.5 in) wide at its broadest point, and 6 cm (2.5 in) thick. Its mass averages 250 g (8 oz) in adult females and 300 g (10 oz) in adult males. The heart rests on the diaphragm, near the midline of the thoracic cavity. It lies in the mediastinum, a mass of tissue that extends from the sternum to the vertebral column between the lungs. About two-thirds of the mass of the heart lies to the left of the bodys midline. Visualize the heart as a cone lying on its side. The pointed end of the heart is the apex, which is directed anteriorly, inferiorly, and to the left. The broad portion of the heart opposite the apex is the base, which is directed posteriorly, superiorly, and to the right. In addition to the apex and the base, the heart has several surfaces and borders 9margins). The anterior surface is deep to the sternum and ribs. The inferior surface is the part of the heart between the apex and the right border and rests mostly on the diaphragm. The right border faces the right lung and extends from the inferior surface to the base. The left border, also called the pulmonary border, faces the left lung and extends from the base to the apex.

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Layers and Coverings of the Heart The heart is located between the lungs in the thoracic cavity and is surrounded and protected by the pericardium ( peri- _ around). The pericardium consists of an outer, tough fibrous pericardium and an inner, delicate serous pericardium. The fibrous pericardium attaches to the diaphragm and also to the great vessels of the heart. Like all serous membranes, the serous pericardium is a double membrane composed of an outer parietal layer and an inner visceral layer. Between these two layers is the pericardial cavity filled with serous fluid. The wall of the heart has three layers: the outer epicardium (epi- _ on, upon; cardia _ heart), the middle myocardium ( myo muscle), and the inner endocardium (endo- _ within, inward). The epicardium is the visceral layer of the pericardium. The majority of the heart is myocardium or cardiac muscle tissue. The endocardium is a thin layer of endothelium deep to the myocardium that lines the chambers of the heart and the valves. Surface Structures of the Heart The human heart has four chambers and is divided into right and left sides. Each side has an upper chamber called an atrium and a lower chamber called a ventricle. The two atria form the base of the heart and the tip of the left ventricle forms the apex. Auricles (auricle _ little ear) are pouch-like extensions of the atria with wrinkled edges. Shallow grooves called sulci (sulcus, singular) externally mark the boundaries between

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the four heart chambers. Although a considerable amount of external adipose tissue is present on the heart surface for cushioning, most heart models do not show this. Cardiac muscle tissue that composes the heart walls has its own blood supply and circulation, the coronary (corona_ crown) circulation. Coronary blood vessels encompass the heart similar to a crown and are found in sulci. On the anterior surface of the heart, the right and left coronary arteries branch off the base of the ascending aorta just superior to the aortic semilunar valve, and travel in the sulcus separating the atria and ventricles. These small arteries are supplied with blood when the ventricles are resting. When the ventricles contract, the cusps of the aortic valve open to cover the openings to the coronary arteries. A clinically important branch of the left coronary artery is the anterior interventricular branch, also known as the left anterior descending (LAD) branch that lies between the right and left ventricles and supplies both ventricles with oxygen-rich blood. This coronary artery is commonly occluded which can result in a myocardial infarct and, at times, death. Great Vessels of the Heart The great veins of the heart return blood to the atria and the great arteries carry blood away from the ventricles. The superior vena cava, inferior vena cava, and coronary sinus return oxygen-poor blood to the right atrium. The superior vena cava returns blood from the head, neck, and arms; the inferior vena cava returns blood from the body inferior to the heart. The coronary sinus is a smaller vein that returns blood from the coronary circulation. Blood leaves the right atrium to enter the right ventricle. From here, oxygen-poor blood passes out the pulmonary trunk, the only vessel that removes blood from the right ventricle. This large artery divides into the right and left pulmonary arteries that carry blood to the lungs where it is oxygenated. Oxygen-rich blood returns to the left atrium through two right and two left pulmonary veins. The blood then passes into the left ventricle that pumps blood into the large aorta. The aorta distributes blood to the systemic circulation. The aorta begins as a short ascending aorta, curves to the left to form the aortic arch, descends posteriorly and continues as the descending aorta. 37

Internal Structures of the Heart The heart has four valves that control the one-way flow of blood: two atrioventricular (AV) valves and two semilunar valves (semi- _ half; lunar _ moon). Blood passing between the right atrium and the right ventricle goes through the right AV valve, the tricuspid valve (tri _ three; cusp _ flap). The left AV valve, the bicuspid valve, is between the left atrium and the left ventricle. This valve clinically is called the mitral valve (miter _ tall, liturgical headdress) because the open valve resembles a bishops headdress. String-like cords called chordae tendineae (tendinous strands) attach and secure the cusps of the AV valves to enlarged papillary muscles that project from the ventricular walls. Chordae tendinae allow the AV valves to close during ventricular contraction, but prevent their cusps from getting pushed up into the atria. The two semilunar valves allow blood to flow from the ventricles to great arteries and exit the heart. Blood in the right ventricle goes through the pulmonary (semilunar) valve to enter the pulmonary trunk, a large artery. The aortic (semilunar) valve is located between the left ventricle and the aorta. These two semilunar valves are identical, with each having three pockets that fill with blood, preventing blood from flowing back into the ventricles. The two ventricles have a thick wall between them called the interventricular septum. Between the two atria is a thinner interatrial septum.

Coronary Circulation There are two major coronary arteries: the right and the left. These two arteries branch out of the aorta immediately after the aortic valve. The right coronary artery splits into the marginal branch, which feeds blood into the right ventricle, and the posterior interventricular branch, which supplies the left ventricle. The left coronary artery is notably larger than the right coronary artery because it feeds the left heart, which, as a result of it's more powerful contractions, requires a more vigorous blood flow. The left coronary artery splits into the anterior interventricular branch and a circumflex branch. The anterior interventricular branch runs towards the apex of the 38

heart, providing blood for both of the ventricles and the ventricular septum. The circumflex branch, on the other hand, follows the groove between the left atrium and the left ventricle, providing blood supply to both of these chambers until it reaches and joins with the right coronary artery in the posterior of the heart. The coronary arteries are especially subject to blockage and narrowing which can cause a depletion of blood to certain parts of the heart, possibly causing a heart attack.

Blood Flow through the Heart The function of the right side of the heart is to collect de-oxygenated blood, in the right atrium, from the body and pump it, via the right ventricle, into the lungs (pulmonary circulation) so that carbon dioxide can be dropped off and oxygen picked up (gas exchange). This happens through the passive process of diffusion. The left side (see left heart) collects oxygenated blood from the lungs into the left atrium. From the left atrium the blood moves to the left ventricle which pumps it out to the body. On both sides, the lower ventricles are thicker and stronger than the upper atria. The muscle wall surrounding the left ventricle is thicker than the wall surrounding the right ventricle due to the higher force needed to pump the blood through the systemic circulation. Starting in the right atrium, the blood flows through the tricuspid valve to the right ventricle. Here it is pumped out the pulmonary semilunar valve and travels through the pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein to the left atrium. It then travels through the mitral valve to the left ventricle, from where it is pumped through the aortic semilunar valve to the aorta. The aorta forks, and the blood is divided between major arteries which supply the upper and lower body. The blood travels in the arteries to the smaller arterioles, then finally to the tiny capillaries which feed each cell. The (relatively) deoxygenated blood then travels to the venules, which coalesce into veins, then to the inferior and superior venae cavae and finally back to the right atrium where the process began.

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Blood Vessels Blood circulates inside the blood vessels, which form a closed transport system, the so-called vascular system. Like a system of roads, the vascular system has its freeways, secondary roads, and alleys. As the heart beats, blood is propelled into the large arteries leaving the heart. It then moves successively smaller and smaller arteries and then into the arterioles, which feed the capillary beds in the tissues. Capillary beds are drained by venules, which in turn empty into the great veins (venae cavae) entering the heart. Thus arteries, which carry blood away from the heart, and veins, which drain the tissues and return the blood to the heart, are simply conducting vessels. Only the tiny hair-like capillaries, which extend and branch through the tissue and connect the smallest arteries (arterioles) to the smallest veins (venules), directly serve the needs of the body cells. The capillaries are the side streets or alleys that intimately intertwine among the body cells. It is only through their walls that exchanges between the tissue cells and the blood can occur. (Marieb, 2006)

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Layers of Blood Vessel Walls The walls of blood vessels have three coats, or tunics. The tunica intima which lines the lumen or interior of the blood vessels, is a thin layer of endothelium (squamous epithelial cells) resting on a basement membrane. Its cells fit closely together and form a slick surface that decreases friction as blood flows through the vessel lumen. (Marieb, 2006) The tunica media is the bulky middle coat. It is mostly smooth muscle and elastic tissue. The smooth muscle, which is controlled by the sympathetic nervous system, is active in changing the diameter of the vessels. As the vessel constrict or dilate, blood pressure increases or decreases, respectively. Marieb, 2006) The tunica externa is the outermost tunic; it is composed largely of fibrous connective tissue. Its function is basically to support and protect the vessels. (Marieb, 2006)

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The Microcirculation The microcirculation is that portion of the circulatory system for exchange of water, gases, nutrients, and waste material. As such, it is the most important part of the cardiovascular system because it is where the exchange with tissues takes place. Although the microcirculation is considered as a closed system, its walls are much more permeable than any other part of the circulation.

Factors Affecting Flow of Blood The flow of a fluid through a vessel is determined by the pressure difference between the two ends of the vessel and also the resistance to flow. Pressure Difference. For any fluid to flow along a vessel there must be a pressure difference otherwise the fluid will not move. In the cardiovascular system, the pressure head or force is generated by the pumping of the heart and there is a continuous drop in pressure from the left ventricle to the tissue and also from the tissue back to the right atrium. (Hinchliff, 2000) Resistance to Flow. Resistance is a measure of the ease with which a fluid flows through a tube: the easier it is the less resistance to flow, and vice versa. In the circulatory system, the resistance is usually described as vascular resistance,

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or also known as peripheral resistance. Resistance is essentially a measure of the friction between the molecules of the fluid, and between the tube wall and the fluid. The resistance depends on the viscosity of the fluid and the radius and length of the tube. (Hinchliff, 2000) Radius of the Tube . The smaller the radius of a vessel, the greater is the resistance to the movement of particles. Small alterations in the size of the radius of the blood vessels, particularly of the more peripheral vessels, can greatly influence the flow of blood. Atheromatous changes in the walls of large and medium-sized arteries cause narrowing of the lumen of the vessels and result in an increased vascular resistance. (Hinchliff, 2000) Length of the Tube. The longer the tube, the greater the resistance to the flow of liquid through it. A longer vessel will require a greater pressure to force a given volume of liquid through it than will a shorter vessel. (Hinchliff, 2000) Viscosity of the Fluid. Viscosity is a measure of the intermolecular or internal friction within a fluid or in other words, of the tendency of the fluid to resist flows. The greater the viscosity of the fluid, the greater is the force required to move that liquid. (Hinchliff, 2000)

Blood Blood is a specialized bodily fluid (technically a tissue) that is composed of a liquid called blood plasma and blood cells suspended within the plasma. The blood cells present in blood are red blood cells (also called RBCs or erythrocytes), white blood cells (including both leukocytes and lymphocytes) and platelets (also called thrombocytes). Plasma is predominantly water containing dissolved proteins, salts and many other substances; and makes up about 55% of blood by volume. Mammals have red blood, which is bright red when oxygenated, due to hemoglobin. Some animals, such as the horseshoe crab use hemocyanin to carry oxygen, instead of hemoglobin.

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By far the most abundant cells in blood are red blood cells. These contain hemoglobin, an iron-containing protein, which facilitates transportation of oxygen by reversibly binding to this respiratory gas and greatly increasing its solubility in blood. In contrast, carbon dioxide is almost entirely transported extracellularly dissolved in plasma as bicarbonate ion. White blood cells help to resist infections and parasites, and platelets are important in the clotting of blood. Blood is circulated around the body through blood vessels by the pumping action of the heart. Arterial blood carries oxygen from inhaled air to the tissues of the body, and venous blood carries carbon dioxide, a waste product of metabolism produced by cells, from the tissues to the lungs to be exhaled. Medical terms related to blood often begin with hemo- or hemato- (BE: haemo- and haemato-) from the Greek word "" for "blood." Anatomically and histologically, blood is considered a specialized form of connective tissue, given its origin in the bones and the presence of potential molecular fibers in the form of fibrinogen.

Constituents of human blood Blood accounts for 7% of the human body weight, with an average density of approximately 1060 kg/m, very close to pure water's density of 1000 kg/m3. The average adult has a blood volume of roughly 5 litres, composed of plasma and several kinds of cells (occasionally called corpuscles); these formed elements of the blood are erythrocytes (red blood cells), leukocytes (white blood cells) and thrombocytes (platelets). By volume the red blood cells constitute about 45% of whole blood, the plasma constitutes about 55%, and white cells constitute a minute volume. Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics; its flow properties are adapted to flow effectively through tiny capillary blood vessels with less resistance than plasma by itself. In addition, if all human haemoglobin was free in the plasma rather than being contained in RBCs, the circulatory fluid would be too viscous for the cardiovascular system to function effectvely.

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Cells 4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In mammals, mature red blood cells lack a nucleus and organelles. They contain the blood's hemoglobin and distribute oxygen. The red blood cells (together with endothelial vessel cells and other cells) are also marked by glycoproteins that define the different blood types. The proportion of blood occupied by red blood cells is referred to as the hematocrit, and is normally about 45%. The combined surface area of all the red cells in the human body would be roughly 2,000 times as great as the body's exterior surface. 4,000-11,000 leukocytes: White blood cells are part of the immune system; they destroy and remove old or aberrant cells and cellular debris, as well as attack infectious agents (pathogens) and foreign substances. The cancer of leukocytes is called leukemia. 200,000-500,000 thrombocytes: Platelets are responsible for blood clotting (coagulation). They change fibrinogen into fibrin. This fibrin creates a mesh onto which red blood cells collect and clot, which then stops more blood from leaving the body and also helps to prevent bacteria from entering the body.

Plasma About 55% of whole blood is blood plasma, a fluid that is the blood's liquid medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.73.0 litres in an average human. It is essentially an aqueous solution containing 92% water, 8% blood plasma proteins, and trace amounts of other materials. Plasma circulates dissolved nutrients, such as, glucose, amino acids and fatty acids (dissolved in the blood or bound to plasma proteins), and removes waste products, such as, carbon dioxide, urea and lactirc acid. Other important components include:

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Serum albumin Blood clotting factors (to facilitate coagulation) Immunoglobulins (antibodies) Various other proteins Various electrolytes (mainly sodium and chloride)

The term serum refers to plasma from which the clotting proteins have been removed. Most of the proteins remaining are albumin and immunoglobulins. The normal pH of human arterial blood is approximately 7.40 (normal range is 7.357.45), a weak alkaline solution. Blood that has a pH below 7.35 is too acidic, while blood pH above 7.45 is too alkaline. Blood pH, arterial oxygen tension (PaO 2), arterial carbon dioxide tension (PaCO2) and HCO3 are carefully regulated by complex systems of homeostasis, which influence the respiratory system and the urinary system in the control the acid-base balance and respiration. Plasma also circulates hormones transmitting their messages to various tissues.

Color Hemoglobin Hemoglobin is the principal determinant of the color of blood in vertebrates. Each molecule has four heme groups, and their interaction with various molecules alters the exact color. In vertebrates and other hemoglobin-using creatures, arterial blood and capillary blood are bright red as oxygen impacts a strong red color to the heme group. Deoxygenated blood is a darker shade of red with a bluish hue; this is present in veins, and can be seen during blood donation and when venous blood samples are taken. Blood in carbon monoxide poisoning is bright red, because carbon monoxide causes the formation of carboxyhemoglobin. In cyanide poisoning, the body cannot utilize oxygen, so the venous blood remains oxygenated, increasing the redness. While hemoglobin containing blood is never blue, there are several conditions and diseases where the color of the heme groups make the skin appear blue. If the heme is oxidized,

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methemoglobin, which is more brownish and cannot transport oxygen, is formed. In the rare condition sulfhemoglobinemia, arterial hemoglobin is partially oxygenated, and appears dark-red with a bluish hue (cyanosis), but not quite as blueish as venous blood. Veins in the skin appear blue for a variety of reasons only weakly dependent on the color of the blood. Light scattering in the skin, and the visual processing of color play roles as well. Skinks in the genus Prasinohaema have green blood due to a buildup of the waste product biliverdin.

Hemocyanin The blood of most molluscs, including cephalopods and gastropods, as well as some arthropods such as horseshoe crabs contains the copper-containing protein hemocyanin at concentrations of about 50 grams per litre. Hemocyanin is colourless when deoxygenated and dark blue when oxygenated. The blood in the circulation of these creatures, which generally live in cold environments with low oxygen tensions, is grey-white to pale yellow, and it turns dark blue when exposed to the oxygen in the air, as seen when they bleed. This is due to change in color of hemocyanin when is it oxidized. Hemocyanin carries oxygen in extracellular fluid, which is in contrast to the intracellular oxygen transport in mammals by hemoglobin in RBCs.

Pancreatic Islets The pancreas, located close to the stomach in the abdominal cavity is a mixed gland. Probably the best-hidden endocrine glands in the body are the pancreatic islets, formerly called the islets of Langerhans. These little masses of hormone-producing tissue are scattered among the enzyme-producing acinar tissue of the pancreas. Two important hormones produced by the islet cells are insulin and glucagons. (Marieb, 2006)

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High levels of glucose in the blood stimulate the release of insulin from the beta cells of the islets. Insulin acts on just about all body cells and increases their ability to transport glucose across their plasma membranes. Once inside the cells, glucose is oxidized for energy or converted to glycogen or fat for storage. These activities are also speeded up by insulin. Since insulin sweeps the glucose out of the blood, its effect is said to be hypoglycemic. As blood glucose levels fall, the stimulus for insulin release ends (negative feedback control). Insulin is the only hormone that decreases blood glucose levels. Insulin is absolutely necessary for the use of glucose by the body cells. Without it, essentially no glucose can get into the cells to be used. (Marieb, 2006) Glucagons act as an antagonist of insulin; that is, it helps to regulate blood glucose levels but is a way opposite to that of insulin. Its release by the alpha cells of the islets is stimulated by low blood levels of glucose. Its action is basically hyperglycemic. Its primary target organ is the liver, which stimulates to break down stored glycogen to glucose and to release glucose into the blood. (Marieb, 2006)

Insulin The main function of the insulin is to participate in maintaining homeostasis of blood glucose level and to promote other metabolic activities that are anabolic. When absorbed nutrients, especially glucose, are in excess of immediate needs insulin promotes storage. It reduces high blood nutrients by:

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Acting on cell membranes and stimulating uptake and utilization of glucose by muscles and connective tissue cells; Increasing conversion of glucose to glycogen, especially in the liver and skeletal muscles; Accelerating uptake of amino acids by cells, and the synthesis of proteins; Promoting synthesis of fatty acids and storage of fat in adipose tissue, and; Preventing the breakdown of protein and fat and gluconeogenesis. Glucagon The effect of glucagon is increasing blood glucose levels by stimulating: Conversion of glycogen to glucose (in the liver and skeletal muscle); Gluconeogenesis, the manufacture of glucose by the body from noncarbohydrate materials. (Burke, 1995) Somatostatin The effect of somatostatin (also produced by hypothalamus) is to inhibit the secretion of both insulin and glucagons. It delays intestinal absorption of glucose. (Smeltzer, 2007)

Metabolism Metabolism is a broad term referring to all chemical reactions that are necessary to maintain life. In involves catabolism, in which substances are broken down to simpler substances, and anabolism, in which larger molecules or structures are built from smaller ones. During catabolism, energy is released and captured to make ATP, the energy-rich molecule used to energize all cellular activities, including catabolic reactions. (Marieb, 2006)

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Just as an oil furnace uses oil (its fuel) to produce heat, the cells of the body use carbohydrates as their preferred fuel to produce cellular energy (ATP). Glucose, also known as blood sugar, is the major breakdown product of carbohydrate digestion. Glucose is also the major fuel used for making ATP in most body cells. Basically, the carbon atoms released leave the cells as carbon dioxide, and the hydrogen atoms removed (which contain energy-rich electrons) are eventually combined with oxygen to form water. These oxygen-using events are referred to collectively as cellular respiration. (Marieb, 2006) The overall reaction is summed up simply as: C6H12O6 + 6 O2 => 6 CO2 + 6 H20 + ATP (energy).

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Nursing Assessment (System Review and Nursing Assessment II)

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Nursing Management
Ideal Nursing Management Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular resistance, vasoconstriction Actions/Interventions Independent Provide calm, restful surroundings, Help reduce sympathetic stimulation; minimize environmental activity/noise. promotes relaxation. Limit the number of visitors and length of stay. Maintain activity restrictions, e.g. Reduces physical stress and tension bedrest/chair rest; schedule periods of that affect blood pressure and the uninterrupted rest; assist client with course of hypertension. self-care activities as needed. Provide comfort measures, e.g. back Decreases discomfort and may reduce and neck massage, elevation of head. sympathetic stimulation. Instruct in relaxation techniques, Can reduce stressful stimuli, promotes guided imagery, distractions. relaxation. Maintain activity restrictions, e.g. Reduces physical stress and tension bedrest/chair rest; schedule periods of that affect blood pressure and the uninterrupted rest; assist client with course of hypertension self-care activities as needed. Provide comfort measures, e.g. back Decreases discomfort and may reduce and neck massage, elevation of head. sympathetic stimulation. Instruct in relaxation techniques, Can reduce stressful stimuli, produce guided imagery, distractions calming effect, thereby reducing BP Dependent Rationale

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Administer medications as indicated; Thiazide diuretics, e.g. chlorothiazide (Diuril); hydrochlorothiazide (Esidrix/HydroDIURIL); bendroflumethiazide (naturetin); indapamide (Lozol); metolazone (Diulol); quenthinazone (Hydromox)

Diuretics are considered first-line medications for uncomplicated stage I or II hypertension and may be used alone or in association with other drugs (such as -blockers) to reduce BP in clients with relatively normal renal function. These diuretics potentiate the effects of other antihypertensive agents as well, by limiting fluid retention, and may reduce the incidence of strokes and heart failure

Nursing Diagnosis: Activity intolerance related to generalized weakness Actions/Interventions Independent Instruct client in energy- conserving techniques e.g., suing chair when showering, sitting to brush teethe or comb hair, carrying out activates at a slower pace Energy-saving techniques reduce the energy expenditure thereby assisting in equalization of oxygen supply and demand Rationale

Encourage progressive activity/self- Gradual activity progression prevents a 0care when tolerated. Provide sudden increase in cardiac workload. assistance as needed. Providing assistance only as needed encourages independence in performing activities

Nursing Diagnoses: Risk for impaired Gas Exchange related to alveolar-capillary membrane changes, e.g. fluid collection/shifts into interstitial space/alveoli Actions/Interventions Independent Encourage frequent position changes Helps prevent pneumonia atelectasis and Rationale

Maintain chair/bed rest, with head of Reduce oxygen consumption/demands bed elevated 20-30 degrees, semi-

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fowlers position. Support arms with and promotes maximal lung inflation. pillows Dependent Administer supplemental oxygen as INcre4ases alveolar oxygen indicated concentration, which may correct/reduce tissue hypoxemia.

Nursing Diagnosis: Knowledge deficit related to Lack of information/misunderstanding of medical condition/therapy needs. Actions/Interventions Independent be alert to signs of avoidance, e.g., Natural defenses mechanisms, such as changing subject away from anger or denial of significance of information being presented or situation, can block learning, affecting extremes of behavior patients responses and ability to assimilate information. Encourage identification/reduction of these behaviors/chemicals have direct individual risk factors, e.g., smoking/alcohol consumption, obesity. adverse effect on cardiovascular function and may impede recovery, increase risk for complications Educate client regarding gradual Gradual increase in activity increases resumption of activities (walking, work, strength and prevents overexertion, recreational activity. may enhance, collateral circulation, and allows return to normal lifestyle. Emphasizes importance of contacting Timely evaluation/intervention physician if chest pain, change in prevent complications. anginal pattern or other symptoms recur. may Rationale

Stress importance of reporting post MI-complication of pericardial development of fever in association inflammation requires further medical w3ith diffuse/atypical chest pain and evaluation/intervention. joint pain

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Nursing diagnosis: Ineffective coping related to situational crisis Actions/Intervention Independent Encourage patient to talk about what is Provides clues to assist patient to happening at this time and what has develop coping and regain equilibrium. occurred to precipitate feelings of helplessness and anxiety. Allow patient to be dependent in the beginning, with gradual resumption of independence in ADLs. Self-care and other activities. Make opportunities for patient to make simple decisions about care/other activities when possible, accepting choice not to do so. Promotes feelings of security (patient will know nurse will provide safety). As control is regained, patient has the opportunity to develop adaptive coping/problem-solving skills. Rationale

Accept verbal expressions or anger, Verbalizing angry feelings in important setting limits on maladaptive behavior process for resolution of grief and loss. However, preventing destructive actions (such as striking out at others) preserves patients self-esteem. Discuss feelings of inability to find meaning in life/reason for living, feelings of futility or alienation from God. Promote safe and hopeful environment, as needed. Identify positive aspects of this experience and assist patient to view it as a learning opportunity. Provide support for patient to problemsolve solutions for current situation. Provide information and reinforce reality as patient begins to ask questions; look at what is happening. Crisis situation may evoke, questioning of spiritual beliefs, affecting ability to cope with current situation and plan for the future. May be helpful while patient regains inner control. The ability to learn from the current situation can provide skills for moving forward Helping/SO to brainstorm possible solutions (giving consideration to the pros and cons of each) promotes feelings of self-control/esteem.

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Provide for gradual implementation and Reduces anxiety of sudden change and continuation of necessary behavior and allows for developing new and creative lifestly changes. Reinforce positive solutions adaptation/ new coping behaviors Dependent Refer to other resources as necessary Additional assistance may be needed (eg. Clergy, psychiatric clinical nurse to help patient resolve problems or specialist/psychiatrist, family/ marital make decisions. therapist, addiction support groups).

Nursing Diagnosis: Family Coping, ineffective: risk for compromised related to prolonged disease/disability progression that exhausts the supportive capacity of family members. Actions/Interventions Independent Evaluate pre-illness/current behaviors Information about family problems that may be interfering with the (e.g., divorce/ separation, financial care/recovery of client limitations, substance use) will be helpful in determining options and developing an appropriate plan of care. Discuss underlying reasons for patient When family members know why behaviors with family. patient is behaving in different ways, it helps them understand and accept/deal with situation Assist family/patient to understand who owns the problem and who is responsible for resolution. Avoid balance blame or guilt. Involve family in information giving, problem solving and care of patient as feasible. Identify other ways of demonstrating support while maintaining patients independence Dependent When these boundaries are defined, each individual can begin to take care of own self and stop taking care of others in inappropriate ways. Information can reduce feelings of helplessness. Involvement in care enhances feelings of control and self worth Rationale

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Refer to appropriate resources for May need additional assistance in assistance as indicated (e.g. resolving family issues. counseling, psychotherapy, financial, spiritual).

Nursing Diagnosis: Therapeutic Regimen: risk for ineffective management related to perceived barriers; economic difficulties, side effects of therapy, mistrust of regimen and/or healthcare personnel; complexity of healthcare system. Action/Intervention Independent Review patients/SOs knowledge and understanding of the need for treatment/medication, as well as consequences of the need for treatment/medication, as well as consequences of actions and choices. Not ability to comprehend information, including literacy, level of education, primary language. Be aware of developmental chronological age. Provides opportunities to clarify viewpoints/misconceptions. Verifies that patient/SO has accurate/ factual information with which to make informed choices. Rationale

and Impacts ability to understand own needs/incorporate into treatment regimen.

Determine cultural, spiritual, and health Provide insight into thoughts/factors beliefs and ethical concerns related to individual situation. Beliefs will affect patients perception of . situation and participation in treatment regimen. Treatment may be incongruent with patients social/cultural lifestyle and perceived role/responsibilities

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Nursing Diagnosis: Pain related to an imbalance in oxygen supply and demand Action/Interventions Position patient in bed in semifowlers position Administer oxygen by way of nasal cannula at 4L/min. maintain oxygen saturation at 92% or above. Administer nitroglycerin and morphine based on vital signs and pain relief. Rationale >this allows for rest and adequate chest excursion, to increase available oxygen and to decrease cardiac work. >to increase oxygen supply. decrease pain and PVCs May

> both medications will help alleviate pain by decreasing venous return to the heart, thereby decreasing cardiac work. Morphine will also help to decrease the patients sensation of pain. >both medications may decrease BP because both will decrease venous return. Intra-arterial blood pressure monitoring may be used if condition warrants.

Monitor BP closely by way of non-invasive BP monitor.

Attach electrodes for continuous >increased rate may indicate heart bedside cardiac monitor. Monitor block; dysrhythmias are common heart rate and rhythm frequently. initially, increased frequency suggests ischemia. Administer and monitor thrombolytic therapy Monitor signs of bleeding; avoid unnecessary venous or arterial punctures. >may help to relieve the coronary occlusion. >thrombolytics cause clot lysis may cause bleeding.

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Nursing Diagnosis: decreased cardiac output related to decreased cardiac contractility and dysrrhythmias. Actions/ Interventions Administer I.V fluids as ordered Rationales >I.V fluid may be necessary to compensate for the decreased venous return caused by nitrates and morphine. >left ventricular failure may develop as a result of the decreased myocardial contractility and/ or the administration of excess fluids. >Monitor urine output hourly >a change in mental status may indicate a decrease in cardiac output. >dysrythmias such as PVCs result in a decreased stroke volume and less coronary artery filling time. Frequent monitoring, especially during the first few hours of an acute MI and during thrombolytic therapy administration, is necessary to prevent and treat lethal dysrhythmias >administration of vasopressors with aqcute MI is controversial in that they may cause an increase in systemic vascular resistance, which increases cardiac work. >these parameters will help to guide fluid volume administration, vasoactive drug administration and assess cardiac performance.

Monitor closely for signs of developing left ventricular failure (e.g auscultate lung sounds for crackles and heart sounds for s3). Monitor urine output hourly Monitor mental status Interpret rhythm strip at least every 4 hours, more frequently as condition warrants. Administer antiarrythmics, if indicated.

Administer vasopressors; titrate to BP response.

Employ hemodynamic monitoring: central venous pressure CVP and pulmonary artery catheter and pulmonary artery pressure.

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Nursing Diagnosis: Anxiety related to fear of death Interventions/ Actions Explain equipment, procedures, and need for frequent assessment to the patient and family. Discuss visiting hours and the need to allow for rest Observe for autonomic signs and symptoms for anxiety (eg increase heart rate, BP and respiratory rate) Administer diazepam (valium) or morphine Offer back massage Rationales >helps conserve energy.

>anxiety is associated with an increase in sympathetic activity, which increases cardiac work.

>may aid in limiting patients anxiety

>touch and massage may promote relaxation.

Maintain continuity of care

>consistency of routine and promotes trust and confidence.

staff

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Nursing Diagnosis: activity intolerance related to imbalance between myocardial oxygen supply and demand. Actions/Interventions Document heart rate and rhythm and BP changes before, during, and after activity as indicated. Correlate with reports of chest pain/shortness of breath. Rationale >trends determine patients response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/ return to bedrest, changes in medication regimen or use of supplemental oxygen.

Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities Instruct patient to avoid increasing abdominal pressure . e.g straining during defecation

>reduces myocardial workload/ oxygen consumption, reducing risk of complications (e.g extension of MI).

>activities that require holding of breath and bearing down can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP.

Explain pattern of graded increase increases of activity level e.g, getting up to commode or sitting in a chair

>progressive activity provides controlled demand on the heart, increasing strength and preventing over exertion.

Review signs and symptoms reflecting intolerance of present activity level.

>palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate changes in exercise regimen or medication.

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Nursing Diagnosis: Ineffective tissue perfusion related to interruption of blood flow. ACTIONS/INTERVENTIONS Investigate sudden changes or continued alterations in mentation e.g, anxiety, confusion, lethargy, stupor. RATIONALE >cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte/ acid-base variations, hypoxia, and systemic emboli.

Inspect pallor, cyanosis, mottling, cool/clammy skin. Note strength of peripheral pulse.

>systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses.

Monitor respirations, note work of breathing

>cardiac pump failure and/ or ischemic pain may precipitate respiratory distress; however, sudden/ continued dyspnea may indicate thromboembolic pulmonary complications. >decreased intake/ persistent nausea may relut in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function.

Monitor intake. Note changes in urine output. Record urine specific gravity as indicated.

>reduces mortality in MI patients, and Administer medications as indicated auch as clopidogrel is taken daily. (plavix) Assessing GI function, noting anorexia, decreased/absent bowel sounds, nausea/vomiting, abdominal, distention, constipation >reduced blood flow to mesentery can produce GI dysfunction. E.g, loss of peristalsis. Problems may be potentiate/ aggravated by use by use of analgesics, decreased activity and dietary changes.

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SOAPIE
S Dali ra ko kapuyon kung ipabakod ug ipalakaw-lakaw as verbalized by the client.

Heart rate of 52 beats per minute O Generalized weakness Cold, clammy skin (Temp-36.8C) A Decreased cardiac output related to underlying physiological condition

SHORT TERM: at the end of 1 hour, the client will be able to verbalize feelings to cooperate P LONG TERM; at the end of 2 days, the client will be able to participate in daily activities a. monitored pulse rate every four hours b. monitored skin temperature every four hours c. instructed patient to report chest pain immediately d. instructed patient to avoid overexertion ( e.g., straining during bowel movements e. administered antiarrythmic drugs, such as cordarone, as prescribed by the doctor To better detect arrhythmias which indicate cardiac arrest or other complications. Cold, clammy skin may indicate decreased cardiac output

This may be a signal of myocardial hypoxia or injury

Overexertion increases myocardial oxygen demand which may cause bradycardia and decreased cardiac output

Antiarryythmic drugs acts on peripheral smooth muscle to decrease peripheral resistancce

At the end of 1 hour, the client verbalized cooperation

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No verbal cues Moist, cool clammy skin (T-36.8C) Non palpable dorsalis pedis both left and right Poor capillary refill- 5 seconds

O Pale extremities Diaphoresis Pulse rate of 52 beats per minute A Ineffective peripheral tissue perfusion related to decreased cardiac output SHORT TERM: at the end of 1 hour, the client will be able to have an improvement on peripheral tissue perfusion P LONG TERM; at the end of 1 week, the patient will maintain improved peripheral tissue perfusion A. Assisted the client to ambulate but within her tolerance B. Monitored and recorded intake and output C. Provided a diet is low in fat and sodium D. Instructed the significant others not to let the client wear tight clothing E. Administered anticoagulants such as clopidogrel as prescribed by the doctor E To prevent thrombus formation, thus, improving blood circulation

May be a sign of decreased renal perfusion

Foods high in fat and sodium contributes to the plaque formation that leads to decreased blood flow.

To prevent impairment of blood flow.

To dilute and enhance further blood flow to periphery

At the end of 1 hour, the client was able to have an improvement on peripheral tissue perfusion

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kinahanglan pa ko agakon para makabakod as verbalized by the client

Heart rate of 52beats per minute O Generalized weakness Unable to prompt up by herself

Activity intolerance related to generalized body weakness.

SHORT TERM: at the end of 1 hour, the client will be able to participate in carrying out activities while on bed with assistance P LONG TERM: at the end of 2 days, the client will be able to continue in performing activities of daily living. A. Taken and recorded vital signs before and after the activities B. Performed passive range of motion C. Encouraged client to have frequent rests during activities D. Provided relief through comfort measures E. Reminded the significant others in assisting the patient This is to provide baseline data To asses the degree of motion

To prevent the patient from fatigue

To enhance ability to participate in activities To improve the mobility of the patient

At the end of 1 hour, the client was able to participate in carrying out activities while on bed with assistance.

Dili man kayo ko gakaon as verbalized by the client

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Decreased consumption of her daily meal- ate 3 tbsp. of her share O Decreased weight (Present weight of 71 kilograms from her Past weight- 73 kilograms)

Imbalanced nutrition: less than body requirements related to loss of appetite

SHORT TERM: at the end of 30 minutes, the patient will increase consumption of daily meal. P LONG TERM: at the end of 1 day, the client will be able to demonstrate behaviors and lifestyle changes to maintain appropriate weight. A. Presented meal in an attractive manner B. Provided small frequent feeding I C. Provided a well-ventilated area, conducive for eating D. reminded the client the importance of eating E. regulated and monitored IV fluids as ordered by the doctor To entice the clients appetite To encourage the client to eat To improve the clients appetite To determine weight loss and weight gain To provide nutritional supplements

At the end of 30 minutes, the patient was able to increase consumption of daily meal (8 tbsp per meal).

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dili ko kaklaro as verbalized by the client S

Cloudiness of the right eye O Presence of senile ring around the patients left eye History of cataract surgery

Risk for injury related to cloudiness of the eye secondary to aging

SHORT TERM: at the end of 1 hour, the client will be able to reduce risk factors and protect self from injury. P LONG TERM: at the end of 3 days, the client will be able to verbalized feeling of safety, comfort and security.

A. Instructed the significant others to never to leave the client B. Placed pillow at the sides of the client I C. Raised side rails. D. Anticipated with the patients needs. E. Provided information regarding condition that may result increased risk of injury

To prevent any accidents that may happen to the client This is to promote safety To prevent patient from falling off the bed To avoid accidents that may cause injury to the client To reduce the risk of possible occurrence of injuries

At the end of 1 hour, the client was able to reduce risk factors and protect self from injury.

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daku man kayo mi ug bayrunon diri, kanusa man ko makauli? as verbalized by the client

Stares blankly for about a minute O Restlessness (consistent in changing side lying position from one side to the other) Financial resources with a Family income of - 15,000 pesos/ month Facial Grimace A Anxiety related to present status secondary to hospital confinement SHORT TERM: at the end of 45 minutes, the client will be able to adapt to the situational crisis and have a positive outlook with her condition. LONG TERM: at the end of 2 days, the patient will be able to cope with the present situation A. Encouraged client to express feelings B. Listened attentively concerning clients feelings C. Diverted clients attention through listening to a soothing music D. Provided a less stressful environment E. Instructed significant others to schedule visiting others One way of releasing tension and assessing the level of anxiety. To identify clients problem regarding the situation

This will help client divert her attention for the time being

To prevent client from an environment that could trigger stress.

To promote restful environment.

At the end of 45 minutes, the client was able to have a sense of control over the current crisis

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di nako ganahan mubalik sa doctor, pareha raman gihapon, nana man akong karaan na record sa ECG, pwede nato as verbalized by the client

Restlessness Information misinterpretation Inadequate follow through of instructions

Knowledge deficit related to disease condition

SHORT TERM: at the end of 1 hour, the client will participate in learning process regarding her current condition LONG TERM: at the end of 2 days, the client will understand the importance of her treatment.

A. Encouraged client to verbalize feelings B. Discussed possible options to the family regarding her present treatment I C. Provided information for client to refer to. D. Provided information about additional learning resources E. Emphasized the importance of follow up check-up

To know clients current problem Giving information to the family members and clients knowledge regarding disease condition helps client cope with present condition To facilitate learning regarding her treatment To promote wellness To have a better understanding of her condition.

At the end of 1 hour, the client was able participate in the learning process.

di ko ganahan muinom sa akong mga tambal kay daghan kaayo. As verbalized by the client

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Non compliance with medication

Risk for ineffective therapeutic regimen

SHORT TERM: at the end of 45 minutes, the client will be able to comply with the medications. P LONG TERM: at the end 2 days, the client will be able to properly comply with the medications A. Encouraged client to verbalize feelings B. Listened attentively to client I C. Discussed to verbalize options regarding treatment of condition D. Refrained family members from verbalizing negative expectations with the presence of the client E. Referred patients concern to the attending physician To express clients concerns By actively listening, this helps in determining clients problems and feel comfortable To provide alternatives and choices regarding the course of treatment To not show inacceptance of the situation To help patient understand the importance of proper compliance

At the end of 1 hour, the family was able to verbalized feelings of control over their plight.

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Progress Notes
Date: February 12, 2008 Day 1 Specific Objectives: At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able to: 1. Be acquainted with the management and staff of Saint Josephs Ward 5. 2. Ask permission from the family and from Mrs. F. to be the subject of the case study. 3. Have the formal/ written consent signed, and receive the managements approval. 4. Inform the family and Mrs. F about the purposes and objectives of the visit. 5. Establish a contract that notes the Nurse Client Responsibilities. 6. Conduct an interview about Mrs. Fs family history. 7. Conduct an assessment about Mrs. Fs past and present health conditions. 8. Identify problems related to Mrs. Fs present health condition. 9. Set goals for care. 10. Inform Mrs. F about follow up visits of the group.

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Problems identified: Blurred vision at the right eye Epigastric pain Nausea and vomiting Pallor Diaphoresis Weak pulses (radial, femoral, popliteal, posterior tibial) Absence of pulse beats at the Dorsalis Pedis site Weakness of lower extremities Restless

Evaluation: After 2 hours, the group was able to meet the objectives for the day. The group was able to meet Mrs. F and the family; explained the purpose of the meeting, established individual roles, identified problems, and set up parameters of succeeding meetings.

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Date: February 13, 2008 Day 2 Specific Objectives: At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able to: 1. Ask consent from the family and Mrs. F for further interview and assessment. 2. Conduct further interview about Mrs. Fs family history. 3. Conduct an assessment about Mrs. Fs past and present health condition. 4. Identify problems related to Mrs. Fs health condition. 5. Apply nursing interventions for the problems identified. 6. Provide health teachings for the improvement of Mrs. Fs health condition. 7. Evaluate progress after providing nursing care. 8. Remind Mrs. Fabout follow up visits of the group.

Problems identified: Blurred vision at the right eye Pallor Diaphoresis Weak pulses (radial, femoral, popliteal, posterior tibial) Absence of pulse beats at the Dorsalis Pedis site Weakness of lower extremities

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 Evaluation:

Restless

After 8 hours, the days objectives were met. The group was able to conduct further assessment; applied nursing interventions for the problems identified, noted new problems and complaints, and reminded Mrs. F about the next visits.

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Date: February 14, 2008 Day 3 Specific Objectives: At the end of 8 hours clinical duty at Maria Reyna Hospital, the group will be able to: 1. Ask consent from the family and Mrs. F for further interview and assessment. 2. Conduct further interview about Mrs. Fs family history. 3. Conduct further assessment about Mrs. Fs past and present health condition 4. Identify problems regarding Mrs. Fs health condition. 5. Render nursing interventions for the problems identified. 6. Evaluate progress after providing nursing care. 7. Provide health teachings for the improvement of Mrs. Fs health condition. 8. Copy data from Mrs. Fs chart. 9. Remind Mrs. F about follow up visits of the group.

Problems identified: Blurred vision Abdominal fullness Diaphoresis Pallor Weak Pulse (femoral, popliteal, posterior tibial) Absence of pulse beats at the dorsalis pedis site Weakness of lower extremities

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Evaluation: After 2 hours, the objectives of the group were met. With the family and Mrs. Fs consent, the group was able to conduct further assessment about Mrs. Fs past and present health conditions and was able to apply nursing interventions in relation to the problems identified by the group and copied data from Mrs. Fs chart and reminded Mrs. F about succeeding visits of the group.

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Date: February 15, 2008 Day 4 Specific Objectives: At the end of 2 hours clinical visit at Maria Reyna Hospital, the group will be able to: 1. Ask consent from the family and Mrs. F for further interview and assessment. 2. Conduct further interview about Mrs. Fs family history. 3. Conduct further assessment about Mrs. Fs past and present health condition. 4. Identify problems regarding Mrs. Fs health condition. 5. Render nursing interventions for the problems identified. 6. Evaluate progress after providing nursing care. 7. Provide health teachings for the improvement of Mrs. Fs health condition. 8. Copy data from Mrs. Fs chart. 9. Remind Mrs. F about follow up visits of the group.

Problems identified: Evaluation: After 2 hours, the group was able to meet the days objectives. The group was able to assess Mrs. F and identified new problems, gave health teachings and reminded Mrs. F about the groups following visits. 82 Blurred vision Diaphoresis Weak pulse (popliteal, posterior tibial) Absence of pulse beats at the dorsalis pedis site Weakness of the lower extremities

Date: February 18, 2008 Day 5 Specific Objectives: At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be able to: 1. Visit Mrs. F at Coca Cola Compound, Aluba, Cagayan de Oro City. 2. Ask consent from the family and Mrs. F for further interview and assessment. 3. Conduct further interview about Mrs. Fs family history. 4. Conduct further assessment about Mrs. Fs condition after discharge. 5. Provide health teachings for the improvement of Mrs. Fs health condition. 6. Remind Mrs. F about the ending of the groups correlation.

Evaluation: After 2 hours, the group was able to meet the objectives. The group was able to visit and examine Mrs. F after being discharged from the hospital. The group was able to impart health teachings such as to return to Maria Reyna Hospital for follow up check up, to maintain prescribed home medications until advised by physician to discontinue and to do exercise regularly. The group also reminded Mrs. F that February 19, 2008 will be the groups last visit.

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Date: February 19, 2008 Day 6 Specific Objectives: At the end of 2 hours home visit at Aluba, Cagayan de Oro City, the group will be able to: 1. Visit Mrs. F at Coca Cola Compound, Aluba, Cagayan de Oro City. 2. Ask consent from the family and Mrs. F for the completion of the interview and assessment. 3. Provide additional health teachings for the improvement of Mrs. Fs health condition. 4. Thank the family and Mrs. F for the approval and cooperation with the group. 5. End the groups correlation with the family and Mrs. F.

Evaluation: After 2 hours, the group was able to meet the objectives for the day. The group was able to complete the interview and assessment of the needed data for the case study and gave a token as a sign of appreciation for the family and for Mrs. Fs approval and cooperation.

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Discharge Plan and Referrals

Medications Last February 16, 2008 Mrs. F was discharged and advised to have her follow-up check-up on February 20, 2008 with the following home medication by instructions: Telmizartan (Priton) 40 mg 1tab. O.D (Angiotensin II receptor blocker). Clopidogrel (Plavix) 75 mg 1 tab O.D (Anti-coagulant). Metoproplol(Neobloc) 50mg tab O.D (Beta Blocker/Anti-Hypertensive). Atorvastatin (Lipitor) 80 mg 1 tab O.D q hs. (Anti-Hyperlipidemic). ISMN (Imdur) 60 mg 1 tab O.D (Anti-anginal/Nitrate/Vasodilator). Trimetazidine (Vastarel) 1 tab BID (Anti-anginal drugs). Amiodarone (Cordarone) 200 mg 1 tab BID (Class III/Anti-arrythmic). Aspirin (Acet) 80 mg 1 tab O.D p.c lunch (Anti-coagulant). Metformin HCL (I-max) 500 mg 1 tab BID (Anti-diabetic). Encouraged the patient and instructed the significant others to follow prescribed home medications and give drugs on time. Instructed the significant others to give drugs with food when indicated.

Activity Encouraged the patient and instructed the significant others to control activities of daily living. Encouraged the patient and instructed the significant others to participate in passive active range of motion as tolerated. Instructed the significant others to provide safety precautions to the patient, especially when ambulating or using the bathroom. Instructed the clients significant others to minimize prolonged exposure to sunlight.

Diet Encouraged the patient and instructed the significant others to prepare foods that are:

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Low calorie - Calorie restriction in individuals with hypertension is recommended. Otherwise normal individuals need the dailyrecommended calorie according to the age, sex and physical activity. Low fat - It is advisable to reduce the fat consumption since hypertension has greater risk of arteriosclerosis. It is better to avoid high intake of animal fat or hydrogenated oils, which contain saturated fatty acids. The cholesterol rich foods such as liver, meat, organ meat, egg yolk, lobster, crab and prawns should be minimized in the diet. The dietary fats should consist of vegetable oil like corn oil, olive oil and sunflower oil. High fiber- Not only does a high fiber diet aid in healthy bowel movements but also research has shown that it also lowers cholesterol. There are even types of fiber that will help reduce the risk of colon cancer. High protein Most high protein foods are extremely low in carbohydrates and extremely low in saturated fat. Therefore, by eating a high protein diet loaded with high protein foods, at the same time you'd end up eating low carbohydrates foods and low saturated fat foods. And, if you didn't already know, in order to lose weight and lose fat, eating low carbohydrates and eating little or no saturated fat is a must. Chicken, lean meats, beef and fish and egg whites. Low sodium and high potassium diet - Help to lower high blood pressure. Moderate sodium restriction 2- 3 gm per day decreases diastolic blood pressure 6- 10 mmHg and enhances the blood pressure lowering effect of diuretic therapy. Potassium intake should be increased. Food sources of potassium should be increased to patients who are on diuretics. For example apricots, tomato, watermelon, banana, leafy vegetables, and potato should be included in the daily diet since they contain low sodium and high potassium. Hypertensive patients with kidney disease should avoid a high intake of potassium as it puts an excessive load on the kidney.

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Oatmeal

Banana

Raw Carrots

Apple

Broccoli

Raw Tomatoes

Cereals

Instructed the significant others to avoid gastric irritant foods, such as spicy products this is to minimize gastrointestinal disorder, such as nausea and vomiting, abdominal pain, CNS disorder like dizziness, headache.

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Treatment

Encouraged patient to verbalize feelings and needs when presence of chest pain, weakness, and prolonged headache, this is to lessen the burden of the patient and for immediate action as well as to minimize entertaining negative thoughts. Encouraged patient and instruct the significant others to monitor weight and blood pressure daily.

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Prognosis
Hypertension: There is no cure for hypertension, but it can be controlled by changes in ones lifestyle and the use of prescribed medications. The major goal of nursing care for hypertensive patients focuses on lowering and controlling the blood pressure without adverse effects and value cost. The patient needs to understand the disease process and how lifes changes and medications can control hypertension; the nurse needs to emphasize the concept of controlling HPN rather than curing it. ` Hypertension is more common in men than women and in people over the age of 65 than in younger persons. Hypertension is serious because people with the condition have a higher risk for heart disease and other medical problems than people with normal blood pressure. Getting regular blood pressure checks and treating hypertension as soon as it is diagnosed can avoid serious complications. If left untreated, hypertension can lead to the following medical conditions:

Arteriosclerosis, also called atherosclerosis Heart attack Stroke Enlarged heart Kidney damage

Risk factors for hypertension include:

Age over 60 Male sex Weight 25Heredity

Diabetes Mellitus: In most patients diabetes can be controlled by diet, exercise and insulin injections. If the condition is not treated, however, some serious complications may result. For example, uncontrolled diabetes is the leading cause of blindness, kidney disease and amputations of arms and legs. It also doubles a persons risk for heart

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disease and increases the risk of stroke. Eye problems also occur more commonly among diabetes than in general population. Diabetes Mellitus (DM) is a common metabolic disorder in aging populations with increased morbidity, disability and premature death. The prevalence of diabetes is about 20% in persons over 65 years of age and about 40% in persons over 85 years. A recent communication from Kolkata (NSR Medical college) as per patients attending OPD service, the prevalence was 11% in persons aged between 65-69 years. In another study at Bhubaneshwar (Orissa), prevalence of diabetes was found as high as 20% in the age group of 65 and above. The vast majority of patients with DM in the elderly are type 2 (NIDDM) diabetics. Very rarely autoimmune destruction of Beta cells leading to Type 1 (IDDM) DM can occur in the elderly. Some cases could be secondary to associated diseases or drugs.

Myocardial Infarction The incidence and prevalence of acute myocardial infarction (MI), increases progressively with age. Based on the official survey of the Department of Health (DOH) Region 10, the rate of Myocardial Infarction morbidity cases was 3,356. The rate was 97.3%. In addition, mortality rates following Acute Myocardial Infarction (ACS) increases exponentially with age. In particular, elderly patients are less likely to report chest pain than younger patients. Confusion or altered mental status may be the presenting manifestation of Acute Myocardial Infarction in up to 20% of patients over 85 years of age. Older patients are more likely to have SILENT or unrecognized MIs as well as MIs without ST-segment elevation. As compared with younger patients who experience heart failure, atrial fibrillation, and cardiac rupture and shock. All of which are associated with increase mortality. Other factors contributing to the poor prognosis following Acute Myocardial Infarction in elderly individuals include: Marked decline in cardiovascular reserve in elderly Increase prevalence of morbid conditions Underutilization of evidence based theories Women have high mortality rate after Acute Myocardial Infarction compared with men. The extent to which their increased risk varies in treatment is not well understood.

From the information stated above, therefore the patient has poor prognosis attributed to age, sex, presence of other diseases as well as financial constraint may a

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hindrance of her treatment. According to Dr. Cristina Cabral-Pauig, cardiologist from the University of the Philippines-Philippine General Hospital said that both hypertension and diabetes are "robust independent risk factors to the development and progression of cardiovascular disease and nephropathy." In addition, hypertension and diabetes together raise CVD risk, even worsen prognosis.

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Evaluation
The mainstay of nursing and medical treatment with the patient having with these conditions is to help the patient to cope, alleviate distress, prevent further complications and help the patient to recover as well as to encourage the patient and the significant others to participate in the therapy. From the initiation of nursing and medical interventions the client showed some signs of recuperation and gradually showed signs of progress. This was evidence form the complete bed rest up to the condition she was given the chance to ambulate gradually as tolerated. On the last day of visitation the patient has returned to her normal daily activity but with controlled environment and efforts in carrying tasks. Upon interview the client showed orientation in time, place and person and was aware of her condition and knows the prohibition in order to prevent complications and aggravations of her condition. Her significant other, were also supportive and showed concern for the patient. From this, our goal was achieved as evidenced by the desire of the patient to go back to her normal daily routine and from the progress of the patient.

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