Trigger 1

At the ER level there 3 important things to do in order to save the patient from a
life threatening situation.

Initial Assessment - (a quick review of the A airway, B- breathing, C- Circulation,

D- disability and E- Exposure). This also includes a quick assessment of the History
and Physical Examination of the patient.

History of Present Illness:

By history we learn that the patient is a known smoker, an alcoholic beverage

drinker 2-4 bottles a day and living a sedentary life with a marked weight gain
of 18kg for the past 10 years making him an obese class 1 patient by Asia
pacific obesity guideline scoring with a BMI of 29.5kh/m2.

Physical Examination:

By physical examination, patient is hypotensive at 90/40, Hyperthermia at

temperature of 38.33, tachycardic at 135bpm, and respiratory rate of 20cpm.

By vital signs alone, we can tell that the patient is having compensatory
tachycardia to increase pumping ability of the heart to facilitate faster
distribution of oxygen to the body due to hypotensive episode, and the
increase in temperature in brought about by the increase metabolic rate of
the body.

Initial Management is done in order to stabilize the patients condition.

Patient arrive at the ER drowsy, sedated, with cool clamy skin and cyanotic (this
means that there is a changes in mentation brought about by the decrease in
oxygen perfusion to the brain also manifested by a low hemoglobin or blood
distribution to the capillaries of the skin giving it a distinct cyanotic discoloration.
The wife has verbalized He had been vomiting and experiencing progressive
weakness earlier in the day. He experienced shortness of breath and chest pain
despite rest and medication, and he was becoming cyanotic, as a nurse by this
manifestation alone we should administer oxygen therapy using nasal cannula at
2LPM.
 Cardiac assessment:
The patient was having s4 and s3 with noted murmur it would be wise to get
an ECG or hooked the patient to a cardiac monitor to assess the current
cardiac status of arrhythmia and signs of heart failure.
Since patient was having Rhonchi both lungs and fine basilar rales bilateral
this would warrant us to do chest X-ray of the patient to see if there are any
cardiomegaly (heart enlargement) or any comorbidity like pneumonia or
signs of pulmonary effusion that result to a decreased in the ability of the
lungs to have an exchange of oxygen and CO2.
Additional Laboratory and Diagnostics
o Arterial Blood Gases May exhibit Respiratory Alkalosis due to
vomiting or Respiratory or Metabolic Acidosis due to altered
cardiac function. However, the most likely result would be
Metabolic Acidosis.
o Hemogluco Test Since the client is obese and has a BMI of
29.5 indicating BMI classification of Obese Class 1, as nurses we
should rule out conditions due to the increased body weight.

Other Managements:

1. Start of venoclysis with appropriate IV fluid

2. Do a blood examination to work up the patient, CBC, creatinine, bun,
sgpt sgot, lipid profile, serum sodium serum potassium, serum calcium,
phosphorous.
3. BP monitoring every 15 for the first hour, every 30 minutes for the next 2
hours, every hour for the next 4 hours until stable then every 4 hours.
4. Administration of appropriate emergency medications as prescribed by
the physician. Such as dopamine drip, norepinephrine drip or
administration of anti-arrhythmic agents.
5. Intubate the client if in respiratory distress such as apnea, decrease
oxygen saturation, or cyanosis.

Initial Impression/Diagnosis:
In this case patient present with an initial assessment of:

1. Heart Failure probably secondary to chronic hypertension or maybe

due to underlying Diabetes Mellitus
2. Acute Respiratory failure probably secondary to pulmonary effusion or
pneumonia sever.
 TRIGGER 2

DRUG STUDY

Generic Dosage, Classification Indications Mechanism of Side effects Nursing

Name Timing Action Considerations
(Brand Name) and General Class Enumerate and
& Route and Family underline May illustrate
Date ordered specific
(actual) indication for the
patient
1.) Monitor the
Normal Saline Isotonic side effects or
Solution volume It is Normal Saline Venous adverse effects
(0.9% Sodium expander indicated as is a sterile, non- Thrombosis then inform the
Chloride a source of pyrogenic Phlebitis patient to prevent
Solution) Electrolyte water and solution for fluid Extravasation anxiety.
replacemnt electrolytes. and electrolyte Hypervolemia
In general, replenishment 2.) Secure
intravenous properly in order
lines should to have a smooth
not be flow.
started
unless the 3.) Check if site
patient appears
currently, or edematous. Re
may soon insert the IV line
need either on the other hand.
fluid
replenishme
nt or
medication
 administrati
on.

If used to
replenish
fluids, a
large bore
IV (18G or
more)
should be
started,
hung with a
1000 mL
bag of
saline.

If saline is
being
started for
medication
administrati
on maintain
at TKVO, or
consider
using a
saline lock
instead of
intravenous
line.

1.) Caution should

Multi Indicated as daily M.V.I. Injection Ash be exercised
Vitamin multivitamin improves the Erythema when
Intravenous Ampule; Nutritional maintenance patient's Pruritus administering this
Infusion IV; Daily supplement dosage for adults condition by Headache multivitamin
(MVII) (vitamin) and children performing the Dizziness formulation to
aged 11 years following Agitation patients on
and above functions: Anxiety warfarin sodium-
receiving Diplopia type
parenteral Facilitati anticoagulant
Urticaria
nutrition. ng retina therapy.
Periorbital
formatio
Digital edema
n 2.) Instruct the
required importance of
for low vitamin
light and supplement.
color
vision. 3.) Follow the diet
Metaboli program given to
zing you by your health
carbohy care provider.
drate
thus
maintain
s normal
growth.
Maintain
ing
many
tissues
of the
body to
prevent
vitamin
B2
 deficienc
y.
Converti
ng food
into
glucose
thus
produce
s
energy.
Raising
the level
of
glutathio
ne thus
prevents
cells
against
peroxida
tive
damage

1.) Caution
Potassium 40 mEq in Potassium To prevent and Replaces Weakness patient not to use
(Klor Con) 100 ml; Supplement treat potassium and Confusion salt substitutes.
D5W over hypokalemia maintains the Flaccid
4 hr BID potassium level paralysis 2.) Monitor ECG
Nausea and electrolyte
Vomiting levels during
Diarrhea therapy.
Abdominal
pain
 3.) Monitor patient
of signs of drug
adverse reaction.

4.) Monitor signs

of overdose (ECG
changes,
Weakness,
Cardiac
Arrhythmias)

5.) Administer
oral drug after
meals or with
food and a full
glass of water to
decrease GI
upset.

1.) Monitor the

Thiamine 100 mg; Vitamins B1 Metabolism for Combines with Itching patients reaction
(Betalines, IM; Daily carbohydrates adenosine Urticarial towards the
Biamine) and for normal triphosphate in Edema medication to
nerve function. the liver. know if any
Kidney, and adverse effects
leukocytes to have occurred.
produce
thiamin 2.) Inform the
diphosphate patient of the side
which acts as effects of the drug
coenzyme in to prevent anxiety.
 carbohydrate
metabolism.

Methylprednis 100 mg; Corticosteroid Prevents the Binds to Shortness of 1.) Taper doses
olone IVq8hr release of activate breath when
(Medrol) substances in the intracellular Swelling discontinuing
body that cause glucocorticoid Wight gain high-dose or long-
inflammation and receptors bind Tarry stool term therapy to
infection. to promote Hypokalemia allow adrenal
regions of DNA Pain of recovery.
and activates extremities
transcription 2.) Do not give live
function virus vaccines
resulting in with
inactivation of immunosuppressi
gene through ve doses of
deacetylation of corticosteroids.
histones.
3.) Do not to stop
taking the oral
drug without
consulting your
health care
provider.

4.) Increase
dosage when
patient is subject
to stress.

Ceftriaxone
(Rocephine) 1 g; Cephalosphorin Treatment for Interferes with Swelling of the 1.) Inspect
q12hr; e Antibiotic bacterial bacterial cell mouth injection sites for
IV infection. wall formation Dizziness induration and
so that wall Fever inflammation.
ruptures, Watery stools Rotate sites. Note
resulting in Difficulty IV injection sites
death of breathing for signs of
bacteria. Nausea phlebitis
Vomiting (redness,
swelling, pain).

2.) Report any

signs of bleeding.

3.) Report loose

stools or diarrhea
promptly.

4.) Monitor for

manifestations of
hypersensitivity.
Report their
appearance
promptly and
discontinue drug.

Dopamine 1600 mg; Vasopressor To correct Stimulates 1.) Inform patient

HCL 500 ml; hypotension; to dopaminergic Headache of the drug side
(Dopastat, D5W increase cardiac and alpha and Anxiety effects.
Intropin, output; to treat beta receptors Nausea
Revimine) shock and of the Vomiting
 correct sympathetic Dyspnea 2.) Monitor for
hemodynamic nervous system Asthmatic possible adverse
imbalances; resulting in a episodes effects.
improve positive Anaphylactic
perfusion to vital inotropic effect reactions 3.) If an increased
organs and increase number of ectopic
cardiac output. beats are
observed, the
dose should be
reduced if
possible.

4.) Do not use if

solution is
discoloured.

1.) Administer
Furosemide 40 mg; IV; Anti - Treatment for Inhibits Na and Vertigo
(Lasix) TID hypertensive pulmonary Chloride Headache with food or milk
edema reabsorptionat Dizziness to prevent GI
the proximal Weakness upset.
and distal Restlessness
tubules and Hypotension
ascends to the Abdominal 2.) Give early in
loop of henle. Discomfort the day so that
Blurred or
increased
Yellow vision
urination will not
disturb sleep.

3.) Measure and

record weight to
 monitor fluid
changes.

4.) Report loss or

gain of more than
3 pounds in 1 day,
swelling in your
ankles or fingers,
unusual bleeding
or bruising,
dizziness,
trembling,
numbness, fatigu
e, muscle
weakness or
cramps.

Carvedilol 3.15 mg; Antihypertensiv Treatment for left Nonselective beta Dizziness 1.) Do not
(Coreg) BID e ventricular blocker with alpha Fatigue discontinue drug
dysfunction after blocking activity Insomnia abruptly after
MI and also Hypotension chronic therapy
prevents or Blurred vision (hypersensitivity
relieve angina. to catecholamine
 Muscle may have
cramps developed,
Peripheral causing
edema exacerbation
Palpitations of angina, MI, and
ventricular
arrhythmias);
taper drug
gradually over 2
weeks with
monitoring.

2.) Give with food

to decrease
orthostatic hypote
nsion and
adverse effects.

3.) Report
difficulty
breathing,
swelling of
extremities,
changes in color
of stool or urine,
very slow heart
rate, continued
dizziness.

4.) Monitor for

orthostatic hypote
nsion and provide
 safety
precautions.

1.) Monitor patient

Captropil 50 mg; Antihypertensiv Treatment for left Inhibits ACE Dizziness closely for fall in
(Capoten) TID e ventricular inhibitors, Fatigue BP secondary to
dysfunction after preventing Fainting reduction in fluid
acute MI conversion of Headache volume (due to
angiotensin I to Malaise excessive
angiotensin II, a Fever perspiration,
potent Tachycardia and dehydration,
vasoconstrictor vomiting,
Hypotension
. Less or diarrhea);
Angina
angiotensin II excessive hypote
decreases Abdominal nsionmay occur.
peripheral
arterial 2.) Take drug 1
resistance, hour before
decreases meals; do not take
aldosterone with food.
secretion,
which reduces 3.) Do not stop
Na and water without consulting
retention and your healthcare p
lowers BP. rovider.

4.) Be careful of
drop in blood
pressure (occurs
most often
with diarrhea,
sweating,
 vomiting,
or dehydration);
if lightheadednes
s or dizziness
occurs, consult
your healthcare p
rovider.

POSSIBLE DIAGNOSTIC TESTS

1. Chest X Ray
2. Electrocardiogram (ECG)
3. Complete Blood Count (CBC)
4. Metabolic Profile
5. Cardiac Enzyme
6. Arterial Blood Gas (ABG)

Why is Potassium and Furosemide given to the client?

Diuretics that exert their primary action on the thick ascending loop of Henle are most commonly used. Most of the
filtered sodium is reabsorbed in the promixal tubule (60-65%) and the loop of Henle (20%). At maximum dose, loop diuretics
can lead to excretion of up to 20-25% filtered sodium. Potassium is given due to the hypokalemic side effect of Furosemide
because it is not a potassium-sparing diuretics.
 TRIGGER 3
Possible Complications:
1. Pulmonary Emboli or Thromboembolism
2. Hypokalemia
3. Recurrence of Cardiogenic Shock
4. Hypotension
5. Dysrhythmias
6. Dyslipidimia
7. Cardiac Plaque
8. Pulmonary Congestion
9. Atherosclerosis
10. Cardiac Arrest
11. Cardiac Aneurysm
12. Diabetes Mellitus
13. Angina
14. Cardiac Cachexia
15. Hypertension

Possible Nursing Diagnosis:

1. Impaired Gas Exchange related to altered blood flow to the lungs
2. Acute Pain related to decreased cardiac tissue perfusion
3. Decrease Cardiac Output related to changes in electrical conduction of the
heart
4. Ineffective Cardiac Tissue perfusion related to reduced coronary blood flow
5. Ineffective Cardiac Tissue perfusion related to left thrombus formation
6. Impaired skin integrity related to invasive surgical procedure
7. Excess fluid volume related to increased isotonic fluid retention
8. Imbalanced nutrition: More than body requirements related to unhealthy eating
habits and sedentary lifestyle
9. Fluid and electrolyte imbalances related to decreased potassium levels
10. Activity Intolerance and fatigue related to decreased cardiac output
11. Anxiety related to breathlessness from inadequate oxygenation
12. Deficient Knowledge related to lack of knowledge on the disease process
 TRIGGER 4

DISCHARGE PLANNING

M_E_T_H_O_D_S RATIONALE/NURSING CONSIDERATIONS

Medications:
Potassium 10 mEq PO TID Given to replenish the lost electrolytes due
to the increased excretion as a side-
effect from another drug (Furosemide).

Furosemide 40 mg TID PO Since the client has bipedal 1:1 pitting

edema up to his mid-calf, the client is
given a loop diuretic to excrete the
excess fluid.

Precautions must be emphasized to

correct or prevent hypokalemia since
Furosemide is the most common reason
for its development.

Procainamide 250 mg BID PO This medication is used to treat a certain

serious, life-threatening irregular
heartbeat (ventricular tachycardia). It is
 used to restore normal heart rhythm and
to keep a regular, steady heartbeat.
Digoxin 0.25 mg OD PO

It increases the strength and efficiency of

heart contractions, and is useful in the
treatment of heart failure and control
the rate and rhythm of the heart.

Also slows electrical conduction

between the atria and the ventricles of
the heart and is useful in treating
abnormally rapid atrial rhythms such as
atrial fibrillation, atrial flutter, and atrial
tachycardia.
Nitroglycerin 1 patch
Treating high blood pressure during surgery,
controlling congestive heart failure
associated with heart attack, treating
chest pain in certain patients, and
lowering blood pressure during surgery.

Chest pain occurs when the heart

needs more oxygen than it can get.
Relaxing blood vessels allows blood to
flow more easily. This reduces the heart's
workload and the amount of oxygen
needed by the heart.
Exercises:
Encouraged light exercise This is to regain and promote contractions
such as walking around of cardiac muscles and regular
the park or basic yoga pumping of the heart, thus delivering
and making sure the better systemic blood flow.
client has a
companion to
supervise them during
the activity.

Treatment: (other than

medication)
Emphasize importance to The Cardiac rehab doesnt change what
adhere to the ordered happened at the past, but it can help
 Cardiac rehabilitation improve the hearts future. Its a
program which would medically supervised program designed
include exercise, to help improve your cardiovascular
lifestyle changes, health if you have experienced heart
education, and attack, heart failure, angioplasty or
emotional support. heart surgery.

It designed to help patients with heart

disease recover faster and return to full
cardiac function.

Help you increase strength, control your

weight, lower your blood pressure,
increase your endurance and improve
your self-confidence.

Effectiveness of the cardiac

rehabilitation program is increased if the
program is strictly complied with since all
programs are individualized and
constantly evaluated.

Health Teachings:
Instruct the client to Adhering to the ordered/prescribed
adhere to his treatment given by the medical experts
pharmacologic may help further promote health,
treatment and his prevent the development of
ordered diet of no- disease/complication, and maintain the
added-salt, and low- health of an individual.
fat, and cardiac
rehabilitation program.
Out-patient follow up:
Instruct the client to The patient may need reminders about
immediately return to follow-up monitoring including periodic
the hospital if chest laboratory testing and ECGs, as well as
pain is felt or other general health screening.
symptoms such as
dizziness, or painful
nape.

Follow-up Monitoring for Earlier detection of another reoccurring

lab and diagnostics heart problem may increase the
 chance of a more effective treatment
and recover.

Diet: DAT
DAT; No-added-salt; Low- Allow the client to eat foods as tolerated or
fat diet as desired; however, food intake must
have no salt added and low fat.

Salt can further damage the arteries

especially since the client has already
experienced MI. Plus it can decrease
the amount of blood flow reaching the
heart due to its strain on the blood
vessels thus for compensation, the
arteries becomes thicker and stronger
resulting to the increase of in Blood
Pressure.

In addition, decreasing the salt intake

can increase the efficiency of the
prescribed cardiac drug.

Low fat diet can help prevent the client

from developing more cardiac diseases
such as Atherosclerosis especially since
the client has smoked in his younger
years.
Spirituality:
Encouraged the client to Allowing the client to participate with his
continue his spiritual spiritual activities may help him acquire
activities such as going hope and a positive perception about
to mass and reading his disease, plus, it may promote
the bible if a Roman wellbeing and wellness.
Catholic or praying in
the Mosque or reading
the Quaran if an Islam.
However, assessment is
needed to identify the
preferred spirituality of
the client.

How might a home health nurse facilitate Mrs. Aquino when caring for the
client?
 Regular monitoring of the patients condition such as monitoring the vital
signs and O2 saturation

Strict medication and diet compliance as prescribed by physician

Daily measurement of intake and output

Daily weight monitoring and calorie intake

Address concerns and provide health education to the patient and the
family