1

I. INTRODUCTION

A.) OVERVIEW OF THE STUDY

Acute myocardial infarction (MI) is defined as death or necrosis of

myocardial cells. It is a diagnosis at the end of the spectrum of myocardial
ischemia or acute coronary syndromes. Myocardial infarction occurs when
myocardial ischemia exceeds a critical threshold and overwhelms myocardial
cellular repair mechanisms that are designed to maintain normal operating
function and hemostasis. Ischemia at this critical threshold level for an extended
time period results in irreversible myocardial cell damage or death.

Critical myocardial ischemia may occur as a result of increased

myocardial metabolic demand and/or decreased delivery of oxygen and
nutrients to the myocardium via the coronary circulation. An interruption in the
supply of myocardial oxygen and nutrients occurs when a thrombus is
superimposed on an ulcerated or unstable atherosclerotic plaque and results in
coronary occlusion. A high-grade (> 75%) fixed coronary artery stenosis due to
atherosclerosis or a dynamic stenosis associated with coronary vasospasm can
also limit the supply of oxygen and nutrients and precipitate an MI. Conditions
associated with increased myocardial metabolic demand include extremes of
physical exertion, severe hypertension (including forms of hypertrophic
obstructive cardiomyopathy), and severe aortic valve stenosis. Other cardiac
valvular pathologies and low cardiac output states associated with a
decreased aortic diastolic pressure, which is the prime component of coronary
perfusion pressure, can also precipitate MI

Myocardial infarction can be subcategorized on the basis of anatomic,

morphologic, and diagnostic clinical information. From an anatomic or
morphologic standpoint, the two types of MI are transmural and nontransmural. A
transmural MI is characterized by ischemic necrosis of the full thickness of the
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affected muscle segment(s), extending from the endocardium through the

myocardium to the epicardium. A nontransmural MI is defined as an area of
ischemic necrosis that does not extend through the full thickness of myocardial
wall segment(s). In a nontransmural MI, the area of ischemic necrosis is limited
to either the endocardium or the endocardium and myocardium. It is the
endocardial and subendocardial zones of the myocardial wall segment that are
the least perfused regions of the heart and are most vulnerable to conditions of
ischemia. An older subclassification of MI, based on clinical diagnostic criteria, is
determined by the presence or absence of Q waves on an electrocardiogram
(ECG). However, the presence or absence of Q waves does not distinguish a
transmural from a non-transmural MI as determined by pathology

A more common clinical diagnostic classification scheme is also based on

ECG findings as a means of distinguishing between two types of MI—one that is
marked by ST elevation and one that is not. The distinction between an ST-
elevation MI and a non-ST-elevation MI also does not distinguish a transmural
from a non-transmural MI. The presence of Q waves or ST segment elevation is
associated with higher early mortality and morbidity; however, the absence of
these two findings does not confer better long-term mortality and morbidity.

The most common etiology of MI is a thrombus superimposed on a

ruptured or unstable atherosclerotic plaque.
.
Myocardial infarction is the leading cause of death in the United States
(US) as well as in most industrialized nations throughout the world.
Approximately 800,000 people in the US are affected and in spite of a better
awareness of presenting symptoms, 250,000 die prior to presentation to a
hospital.4 The survival rate for US patients hospitalized with MI is approximately
90% to 95%. This represents a significant improvement in survival and is related
to improvements in emergency medical response and treatment strategies.
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In general, MI can occur at any age, but its incidence rises with age. The
actual incidence is dependent upon predisposing risk factors for
atherosclerosis, which are discussed below. Approximately 50% of all MI's in
the US occur in people younger than 65 years of age. However, in the future,
as demographics shift and the mean age of the population increases, a
larger percentage of patients presenting with MI will be older than 65 years

B.) OBJECTIVES OF THE STUDY

The main reason and purpose student nurses conduct care study and
exposure in the clinical area is for them to identify problems encountered by the
clients; this is one of their tools of learning knowledgeably and skillfully.
We, as health care providers, it is indeed our vocation to adjoined hands
w/ the health team for the promotion of wellness of our clients. Our main
objectives for this study are the following:

• To identify the chief complaints and admitting diagnosis of our patient so

that we can give specific nursing interventions.
• To determine the family and personal health history of our patient that
may affect present health condition
• To identify the cause and effect of the main problem through a correct
analysis of the pathophysiology of the case.
• To determine the medical management given through identifying the
significant implication of the laboratory and diagnostic examinations
ordered as well as the medical orders and its rationale.
• To make a nursing care plan for the different health problems
encountered by the client.
• To establish an ideal plan of care for a specific diagnosis or problem of
the client.
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• To evaluate the effectiveness of the actual nursing care plan that was
established.
• To impart health teachings to the client giving emphasis on his
medications, exercises, treatment, out- patient follow- up and diet
• To give referrals and follow-up for the health promotion of the client.

In general, this study aims to enhance the skills and knowledge of the
students in providing holistic care to the patient. Students logically search further
knowledge in order to attain the desired goal and intervention for the wellness of
the patient.

C.) SCOPE AND LIMITATION

Prior to the day of duty, the group has already chosen a patient for care
study. They performed a physical assessment to the patient to properly identify
the nursing problems, which require necessary and direct interventions and
medical regimen. The study on medications and doctor’s order were limited to
our chosen patient

The preventive care and anticipatory guidance are integral to nursing

practice. Thus, this care study focuses on the particular case of the patient. Since
the patient’s diagnosis is more on cardiovascular disease, the group has focused
on acute myocardial infarction as one of his admitting diagnosis. However, the
group did not just limit the interventions on monitoring cardiac activity of the
patient. Any symptoms and unusualties were kept watch and monitored. Any
Referrals and follow-up, so as with the nursing management were fully granted
and analyzed for the said case.

Supposedly, this case study should be focused on Gynecology concept

but due to the unavailability and presence of gyne patient in Cagayan de Oro
Polymeric General Hospital, the concept is focused on medical from Station 7.
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The care for our chosen patient is only limited for 2 days of duty excluding the
physical assessment done prior to the day of duty.

II. HEALTH HISTORY

A.) PATIENT’S PROFILE

Name of Patient: ?
Sex: Male
Age: 64 years old
Religion: Roman Catholic
Civil Status: Married
Occupation: ?
Income: P 6,000/ month
Nationality: Filipino
Date Admission: June 29, 2007
Time: 09:40 pm

BASELINE VITAL SIGNS

Temperature: 36.6 C
Pulse Rate: 54 bpm
Respiratory rate: 18 cpm
Blood Pressure: 130/100 mmHg
Height: 5’3’’
Weight: 55.5 kgs

Chief complaints: epigastric pain

Admitting Diagnosis: Acute myocardial infarction;
Hypertensive cardiovascular disease;
ruled out PUD; diabetic neprhopathy
Attending Physician: Dr. Alenton
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B.) FAMILY AND PERSONAL HEALTH HISTORY

?, 64-year-old, male, a resident of ? has a critical health problem. He said

that he was an alcohol drinker during his adolescence and late adulthood and

confessed that he only drinks 2-6 glasses even more on occasional basis;

however, he has no history of cigarette smoking. At fist, he experienced

hypertension in the year 1998 when he was still 55 years old. On the year 2006,

because of over workload and emotional stress, Mr. Agustin has experienced

severe chest pain and that same year he was diagnosed of having Diabetes

Nephropathy and Chronic Renal Insufficiency and was admitted at Northern

Mindanao Medical Center. During his admission last 2006, Mr. Sarmiento has

been transfused with 5 bags of Packed Red Blood Cell and there were no reports

of allergic reaction. At that time, he was advised by the doctor to have his

monthly check-up for his health problems.

According to the patient’s wife, there is no history of health problems from

their family. Nobody aside from Mr. Agustin Sarmiento has been admitted for

chronic illness. His children were neither non-smoker nor alcoholic but they do

drink alcohol occasionally Although there were presence of minor illnesses

before like cough, colds, LBM but they were able to catch on the treatment

regimen as a home care management.

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C.) CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

On the 29th of June, Mr. ? has experienced chest pain with complaints of

acute epigastric pain, growing in character and on and off. The patient was

anorexic and hypertensive (180/ 60 mm Hg). With the help of his family he went

to the hospital for check-up, they thought that it was just an ulcer, but the doctor

came out to have a diagnosis of Acute myocardial infarction; Hypertensive

cardiovascular disease; ruled out PUD; diabetic neprhopathy, and due to the

severity of pain he was prompted for admission in the Polymedic General

Hospital.

III. DEVELOPMENTAL STATUS

ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY

Later Maturity (60 y.o- )

The fact that man learns his way through life is made radically clear by
consideration of the learning tasks of older people. They still have new
experiences ahead of them, and new situations to meet. At age sixty-five when a
man often retires from his occupation, his changes are better than even of living
another ten years. During this time the man or his wife very likely will experience
several of the following things: decreased income, moving to a smaller house,
loss of spouse by death, a crippling illness or accident, a turn in the business
cycle with a consequent change of the cost of living. After any of these events
the situation may be so changed that the old person must learn new ways of
living.
The developmental tasks of later maturity differ in only one fundamental respect
from those of other ages. They involve more of a defensive strategy--of holding
on the life rather than of seizing more of it. In the physical, mental and economic
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spheres the limitations become especially evident; the older person must work
hard to hold onto what he already has. In the social sphere there is a fair chance
of offsetting the narrowing of certain social contacts and interests by the
broadening of others. In the spiritual sphere there is perhaps no necessary
shrinking of the boundaries, and perhaps there is even a widening of them.

Our patient Agustin Sarmiento is already at the later maturity stage. At

his age he will be adjusting in decreasing physical strength and health, adjusting
to retirement and reduced income, adjusting to death of spouse, establishing an
explicit affiliation with one's age group, meeting social and civic obligations,
establishing satisfactory physical living arrangements: The principal values that
older people look for in housing, according to studies of this matter, are: quiet,
privacy, independence of action, nearness to relatives and friends, residence
among own cultural group, closeness to transportation lines and communal
institutions like libraries, shops, movies, churches, etc.

ERIK ERICKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

Ego Integrity vs Despair (65-)

Erik Erikson adapted and expanded Freud’s theory of development to
include the entire life span, believing that people continue to develop throughout
life. He describes eight stages of development. Erikson envisions life as a
sequence of levels of achievement. Each stage signals a task that must be
achieve. The resolution of the task can be complete, partial or unsuccessful.
Erikson believes that the greater the task achievement, the healthier the
personality of the person; failure to achieve the task influences the person’s
ability to achieve the new task. This developmental task can be viewed as a
series of crisis and successful resolution of this crisis and successful resolution of
these crisis is supportive to the person’s ego failure to resole the crisis is
damaging to the ego.
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Our patient Agustin Sarmiento belongs to the older adult stage. His
central task is Ego Integrity versus Despair. Ego integrity is the ego's
accumulated assurance of its capacity for order and meaning. Despair is signified
by a fear of one's own death, as well as the loss of self-sufficiency, and of loved
partners and friends. He must learn to accept the life that he has led (good and
bad) to have a life in facing death. As he learns to live with his choices and the
certainty of death, he fined a inner-strength to go on with integrity. Some despair
is inevitable, a he mourn his own deaths. When he recognizes all that he have
been, are and will be, then we show his wisdom.

KOHLBERG’S STAGES OF MORAL DEVELOPMENT

Post conventional (Universal Ethical and Principle Orientation

Lawrence Kohlberg’s theory specifically addresses moral development in

children and adults. The morality of an individual’s decision was not Kohlberg’s
concern; rather he focused on the reasons of an individual makes a decision.
According to Kohlberg, moral development progress to three levels and six
stages. At Kohlberg first level, called the premolar or preconventional level,
children are responsive to cultural rules and labels of good and bad, right and
wrong. However, children interpret these terms of the physical consequence of
their action, that is, punishments or reward. At the second level, the conventional
level, the individual is concerned about maintaining the expectation of the family,
group or nation and sees this is right. The emphasis at third level is conformity
and loyalty to one’s own expectation as well as society’s. level three is called the
post conventional, autonomous or principal level. At this level people make an
effort to define valid values and principles without regard to outside authority or to
the expectation of others.

Our patient Agustin Sarmiento belongs to the Post Conventional level

and on the Universal Ethical principle orientation stage. His decisions and
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behaviors re based on internalized rules, on conscience rather than social laws,

and on self- chosen ethical and abstract principles that are universal,
comprehensive and consistent.

IV. MEDICAL MANAGEMENT

A.) DOCTOR’S ORDER

DATE DOCTOR’S ORDER RATIONALE

June 29, 2007

9:50pm  Please admit under  For proper monitoring
the serviceof Dr. of the patient’s
Hgt:188mgs/dL Alenton condition

BP: 180/60mmHg  Secure consent to  To have consent in

care rendering medical
HR:92bpm treatment to patient

 TPR qh  To have baseline data

and monitor patient’s
condition

 Diabetic diet  Diet prescribed in

treatment of type 2
Diabetes mellitus

 Lab. CBC,  To have baseline data

crea,K,Hgt stat. in planning of giving
FBS, lipid profile, treatment and care to
ECG the patient

 IVF PNSS1L @  To keep vein open; to

10gtts/min have patent line in
cases of administering
IVT drugs
 Meds.
ISMO 60g  Antianginals; to
Isordil 5g SL PRN prevent situations that
may cause anginal
attacks of the patient
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Zantac IVT now then  Antiulcer drug; to

q8h reduce gastric acid
secretions
 Please refer
accordingly

 Troponine T now  To measure levels of

cardiac troponins

11:07pm

 Blood typing now  To determine blood

 Cross-matching now type of the patient &
the presence of ABO
and Rh factor

 Transfuse 2’U’ PRBC  For blood replacement

 Repeat ECG in AM  For continued

surveillance of the
heart’s electrical
activity
June 30,2007
11:00am
 Tramadol 50mg IVT  Relieve of moderate to
now severe pain

 Pantoprazole  Inhibits proton pump

(Ulcepraz) 40g IVT activity thus
OD,start now suppresses gastric
2:55pm
acid secretion
BP:180/100mmHg
 Please give captopril  To lower down BP of
25mg tab SL now the patient

 Get BP & HR after 15  To determine the

minutes effectivity of the
8:00pm medication (captopril)

 Tramadol 50mg IV  Relieve of moderate to

now then PRN severe pain

 Arixtra 25mg SC now  Anticoagulant drug; to

then OD maintain arterial
patency
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 To reduce the
 Plavix 75mg 4 tabs thrombotic events in
now then 1tab OD patient with
atherosclerosis

 Increases myocardial
 O2 inhalation 2L/min oxygen supply &
relieves pain

 For continued
 Repeat ECG in AM surveillance of the
heart’s electrical
activity
 To monitor the health
 VS qh & record status of the patient &
have baseline data in
giving medications

 Adjunct to diet to
 Lipitor 1 tab OD start reduce LDL
tonight cholesterol, total
cholesterol, and to
increase HDL
cholesterol of the
patient
July 1. 2007
 To determine the level
 CBC after 2’U’ PRBC of the blood
components of the
patient after
July 2, 2007
transfusion
12:20am
BP: 190/90mmHg
 Antihypertensive drug;
 Give captopril 25mg to lower the BP of the
10:25am
tab SL now, T.O. patient
BP: 160/80mmHg
Dr. Taboclaon
HR: 88bpm  Antihypertensive drug;
 Give captopril 25mg to lower the BP of the
SL now, T.O. patient
Dr. Espina
 To keep vein open; to
 IVF PNSS1L @ have patent line in
10gtts/min cases of administering
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IVT drugs
BP: 200/80mmHg
 Antihypertensive drug;
HR: 94bpm  Give captopril 25mg to lower the BP of the
tab SL now patient
 For hypertension; For
 Bepridil (Vascor) 10 chronic stable angina,
mg. 1 tab now then used alone or in
OD P.O. combination ĉ B-
blockers nitrates
 Increases myocardial
 O2 inhalation 2l/min oxygen supply &
relieves pain
July 3, 2007
BP: 200/110mmHg
 Antianginal; to reduce
 Give Isordil 5mg tab cardiac oxygen
SL for 3 doses q 5 demand by
minutes if chest pain decreasing preload
is not relieved and afterload.

 Increases myocardial
 Increase O2 oxygen supply &
12:50pm inhalation to 4L/min relieves pain

 Antihypertensive drug;
 Give captopril 25mg to lower the BP of the
tab SL now patient

 Antianginal; to reduce
 Give Isordil 5mg SL cardiac oxygen
now demand by
decreasing preload
and afterload

 For continued
 Repeat ECG in AM surveillance of the
5:30pm heart’s electrical
activity
 Antihypertensive drug;
 Therabloc 50mg 1tab to lower the BP of the
now then OD patient

 To keep vein open; to

 IVF PNSS1L @ have patent line in
10gtts/min cases of administering
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IVT drugs

B.) LABORATORY AND DIAGNOSTIC EXAMINATIONS

RESULTS IMPLICATIONS
1.) HEMATOLOGY
Date: June 30, 2007
Time: 3: 46 pm

Cross- matiching
Patient’s blood type Blood Rh (D) positive RBCs have antigen- can
Donor’s blood type Blood Rh (D) positive initiate antibodies reaction

Bag serial # (s)

35147 segment
36353022
35260 segment
36352489
Re-screening Not done
Blood component Packed red blood cell
Remarks Compatible
Method Dia- med microsystem

RESULTS REFERENCE IMPLICATIONS

VALUES
1.) BLOOD
CHEMISTRY
Date: June 30,
2007
Time: 5:00 am

Lipid Profile 221.64 mgs/dl <200.00 Increased- Risk

Triglycerides of atherosclerotic
occlusive
coronary
diseases and
peripheral
28.39 mgs/dl 30.00 – 85.00 vascular disease
HDL Decreased- HDL
cholesterol is
lower in patients
with increased
risk for coronary
166.01 mgs/dl <150.00 heart disease
LDL Increased-
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higher in patients
with increased
risk for coronary
44.33 mgs/dl 0.00- 40.00 heart disease
VLDL . Increased- Risk
of nephrotic
106.18 mgs/dl 70.00- 99.00 syndrome
Fasting blood Increased- risk
sugar for diabetes
mellitus and
chronic renal
insufficiency

3.)
HEMATOLOGY
Date: June 30,
2007
Time: 1:02 am Increased Troponin levels
rise rapidly and
Troponin- T are detectable
within 1 hour of
myocardial cell
injury and renal
diseases
ABO + Rh
Blood Rh (D) positive
Blood group

4.) CHEMISTRY
Date: June 29,
2007
Time: 11:43 pm
6.17 mgs/ dl 0.90 – 1.50 Increased- risk
Creatinine of nephritis;
chronic renal
insufficiency;
diabetic
nephropathy;
reduced renal
blood flow

5.)
HEMATOLOGY
Date: June 29,
2007
Time: 11:43 pm
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Complete blood 2.57x 10^9/L 5.0- 10.0 Decreased- risk

count of renal failure
Total RBC and dietary
• g/dl 13.70- 16.70 deficiency
Decreased- risk
Hgb of kidney disease
and dietary
28.0 40.00- 49.70 deficiency
Decreased- risk
Hct of nutritional
108.9 70.00- 97.00 deficiency
Increased- RBC
MCV is macrocytic;
risk of foilc acid
28.2 32.0- 35.0 deficiency
Decreased- risk
MCHC of iron deficiency
anemia
70.9 54.0- 67.0
Differential Increased- acute
count bacterial
Neutrophils infection,
physical or
emotional stress

6.)
HEMATOLOGY
Date: July 1, 2007
Time: 6: 36 pm

Complete Blood
Count 3.49 x10^ 9/L 3.69- 5.90 Decreased- risk
Total RBC of renal failure;
dietary deficiency
11.1 g/dl 13.70- 16.70 Decreased- risk
Hgb of dietary
deficiency and
kidney disease
32.5 40.0- 49.70 Decreased- risk
Hct of nutritional
deficiency

Differential 66.0 54.0- 62.0 Increased- acute

count bacterial
Neutrophils infection;
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physical or
15.4 20.0- 40.0 emotional stress
Increased- viral
Lymphocytes 13.1 4.0- 10.0 infection
Increased- viral
Monocytes infection; other
chronic disease
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C.) DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M.
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
Isosorbide 7-2-07 Antianginals 5 mg tab Thought to Acute anginal Contraindicated Flushing, To prevent
dinitrale SL for 3 reduce cardiac attacks potentials ĉ vascular tolerance a
(Isordil) doses every 5 oxygen hypersensitivity headache, nitrate-free
minutes if demand by or idiosyncrasy cerebral interval of 8 to
chest pain is decreasing to nitrates & in ischemia 12 hours per
not relieved preload & those ĉ severe associated ĉ day is
afterload: also, hypolension postural recommended.
may increase hypotension,
blood flow
N/V
through the
weakness,
collateral
coronary restless,
vessels pallor,
persipiration &
collapse
Bepridil 7-2-07 Calcium 10 mg. 1 tab Inhibits calcium Hypertension Pts. ĉ history of Rarely: CHF,
(Vascor) Channel Blocker now then OD ion influx For chronic angineurotic fatigue, hypotension,
Antianginal P.O. across cell stable angina, edema & other dizziness, hot- hepatic injury,
Antihypertensiv membrane used alone or allergic flush, pregnancy C,
e during cardiac in combination reactions due to diarrhea, lactation, renal
depolarization, ĉ B-blockers ACE inhibitors: nausea, disease,
produces, nitrates pregnancy vomiting concomitant B-
relaxation of lactation Discomfort in blocker
coronary
the throat, therapy
vascular
non-
muscle
diseases productive
coronary cough,
vascular palpitation
arteries, headache &
myocardial 02 rash
delivery in pts ĉ
vasospastic
angina SA/AV
node
conduction
inhibits fast
sodium current.
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DRUG STUDY

Name of Patient: SARMIENTO, AGUSTIN M.

Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
Ranitidine 6-29-07 Anti-ulcer drug 50 mg IV q Completely NSAID- Contraindicated Occasionally, Assess pt. for
Hydrochloride 9:45 pm 8H inhibits action associated in patients reversible abdominal
(Zantac) 6-2-10 of histamine on peptic ulceration hypersensitive hepatitis. Rarely pain. Note
the H2 at to drug and agranulocytosis presence of
receptors sites those ĉ acute , acute blood in
of parietal cells, porphyria acute pancreatic, emesis, stool
decreasing dosage in pt. ĉ hypersensitivity, or gastric
gastric acid impaired renal reversible aspirate
secretion function mental
confusion, skin
rash; headache
Olmesartain 6-29-07 ACE inhibitors 20 g/mL Selectively For Contraindicated CNS: headache Administers
Medoxomil antihypertensiv 1 tab OD blocks the hypertension, ĉ CU: regard to
(Olmetec) e binding of alone or in hypersensitivity hypertension meals
angiotensin to combination ĉ to any SKIN: rash, dry
specific issue other component of GI: diarrhea, Monitor pt.
receptors found antihypertensiv the drug, abdominal pain closely in any
in the vascular e pregnancies nausea, situation that
smooth muscle lactation constipation may lead to a
& adrenal gland decrease BP
this action Use caution ĉ Respiratory 20 to
blocks the renal URL, seduction in
vasoconstrictio dysfunction symptoms, fluid volume
n effect of the bronchitis,
rennin. cough,
Angiotensin angioedema,
system as well flue like
as the release symptoms
of aldosterone
to decrease BP.

DRUG STUDY
 20
Name of Patient: SARMIENTO, AGUSTIN M.
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
tramadol HCI 6-30-07 Opioid 50 mg IV now A centrally For moderate Contraindicated Respiratory Releases pt’s
(Dolmal) Analgesics then PRN for acting to severe pain in patients depression, level of pain at
moderate to synthetic hypersensitive palpitations, least 30 min.
severe pain analgesic to drug or other chills, chest after
compound not opioids, in pain, decrease administration.
chemically breast feeding in BP, Monitor CV
related to women and in arrhythmia, and respiratory
opioid. those ĉ acute vomiting, status w/hold
Thought to intoxication nausea, GI dose & notify
bind to opioid from alcohol distention, prescribe if RR
receptors & of use cautiously borborygymi, is below 12
norepinephrine in pts. at risk for urticaria, cm. Monitor
& serotonin renal or hepatic excessive bowel &
impairment bronchial bladder
secretions function
anticipate
need for
laxative for
better
analgesic
effect give
drug before
onset of pain.
pantoprazole 6-30-07 Antiulcer 40 mg IV OD Inhibits proton Doudenal & Contraindicated Headache, Stop treatment
sodium drugs (-6) pump activity gastric ulcer in in pts. diarrhea, ĉ IV
(ulcepraz) by finding to combination ĉ hypersensitive rarely, nausea, pantoprazole
hydrogen 2 appropriate to any upper when P.O. form
potassium antibiotics for component of abdominal is warranted
oderosine the reduction the formulation pain, drug can’t be
triphosphatase, of H Pylon in safety & flatulence, skin given regard to
located at pts. ĉ peptic efficacy of using rash, pruritus meals
secretory or dizziness, symptomatic
ulcer of the the IV for
surface of edema, fever, response to
objective of mutation to
gastric parietal onset of therapy doesn’t
cells, to reducing the start, therapy depression & preclude the
suppress recurrence of for GERD are disturbance in presence of
gastric acid duodemal are unknown. vision gastric
secretion unknown malignancy.
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DRUG STUDY

Name of Patient: SARMIENTO, AGUSTIN M.

Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
captopril 7-2-07 Antihypertensiv 1. 25 mg Tab Inhibits ACE, Hypertension Contraindicated CNS: Monitor
(Capoten) e SL now preventing diabetic in pts. dizziness patient’s blood
12:10 pm conversion of nephropathy hypersensitive fatigue; rash, pressure &
Angiotensin II, to drug or ACE pruritus, pulse rate
2. 25 mg ½ a potent inhibitors use flushing, frequently
tab vasoconstrictor cautiously in angioedema, elderly pts
SL now less pts. ĉ impaired loss of taste may be moiré
angiotensin II renal function perception; sensitive to
decreasing stomatitis, GI drug’s
aldosterone irritation & hypotensive
secretion, abdominal effects in
which reduces pain; patients ĉ
sodium & leucopenia; impaired renal
water retention cough function or
& lowers blood collagen
pressure. vascular
disease,
monitor WBC
and differential
counts before
starting
treatment,
every 2 wks
for the first 3
months of
therapy and
periodically
thereafter.

DRUG STUDY
 22

Name of Patient: SARMIENTO, AGUSTIN M.

Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicatio Side Effects/ Nursing
Generic Ordered Frequency Action Indication n Toxic Effects Precaution
(Brand) Route (why drug is
ordered)
atenol 7-3-07) Antihypertensive 50 mg 1 tab A beta-blocker Hypertension Contraindicated CNS: fatigue Check apical
(Therabloc) s now then OD that Angina in patients ĉ dizziness pulse before
(-6-) selectively Pectoris, sinus CV: hypotension giving drug if
blocks beta- Acute MI bradycardia, heart failure slower than
adrenergic heart blocker GI: nausea, 60 beats /min.
receptors, greater than diarrhea withhold drug
decreases first degree Musculoskeletal: & call
cardiac output overt cardiac leg pain prescriber.
and cardiac failure, or Respiratory Monitor pts
oxygen cardiogenic bronchospasm blood
consumption shock use Skin: rash pressure drug
and cautiously in pts may mask
depresses at risk for heart signs &
rennin failure diabetes symptoms of
secretion & impaired hypoxemia in
renal function diabetic pts
drug may
cause
changes in
exercise
tolerance &
ECG
 23
DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M.
Generic name Brand Date Ordered Classification Dose/ Mechanism Specific Contra- Side Nursing
of Ordered Name Frequency/ Of Indication Indication Effects/ Precaution
Drug Route Action Toxic
Effects
Senna Senokot 7-3-07 Laxatives 2 tabs Stimulant laxative Acute Contraindicated GI: nausea, Before giving
tonight -9 that increases constipation in pts. ĉ abdominal drug for
pm peristalsis, preparation, for ulceration bowel cramps constipation
probably by bowel lesions, fecal GU: red-pink determine
relaxing the effect elimination infaction, S/sx of discoloration in whether pt. has
on smooth appendicitis, alkaline urine, adequate fluid
muscle of the acute surgical yellow brown intake exercise
intestine. Drug abdomen, N/V discoloration in & diet
also promotes abdominal pain acid urine Limit diet to
fluids clear liquids
accumulation in after X-prep
colon and small liquid is taken.
intestine.
fondaparimux Arixtra 6-30-07 Anticoagulants 2.5 mgs SC Binds to To prevent Contraindicated CNS: fever, Give by S.C.
sodium now then antithrombin III deep-vein in pts with dizziness, injection only
OD 9 pm-8 (at-III) and thrombosis creatirine confusion never I.M.
am potentates the (VDT) w/c may clearance less CU: Don’t mix ĉ
neutralization of lead to acute than 30 mL/min. hypotension, other injections
factor Xa by III pulmonary and in those edema or infusions to
which interrupts embolism who are GI: nausea avoid loss of
coagulation and hypertensive to GU: UTI, urine drug don’t
inhibits formation the drug or retention expel air
of thrombin and weigh less than Hematologic: bubble from
blood clots. 50 kgs. hemorrhage, the syringe
thrombocylopeni
a
clopidogrel Plavix 6-30-07 Antiplatelet 45 mgs, 4 Inhibits the To reduce Contraindicated GI Bleeding Platelet
bisulfate agents tabs now, binding of thrombotic in patients purpora, aggregation
then 1 tab adenosine events with hypersensitive bruising, wont return
OD P.O. 10- diphosphale to its acute coronary to drug or its hematoma, normal for at
6 platelet, receptors syndrome, ĉ components and epistaxis, least 5 days
infecting ADP- atherosderosis in those with hematutia, after drug has
mediated documented by pathologic ocular been stopped
activation and recent MI, or bleeding (such hemorrhage
subsequent established as peptic ulcer) intracranial Don’t confuse
platelet peripheral use cautiously in bleeding, plavix with
aggregation artenal patients at risk abdominal pain, Paxil
clopedogiel disease. for increased dyspepsia
irreversibly bleeding from gastritis &
modifies the trauma or other constipation,
platelet ADP pathologic rash, pruritus
receptor conditions
 24
DRUG STUDY
Name of Patient: SARMIENTO, AGUSTIN M.
Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
name of Name Ordered Frequency/ Of Indication Indication Effects/ Precaution
Ordered Route Action Toxic
Drug Effects
isosorbide Imdur 6-30-07 Anti-anginal 60 mgs 1 Tab Thought to Acute anginal Contraindicat CNS: To prevent
mononitate OD P.O. reduce attacks, post-MI ed in pts. headache tolerance a nitrate
-6- cardiac angina; to hypersensitiv CV: free interval of 8 to
60 mgs ½ tab oxygen prevent situations e or orthostatic 12 hours per day is
OD P.O. demand by that may cause idiosyncratic hypotensio recommended.
-6- decreasing anginal attacks to nitrates & n, The regimen for
preload and in those ĉ tachycardia isosobide
afterload.. severe , mononitrate (1
drug also hypotension palitations, tab.) on awakening
may blood or acute MI ĉ edema with the second
through low left nausea dose in 4 hrs. or 1
collateral ventricular extended release
coronary filling tab. Daily is
vessels pressure. intended to
minimize nitrate to
tolerance by
providing a
substantial nitrate
free interval
Monitor BP and
intensely and
duration of drug
response
atorvastatin Lipitor 6-30-07 Antilipemics 80 mgs 1 tab Inhibits HMG- Reduction of Withhold or GI Use only after diet &
OD tonight COA elevated total L stop drug in disturbances other condition
reductase, an LDL cholesterol, pts. at risk for , headache, therapy prove
early (and apolipoprotein B renal failure myalgia infective Pt should
asthenia, follow a standard low
rale-limiting) & triglycerides & caused by insomnia cholesterol diet
step in increase HDL rhabdomyoly muscle before & during
cholesterol cholesterol in pts. sis resulting cramps, therapy.
biosynsthesis ĉ primary from trauma, bronchitis, Before starting
hypercholesterole in serious rash treatment assess pt
mia acute infection, flu for underlying
conditions like causes for
like myopathy syndrome hypercholesterolemi
allergic a.
reactions
 25

IV. ANATOMY AND PHYSIOLOGY

Human system is also called our cardiovascular system, and is composed of

our heart plus our arteries and veins. In a person’s heart, the atria (plural of atrium)
receive blood from the veins and the ventricles send blood to the arteries. As the
arteries become more finely divided, they are called arterioles. The finest divisions of
our vascular system are called capillaries. As the vessels get larger again, the smallest
are called venules which join and enlarge to form veins. Note that the distinction
between arteries and veins is by direction of blood flow, not oxygen content. Veins
carry blood toward the heart and arteries carry it away from the heart. Because of this,
not all arteries carry oxygenated blood. The two major exceptions, in which arteries
are carrying deoxygenated blood are the pulmonary artery which carries
deoxygenated blood from the heart to the lungs (to pick up oxygen there) and the
umbilical arteries which carry deoxygenated blood away from the baby’s body to the
placenta (to pick up oxygen there). We have double circulation: we have a separate
pulmonary circuit to the lungs and a systemic circuit to the body.
 26

The path of blood flow in a human, then, is as follows:

1. The superior (a) and inferior (b) vena cava are the main veins that receive
blood from the body. The superior vena cava drains the head and arms, and the
inferior vena cava drains the lower body.
2. The right atrium receives blood from the body via the vena cavae. The atria are
on the top in the heart.

3. The blood then passes through the right atrioventricular valve, which is forced
shut when the ventricles contract, preventing blood from reentering the atrium.

4. The blood goes into the right ventricle (note that it has a thinner wall; it only
pumps to lungs). The ventricles are on the bottom of the heart.

5. The right semilunar valve marks the beginning of the artery. Again, it is
supposed to close to prevent blood from flowing back into the ventricle.
 27

6. The pulmonary artery or pulmonary trunk is the main artery taking

deoxygenated blood to the lungs.

7. Blood goes to the right and left lungs, where capillaries are in close contact with
the thin-walled alveoli so the blood can release CO 2 and pick up O2.

8. From the lungs, the pulmonary vein carries oxygenated blood back into the
heart.

9. The left atrium receives oxygenated blood from the lungs.

10. The blood passes through the left atrioventricular valve.

11. The blood enters the left ventricle. Note the thickened wall; the left ventricle
must pump blood throughout the whole body.

12. The blood passes through the left semilunar valve at the beginning of the aorta.

13. The aorta is the main artery to the body. One of the first arteries to branch off is
the coronary artery, which supplies blood to the heart muscle itself so it can
pump. The coronary artery goes around the heart like a crown. A blockage of the
coronary artery or one of its branches is very serious because this can cause
portions of the heart to die if they don’t get nutrients and oxygen. This is a
coronary heart attack. From the capillaries in the heart muscle, the blood flows
back through the coronary vein, which lies on top of the artery.

14. The aorta divides into arteries to distribute blood to the body.
 28

15. Small arteries are called arterioles.

16. The smallest vessels are the capillaries.

17. These join again to form venules, the smallest of the veins.

These, in turn, join to form the larger veins, which carry the blood back to the superior
and inferior vena cava.

PHYSIOLOGY OF THE HEART

The work of the heart is to pump blood to the lungs through pulmonary
circulation and to the rest of the body through systemic circulation. This is
accomplished by systematic contraction and relaxation of the cardiac muscle in the
myocardium.

Conduction System
An effective cycle for productive pumping of blood requires that the heart be
synchronized accurately. Both atria need to contract simultaneously, followed by
contraction of both ventricles. Specialized cardiac muscle cells that make up the
conduction system of the heart coordinate contraction of the chambers.

Cardiac Cycle
The cardiac cycle refers to the alternating contraction and relaxation of the
myocardium in the walls of the heart chambers, coordinated by the conduction system,
during one heartbeat. Systole is the contraction phase of the cardiac cycle, and
diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8
second.
 29

Heart Sounds
The sounds associated with the heartbeat are due to vibrations in the tissues
and blood caused by closure of the valves. Abnormal heart sounds are called
murmurs.

Heart Rate
The sinoatrial node, acting alone, produces a constant rhythmic heart rate.
Regulating factors are reliant on the atrioventricular node to increase or decrease the
heart rate to adjust cardiac output to meet the changing needs of the body. Most
changes in the heart rate are mediated through the cardiac center in the medulla
oblongata of the brain. The center has both sympathetic and parasympathetic
components that adjust the heart rate to meet the changing needs of the body.
Peripheral factors such as emotions, ion concentrations, and body temperature may
affect heart rate. These are usually mediated through the cardiac center.
 30

PATHOPHYSIOLOGY OF MYOCARDIAL INFARCTION

Predisposing factors Precipitating Factors:

• Age- 64 y.o • Coronary atherosclerotic heart
• Hypertension disease
• High HDL; Low LDL • Coronary thrombosis/ embolism
• Diabetes Mellitus • Decreased blood flow

Myocardial ischemia Myocardial Oxygen supply Cellular Hypoxia

Cardiac output Altered Cell Membrane Int.

Myocardial Conractility

Arterial Pressure Stimulation of Stimulation of

Baroreceptors Sympathetic Receptors

Peripheral vasoconstriction Afterload

Decreased
Myocardial Contractility Heart rate Diastolic Filling Myocardial Tissue
Per.

Increased myocardial
oxygen demand

S/Sx:- chest pain, oliguria, ECG changes, Elevated CK-M, Troponin T, LDH, AST
Myocardial
Oxygen Demand
 31

 Mechanisms of Occlusion

Most MIs are caused by a disruption in the vascular endothelium

associated with an unstable atherosclerotic plaque that stimulates the formation
of an intracoronary thrombus, which results in coronary artery blood flow
occlusion. If such an occlusion persists long enough (20 to 40 min), irreversible
myocardial cell damage and cell death will occur. 5

The development of atherosclerotic plaque occurs over a period of years

to decades. The initial vascular lesion leading to the development of
atherosclerotic plaque is not known with certainty. The two primary
characteristics of the clinically symptomatic atherosclerotic plaque are a
fibromuscular cap and an underlying lipid-rich core. Plaque erosion may occur
due to the actions of metalloproteases and the release of other collagenases and
proteases in the plaque, which result in thinning of the overlying fibromuscular
cap. The action of proteases, in addition to hemodynamic forces applied to the
arterial segment, can lead to a disruption of the endothelium and fissuring or
rupture of the fibromuscular cap. The degree of disruption of the overlying
endothelium can range from minor erosion to extensive fissuring that results in
an ulceration of the plaque. The loss of structural stability of a plaque often
occurs at the juncture of the fibromuscular cap and the vessel wall—a site
otherwise known as the plaque's "shoulder region." Any amount of disruption of
the endothelial surface can cause the formation of thrombus via platelet-
mediated activation of the coagulation cascade. If a thrombus is large enough to
completely occlude coronary blood flow for a sufficient time period, MI can result.

• Mechanisms of Myocardial Damage

The severity of an MI is dependent on three factors: the level of the

occlusion in the coronary artery, the length of time of the occlusion, and the
presence or absence of collateral circulation. Generally speaking, the more
proximal the coronary occlusion, the more extensive is the amount of
 32

myocardium at risk of necrosis. The larger the MI, the greater is the chance of
death due to a mechanical complication or pump failure. The longer the time
period of vessel occlusion, the greater the chances of irreversible myocardial
damage distal to the occlusion.

The death of myocardial cells first occurs in the area of myocardium that
most distal to the arterial blood supply—that is, the endocardium. As the duration
of the occlusion increases, the area of myocardial cell death enlarges, extending
from the endocardium to the myocardium and ultimately to the epicardium. The
area of myocardial cell death then spreads laterally to areas of watershed or
collateral perfusion. Generally, after a 6- to 8-hour period of coronary occlusion,
most of the distal myocardium has died. The extent of myocardial cell death
defines the magnitude of the MI. If blood flow can be restored to at-risk
myocardium, more heart muscle can be saved from irreversible damage or
death.
 33

VII. NURSING MANAGEMENT

A.) IDEAL NURSING CARE PLAN

• Nursing Diagnosis:

Acute pain may be related to tissue ischemia secondary to coronary artery

occlusion

• Possibly evidenced by

Reports of pain with our without radiation

Facial grimacing
Restlessness, changes in level of consciousness
Changes in pulse, BP

• Desired outcomes

Patient will verbalize relief control of pain

Demonstrate use of relaxation techniques
Display reduced tension, relaxed manner, ease of movement

INTERVENTIONS RATIONALE
Independent
1. Obtain full description of pain from Pain is a subjective experience and
patient including location, intensity (0- must be described by the patient.
10), duration; quality (dull/crushing); Assist patient to quantify pain by
and radiation comparing it to other experiences.

2. Instruct patient to report pain Delay in reporting pain hinders pain

immediately relief/ may require increased dosage of
medication to achieve relief. In addition,
severe pain may induce shock by
stimulating the sympathetic nervous
system, thereby creating further
damage and interfering with diagnosis
and relief of pain.

3. Provide quiet environment, calm Decreases external stimuli, which may

activities, and comfort measures (e.g., aggravate anxiety and cardiac strain
dry/ wrinkle—free linens, backrub). and limit coping abilities and
Approach the patient calmly and adjustment to current situation.
confidently

4. Assist/ instruct in relaxation Helpful in decreasing perception of/

 34

techniques, e.g, deep/ slow breathing, response to pain. Provides a sense of

distraction behaviors, visualization, having some control over the situation,
guided imagery increase in positive attitude.

Collaborative
5. Administer supplemental oxygen by Increases amount of oxygen available
means of nasal cannula for myocardial uptake and thereby may
relieve discomfort associated with
tissue ischemia
Administer medications as
indicated, e.g.:

• Antianginals, e.g nitroglycerin Nitrates are useful for pain control by

(Nitro-Bid, Nitro-stat, Nitro-Dur) coronary vasodilating effects, which
may increase coronary blood flow and
myocardial perfusion. Peripheral
vasodilation effects reduce the volume
of blood returning to the heart
(preload), thereby decreasing
myocardial work and oxygen demand.

• Beta-blockers, e.g., atenolol, Important second-lineagents for pain

pindolol, propanolol control through effect of blocking
sympathetic stimulation, thereby
reducing heart rate, systolic BP, and
myocardial oxygen demand.

• Analgesics, e.g., morphine Although IV morphine is the usual drug

sulfate (Demerol)
of choice, other injectable narcotics
may be used in acute phase/ recurrent
chest pain unrelieved by nitroglycerin to
reduce severe pain, provide sedation,
and decrease myocardial workload.

• Nursing diagnosis

Risk for decreased cardiac output may include changes in rate,

rhythm, electrical conduction, reduced preload/ increased SVR,
infracted/dyskinetic muscle

• Possibly evidenced by

Presence of signs and symptoms establishes actual diagnosis

• Desired outcomes

Patient will demonstrate hemodynamic instability, e.g., BP, cardiac
output within normal range, adequate urinary output, decreased/
absent dysrhythmias,
Report decreased episodes of dyspnea,angina
Demonstrate an increase in activity tolerance
INTERVENTIONS
Independent
1. Evaluate quality and equality of
pulses, as indicated
2. Auscultate heart sound
Note development of S3,S4
3. Monitor heart rate and rhythm.
Document dysrhythmias via
telemetry
4. Provide small/ easily digested
meals. Restrict caffeine intake, e.g.,
coffee, chocolate, cola
Collaborative
5. Administer antidysrhythmics drugs
and ACE inhibitors as indicated
• Nursing diagnosis
35
RATIONALE
Decreased cardiac output results in
diminished weak/ thready pulses.
Irregularities suggest dysrhythmias,
which may require further evaluation.
Monitoring.
S3 is usually associated with HF, but it
may also be noted with mitral
insufficiency (regurgitation) and left
ventricular overload that can
accompany severe infarction.
S4 may be associated with myocardial
ischemia, ventricular stiffening and
pulmonary or systemic hypertension
Heart rate and rhythm respond to
medication and activity, as well as
developing complications/
dysrhythmias, which could compromise
cardiac function or increase ischemic
damage.
Large meals may increase myocardial
workload and cause vagal stimulation
resulting in bradycardia/ ectopic beats.
Caffeine is direct cardiac stimulant that
can increase heart rate.
Dysrhythmias are usually treated
symptomatically, except for PVCs,
which are often treated prophylactically.
Early inclusion of ACE inhibitor therapy
enhances ventricular output, increases
survival and may slow progression of
heart failure.
 36

Tissue perfusion, altered, risk factors may include reduction/

interruption of blood flow, e.g., vasoconstriction, hypovolemia/
shunting and thromboembolic formation

• Possibly evidence by

Presence of signs and symptoms establishes an actual diagnosis

• Desired outcome

Patient will demonstrate adequate tissue perfusion as individually

appropriate, e.g. skin warm and dry, peripheral pulses
present/strong, vital signs within patient’s normal range, patient
alert/ oriented, balanced intake/ output,absence of edema, free of
pain/ discomfort.

INTERVENTIONS RATIONALE
Independent
1. Inspect for pallor, cyanosis, Systemic vasoconstriction resulting
mottling, cool/ clammy skin. Note from diminished cardiac output may be
strength of peripheral pulses evidenced by decreased skin perfusion
and diminished pulses.

2. Encourage active/ passive leg Enhances venous return, reduces

exercises, avoidance of isometric venous stasis, and decreases risk of
exercises thrombophlebitis; however, isometric
exercises can adversely affect cardiac
output by increasing myocardial work
and oxygen consumption.

3. Monitor respirations, note work of Cardiac pump failure may precipitate

breathing respiratory distress, sudden/ continued
dyspnea may indicate thromboembolic
pulmonary complications

4. Monitor intake, note changes in Decreased intake/ persistent nausea

urine output. Record urine specific may result in reduced circulating
gravity volume, which negatively affects
perfusion and organ function. Specific
gravity measurements reflect hydration
status and renal function.
Collaborative
5. Administer medications, e.g.:
 37

• Ranitidine (Zantac), Reduces or neutralizes gastric acid,

antacids preventing comfort or gastric irritation,
especially in presence of reduced
mucosal circulation

• Nursing diagnosis

Activity intolerance may be related to imbalance between

myocardial oxygen supply and demand; presence of
ischemia/necrotic myocardial tissues; cardiac depressant effects of
certain drugs (Beta- blockers, antidysrythmics)

• Possibly evidenced by

Alterations in heart rate and BP with activity

Development of dysrythmias
Changes in skin color/ moisture
Exertional angina
Generalized weakness

• Desired outcomes

Patient will demonstrate measurable/ progressive increase in

tolerance for activity with heart rate/ rhythm and BP within patient’s
normal limits and skin warm, pink, dry.
Report pain absent/ controlled within time frame for administered
medications

INTERVENTIONS RATIONALE
Independent
1. Promote rest (bed/ chair) initially. Reduces myocardial workload. Oxygen
Limit activity on basis of pain/ consumption, reducing risk of
hemodynamic response. Provide complications (e.g., extension of MI)
nonstress diversional activities.

2. Instruct patient to avoid increasing Activities that require holding the breath
abdominal pressure, e.g., straining and bearing down (Valsalva maneuver)
during defecation can result in bradycardia, temporarily
reduced cardiac output, and rebound
tachycardia with elevated BP.

Progressive activity provides a

3. Explain pattern of graded increase controlled demand on the heart,
 38

of activity level, e.g., getting up in increasing strength and preventing

chair when there is no pain, overexertion
progressive ambulation, and resting
for 1 hour after meals
Lengthy/ involved conversations can be
4. Limit visitors and or/ visit by patient, very taxing for the patient; however,
initially periods of quiet visitation can be
therapeutic

Collaborative Provides continued support/ additional

5. Refer to cardiac rehabilitation supervision and participation in
program recovery and wellness process

• Nursing diagnosis

Anxiety may be related to threat to or change in health and

socioeconomic status; threat of loss/ death; unconscious conflict
about essential values, beliefs, and goals of life

• Possibly evidenced by

Fearful attitude
Apprehension, increased tension, restlessness, facial tension
Uncertainty, feelings of inadequacy
Somatic complaints/ sympathetic stimulation
Focus on self, expressions of concern about current and future
events
Fight or flight behavior

• Desired outcomes

Patient will recognize feelings; identify causes, contributing factors;

verbalize reduction of anxiety/ fear; demonstrate positive problem-
solving skills; identify/ use resources appropriately

INTERVENTIONS RATIONALE
Independent
1. Maintain confident manner (without Patient and SO can be affected by the
false reassurance) anxiety/uneasiness displayed by health
team members. Honest explanations
can alleviate anxiety.

2. Accept but do not reinforce use of Denial can be beneficial in decreasing

denial. Avoid confrontations. anxiety but can postpone dealing with
 39

the reality of the current situation.

Confrontation can promote anger and
increase use of denial, reducing
cooperation and possibly impeding
recovery.

3. Encourage patient/ SO to Sharing information elicits support.

communicate with one another, Comfort and can relieve tension of
sharing questions and concerns unexpressed worries

4. Provide rest periods/ uninterrupted Conserves energy and enhances

sleep time, quiet surroundings, with coping abilities
patient controlling type, amount of
external stimuli

Collaborative
5. administer antianxiety/ hypnotics as Promotes relaxation/ rest and reduces
indicated, e.g., diazepam (Valium), feelings of anxiety
lorazepam (Ativan), flurazepam
(Dalmane)

B.) ACTUAL NURSING MANAGEMENT

(SOAPIE FORM)

“Ah! Dili jud makatarong ug tulog. Maka mata-mata man jud labi
S na dini sa hospital. Ug tigulang naman “ as verbalized by the
patient

 verbalizations of interrupted sleep

 complaints of not feeling rested
O
 yawning
 pain/ discomfort

Sleep pattern disturbance related to internal factors such as

illness, psychologic stress and external factors such as facility
A routines

P At the end of 2 days, the patient will be able to report improvement

of sleep/ rest pattern and verbalize increased sense of well- being
and feeling rested.
 40

At the end of 4 hours, the patient will be able to get enough

uninterrupted sleep/ rest.

1. provided comfortable bedding and some of own possession,

e.g., pillows

Rationale:
Increases comfort for sleep as well as physiologic and psychologic
support

2. Maintained environment conducive to sleep/ rest (e.g. quiet

comfortable temperature, ventilation and closed door)

Rationale:
This Provides atmosphere conducive to sleep
I
3. Encouraged position of comfort, assist in turning

Rationale:
Repositioning alters areas of pressure and promotes rest

4. Provided nursing aids (e.g. back rub, bedtime care, pain relief,
comfortable position [semi- fowler’s], relaxation techniques)

Rationale:
To promote rest, relaxation; to induce sleep

5. Attempted to allow for sleep cycles for at least 90 minutes

Rationale:
Experimental studies have indicated that 60- 90 minutes are
needed to complete one sleep cycle and the completion of an
entire cycle is necessary to benefit from sleep.

At the end of 4 hours, the patient was able to have sleep and
verbalized of feeling rested.
E
At the end of 2 days, the patient was able to verbalize a fair
improvement of his sleep/ rest pattern in between his medication/
treatment regimen.
 41

S “Dili ko palakwon sa doctor kay dili pwede sa ako mangusog kay

sakit akong heart” as verbalized by the patient

O  patient report chest pain with radiation to epigastrium

 pain scale of 6
 facial grimaces
 changes in vital signs, baseline: HR=54 bpm, BP=140/90
mmHg

A -Acute pain related to tissue ischemia of myocardial tissue

secondary to myocardial infarction.

P At the end of 30 minutes, patient will be able to verbalize relief of

pain, display reduced tension, relaxed manner and ease of
movement

1.) Obtained full description of pain from patient including

location, intensity (0-10), duration, quality and radiation.
Rationale:
Pain is a subjective experience and must be described by the pt.
Assist pt. to quantify pain by comparing it to other experiences.

2.) Maintained bed rest at least during periods of pain.

Rationale:
To reduce workload of the heart
I

3.) Positioned patient comfortably, in moderate high back rest

Rationale:
This allows for lung expansion by lowering the diaphragm
 42

4.) Instructed patient in relaxation techniques, i.e., deep/slow

breathing
Rationale:
Helpful in decreasing perception of/ response to pain. Provides a
sense of having some control over the situation, increase in
positive attitude.
COLLABORATIVE
5.) Administered supplemental oxygen by means of nasal cannula
@ 3L/min.
Rationale:
Increases amount of oxygen available for myocardial uptake and
thereby may relieve discomfort associated with tissue ischemia
Administered medications as indicated such as:
• Isosorbide dinitrate (Isordil) 5 mg tab SL for 3 doses every
5 minutes if chest pain is not relieved
• Isosorbide mononitrate (Imdur) 60 mg ½ tab
OD P.O
Rationale: to reduce cardiac oxygen demand by decreasing
preload and afterload. Increases blood flow through the
collateral coronary vessels.

E At the end of 30 minutes, patient was able to verbalize a slight

relief of chest pain and demonstrated the use of relaxation
techniques.

S “Dili ko pwede mangusog kay magsakit akong heart.” as verbalized by

the patient.

O  weakness
 43

 Patient’s report of pain

 Changes in v/s

A Ineffective cardiopulmonary tissue perfusion related to reduced

coronary blood flow.

P At the end of 2 hours, patient will verbalize a relief from pain and
discomfort.

1.) Initially assess document and report to the following physician.

Patients description of chest discomfort, including location, intensity,
radiation, duration and factors that affect it. Other symptoms such as
nausea, diaphoresis complains of universal fatigue.

I 2.) Monitored respiration and note work of breathing.

3.) Assess GI functions and monitor fluid intake and urine output.

4.) Obtained a 12- lead ECG recording during the symptomatic event
as prescribed to determine extension of infarction

COLLABORATIVE:
5.) Administered oxygen @ 3L/min via nasal cannula.
Rationale:
Increases amount of oxygen available for myocardial uptake and
thereby may relieve discomfort associated with tissue ischemia

E At the end 2 hours, patient verbalizes the relief from discomfort around
the chest.
 44

S “Hypertensive nako dugay ra kadto pa ning 55 anyos pa ako edad.” as

verbalized by the patient.

 Elevated BP=140/90 mmHg

 Increased creatinine= 6.17 mgs/dl
O
 Urine output of less than 30 ml/hr

A Decreased cardiac output related to diminished blood flow caused by

increased vascular resistance.

P At the end of 1 hour, patient will be able to achieve and maintain BP

within acceptable range.

1.) Monitored BP using proper equipment with cuff bladder that is two-
thirds diameter.
Rationale:
To detect changes from baseline that indicate changes in
cardiovascular status

I 2.) Maintained fluid and dietary sodium restrictions.

Rationale:
To reduce fluid restriction which contributes to hypertension

3.) Discouraged intake of coffee, tea, cola and chocolate which are
high in caffeine.
Rationale:
Caffeine stimulates sympathetic nervous system
 45

4.) Maintained physical and emotional rest.

Rationale:
Sedatives can be used to reduce stress and associated
vasoconstriction; to reduce cardiac workload

5.) Administered antihypertensive as prescribed:

• atenol (Therabloc) 50 mg 1 tab now then OD
Rationale:
A beta-blocker that selectively blocks beta-adrenergic receptors,
decreases cardiac output and cardiac oxygen consumption and
depresses rennin secretion

E At the end of 1 hour, patient was able to maintain BP within individually

acceptable range.

VIII. REFERRALS AND FOLLOW – UP

(Health teaching)
 Advised patient to take prescribed medication at
regular basis;
Atenolol( therabloc) 50 mg.tab once a day P.O
Medication Clopidogiel ( plavix) 75 mg. tab once a day P.O
ISMN ( Imdur) 60 mg tab once a day P.O
Atorvastatin calcium ( lipitor) once a day P.O

At the hospital, patient is advised to initiate gradual

exercise such as;
a) Lying or sitting exercises ( arms, legs, trunk)
b.) Exercise progress to standing and slow walking in
Exercise the hall.
c.) Exercise must be done twice a day for about 20
minutes
d.) Exercises (Deep, pursed lip or deep breathing
exercises)

In the hospital, patient is provided with the following

treatment ;
 46

a.)Supplemental oxygen by nasal cannula @ 2-4

L/min.
Treatment b.)Cardiac monitoring for continued surveillance of
hearts activity.
c.)Frequent monitoring of vital signs including
temperature , pulse rate ( apical/ radial) and blood
pressure and intake and output
d.)Pharmacologic management to stabilize client
condition.

Out patient  When the patient will be discharge, out patient

program consist of supervised , oven ECG monitored
, exercised training based on the results of exercised
stress test .support and guidance related to the
treatment of the disease and education and
counseling related to lifestyle modification .

 Client is advised to follow the prescribed

recommended diet ;
a) Diabetic diet: eat complex CHO foods with high
Diet fiber content avoid added sugar and concentrated
sweets and all other CHO foods and eat regularly.
b) Eat foods low in calorie, saturated fats and
cholesterol; restriction of sodium; avoidance of
spicy foods soft fiber food and take small frequent
feedings

Recommendations

 Advised the patient for followed up check up from his assigned physician.
 Advised patient peer for frequent monitoring of his vital sign to avoid any risk
and possible complication
 Explain the purpose and preparation for diagnostic test to have clear
understanding of procedures and what is happening increase feeling of
control and lessens anxiety.
 Provide positive reinforcement for gains/ improvement and participation in self
care/treatment program. This encourages continuation of healthy behavior.
 47

 Advice patient to take his medication at home as prescribed by the physician

for continues medication treatment.
 Suggest engaging in relaxing, non strenuous activity to avoid any risk due to
over stress
 Teach client on coping mechanisms with recurring pain and other clinical
manifestations
 Encourage patient to eat nutritious food like vegetable fruits, foods the high
fiber contain like cereal and foods rich in protein.

IX. EVALUATION & IMPLICATION (PROGNOSIS)

This case study was done successfully although we experienced some

difficulties analyzing the health status of the client and understanding the medical
orders given. Using our critical thinking, we were able to carefully identify the
problem of our patient who needs direct interventions for the wellness of his
health. Moreover, the group was able to discuss some health teachings as stated
above for the improvement of the client’s health and fast recovery.

The patient was able to understand the imparted health teachings and
verbalized to consistently follow his treatment regimen in home care
management. Although patient’s blood pressure did not lower down to his normal
range of blood pressure, other clinical manifestations such as severe chest pain
was not subjectively verbalized by the patient and labored breathing was not
evident. Still, patient has unproductive, dry cough. Mr. Sarmiento is progressing
well in his health condition and is for discharge any soon. Patient may have an
uncomplicated episode of myocardial infarction and may return to normal
activities and lifestyle with moderation and modification to some of those.

X. DOCUMENTATION

Upon assessment last July 3, 2007, patient X was received with a diagnosis
of Acute myocardial infarction; Hypertensive cardiovascular disease; ruled out
 48

PUD; diabetic nephropathy. Pt. was sitting on bed and complaint on pain on
chest area upon coughing was noted. Instructed to do deep, breathing exercises
everytime chest pain is recurring. Pertinent data about the patient’s family and
personal health history were gathered.

The next day on the group’s duty, pt. has oxygen inhalation regulated at
3l/min via nasal cannula and vital signs were monitored every 4 hours with
special consideration to the client’s blood pressure. Due medication were
properly given and kept patient in moderate, high back rest and kept comfortably
on bed, keeping back dry. Pt. was observed for any unsualties during the shift.
No further complaints were noted from the patient.

On the 2nd day of duty the doctor ordered that client may go home the next
day if stable. So, the group imparted health teachings important for the client to
follow as his home care management. We helped the client in discharged
planning and reminded them the health teachings that we had discussed.

This study also tests our abilities and skills on how to find answers to the
patient’s problem, what action to be done in order to solve it and how to properly
and correctly use our initiative for the success and for the good outcome of our
care study. This is one of our tasks as a student or future nurses and it serves as
our training ground backed up with strict training in order for us to become
equipped, productive, efficient, and world-class nurses in the future.

B I B L I O G R A P H Y

• Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10 th edition)

Lippincott-Raven Publisher.Copyright 1996
 49

• Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education
Inc.,Copyright 2000

• Mosby’s Pocket Dictionary of Medicine, Nursing and Allied Health (4 th

edition) Elsevier(Singapore) PTE LTD> Copyright 2002

• Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing

Patient Care(6th edition) F.A Davis Company. Copyright 2000

• Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition).

Addison esley Longman Inc. 1998.

• MacMahon, S. Blood pressure and the risk of cardiovascular disease. N

Engl J Med 2000; 342:50

•
• HTML1Rollins Gina. "With smoking cessation drugs, dosing is key", ACP-
ASIM Observer, 22(4); 1,16-17.

W E B L I O G R A P H Y

• http://biology.clc.uc.edu/courses/bio105/circulat.htm
• wwwmedlib.med.utah.edu\webpath\TUTORIAL\MYOCARD\MYOCARD

• Research Paper help

• https://www.homeworkping.com/
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