A care for client with Acute Coronary Syndrome In partial fulfillment of Related Learning Experience (R.L.E)
Submitted By: Roderos, Mitch Angela
BSN 4C GROUP II S.Y 2011-2012
Clinical Instructor Ms. Virginia Lorda
1
INTRODUCTION Coronary artery disease (CAD) is an umbrella term used to cover any group of clinical symptoms compatible with acute myocardial ischemia. Acute myocardial ischemia is chest pain due to insufficient blood supply to the heart muscle that results from coronary artery disease (also called coronary heart disease). also called coronary heart disease (CHD), a single largest killer of American men and women in all cultural groups (American Heart Association [AHA 2003). According to the AHA, CHD caused more than 1 out of every 5 deaths in the United States in 2000. From 1990 to 2000, the death rate from CAD declined 25%. Multiple factors can be identified as contributing to the declined in CAD. These factor include more effective medical treatment and an increase awareness and emphasis on reducing the major modifiable cardiovascular risk factor (e.g., high blood pressure [BP], smoking, high cholesterol, obesity, diabetes). (Principles of Medical Surgical Nursing Lemone, Burke Vol. 2 4the Edition 2007 page 974-975) In Acute coronary syndrome, it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (―clumping‖), thrombus (clot) formation, and vasoconstriction. The amount of disruption of atherosclerotic plaque determines the degree of obstruction of the coronary artery and the specific disease process (unstable angina or myocardial infarction [MI]. Between 10% and 30 % of the client with unstable angina progress to having an MI in 1 year and 29% die of MI in 5 years (AHA, 2003). Acute coronary syndrome (ACS) is a condition of unstable cardiac ischemia. ACs includes unstable angina and acute myocardial ischemia with or without significant injury of the myocardial tissue. As estimated 1.4 million Americans are admitted to the hospital annually with ACS (Kasper et. al.., 2005).
Fast Facts:
Acute coronary syndrome (severe cardiac ischemia), a common cause of hospital admission, includes unstable angina and acute myocardial infarction. Unstable angina is characterized by injury to myocardial cells; with prompt restoration of blood flow, muscle tissue recovers. Myocardial infarction is characterized by necrosis and death of myocardial cells; scar tissue forms and functional muscle is lost. ACS is the most common identified cause of sudden cardiac death (American Heart Association [AHA], 2005).
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A. DEMOGRAPHIC DATA 1.
Client‘s name : Patient D.V
2.
Gender: Male
3.
Age, Birth date and Birth place: 59 years old, April 24,1952 at Tarlac
4.
Marital Status: Single
5.
Nationality: Filipino
6.
Religion: Romasn Catholic
7.
Address: 15 Natividad St. Bangkal Quezon City
8.
Educational Background: College Undergraduate
9.
Occupation: The client manages his own karinderya
10. Usual Source of Medical Care: Ospital ng Makati
B. SOURCE AND RELIABLITY OF INFORMATION
Patient‘s Chart
Patient Himself
C. REASON FOR SEEKING CARE “Naninikip ang dibsdib” As verbalized by the patient
D. HISTORY OF PRESENT ILLNESS November 20,2011 2 hours prtor to admission – Patient was watching television (FPJ movie) when patient complained of chest pain radiating to the left sshoulder. No medication takeb few hour persistence Upon Admission - Patient‘s vital signs was taken and recorded of blood pressure of 130/70, PR: 84, RR: 26, Temp: 36.4 with general survey of Levigne‘s sign, Facial Grimace and Dyspnea
E. PAST MEDICAL HISTORY Pediatric/Childhood/ Adult Illness: Mumps (7 y/o); Chiken Pox (17 y/o) Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0) Serious/ Chronic Illnesses: The client has Hypertension X4, HBP of 200/100 UBP 150/80 Hospitalizations: There was no recorded previous hospitalization for the past year 2010 Operations: No known operations Immunizations: The client verbalized of having complete immunization of DPT, OPV, BCG and Measles vaccine.
Allergies: No known Allergies Medications prior to confinement: The client took Norvasc 10 g/tab Last Examination Date: November 20, 2011 3
F. FAMILY HISTORY
Father
Mother
(+) HPN
(+) HPN
(+) DM
(+) Asthma
( 65 y/o
63 y/o
58 y/o
59 y/o
(+) Asthma
27 y/o
(+) Asthma
LEGEND
Male
Female
Client
Deceased
1.) Heredo-Family Illness: Maternal – Patient B‘s mother is known to have High blood pressre and Asthma. Currently, his older sister next to him has asthma and so as his only daughter started when she was 2 years old. FatherPatient’t B‘s father has no known family illness running in their blood.
G. SOCIO-ECONOMIC The client consists of a nuclear family and lives together with his aged mother, wife and his daughter. The client states that he contributes for the family financial expenses by the help of their Karinderya and his working daughter. Financial Resources are adequate enough to provide for them for the expenses of their everyday living.
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DEVELOPMENTAL HISTORY
Erik Erickson
Age
Task
Patient’s Description
Psychosocial Theory
30-65 years Erikson's analysis of this stage
The client is presently
Vs.
old middle
was strongly oriented towards
enjoying himself at his senior
Stagnation
age
parenting. Generatively
years. The client states that
potentially extends beyond
he enjoys managing their
one's own children, and also to
karinderya to spend time and
all future generations, which
to contribute in generating
gives the model ultimately a
income. The client is well
very modern globally
established from raising his
responsible perspective.
daughter well.
Generativity
Having children is not a prerequisite for Generativity,
The client stated the he had
just as being a parent is no
lived his life productively.
guarantee that Generativity
The client exhibits
will be achieved. Caring for
generativity from Erickson‘s
children is the common
psychosocial development.
Generativity scenario, but
The client stated that he had
success at this stage actually
worked hard on his younger
depends on giving and caring -
years to have a stable life.
putting something back into
He stated that he doesn‘t
life, to the best of one's
have anything to ask for,
capabilities.
except to have longer life to spend his golden years with
Stagnation is an extension of
his beloved family.
intimacy which turns inward in the form of self-interest and self-absorption. It's the disposition that represents feelings of selfishness, selfindulgence, greed, lack of interest in young people and future generations, and the wider world. Adults need to create or nurture things that will outlast them, often by having children
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or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world
H. REVIEW OF SYSTEMS 1. Regional Examinations (December 1, 2011 9:30 am)
Vital Signs:
Temp : 37.51°c RR: 26 cpm PR: 86 cpm BP: 100/70mmHg
General Assessment: Patient is seen conscious and coherent; garbed in hospital gown,sitting on bed without difficulty. Skin is clean and smooth with normal skin turgor. Nails are long but not dirty and with normal capillary refill. Patient is with ongoing oxygen therapy via Nasal Cannula regulated at 4 Liters per minute, and hooked with D5W 500 cc X 10 cc/hr Infusing well at his left matacarpal vein.
Date of
System
Normal Findings
Integumentary
Smooth and good skin
Actual Findings
Assessment December 1,2011
turgor, no lesions or any discoloration, no clubbing, no breaks &abnormal curvature.
I: Brown color, no lesion, no swelling and edema. Normal looking Visible veins on both arms Has a temperature of 37.51°c. In nails: Long and clean nails and round nails. Pink Nail bed P:
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Warm, soft, smooth, and has a good skin turgor. In nails: Hard, immobile, and smooth. December 1,2011
Hair and Head
No lesion, no tenderness, no pain on palpation, no masses, no lumps, no nodules or depression, symmetrical
I: -His hair color is black, hair is evenly distributed, -Has thick hair. -No presence of parasite and dandruff. -In scalp: Symmetrical and round and no lesion. P: -Hair texture is smooth and soft. -In head the texture is smooth and firm.
December 1,2011
Eyes
Eyelid intact, no redness, swelling, discharge or lesions. Eyeballs are moist & glossy, conjunctiva
I: -Lid margins moist and light pink, lashes short, evenly spaced and curled outward.
numerous small blood
-Bulbar conjunctiva is clear with tiny
vessels. Sclera white.
vessels visible, palpebral conjunctiva
Good eye contact.
is light pink with no discharge, white sclera. - In PERRLA: *Cornea is transparent and the shape of the iris and pupil is round and equal. *The left and right eye has a good reaction to light (constrict and dilate) -In extra ocular movements: *Both eyes coordinated well in all directions.
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December 1,2011
Ears
Ears are symmetrical with 10 degrees angle. Color is same in facial
I: -Equal size and similar appearance.
with no tenderness or
-No lesions, brown in color same with
any nodule and
his complexion.
without any presence
P:
of discharge. -Warm, smooth, no nodules and no tenderness in auricle and tragus. December 1,2011
Mouth and
32 adult teeth are
Throat
present with moist and pink mucous membrane without any lesions or swelling.
I & P: -Lips and surrounding tissue relatively symmetrical.No lesions, swelling and drooping. -Lip is light pink; moist, smooth and with no lesions. -Buccal mucosa is light pink, moist and without lesions.-Gums are light pink, and moist. -In tongue: *Moist, some papillae present, symmetrical appearance, midline fissures present and the color is pink and color white at the center and no lesions as well as the sides of the tongue. *Hard palate: slightly pink. *Soft palate: pink, -Has 32 teeth and stained with a hint of yellow color.
December 1,2011
Neck
No tenderness on palpation, no pain, symmetrically align, no enlarged lymph nodes, no tracheal lateral deviation.
I: -Neck is symmetric with head centered and without bulging masses. P: -Smooth skin, firm, and none tender and none enlarged nodules.
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December 1,2011
December 1,2011
Breast and
No palpable nodules
I:
Axillae
and lesions. Breast is
-Nipples have no discharges and not
firm and round.
cracked.
Intercostals spaces are
I:
Respiratory
even and relaxed; chest symmetry is
-The color of his chest is similar to his complexion.
equal, no pain or tenderness, and no abnormal breath
-With Chest in drawing -Chest symmetry is equal
sound. -Thorax: is straight. -The RR of the patient is 26cpm. -Dyspneic, with Nasal Flaring -Chest X-Ray impression of pulmonary congestion P: No pain or tenderness. A: Lung is clear to auscultation on inspiration and expiration. December 1,2011
Cardiovascular
No fatigue on simple activities, no arrhythmias and heart murmurs. PR=60100bpm.
PR : 86 bpm BP: 100/70 mmHg I:-Neck veins are not distended. P: -No vibrations or palpitation in aortic, pulmonic, or tricuspid area. A:-No murmur sound heard. Chest X-Ray reveals atheromatous aorta
December 1,2011
Abdominal
No pain, No palpable masses and tenderness, Flat and round.
I: -Flat abdomen P: -No tenderness, lesions and masses
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December 1,2011
Musculoskeletal Have good range of
-Does not need assistance to stand and
motion and no
toes point straight ahead. Able to
limitation of
shrug shoulders against resistance.
movements. December 1,2011
Neurologic
Have no tremors
-No presence of tremors, oriented, no
paralysis. Oriented, no
history of seizures, mental dysfunction
history of seizures,
or hallucinations.
mental dysfunction or hallucinations. December 1,2011
Lympathic
Has no bleeding
No swollen lymph nodes.
tendencies, normal lymph nodes.
2. Laboratory Studies/Diagnostics 11/20/11 Clinical Chemistry Section
Test Name
S.I
Unit
Range
Conversion
Result Creatinine
157
Unit
Result
Interpretation
Result Umol/L
53-115
1.78
mg/dL
0.60-
Above Normal
1.30 AST
40
u/L
15-37
40
u/L
15 – 37
Above Normal
SGPT
39
u/L
30-65
39
u/L
30 - 65
Normal
Na
136
mmol/L
136-145
136
mmol/L 136-145
Normal
K
3.6
mmol/L
3.5-5.1
3.6
mmol/L 3.5-5.1
Normal
Chloride
102
mmol/L
98 - 107
102
mmol/L 98 - 107
Normal
Conversion
Unit
Result
Interpretation
11/24/11 Clinical Chemistry Section
Test Name
S.I
Unit
Range
Result
Result
BUN
17.4
mmol/L
2.5-6.4
48.74
mg/dl
7.0-18.0
Above Normal
Creatinine
154
Umol/L
53-115
1.74
mg/dl
0.60-1.30
Above Normal
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11/27/11 Clinical Chemistry Section
Test Name
S.I
Unit
Range
Conversion
Result
Unit
Result
Interpretation
Result
Glucose (fasting)
2.10
mmol/L
Uric Acid
371
4.1-5.1
30-45
mg/dl
73-99
Below Normal
Ummol/L 165-428
6.22
mg/dl
2.6 – 7.2
Normal
Cholesterol Total 2.69
mmol/L
1.3-5.2
103.46
mg/dl
50-200
Normal
Triglycerides
0.60
mmol/L
0.17-1.70
53.33
mg/dl
15-150
Normal
HDL
0.66
mmol/L
1.04 -
25.38
mg/dl
40-60
Normal
63.08
mg/dl
72.69-
Below Normal
1.55 LDL
1.64
mmol
1.89-3.09
118.85 AST (SGOT)
66
u/L
15-37
66
u/L
15-37
Above Normal
ALT (SGPT)
66
u/L
30- 65
66
u/L
30-55
Above Normal
11/28/11 Glycohemoglobin Test
Test Name
Result
Glycohemoglobin Test
2.10
Reference Range 4.1-5.1
Interpretation Below Normal
11/21/11
Test Name
S.I
Unit
Range
Result CK-MB
110
Conversion
Unit
Result
Interpretation
Result u/L
7-25
110
u/L
7-25
Above Normal Damage to cardiac cells, indication of myocardial infarction
11/27/11
Test Name Troponin I
Result Positive
Interpretation Indicates myocardial infarction
11/28/11
Test Name Troponin I
Result Negative
Interpretation Does not indicate myocardial injury
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11/20/11 Hematology
Laboratory (Date)
Normal Value
Result
Interpretation/Significance
15
Normal
0.55
Normal
11/20/11 M - 14-18 g/dl Hemoglobin
F – 12 -16 g/dl
Hematocrit
M – 0.40 – 0.54 F – 0.37 – 0.37
White Blod Cells
4.0 – 11.0
15.5
Above Normal
Red Blood Cells
M – 5.0 -6.4
6.3
Below Normal.
DIFFERENTIAL COUNT Segmenters
0.5 – 0.7
0.96
Above Normal
Lymphocytes
0.2 – 0.4
0.3
Above Normal
Monocytes
0.02 – 0.05
0.01
Above Normal
Platelet
150- 300
195
Normal
11/21/11 Blood Coagulation Test
Reference
Results
Interpretation
Protrombin Time
10.4 – 14
13.9
Normal
% Activity
73-127%
72.6%
Normal
INR
0.88 – 1. 21
1.21
Normal
Activated PTT
36.4 – 41.25 sec
46.1 sec
Above Normal
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3. Other Assessment Toolss Procedure 11/26/11
Indication
Results
The acid-fast stain is
Microscopic
an especially
Examination :
important test for the Acid Fast Stain
genus Mycobacteriu
Specimen
m, to rule out pulmonary tuberculosis.
Nursing intervention Pre Advise patient to drink a lot of fluids the night before the test. It makes the test more accurate if it's done first
Negative
thing in the morning. Advised patient not to take antibiotics and some sulfonamides because it may interfere with test results, causing the results to be falsely negative. Prior to breakfast, the patient will be asked to provide a 5-10 mL specimen of sputum delivered into a sterile cup with a screw top lid. Intra
Asked patient to cough deeply and spit
the substance that comes up from the lungs (sputum) into a container.
Patient may be asked to inhale a mist of salty steam in order to cough more deeply and produce sputum.
Post
Place it in a sterile container, label appripiately and immdiately forward in the laboratory.
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Procedure 11/19/11
X-ray
Indication
Results
CT scanning or
There are fluffy
sometimes called
infiltrates noted
CAT scanning is a
with accentuation
noninvasive medical
of the pulmonary
test that helps
vasculature
Nursing intervention Pre
jewelry, eyeglasses, dentures and hairpins. Patient may also be asked to remove hearing aids and
physicians diagnose
removable dental work.
and treat medical conditions.
Remove all Metal objects including
The heart is not
Instruct not to eat or drink anything for several hours beforehand,
enlarged CT scanning
especially if a contrast material will
combines special x-
be used in exam.
ray equipment with
The aorta shows
sophisticated
some calcifications
computers to produce
along it‘s walls
Intra
A chest ct scan takes about 30
multiple images or
mins., which includes preparation
pictures of the inside
time
of the body. These
Diaphragm and
cross-sectional
sinuses are intake
that moves through the hole
images of the area being studied can then be examined on
to a CD.
While inside the scanner, an x-ray tube moves around your body. You will wear soft buzzing, clicking or
Impression:
a computer monitor, printed or transferred
Patient mat lie on a narrow table
whirring noises as the scanner takes Pulmonary congestion and
pictures
edema R/O
The technician will ask you to lie still and hold your breath for short
pneumonia
periods. these measures help make
athermanous aorta
the picture as clear as possible the scan itself
Post
CT exams are generally painless, fast and easy.
After a CT exam, you can return to your normal activities.
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Procedure
Indication
Results
Nursing intervention
11/21/11 5:00 am
Electrocardiogram
Abnormal ECG
Pre
Electrocardiogram
(ECG) provides 12
Lateral
vector views of the
Infarction
heart‘s electrical
Anteroseptal
activity as reflected by
Infarction
electrical potential
Marked right
differences between
axis deviation
objects including jewelry,
positive and negative
With runs of
eyeglasses, dentures and hairpins.
electrodes placed in
PVC
Patient may also be asked to
Explain the procedure to the patient.
Instruct patient to wear comfortable, loose-fitting clothing
Instruct to remove all Metal
the limbs and chest
remove hearing aids and
wall. ECG is crucial
removable dental work.
for establishing many
In some instances, men may
cardiac diagnoses,
require the shaving of a small
especially arrhythmias
amount of chest hair to obtain
and myocardial
optimal contact between the leads
ischemia.
and the skin Acute
11/21/11 12:00 pm
anteroseptal
Intra
Electrocardiogram
infarction
EKG leads are attached to the
Lateral
body while the patient lies flat on
Infarction
a bed or table. Leads are attached
Ventricular
to each extremity (four total) and
Premature
to six pre-defined positions on the
Contraction
front of the chest. A small amount of gel is applied to the skin, which allows the electrical impulses of the heart to be more easily
11/21/11 11:00 pm
Prior to streptokinase
Lateral
Electrocardiogram
therapy
Infarction Anteroseptal
transmitted to the EKG leads.
Instruct that the test takes about five minutes and is painless.
Infaction Poor right progression
11/21/11 8:00 pm
Acute anterior
Electrocardiogram
infarction Abnormal Q Ventricular premature contraction
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I. FUNCTIONAL ASSESSMENT HEALTH PERCEPTION-HEALTH MANAGEMENT
Prior to admission, patient sees health being able to do everyday things well according to the manner he wants it. The client stated he doesn‘t easilly get sick and when he does, he just let it subside not until if his condition worsens, that‘s the time when he would visit the hospital. The client does not use any vitamins and medications. Client has not experienced colds in the past month. The client stated that he would eat lots of nutritious foods and keeping himself physically fit is his way to keep himself healthy
SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN Before the patient was admitted, he sees himself being able to do things according to the manner he wants it. He does not mind his health not until the manifestation of discomfort brought from his disease. Presently, the client verbalized difficulty of being sick; he stated that he will find it hard to adjust from it. That client claims that he acquired his disease due to over fatigue and abusing his body by work when he was young back then. The client verbalizes a decrease in self-perception due to aging and performing strenuous activities due to presence of exertional dyspnea.
ACTIVITY/EXERCISE PATTERN Prior to confinement, the client claims his activities as sort of exercise by means of managing their mini Karinderya for the whole day. Presently, the patient is confined in the primary holding unit. The client assumes full self care on himself. The client is on bed rest and does minimal activities. Feeding
0
Grooming
0
Bathing
0
Gen. Mobility
0
Toiling
0
House
0
maintenance Bed mobility
0
Dressing
0
Legends: Level 0 – Self Care Level I – Use of equipments Level II– Assistance from another person Level III –Requires assistance from another person or device Level IV – Dependent and does not participate
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SLEEP/REST PATTERN Before the client was admitted, the client stated that he is usually sleeps late because of their Karinderya. The client states that he has 7 hours of sleep everyday without the any use of sleeping aids. He stated that the client would take a nap at noon for about 2 hours. Presently, The client has no difficulty of sleeping except from some external factors such as the noise of other patients that he shares the ward with. The client does not use any sleeping pills but prefers to play music in his radio to induce sleep. The client verbalizes of having siesta after taking his lunch NUTRITIONAL-METABOLIC PATTERN The client eats three times a day with low salt and low fat diet. The client has good appetite and has no known food allergies. Wound heals normally. He recalled that his last meal was noodles and bread and half of one serving. The client has no known allergies and drinks 450 ml of water noted on our 6- 2 morning shift last December 1, 2011. The client has no dental problems, no foul odors and excess perspiration.
ELIMINATION PATTERN The client states that he defecates once a day usually in the morning in soft brown stool without difficulty and use of laxatives. The client urinates 3x day or more varying in his fluid intake; he verbalizes no difficulty in voiding. SEXUALITY/REPRODUCTIVE The patient is not sexually active and was circumcised at the age of 12. The client is married with his wife for almost 40 years. The client displays intimate close relationship to his wife. The client states that he depends most on her wife for taking care of him and in giving him medication and her attention at him, since he tends to be forgetful. The patient‘s wife is not around during the interview.
INTERPERSONALRELATIONSHIPS/RESOURCES The client is the youngest son among his 3 siblings. The client is married to his wife for 40 years and is a father to his only daughter. He stated that there are no family quarrels so far. The client is a humorous person, that made gave them openness and good bonds. The client stated that he decides on the facing family‘s major decisions with the help of his wife. The client stated that he muses with his present life COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN The client states the he has no stressful situation encountered presently. Since he stated that he is feeling a lot better than his admission. The client states that whenever he encounters a
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difficult situation, he would think about it several times prior to decision making. The client verbalized that he can control his emotions. VALUES/ BELIEFS The Client is a Roman Catholic.. The client stated that he barely attends the church because of several preoccupations. he believes that he got his illness as God ‗warning towards his way of living. He stated that he will stop from over abusing his body and he would adhere to healthy lifestyle. PERSONAL/SOCIAL HISTORY Habits: The client is known to be a hard-working man. Patient D.V stated that he cannot tolerate not to do anything during his free time. He make sure that his goals are achieved at the end of the day Vices: The client stated does not consume alcoholic beverages and does not smoke. Lifestyle: The client was known to live in a stressful lifestyle. The client states that he is skillful Client’s usual daily life: The client‘s typical day is working as chef in his mini Karinderya that run every day but closes half-day during Sundays. Patient D.V states that he prefers to be with his family watching television or taking siesta during his free time. Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings. Travel: The client has no previous local and intonation travel for the past 4 months. J. ENVIRONMENTAL HISTORY
The client lives together with his family composed of 4 house hold members. A bungalow type of house with 209 square meters is owned by the patient residing near the highway. The client narrated that it is a cemented house with 2 bedrooms and 1 bath room. The house is fully ventilated and well lit of 12 windows. Their doors for about the size of 180X1 meter. The client stated that their surroundings are well-sanitized. Their electricity supply comes from Meralco and their water supply are from Deep well. They order Mineral water for drinking. The client‘s residence is advantageous, since it is near the public market, transportation, at school and Hospital.
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K. PEDIATRIC HISTORY L. MATERNAL AND BIRTH HISTORY
Birth date: April 24,1952
Hospital: Not assessed
Birth weight: Unrecalled Type of delivery: Normal Spontaneous Delivery Condition after birth: In fine stable condition
Mother: Complications of delivery: None Anesthesia drug guring labor: Unrecalled Exposure to Teratogenic Agents during Pregnancy: None
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I.
PATHOPHYSIOLOGY CLIENT-BASED
Predisposing Factor
Precipitating Factor
Age (75 years old) Gender (Male)
Diet (Cholesterol rich foods) Stressful Lifestyle
Plaque Formation
Atherosclerotic plaque ruptures or erodes
Thrombin is generated and Fibrin is deposited
Platelet Aggregation
Clots are being formed
Thickening and narrowing of arterial vessels
Obstruction in Blood Flow
Cells become ischemic
Myocardial cell contract less effectively
Lactic acid is secreted
Decrease O2 supply to myocardium
Decrease Cardiac Output Stimulate pain Receptor Decrease O2 supply to the different part of the body
D.O.B.
Chest Pain
Pallor
Body Weakness
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II.
CONCEPT MAPPING 1. Ineffective Airway Clearance related to increased tracheobronchial secretions as evidenced by productive cough
5. Risk for decreased cardiac output related to degeneration of cardiac muscle
T/C Acute Coronary Syndrome Probably MI, Has CVD, Heart dysrhytmia not in failure 2. Ineffective tissue perfusion: Patient B.R; 25 y/o Male.
cardiopulmonary related to
Temp.: 37.5°c RR: 19cpm PR: 86 cpm BP: 100/70mmHg. Dyspnea Productive cough in whitish sputum Chest X-Ray result of Pulmonary Congestion and Edema Weak looking Facial Grimace Presence of arrhytmias Positive Troponin I Elevated Ck-MB With Verbal Reports of Weaknhess With Exertional dypnea With verbal expression of worry
4. Anxiety related to fear of death, change in health status
reduced coronary blood flow as evidenced by chest pain
3. Activity Intolerance related to imbalance in oxygen supply and demand as evidenced by fatigue
III.
PROBLEM LIST Actual Problem Number
1
Problem
Remarks
Ineffective Airway Clearance
The client presently exhibits
related to increased
dyspnea and productive cough in
tracheobronchial secretions as
whittish secretions. Moreover,
evidenced by productive cough
Pulmonary congestion is noted upon chest X-ray.
2
Ineffective tissue perfusion:
Presence of a Positive Troponin I
cardiopulmonary related to
indicates myocardial injusry, thus
reduced coronary blood flow as
a presence of a decrease in oxygen
evidenced by chest pain
supple results in the failure to nourish the tissues at capillary level
3
Activity Intolerance related to
Due to imbalance ratio of oxygen
imbalance in oxygen supply and
of supply and demand and
demand as evidenced by verbal
presence of productive cough has
reports of weakness
led the patientInsufficient physiological or psychological energy to complete required or desired daily activities
4
Anxiety related to fear of death
Patient D.V verbalized a
and change in health status as
generalized, unidentified feeling of
evidenced by verbal expression
discomfort due to his experience
of worry
of Chest Pain
Potential Problem Number 1
Problem
Remarks
Risk for decreased cardiac
The client is at reisk for decreased
output related to degeneration
cardiac due to history of a positive
of cardiac muscle
troponin I and elevated CK-MB indicating a myocardial injury. Therefore, it is possibible that there may be presence of inadequate blood pumped by the heart to meet the metabolic demands of the body due to degeneration of cardiac muscle.
IV. Cues/Needs
NURSING CARE PLAN Nursing
Planning
Implementation
Rationale
Evaluation
Monitor Respirations and breath sounds, noting rate and sounds
Indication of respiratory distress and/or accumulation of secretions
After 9 hours
Diagnosis Subjective:
Ineffective
After 9 hour of
―Matatagalan pa
Airway
nursing
bago bumalik ang
Clearance
intervention, the
kulay ko‖ as
related to
client will be able
verbalized by the
increased
to demonstrate
patient
tracheobronch
behaviors to
ial secretions
maintain clear
as evidenced
airway
Objective:
Dyspnea by productive Productive cough cough in whitish sputum Chest X-Ray result of Pulmonary Congestion and Edema Weak looking Facial Grimace
of nursing intervention,
Elevated head of bed, changed position every 2 hours PRN
To decrease pressure on the diaghraphm
Kept area patient‘s sorrounding clean and free from draughts by means of instructing to reduce things and place only valuable things in his bed, and fixed the patien‘t bed linen
To prevent aggravation of condition
Instruct patient to do deep breathing by asking tha patient to inhale deeply and exhale slowly. and coughing exercises
To maximize effort on expectorating secretions.
Encourage the patient to increase fluid intake for at least 2000 ml/day. Within cardiac tolerance
Hydration can liquefy viscous secretions and improve secretion clearance.
Asisted client with postural drainage and percussion if not contraindicated by condition
To loosen viscous
Auscultate breath sounds and assess air movement
To determine progress
the client was able to demonstrate behaviors to maintain clear airway
Administered bronchodilators as prescribed by the physician.
To provide pharmacological treatment and for fast recovery
Instruct home regimen interventions such as boiling water and instruc the patient to inhale the steam to serve as an alternative to nebulaization
To provide cost reducing ways in improving expotorating secretions.
Referred to respiratory therapist for adjunct treatment modalities.
To determine effectiveness of drug theraphy
Cues/Needs
Nursing
Planning
Implementation
Rationale
Evaluation
Diagnosis Subjective:
Ineffective
After 8 hours of
“Ang Sikip ng
tissue
Nursing
dibdib ko‖ as
perfusion:
verbalized by the patient
Intially Assess, document and reposrt
These data assist in
After 8 hours
determining the cause and
of Nursing
intervention, the
effect of the chest discomfort
intervention,
cardiopulmon
client will be
and provide a baseline with
the client
ary related to
free from chest
which post-therapy symptoms
remained
reduced
pain/discomfort
can be compared.
free from
the physician about the following:
Objective:
coronary
chest
Presence of arrhytmias Positive Troponin I Elevated CkMB Chest Pain
blood flow as
a.) The patient‘s description of chest
evidenced by
discomfort,including location,
determining the cause and
chest pain
intensity,radiation, duration, and
effect of the chest discomfort
factors that
and provide a baseline with
affect it. Other symptoms
such
as nausea, diaphoresis, or complaints
These data assist in
which post-therapy symptoms can be compared.
of unusual fatigue.
b.) The effect of chest
discomfort on
cardiovascular
contractility and ventricular
perfusion—to the heart (eg, change in blood pressure,
MI decreases myocardial
heart
sounds), to the brain (eg, changes in
compliance and may produce dysrhythmias. Cardiac output
pain/discomf ort
LOC), to the kidneys (eg, decrease in
is reduced, resulting in
urine output), and to the skin (eg,
reduced
color, temperature).
and decreased organ
blood pressure
perfusion.The heart rate may increase as a ompensatory mechanism to maintain cardiac output.
Obtain a 12-lead ECG recording during
An ECG during symptoms
symptomatic event, as prescribed, to
may be useful in the
determine extension of infarction.
diagnosis of an extension of MI.
Administer oxygen as prescribed
Oxygen therapy may increase the oxygen supply to the myocardium if actual oxygen saturation is less than normal.
Adminiser medications as prescribed
Medication therapy is the first line of defense in preserving myocardial tissue. The side effects of these medications can be hazardous and the patient‘s status must be assessed
Ensure physical rest: use of the
Physical rest reduces myocardial
bedsidecommode with assistance;
oxygen consumption. Fear and
backrest elevated to promote comfort;
anxiety precipitate the stress
diet as tolerated; arms supported during
response; this results in
upper extremity activity; use of stool
increased
softener to prevent straining at stool.
levels of endogenous
Provide a restful environment, and allay catecholamines,which increase fears and anxiety by being supportive,
myocardial oxygen
calm, and competent. Individualized
consumption.
visitation is based on patient response.
Also, with increased epinephrine, the pain threshold is decreased, and pain increases myocardial oxygen consumption
Cues/Needs
Nursing
Planning
Implementation
Rationale
Evaluation
Diagnosis Subjective:
Activity
After 8 hours of
―Mabilis akong
Intolerance
nursing intervention,
hingalin kahit sa pag
related to
gawa ng mga simpleng
imbalance in
The client marks to have
After 8 hours
pulmonary congestion and under
of nursing
the client will
observation to have acute
intervention,
participate willingly
coronary syndrome
the client
bagay‖ as verbalized by oxygen supply
in necessary and
the patient
desired activities.
Objective: With Verbal Reports
Determine factors contributing to fatigue
participated Evaluate client‘s percieved
To provide comparative baseline
willingly in
evidenced by
limitations by asking past
data and to provide information
necessary
verbal reports
activities and present
about needed intervention
and desired
of weakness
activities
and demand as
Assess cardiopulmonary
activities.
Manifestations results
The client
intolerance of activity
verbalized of
of Weaknhess
response to physical activity,
With Exertional
including vital signs before,
incorporating
during and after activity
such
dypnea Facial grimace
exercises and Provide and monitor response to supplemental exygen
To provide an increase in
exposure to
oxygen supply
sunlight in his daily living
Assist client wit activities
To protect the client from injury
when walking to the wash room, getting up in bed and lying back to bed Provide intervals of rest between activities Encourage and acknowledge the difficulty of the situatio
To minimize occurrences of fatigue
Helps to minimize frustration and rechannel energy
of the client Encouraged patient to expose
Sunlight is rich in Vitamin D and
himself in sun light around 7- will help the client to increase vitality 8 am Assist and provide passive and active ROM
To maintain and enhance muscle tone of client
Cues/Needs
Nursing Diagnosis
Planning
Implementation
Rationale
Evaluation
Subjective:
Anxiety related to
After 8 hours
Assess, document, and report to
These data provide information
After 8 hours
―Mamamatay na
fear of death and
of nursing
the physician the patient‘s and
about the psychological well-
of nursing
ata ko‖ as
change in health
intervention
family‘s level
being and a baseline. Causes of
intervention
verbalized by the
status as evidenced
the client will
of anxiety and coping
anxiety are variable and
the client
patient
by verbal
manifest
mechanisms.
individual, and may include acute
manifest
illness, pain, disruption of ADL
reduction of
and anxious family members
anxiety
expression of worry reduction of Objective:
anxiety
With verbal
can transmit anxiety to the
expression of
patient.the nurse must also
It was
worry
identify strategies to reduce the
observed an
family‘s fear and anxiety.
increase of
Decreased mental concentration
social Assess the need for spiritual
If a patient finds support in a
interaction to
counseling
religion, religious
relatives and
and refer as appropriate.
Counseling
other people.
Allow patient and family to
Unresolved anxiety serves as the
express anxiety and fear:
stress response that increases
a. By showing genuine interest
myocardial oxygen consumption.
and concern b. By facilitating
communication (listening, reflecting, guiding) c. By answering questions The presence of supportive family Encourage the presence of the
members may reduce both
family relative to assist
patient‘s and
in reducing the patient‘s level of family‘s anxiety. anxiety Encourage active participation in a cardiac rehabilitation
Prescribed cardiac rehabilitation
program by educating the uses
may help to eliminate fear of
of his medications, the need for
death, reduce anxiety, and
diet modification and exercise
enhance feelings of wellbeing.
Teach stress reduction techniques. Such as a.) Deep Breathing
Stress reduction may help to
b.) Pursed Lip Breathing
reduce myocardial
c.) Music Therapy by
oxygen consumption and may
means of listening to music available in his resources
enhance feelings of well-being.
Cues/Needs
Nursing Diagnosis
Planning
Implementation
Rationale
Evaluation
Subjective:
Risk for decreased
At the end of 1
Keep client on bed or chair rest
Decreased oxygen consumption
At the end of
―Sa awa ng Diyos
cardiac output
week of
in position of comfort.
and risk for decompensation.
2 weeks of
e gumaan na kahit
related to
nursing
papano ang
degeneration of
intervention,
Administer high-flow oxygen
To increase oxygen available for
intervention,
pakiramdam ko‖
cardiac muscle
the client will
via mask as indicated
cardiac function/tissue perfusion
the client will
nursing
as verbalized by
display
displayed
the patient
hemodynamic
Decrease Stimuli, provide quiet
stability.
environment.
To promote adequate rest
stability
Objective: Presence of arrhytmias
Elevate legs when in sitting
hemodynamic
To enhance venous return
position.
Provide fluids/electrolytes as
To minimize dehydration and
indicated
dysrhtmias.
Encourage changing positions
To reduce risk for orthostatic
slowly, dangling legs before
hypotension
standing Early detection in changing in Monitor vital signs, watch out
these parameters promotes timely
for circulatory failure.
intervention.
MEDICAL-SURGICAL MANAGEMENT i. DRUG NAME
Pharmacotherapeutics MECHANISM OF
INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHING
ACTION Generic Name:
Morphine Sulfate
Brand Name:
Classification:
Moderate to severe CNS: dizziness, headache,
receptors in the
pain. Also
sedation, confusion,
CNS. Alters the
provides:
dysphoria, euphoria, floating
perceptions of the
Analgesia during
feeling, hallucinations,
and respiration before and
patient to call for assistance when
response to painful
labor, sedation
EENT: blurred vision,
periodically during
ambulating and to avoid activities requiring
stimuli while
before surgery,
diplopia, miosis (high doses)
administration. If respiratory
alertness until response to the medication is
producing
supplement to
. RESP: respiratory
rate is <10/min, assess level of
known.
generalize CNS
balance analgesia.
depression. orthostatic
sedation. Physical stimulation
depression.
hypotension, palpitations,
may be sufficient to prevent
patients.
GI: dry mouth, nausea,
significant hypoventilation.
Narcotic
vomiting, constipation, ileus.
Analgesic
Assess type, location, duration
Binds to opiate
and intensity of pain
Assess blood pressure, pulse,
Instruct patient on how and when to ask for pain medication.
May cause drowsiness or dizziness. Advice
Caution patient to change positions slowly to minimize orthostatic hypotension.
Advice patient that frequent mouth rinses,
Assess previous analgesic
good oral hygiene, and sugarless gum or
urinary urgency. clammy
history. It may induce
candy may decrease dry mouth.
feeling, sweating. physical
withdrawal symptoms
Encourage patient to turn, cough, and
Dosage:
dependence, psychological
breathe deeply every 2 hr to prevent
TIV prn for Chest
dependence, tolerance,
atelectasis.
Pain
Advise patient to avoid concurrent use of alcohol or other CNS depressant
DRUG NAME
MECHANISM OF
INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHINGS
ACTION Generic Name:
Clopidogrel
Brand Name:
Plavix
Classification:
Platelet
Instruct to Avoid taking OTC medications
MI during treatment
containing aspirin or NSAIDs without
Monitor liver function studies:
consulting health care professional.
Treatment of
CNS: Headache, dizziness,
aggregation by
patients at risk for
weakness, syncope, flushing
blocking ADP
ischemic events—
CV: Hypertension, edema
receptors on
history of MI,
Dermatologic: Rash,
AST, ALT, bilirubin,
platelets,
ischemic stroke,
pruritus
creatinine if patient is on long-
preventing
peripheral artery
GI: Nausea, GI distress,
term therapy
clumping of
disease
constipation, diarrhea, GI
platelets
Treatment of
Instruct patient to take medication as ordered
Advise patient to notify health care professional promptly if fever ,chills ,sore
bleed
CBC,Hgb, Hct, protime,
throat or unusual bleeding occurs
patients with acute
Other: Increased bleeding
cholesterol if the patient is on
coronary
risk
long-term therapy;
syndrome
thrombocytopenia and neutropenia may occur.
Assess for symptoms of stroke,peripheral vascular
Dosage:
disease or MI 75 g/ tab
Monitor blood studies:
Aggregation Inhibitors
Assess for symptoms of stroke,
Inhibits platelet
Precautions:
Bleeding disorders, recent surgery, hepatic impairment, pregnancy
DRUG NAME
MECHANISM OF
INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHING
ACTION Generic Name:
Acts on blood vessels, It used for the
Orthostatic hypotension;
GI, respiratory system symptomatic relief of palpitations; bradycardia; Diphenhydramine
Benadryl
1 tab
Assess movement disorder
Inform patient that drug may cause dry
extrasystoles; faintness.
Assess nausea and
mouth
receptor
decreases
site; and angio edema, allergic rhinitis, and
term therapy
activities with alertness
tachycardia;
of histamine including urticaria
Drowsiness; sedation;
vomiting
response by blocking conjunctivitis, and in
dizziness, disturbed
histamine;
coordination. Nasal
reaction (skin itching,
stuffiness; dry mouth;
rash, inflammation )
causes pruritic skin heart
vasodilation,
rate, disorders. It is used for its anti- emetic
CNS depressant
treatment of nausea and vomiting,
Dosage:
Monitor CBC during long
Avoid hazardous activities and requiring
effects
secretions; significant properties in the Antihistamine
tachycardia; reflex
increase Classification:
Assess respiratory status
by antagonizing the allergic conditions
H1Brand Name:
nose and throat; sore throat.
Assess for allergic
Avoid alcohol
Avoid alcohol, other depressants
DRUG NAME
MECHANISM OF INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHING
ACTION Generic Name:
Convert
Acute
Brand Name:
Classification:
Explain purpose of medication and the need
plasmin, which is Thrombosis,
gingival bleeding,
and at least every 4hr for the duration of therapy.
for close monitoring to
then able to degrade Massive
periorbital edema, GI
Inquire about previous reaction to anistreplase or
patient and family.
fibrin
present
in Pulmonary
bleeding,
streptokinase therapy. Assess patient for hypersensitivity
clots.
Lysis
of Emboli,
bronchospasms,
reaction (rash,dyspnea, fever, changes in facial color,
report hypersensitivity
throbi in coronary AcuteIschemic
hemoptysis, allergic
swelling around the eyes, wheezing). If these occur,
reactions and bleeding or
arteries,
reactions, ecchymoses,
inform physician promptly. Keep epinephrine, an
bruising
flushing
antihistamine, and resuscitation equipment close by in the
preservation
with Stroke, of Occluded
Central venous
function. Lysis of access
pulmonary emboli 1 tab
Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every 15-30 min during the next 8hr,
to Coronary
ventricular Dosage:
Hemorrhage, epistaxis,
plasminogen Streptokinase
CNS: Intracranial
or
deep
vein
thrombosis
Explain the need for bed rest during therapy to
Assess neurologic status throughout therapy. Altered
avoid therapy.
Instruct patient to avoid
Assess intensity, character, location, and radiation of chest
unnecessary procedures
pain. Note presence of associated symptoms (nausea,
that is prone to bleeding
vomiting diaphoresis.)
or bruising such as
Monitor heart sounds all breath frequently. Inform
shaving and vigorous
physician if sign of CHF occur (rales/crackles,dyspnea, S,
tooth brushing
heart sounds jugular venous distension, relived CVP).
Instruct the patient to
event of an anaphylactic reaction.
sensorium may be indicative of intracranial bleeding.
Monitor ECG continuously. Notify physician if significant arrhythmias occur.
DRUG NAME
MECHANISM OF
INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHING
ACTION
It increases neuronal
General
CNS: Transient, mild
membrane
Indications
drowsiness initially; sedation,
permeability to
- Short-term
depression, lethargy, apathy,
chloride ions by
management of
fatigue, disorientation,
binding to
anxiety
restlessness, confusion,
diazepam; dose should be reduced by at
stereospecific
- Insomnia
delirium, headache, slurred
least one-third or eliminated.
benzodiazepine
associated with
speech, dysarthria, stupor,
receptors on the
anxiety
rigidity, tremor, mild
postsynaptic GABA
- Sleepwalking
paradoxical excitatory
neuron within the
- Night terrors
reactions, extrapyramidal
CNS and enhancing
- Premedication
symptoms, visual and auditory
Antiepileptic,
the GABA
before
disturbances
Anxiolytic,
inhibitory effects
anaesthesia
CV: Bradycardia, tachycardia,
Skeletal muscle
resulting in
- Adjunct in the
CV collapse, hypertension and
relaxant
hyperpolarisation
management of
hypotension, edema
and stabilization
seizures
Dependence: Drug dependence
- Muscle
with withdrawal syndrome
Generic Name:
Diazepam
Brand Name:
Valium
Classification:
Dosage:
spasms 5g TIV
Discuss risk of fetal abnormalities with
Avoid hazardous activities
patients desiring to become pregnant.
and requiring activities with
Assess for hypersensitivity.
alertness
Reduce dose of opioid analgesics with IV
Inform patient that drug may cause dry mouth
Instruct about side effects of drug: Drowsiness, dizziness,
administration.
GI upset, dreams, difficulty
Do not administer intrarterially; may
concentrating, fatigue,
produce arteriospasm, gangrene.
nervousness, crying
Carefully monitor P. BP, respiration during
Change from IV therapy to oral therapy as soon as possible.
Observe the 15 rights of drug
IV administration.
Avoid alcohol, other depressants
Instruct not to stop taking the drug without consulting the health care provider.
Do not use small veins for IV injection.
Instruct to take drug exactly as prescribed.
DRUG NAME
MECHANISM OF
INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHING
ACTION Generic Name:
Potentiate
inhibitory Prevention of
CNS: Dizziness,
Assess for signs of bleeding and
Advise patient to report any
effect of antithrombin ischemic
headache, Insomnia
hemorrhage (bleeding gums: nosebleed
symptoms of unusual
on
CV: Edema GI:
unusual bruising black tarry stools
bleeding or bruising
Constipation,Nausea,
hematuria fall in hematocrit or blood
dizziness itching rash fever
treatment of deep
reversible increase in
pressure guaiac positive stools); bleeding
swelling or difficulty
vein thrombosis in
liver enzymes GU:
from surgical site notify physician if these
breathing to health care
patients at risk for
urinary retention
occur,.
professional immediately.
thromboembolism
Derm: ecchymoses,
complications due to
pruritus, rash,urticaria
increased thrombosis symptoms depend on
aspirin or NSAIDs without
severly restricted
Hemat: bleeding,
area of involvement. Monitor neurogical
consulting healt care
Anticoagulant,
mobility during acute
anemia,
status frequently for sign of neurological
professional while on
AntiThrombotic
illness
thrombocytopenia
impairement may required urgent
therapy.
Misc: Fever
statement.
Enoxaparin
factor
thrombn. Brand Name:
Lovenox
Classification:
Dosage: 60 g SQ BID
Xa
and complications from
Prevents unstable angina,
thrombus prevention
Assess for evidence of additional or
Monitor for hypersensitivity reactions report signs of physician.
Instruct patient not to take
DRUG NAME
MECHANISM OF
INDICATION
SIDE EFFECTS
NURSING IMPLICATION
PATIENT TEACHING
ACTION Generic Name:
Pantaprazole
Inhibits activity of
Short-term treatment
CNS:Headache ,
acid (proton) pump
of active
dizziness,asthenia, vertigo,
and binds to
duodenal ulcer;
insomnia, apathy,
hydrogen-potassium
First-line
adenosine
1. Assessment
History:
Tell patient to swallow tablets or capsules whole
Hypersensitivity to omeprazole or
and not to open, crush, or
anxiety,paresthesias,
any of
chew them.
therapy in treatment
dream abnormalities
its components; pregnancy, lactation
triphosphatase at
of
Dermatologic:
secretory surface of
heartburn or
Rash,inflammation,
gastric parietal cells
symptoms of
urticaria, pruritus,
urinary
hazardous activities if he
Classification:
to block formation of
gastroesophageal
alopecia, dry skin
output, abdominal exam; respiratory
gets dizzy.
Proton Pump
gastric acid..
reflux
GI:
auscultation
Inhibitors, Gastric
disease (GERD);
Diarrhea,
Interventions
Acid suppressor
Short-term
abdominal pain,
2. Administer before meals. Caution patient
alcohol which stimulate
treatment of active
nausea, vomiting,
to swallow capsules whole,not to open,
stomach acid or delay ulcer
benign
constipation, dry
chew, or crush them.
healing.
Brand Name:
Protonix
Dosage:
Skin lesions; reflexes, affect;
Dosage adjustments may be necessary in
severe
Asians and patients with hepatic
erosive esophagitis,
impairment.
poorly
Administer antacids with omeprazole, if
responsive
needed
Instruct patient to take drug 30 minutes before meals.
Physical:
gastric ulcer; GERD, mouth, tongue atrophy
symptomatic GERD;
Caution patient to avoid
Instruct to avoid beverages rich in nicotine, caffeine and
DISCHARGE HEALTH TEACHING Content M-medication
To adhere in prescribed therepautic regimen for health maintainance and resistance.
E-exercise
To promote a healthy lifestyle, maximizing the level of health and increase
Strategy Instruct
patient
to
take
the
prescribed
medications as ordered by the physician. Instruct patient to avoid taking OTC drugs unless given with medical advice Encourage patient to include atleast 30 minutes of walking or jogging or perfrom tolerated and preferred activities as a means of exercise
the body‘s immunity. Educate T-treatment
client
by
adhering
maintainance
Attending the follow up
theraphy, appropriate diet and having exercise
check up.
will reduce likelihood of occurances and aggravation of disease.
H-health
Health teaching about the
teaching
disease, exercise and diet.
Instruct
the
patient
about
home-made
interventions in reducing blood pressure such as: a.) Pineapple or Calamansi juice to reduce blood pressure b.) Chewing of raw or fried garlic after meals c.) Refrain from consumption of caffeineted beverages, such as coffee and chocolate
O-OPD
Instruct that they need to have a health check up.
Emphasize the importance of adhering to medications and attending follow-up check up. Encourage patient to adhere to weekly blood pressure monitoring
D-diet
Instruct patient to avoid consumption of salty
Maintain and ensure adequate intake for
and fatty foods. Instructed patient to limit consumption of high
noursihment,
caloric foods such as rice to reduce occurences of high blood pressure and increase in blood sugar. S-signs
and If any signs of symptoms are
symptoms
Advise
patient
to
refer
to
health
present go to the nearest
professional for sudden onset of blurry vision,
hospital for check up.
intense head ache, chest pain unrelieved with rest and medications
V.
care
ONGOING APPRAISAL
Patient D.V, a 59 year old male, has been admitted to Ospital ng Makati last November 20, 2011 with the chief complaint of chest pain. Upon assessment, it was observed that the patient is conscious, with general survey of Levigne‘s sign, Facial Grimace and Dyspnea . The client is admitted in Emergency Room and inserted of D5W 500cc X 10cc/hr at left metacarpal vein with laboratory tests rendered such as CBC, PTT, BUN, Creatinine, Serum Na, K, Trop I, CK-MB, ECG, and CBG. Chest X-Ray was ordered and for oxygen therapy at 4 liters per minute. Patient D.V was initially treated with morphine TIV for his chest pain, ISDN 80 cc D5W + 20 g, Clopidgogrel 75 g/Tab,. The patient is ordered for streptokinase therapy 1-5 MIV in 90 ml D5W. Prior to therapy, the given Diphenhydramine 50 g TIV, Hydrocholine 100g IV, Diazepam 5g TIV for anxiety, Pantaprazole 10 g TIV OD and Enoxaparin 60 g SQ BID . Presently, the patient‘s condition is stable. Negative of Troponin I, Normal Cholesterol Therapy due to streptokinase therapy and for 2-D echocardiogram with heplock inserted and latest vital signs of Temp.: 37.5°c
RR: 19cpm
PR: 86 cpm
BP: 100/70mmHg.
